<DOC>
[108th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:95460.wais]
HEALTH INFORMATION TECHNOLOGY: IMPROVING QUALITY AND VALUE OF PATIENT
CARE
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTH CONGRESS
SECOND SESSION
__________
JULY 22, 2004
__________
Serial No. 108-132
__________
Printed for the use of the Committee on Energy and Commerce
Available via the World Wide Web: http://www.access.gpo.gov/congress/
house
__________
U.S. GOVERNMENT PRINTING OFFICE
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COMMITTEE ON ENERGY AND COMMERCE
JOE BARTON, Texas, Chairman
W.J. ``BILLY'' TAUZIN, Louisiana JOHN D. DINGELL, Michigan
RALPH M. HALL, Texas Ranking Member
MICHAEL BILIRAKIS, Florida HENRY A. WAXMAN, California
FRED UPTON, Michigan EDWARD J. MARKEY, Massachusetts
CLIFF STEARNS, Florida RICK BOUCHER, Virginia
PAUL E. GILLMOR, Ohio EDOLPHUS TOWNS, New York
JAMES C. GREENWOOD, Pennsylvania FRANK PALLONE, Jr., New Jersey
CHRISTOPHER COX, California SHERROD BROWN, Ohio
NATHAN DEAL, Georgia BART GORDON, Tennessee
RICHARD BURR, North Carolina PETER DEUTSCH, Florida
ED WHITFIELD, Kentucky BOBBY L. RUSH, Illinois
CHARLIE NORWOOD, Georgia ANNA G. ESHOO, California
BARBARA CUBIN, Wyoming BART STUPAK, Michigan
JOHN SHIMKUS, Illinois ELIOT L. ENGEL, New York
HEATHER WILSON, New Mexico ALBERT R. WYNN, Maryland
JOHN B. SHADEGG, Arizona GENE GREEN, Texas
CHARLES W. ``CHIP'' PICKERING, KAREN McCARTHY, Missouri
Mississippi, Vice Chairman TED STRICKLAND, Ohio
VITO FOSSELLA, New York DIANA DeGETTE, Colorado
STEVE BUYER, Indiana LOIS CAPPS, California
GEORGE RADANOVICH, California MICHAEL F. DOYLE, Pennsylvania
CHARLES F. BASS, New Hampshire CHRISTOPHER JOHN, Louisiana
JOSEPH R. PITTS, Pennsylvania TOM ALLEN, Maine
MARY BONO, California JIM DAVIS, Florida
GREG WALDEN, Oregon JANICE D. SCHAKOWSKY, Illinois
LEE TERRY, Nebraska HILDA L. SOLIS, California
MIKE FERGUSON, New Jersey CHARLES A. GONZALEZ, Texas
MIKE ROGERS, Michigan
DARRELL E. ISSA, California
C.L. ``BUTCH'' OTTER, Idaho
JOHN SULLIVAN, Oklahoma
Bud Albright, Staff Director
James D. Barnette, General Counsel
Reid P.F. Stuntz, Minority Staff Director and Chief Counsel
______
Subcommittee on Health
MICHAEL BILIRAKIS, Florida, Chairman
RALPH M. HALL, Texas SHERROD BROWN, Ohio
FRED UPTON, Michigan Ranking Member
JAMES C. GREENWOOD, Pennsylvania HENRY A. WAXMAN, California
NATHAN DEAL, Georgia EDOLPHUS TOWNS, New York
RICHARD BURR, North Carolina FRANK PALLONE, Jr., New Jersey
ED WHITFIELD, Kentucky BART GORDON, Tennessee
CHARLIE NORWOOD, Georgia ANNA G. ESHOO, California
Vice Chairman BART STUPAK, Michigan
BARBARA CUBIN, Wyoming ELIOT L. ENGEL, New York
JOHN SHIMKUS, Illinois GENE GREEN, Texas
HEATHER WILSON, New Mexico TED STRICKLAND, Ohio
JOHN B. SHADEGG, Arizona DIANA DeGETTE, Colorado
CHARLES W. ``CHIP'' PICKERING, LOIS CAPPS, California
Mississippi CHRIS JOHN, Louisiana
STEVE BUYER, Indiana BOBBY L. RUSH, Illinois
JOSEPH R. PITTS, Pennsylvania JOHN D. DINGELL, Michigan,
MIKE FERGUSON, New Jersey (Ex Officio)
MIKE ROGERS, Michigan
JOE BARTON, Texas,
(Ex Officio)
(ii)
C O N T E N T S
__________
Page
Testimony of:
Blumenthal, David, Director, Institute for Health Policy,
Massachusetts General Hospital/Partners Health Care System. 43
Diamond, Carol, Managing Director, Markle Foundation......... 47
Kolodner, Robert M., Acting Chief Health Informatics Officer
and Deputy Chief Information Officer for Health, U.S.
Department of Veterans Affairs............................. 32
Shortliffe, Edward H., Professor and Chair, Department of
Biomedical Informatics, Professor of Medicine and of
Computer Science, Deputy Vice President for Strategic
Information Resources, Columbia University Medical Center,
Director, Medical Informatics Services, New York
Presbyterian Hospital...................................... 55
Thompson, Hon. Tommy G., Secretary, U.S. Department of Health
and Human Services......................................... 6
Material submitted for the record by:
American Clinical Laboratory Association, prepared statement
of......................................................... 70
Veterans Affairs, Department of, response for the record to
questions of Hon. John D. Dingell.......................... 71
(iii)
HEALTH INFORMATION TECHNOLOGY: IMPROVING QUALITY AND VALUE OF PATIENT
CARE
----------
THURSDAY, JULY 22, 2004
House of Representatives,
Committee on Energy and Commerce,
Subcommittee on Health,
Washington, DC.
The subcommittee met, pursuant to notice, at 2 p.m., in
room 2322, Rayburn House Office Building, Hon. Michael
Bilirakis (chairman) presiding.
Members present: Representatives Bilirakis, Hall, Shimkus,
Wilson, Shadegg, Buyer, Barton (ex officio), Eshoo, Stupak,
Green, Capps, and Rush.
Staff present: Chuck Clapton, majority counsel; Nandan
Kenkeremath, majority counsel; Bill O'Brien, projects
assistant; Eugenia Edwards, legislative clerk; Amy Hall,
minority counsel; Bridgett Taylor, minority professional staff;
and Purvee Kempf, minority professional staff.
Mr. Bilirakis. Good afternoon. The hearing will now come to
order. Today's hearing will provide the subcommittee with an
opportunity to learn more about the issues surrounding health
information technology and to hear about the administration's
new strategic information technology framework, which was
released yesterday.
We will also have a chance to better understand the
potential that health information technology holds for
improving America's health care system by reducing medical
errors and improving the quality and cost of health care. The
witnesses we have before us today will also be able to discuss
the barriers that have slowed the adoption of this technology
by hospitals, doctors and other health care providers.
I would like to first thank the Secretary of the Department
of HHS, Mr. Tommy Thompson, who will discuss the framework for
health information technology, and I also know that if you have
a cause, it's usually going to find its way up toward the top.
I applaud all of your efforts in this area.
Since you became Secretary, I know that promoting the
adoption of the health information technologies will provide a
framework for allowing information technology in the health
business processes across the Federal Government. And, again, I
thank you for coming and look forward to your testimony.
Developing health information technology just makes sense.
The health care industry has been dragging its feet in this
area, and it is progressing much slower than other sectors of
the economy. I was pleased that the Medicare Prescription Drug
and Modernization Act, MMA, enacted last year included a
provision that required HHS to adopt final prescribing
standards by 2008. Additionally, MMA provides for grants to
physician offices to enable the purchase of need prescribing
systems. While these are good first steps, there is so much
more that needs to be done.
I look forward to hearing from the rest of our witnesses as
well. We have two panels of experts in the field of health
information technology, and I certainly appreciate all of the
witnesses sharing their insights with us this afternoon. Thanks
for being here, and I would now yield to Mr. Stupak from the
upper peninsula of Michigan. I had the real pleasure of getting
to see that area this past weekend and it is paradise in the
summer. And he is serving as ranking member of this
subcommittee. Mr. Stupak, please proceed.
Mr. Stupak. Thank you, Mr. Chairman, and you should come
back in January or February. It is lovely then.
Mr. Chairman, thank you for calling this hearing today to
discuss one of the most important ways we can lower the cost of
health care, improve quality and reduce errors: Expanding the
use of health care information technology. Mr. Secretary, it is
always good to see you before the committee, and I would like
to thank all the other panelists who will be testifying here
today.
It is clear that we are behind the curve in what needs to
be done when we talk about telecommunications and telemedicine.
More than 90 percent of the about 30 million health care
transactions each year in the United States are still conducted
on paper, phone or fax. Fewer than 20 percent of U.S. primary
doctors use electronic medical records. Patients are still
paying billions more every year than they should. The
administration estimates we can save $140 billion annually with
upgrade.
Industry says we can save even more. The CEO of Cisco says
we can cut health care costs by 25 percent. We could also save
thousands of more lives. The Institute of Medicine has called
the development of electronic health records and other IT
advances essential to reducing the number of medical errors.
The Center for Information Technology Leadership found that
more than 2 million adverse drug events could be prevented each
year using IT and over 190,000 hospitalizations could be
prevented each year.
There is study after study about the benefits of health
care IT. We need to get moving. We have an entire baby boomer
generation increasingly using our health care system. We need
real investments yesterday, not tomorrow. I look forward to
hearing the details of the President's strategic plan announced
yesterday, and I am glad the administration is talking about
this. The Press Releases, task forces, and strategic plans
won't mean a whole lot unless they are backed up with real
funding and real incentives to implement upgrades.
The President proposed $50 million in grants to hospitals
in 2004, and he proposed $50 million in grants to States in
2005. One hundred million over 2 years is not going to cut it.
The State of Massachusetts alone needed more than $100 million
to implement just electronic prescribing technology Statewide.
The Mayo Clinic spent over $100 million in 1 year on IT
upgrades. We need to also give incentives to providers who use
IT. Technology doesn't do a lot of good if it isn't used. We
should give providers of Medicare payment increases if they use
health care IT.
Finally, when we talk about health care technology, it is
important that we recognize the special challenges and
circumstances faced by rural providers. An urban-centric
program is not going to work in rural America. Rural providers
do not have the resources big health care systems have, and
they may not be able to move as quickly or easily to implement
IT. And, frankly, I am more than a little concerned that rural
providers will be left behind.
The administration's track record with one type of health
IT, telemedicine, tells me I should be concerned. The
administration's 2005 budget contains only $4 million for rural
telemedicine grants programs. In addition, Medicare's
reimbursement for telehealth is extremely limited to only a few
providers for only a few procedures. As you know, rural
providers care for more Medicare beneficiaries than their
counterparts. HHS has said that rural providers aren't
interested in real health; but it is not a matter of interest,
it is a matter of affordability.
Telemedicine isn't the only area where rural providers have
concerns. The quality improvement organizations are supposed to
help providers implement IT upgrades to help improve the
quality of health care provided. But what we have found is that
the quality improvement organizations don't work well, if at
all, with smaller facilities. I am concerned that any health IT
initiative could again leave rural providers behind. We need to
make sure that doesn't happen.
And with that, Mr. Chairman, I guess I have a minute left,
I will yield back the balance of my time.
Mr. Bilirakis. The Chair thanks the gentleman. Gentlelady
from New Mexico, are you prepared for an opening statement?
Mrs. Wilson. Thank you, Mr. Chairman. I appreciate your
holding this hearing today. I am particularly interested in
looking at and talking to you, Mr. Secretary, about the impact
that technology can have on medical records and improving the
health status and quality for those particularly low-income
Americans who depend on some of our public programs.
We have had several hearings on Medicaid here as well as
round tables in the Medicaid Task Force that I Chair, asking
various State officials about the health status and what
indicators they look for and what systems they have, and they
usually look at us with a perplexed look, because they don't
really look at Medicaid that way. Medicaid is a system that
pays claims. It is not one that is designed to improve people's
health, and the information systems that back it up are
generally fairly primitive.
Putting health indicators and medical records in electronic
format I think would make it easier for the government to
collect data on quality and also to move toward improving the
health of people who depend on these public programs. There are
a lot of private hospitals and hospital systems in my district
that have made a lot of improvements in health information
technology, including medical records, but many of them are
very far behind what we need nationwide.
In many ways, the Veterans Administration seems to be ahead
of the curve on using information systems. I have seen their
health care records, and of course I asked, ``How did you get
the docs to use it?'' And being the VA, they said, ``Well, we
ordered them to.'' Not every hospital, I guess, is so
fortunate, but if you are retired or disabled veteran in
Albuquerque and you visit your daughter-in-law in New Jersey
and you get ill, the VA hospital in New Jersey can call up all
of your medical records immediately online, and the system is
integrated with pharmacy, with medical x-ray and all kinds of
other things.
The Federal Government, I think, can lead the way, not only
with the proposals that you have come forward with but also by
encouraging and moving toward the wide-scale adoption of
standardized health information technology systems because of
our buying power in Medicare and Medicaid. Medicaid patients
often get care at different points of entry. They are often
very mobile people, and it is a very difficult population to
serve. If hospitals can communicate better in a particular
community but also around the country via an electronic
network, it would cut down the cost and improve the quality of
care for people who depend on public systems.
So I wanted to encourage you to keep Medicaid in mind when
you are studying these issues and creating these demonstration
projects that link various providers and beneficiaries
electronically. Look forward to hearing your testimony about
health information technology, and particularly interested in
how public health programs, such as Medicaid, can benefit from
this new emerging area. Thank you, Mr. Chairman.
Mr. Bilirakis. The Chair recognizes the gentlelady from
California, Ms. Capps, for her opening statement.
Ms. Capps. Mr. Chairman, I would prefer to waive my opening
statement in favor of 3 more minutes for questions.
Mr. Bilirakis. By all means. Thank you. Mr. Shimkus.
Mr. Shimkus. Mr. Chairman, I would like to waive in respect
to the Secretary's time. Welcome here.
Mr. Bilirakis. Thank you, sir. Mr. Rush just came in. Do
you have an opening statement or would you rather waive and use
your time later on?
Mr. Rush. Mr. Chairman, I think I will waive my statement
and use my additional 3 minutes for questioning.
[Additional statements submitted for the record follow:]
Prepared Statement of Hon. Joe Barton, Chairman, Committee on Energy
and Commerce
Thank you, Chairman Bilirakis, for holding this important hearing
today. Medical science in recent years has produced tremendous
discoveries that have revolutionized how we treat diseases and care for
patients. Unfortunately, the medical records and information
technologies needed to take advantage of these discoveries remain
locked in an era where cutting edge technologies were slide rules and
computers the size of this hearing room. We should be able to do
better.
Physicians should not have to rely on bulky and often incomplete
medical records. Pharmacists should not have to rely on handwritten and
often illegible prescriptions. Most importantly, patients should not
have to bear the increased risk of medical errors and pay the inflated
costs that result from the use of antiquated health information
systems. Other sectors of our economy have adopted the widespread use
of electronic forms and records. So why hasn't the majority of the
healthcare sector caught up? This is just one of the questions I hope
this hearing will address.
President Bush has called for electronic health records for most
Americans within 10 years. I applaud the President for issuing this
challenge. It has been estimated that if most patient records were in
electronic form the savings could amount to about $140 billion a year.
The potential savings offered by technology is staggering and could go
a long way towards slowing the tremendous growth in healthcare costs
that we've seen over the years.
I would like to extend my thanks to the Secretary of HHS, Tommy
Thompson, for appearing before the Committee today. Yesterday Secretary
Thompson released the first outline of a 10-year plan to transform the
delivery of health care by building a new health information
infrastructure, including electronic health records and a new network
to link health records nationwide. The system will enable physicians
and other healthprofessionals to electronically tap into a wealth of
treatment information as they care for patients. The proper use of
health information technology promotes knowledge and responsibility for
health care decisions and helps them to be smarter consumers of
healthcare.
In addition, Secretary Thompson has announced plans to create an
Internet portal allowing beneficiaries to access their personal
Medicare information. There are a number of other exciting new
initiatives that we will learn about today. The Committee offers its
support to these efforts and wants to work closely with the
Administration on these efforts to help modernize the use of health
information technology.
I also appreciate Dr. Kolodner from the Department of Veterans
Affairs for agreeing to testify. The VA has done extensive work in this
area and I'm pleased that they could be here today to testify as to
their experience using this technology.
We would do a disservice to all Americans if we ignored the
benefits that health information technology can offer. This technology
can transform our healthcare system and bring it into the 21st century,
resulting in lower costs and greater quality of care. Once again, I
thank Chairman Bilirakis for holding this hearing.
______
Prepared Statement of Hon. Gene Green, a Representative in Congress
from the State of Texas
Thank you, Mr. Chairman and Ranking Member Brown for holding this
hearing on the Administration's initiative to implement a national
health care information technology system.
This hearing is certainly timely, as it comes on the heels of
Secretary Thompson's release of the Administration's outline to improve
IT in the health care sector.
Secretary Thompson, we are pleased to have you here today and thank
you for appearing before us to share the details of your plan.
Without doubt, information technology usage rates in the health
care sector fall far behind IT usage in other cutting-edge US
industries.
We're all aware of the benefits that improved IT would bring the
health care sector and the patients it serves.
With integrated information technology, patients could manage their
electronic health records and avoid having to haul multiple records to
their various physicians.
I know of a case where a woman spent years trying to manage her
scoliosis.
As such, she endured yearly x-rays and painful exams to determine
whether her condition had worsened and would require surgery.
Imagine her frustration when she recently went in for her annual
check-up only to find that this year's x-ray was basically useless
because the physician had lost the x-rays from previous years.
With no records, no comparison could be made.
And the woman had to make her health care decisions based on a
guess, rather than conclusive proof, about whether her condition had
worsened.
This is just one example of a mistake that information technology
and electronic medical records could have alleviated.
Unfortunately, many of the mistakes have much larger consequences.
The Institute of Medicine estimates that between 44,000 and 98,000
Americans die each year due to medical errors.
The same report acknowledged that electronic health records could
prevent many of those deaths through improved health care safety.
We all can agree that the need for health care IT solutions is
clear.
We must now facilitate the creation of a comprehensive system that
operates effectively and yields significant benefits for both patients
and providers.
The question is, what is the best approach?
For this system to work, it is imperative that we have uniform
standards.
But standards aren't worth a hill of beans if we don't have the
infrastructure to apply them to.
If we're going to make this a national strategy, the federal
government is going to have to put its money where its mouth is.
And we're going to have to devise the incentives to encourage the
providers to get on board.
Make no mistake, the days of paper records should be well behind
us.
It's a matter of efficiency and quality of care.
But in implementing this plan, we have to take every possible
opportunity to ensure that patient privacy is held paramount.
Our relatively short experience with the Internet has taught us
that information technology can be easily manipulated for mischievous
purposes.
I have real concerns about the consequences to the patient if
medical records get into the wrong hands.
And I hope that the consortium implementing the Administration's
strategy will place tremendous weight on ensuring patient privacy.
I thank Secretary Thompson and all of our distinguished witnesses
for appearing before us today.
I look forward to hearing your testimony.
With that, Mr. Chairman, I yield back the balance of my time.
Mr. Bilirakis. Okay. Thank you. All right. That being the
case, I would like to welcome, the Honorable Tommy Thompson,
who is the Secretary of the U.S. Department of Health and Human
Services, former Governor.
Mr. Thompson, please proceed.
STATEMENT OF HON. TOMMY G. THOMPSON, SECRETARY, U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Mr. Thompson. Thank you very much, Mr. Chairman, and thank
all the members of the subcommittee for being here, and I thank
you so very much for holding this hearing. This is a topic that
I am very passionate about. When I started as Secretary, a
little over 3\1/2\ years ago, the media asked me what were some
of the things I wanted to do, and I said I wanted to transform
the practice of medicine. And the way to transform the practice
of medicine is really start using technology to its fullest.
I have with me David Brailer, who is the new head of the
Office of the National Coordinator for Health Information
Technology, who has worked extremely hard putting together a
draft program, which we unveiled yesterday at a summit. When I
first started talking about this about 3\1/2\ years ago, I was
lucky to get 50 people to come to a summit. A month ago, we had
over 500 individuals, yesterday we had 2,300 individuals from
all over the country, representing all major technology
companies, all health care industry, and today they are working
on implementing the strategies that we laid out yesterday.
I don't know how many of you read, ``The Tipping Point,''
the book, ``The Tipping Point,'' but I really think we are now
at that point, that we have reached a tipping point, and, as I
said yesterday, this is the decade of medical informatics in
this country, and we have an opportunity to change that.
Virtually every other sector of the economy is charging
ahead into the 21st century except health care, and it is time
for the health care industry to catch up. Mr. Chairman and
members, you can use your bank card in virtually any ATM in the
world. You can go to Bangkok. I just came back from Moscow
where I needed some money, went to the ATM and got cash. You
can use it any place in the city, any city in America, get your
money and find out what your balance is in your checking
account. But if you show up in an emergency room 20 miles from
your home, you will have to scramble to track down your medical
history.
Yesterday, we had an individual who was a consumer, an
informatics consumer, 44 years of age, he has arrhythmia, and
the doctor put him on different medications. He overdosed and
he passed out. He went to the hospital, they went through many
different repeat tests, they didn't even have his current
folder because the data wasn't shared. The cost of the
duplicate test was more than $10,000. Now, this is an
information that is an expert on informatics. That happens
every single hospital, every single day in America. That just
shows you what we need to do in order to improve it.
If you have a dog, you get an electronic reminder to update
your dog's shots like here when you go to the veterinary. Many
vets even offer an electronic health record for your dog. Got
electronic health records for dogs and cats, but we don't have
it for humans. We can alert individuals to have their dogs come
in for shots. What about our children? Don't you think it is
about time to have our children be able to have this kind of
reminder?
Americans spend more resources on health care than people
in any other industrialized nation. We get the right treatment,
however, according to the RAND study, only 55 percent of the
time. For a budget that spends $1.5 trillion, 15 percent of the
Gross National Product, I think it is time that we get what we
paid for. Think how much better our record will be when health
care catches up with banking, journalism and veterinarians. Can
you imagine the news media having to go back to typewriters or
lenotype to put out their press or put out their newspapers?
Some of you may think that is a good idea, but the press would
never go there and they put it all out by computers. It is time
for health care to get into the 21st century.
Patients deserve advice and care from providers who are
fully informed about their medical history, including past
injuries, tests, diagnoses and treatments, as well as whatever
research results and public health notifications might be
relevant. They shouldn't have to wait for redundant tests like
this David individual who had to yesterday, and 20 miles from
where his hospital was he had to go through all the tests
again. It just doesn't make any sense. Ten thousand dollars
more he had to spend in redundant tests that he had in his home
hospital 20 miles away.
Doctors deserve to focus on the quality of their care, not
the quantity of their paperwork. Both patients and doctors
deserve systems, Mr. Chairman and members, that will prevent
medical errors before they become medical and legal problems.
To achieve these goals, Americans deserve a seamless and a
secure national health information infrastructure. This system
must provide accurate, current patient data to providers
wherever they are in time to be useful, even in an emergency.
It must allow the doctors to prescribe medications
electronically, so that medications can be checked for safety
before they are administered, and it must do all this while
continuing to keep personally identifiable health information
private and secure from unauthorized uses or disclosures.
A good health information system could save our economy and
save the medical system $131 billion a year. That is about 10
percent of our total health care spending in America. We all
know that a system that is safer, faster, more profitable, more
efficient is inevitable. It is inevitable because sooner or
later patients are going to demand it when choosing doctors,
hospitals and pharmacies. Our health care system needs all the
help that it possibly can get.
Health information technology is some of the best medicine
we have. We have taken several steps in the past few years in
the Department in order to really start moving down the
football field toward a touchdown for medical technology. We
have now demanded bar coding on medicines to prevent medical
errors. Can you imagine that until a couple years ago we didn't
have any rules on bar coding of medicines in America? Our
groceries, any time you go into a store right now, you go
through a grocery store, they swipe all the groceries. Don't
you think it is much more importantly to have that kind of
technology for pharmacists and for drugs? That is what we are
doing, finally.
We have adopted standards for the electronic exchange of
medical information. We didn't have standards in this field.
Now we have 20 out of the 24 domains in which we have reached
unanimous consent for standards. We have licensed a
standardized lexicon of diagnosis and treatments called SNOMED.
We paid for this through the Department, $14 million. We have
got it licensed. We are now allowing it free of charge to
hospitals and clinics and to technology companies to put it in
their software.
In April, President Bush identified health as one of the
most important technology areas for America's future. He said
that within 10 years we should have electronic health records
for most Americans. I absolutely believe and know that we can
do it a lot sooner, evidenced yesterday by the fact that 2,300
people from all over this country came to Washington, D.C. to
talk about this subject and how we can do it much faster.
Yesterday, my Department released a framework for strategic
action, and it is called here, ``The Decade of Health
Information Technology,'' and it is a very good report, and we
are very happy with it, because it sets out the guidelines, how
we get there, how we make the touchdown. We set out four
achieving overarching goals for the health information
technology effort. We need to bring these information tools
directly to each point of care.
Some private initiatives are already underway in
Indianapolis and Santa Barbara. Indianapolis and Santa Barbara
are far ahead of the other ones as far as developing
synchronized communication systems that can talk to one
another, interoperability between those differing clinics. But
we need them in all clinical settings across America. We need
to then interconnect all these clinical settings across
America.
We need to allow patients to become informed consumers and
participants in their care. We call this aspect the personal
health record. We want to be able to allow individuals--we're
setting up a portal in Indianapolis for the first time for
Medicare people to call in. We are going to have that set up in
order to get their records, be able to have somebody determine
their records.
I don't know if you have ever seen the explanation of
benefits. I don't know if any of you have ever taken care of
somebody on Medicare that has been in the hospital. They send
you an explanation of benefits. I used to be a lawyer
practicing and people would bring boxes of these in. Nobody
could understand them, nobody can decipher them, nobody knows
what they mean. And so we are changing that, and we are putting
in for the first time a demonstration program in Indianapolis
so that you are going to be able to call in and get a simple
explanation of what the doctors and what the hospital did for
you and what the costs are. It is a giant step forward, and we
are hoping that this will become uniform across America so that
a patient and all their doctors will be able to see the data
that the others have entered.
This is going to ensure that treatment and diagnosis
decisions can be informed decisions. If you turn up in the
emergency room, the staff can see not only that you have
diabetes but what your blood sugar was the last time you
checked it. Now, this is very important for somebody that is
diabetic that ends up in the emergency room, and this is just
common knowledge, common information. The technology is there
to give it.
Right now in America, we have upwards to 98,000 people die
each year from medical mistakes. Most of those could be changed
and completely stopped by new technology, and now it seems to
me that is a huge cost to America and to the health care system
to have that kind of mistakes in the health care delivery
system. We need to improve population health and research with
information technology. Health information electronic form and
without personal identification can help us measure quality of
care and respond much more quickly to disease outbreaks.
We are also doing something else, members of the committee.
All of our departments in the Department of Health and Human
Services have set up software systems in the past that are
different; they are not interoperable. So we have statistics
across America on infections, on different kinds of diseases,
on kinds of suicides and so on. We are now going to make all of
those interoperable so that you are going to be able to call in
and get all this information up to date on one web page. We
also are going to try and use technology to get the treatment
that comes out of NIH from the lab to the bedside much quicker,
and we are going to be able to highlight that and be able to
use technology to do it.
Congress on both sides of the aisle has provided billions
of dollars to improve the research out at NIH. The big problem
we have is getting that research into therapies and treatments,
to the bedside quicker. Technology can accomplish that. That is
part of our plan in order to do it. Our doctors have worked in
the dark long enough. Working together, ladies and gentleman on
this committee, we can give them light.
And I just would like to tell you, you know I am passionate
about it, I believe that this is truly the thing that can
transform health care for the better in America. It can reduce
mistakes: It can improve the quality and improve the profits
and improve the reductions of tax dollars. Now, to me, that is
a wonderful plan. All we have to do on a bipartisan basis is
come together and get it done. And so thank you very much, Mr.
Chairman, for this opportunity for me to talk to you about
technology, and thank you very much for holding this hearing.
[The prepared statement of Hon. Tommy G. Thompson follows:]
Prepared Statement of Hon. Tommy G. Thompson, Secretary, Department of
Health and Human Services
Good morning Mr. Chairman and members of the subcommittee. Thank
you for inviting me here today to discuss the Administration's efforts
to increase the use of information technology throughout the health
care industry. As you know this has been and continues to be a high
priority for the President and me. The time is right to take action and
it is the goal of this Administration and my Department to promote and
encourage the development of a nationwide information technology
infrastructure that will transform America's health care and improve
quality, decrease medical errors and reduce health care costs.
Electronic health information will provide a quantum leap in achieving
more efficient and effective health care. We cannot wait any longer.
The most incredible feature of this twenty-first century medicine
is that we hold it together with nineteenth century paperwork. This is
just inexcusable. And it has to change.
Patients deserve advice and care from providers who are fully
informed about their medical history, including past injuries, tests,
diagnoses, and treatments, as well as whatever research results and
public health notifications might be relevant. They shouldn't have to
wait for redundant tests or calls to their previous doctors.
Doctors deserve to focus on the quality of their care, not the
quantity of their paperwork. And both patients and doctors deserve
systems that will prevent medical errors.
To achieve these aims, Americans deserve a seamless and secure
national health information infrastructure. This system must provide
accurate, complete patient data to providers wherever they are, in time
to be useful-even in an emergency. It must allow doctors to prescribe
medications electronically, so the medications can be checked for
safety before they are administered. And, it must do all this while
continuing to keep personally identifiable health information secure
and safe from unauthorized uses or disclosures.
Yesterday, my Department released a Framework for Strategic Action
entitled, The Decade of Health Information Technology: Delivering
Consumer-centric and Information-rich Health Care. This framework will
guide discussion, investigation and experimentation to accelerate
widespread adoption of health information technology in both the public
and private sectors.
BACKGROUND
On April 27, 2004, President Bush called for widespread adoption of
interoperable electronic health records (EHR) within 10 years and also
established the National Coordinator for Health Information Technology
position. I appointed David Brailer, MD, to this position on May 6,
2004. The President's Executive Order tasked the Office of the National
Coordinator for Health Information Technology (ONCHIT) to report on its
progress on the development and implementation of a strategic plan
within 90 days of operation. Yesterday, ONCHIT accomplished this task.
The benefits of information technology are evident in our everyday
lives, from banks to grocery stores. However, the benefits of
information technology have not been applied as effectively to the
nation's health information systems. Transfer of information remains
primarily a paper-based process. Hospitals' use of electronic health
records (EHR) in 2002 was reported at 13 percent; and for physicians'
practices at 14 percent to a possible high of 28 percent. Some reasons
for slow health IT adoption include the following:
The size and variety of America's health system is large and
locally based with many stakeholders. This strategic plan is aimed at
bringing together federal leadership along with the many stakeholders
to take action.
A previous lack of cohesive federal policies supporting health
information technology has also contributed to the lack of technology
development. Efforts have been accelerated and are a pertinent part of
the strategic plan in which DoD, VA, and OPM have released reports as
well to address accelerating federal action.
Perceived lack of return on investment has played a large role in
limiting the adoption of health IT [HIT]. The Health Information
Technology Leadership Panel announced at yesterday's Summit will
evaluate the costs and benefits to society and identify immediate steps
for both the private and public sector to take to drive adoption.
Additional steps will be taken to identify the best mechanisms to
support training, private sector certification of EHRs, and alignment
of incentives as well as other related issues.
CURRENT FEDERAL HEALTH INFORMATION TECHNOLOGY PROGRAMS
I have vigorously pursued health information technology since I
became Secretary. Specifically, I have supported the efforts of the FHA
to provide a framework for aligning and integrating information
technology within the health business processes across the federal
government. In addition, since March 2003, I have announced federal
adoption of twenty privately developed health information standards.
These data standards were selected through collaborative inter-agency
work within the Consolidated Health Informatics [CHI] Presidential E-
Government Initiative. Adoption of health data standards within an
architectural framework will allow federal agencies to share data and
to achieve interoperability. In FY 2004, total federal spending on HIT
will total over $ 900 million. HHS alone will obligate close to $250
million related to HIT in FY 2004. These federal HIT initiatives range
from supporting research in advanced HIT (e.g., high speed Internet,
imaging, bioinformatics) to the development and use of electronic
health record (EHR) systems.
Standards and Implementation within the Federal Health Architecture
HHS, DoD and VA support the Federal Health Architecture (FHA), the
goal of which is to develop a consistent and common architecture for
HIT across all federal agencies. This architecture allows for a
disciplined approach to information technology investment, and provides
a framework for implementation of health data standards.
My Department has led the government-wide effort in endorsing and
adopting health information technology standards for government use
through the Consolidated Health Informatics (CHI) initiative. Standards
adoption has been a core federal initiative led by HHS, DoD, and VA,
and has been vetted to the private sector through the National
Committee for Vital and Health Statistics (NCVHS). Through the
leadership of the ONCHIT, we hope our efforts will stimulate the
industry to adopt the standards agreed upon by these large federal
health care providers and payors. CHI is one of the 24 e-Gov
initiatives supporting the President's Management Agenda.
As a result of HHS's acquisition of a license for SNOMED CT, which
I announced in May 2003, this medical vocabulary now can be downloaded
for free by anyone in the United States through HHS's National Library
of Medicine.HHS is also contracting with the Health Level 7 (HL7)
standards development organization to create a standard that would
allow interchange of complete electronic health records between any two
systems. This is critical to achieving the interoperability we need to
be able to ensure that patients' records are always available when and
where they are needed. We expect this standard to be available in 2005.
E-prescribing
The new Medicare law requires HHS to recognize or adopt initial e-
prescribing standards by September 2005, to pilot test them in 2006 as
we roll out the new Medicare drug benefit, and to promulgate final
standards no later than 2008. The MMA further provides for grants to
physician offices to enable the purchase of e-prescribing systems.
Population HIT
NIH is working to develop an information technology infrastructure
to support clinical research. This will enable a system that can
interface with health information exchange networks. CDC is
facilitating the implementation of a public health information
infrastructure and has already demonstrated results. The incident
reporting times have dropped from an average of 30 days to 1-2 days.
The Public Health Information Network (PHIN) supports a broad range of
public health activities including interoperability with clinical care.
Facilitation and Support
The Agency for Health Research and Quality (AHRQ) will spend $50
million in FY 2004 on HIT research and demonstration projects aimed at
improving the safety, quality, efficiency, and effectiveness of care.
These funds will also support establishment of a Health Information
Technology Resource Center to provide technical assistance, education
and expert HIT support to HHS grantees.
The Health Resources and Services Administration (HRSA) with the
Foundation for e-Health Initiative announced $2.3 million in contracts
to support the Connecting Communities for Better Health program. The
program is providing seed funds to implement health information
exchanges, including the formation of regional health information
organizations.
FRAMEWORK FOR A STRATEGIC PLAN
Yesterday, we released the Department's framework for a strategic
plan. This is the nation's first strategic framework report on the 10-
year initiative to develop electronic health records and other
applications of health information technology. The framework
exemplifies our commitment to working closely with the private sector
to bring about the enormous benefits of modern information technology
for our health care system. Yesterday, I also held a Summit that
provided a forum where leaders from the public and private sectors
could provide feedback on this strategic plan to realize the
President's vision.
There are four major goals that will be pursued in realizing this
vision for improved health care:
<bullet> Inform clinical practice
<bullet> Interconnect clinicians
<bullet> Personalize care
<bullet> Improve population health
Inform Clinical Practice
This goal centers on efforts to bring electronic health records
directly into clinical practice. Both patients and doctors deserve
systems that will improve care and make health care delivery more
efficient. Providing complete and useful patient information to
clinicians when and where they need it is fundamental to achieving the
goal of informing clinical practice. Three strategies will enable
realization of this goal:
<bullet> Incentivize EHR adoption--The transition to safe, more consumer-
friendly and regionally integrated care delivery will require
shared investments in information tools and changes to current
clinical practice. Options for reducing the financial
disincentives to electronic health records (HER) adoption
should meet at least the following four criteria:
1. Business case improvement. Policy options should consider, in
part, the economic expense borne by a hospital or physician
when purchasing or using an HER.
2. Compatibility with existing programs and regulations. Policy
options for HER adoption should be compatible with or
incrementally build on existing reimbursement and
regulations.
3. Budget cost-effectiveness. Policy options should be cost-
effective and deliver the largest impact for the smallest
expenditure.
4. Stakeholder alignment. Policy options should align physicians,
hospitals, and other stakeholders toward a common goal of
improving quality and efficiency.
<bullet> Reduce risk of EHR investment--Clinicians who purchase EHRs and who
attempt to update their clinical practices and office
operations face a variety of risks that make the decision
unduly challenging. Low cost support systems that reduce risk,
failure, and partial use of EHRs are needed.
<bullet> Promote EHR diffusion in rural and underserved areas--Practices and
hospitals in rural and other underserved areas lag in EHR
adoption. Technology transfer and other support efforts are
needed to ensure widespread adoption. Currently, there are
pilot projects underway that are assessing the feasibility of
transferring federal applications, such as VA's computerized
patient record system, in rural and underserved areas.
Interconnect Clinicians
Clinicians will be able to obtain more comprehensive health
information quickly as they care for patients if we have an
interoperable information infrastructure. Interconnecting clinicians
will allow information to be more accessible by providers as consumers
move from one point of care to another. Three strategies for realizing
this goal are:
<bullet> Foster regional collaborations--Local oversight of health information
exchange that reflects the needs and goals of a population
should be developed.
<bullet> Develop a national health information network--A set of common
intercommunication tools such as mobile authentication, Web
services architecture, and security technologies are needed to
support data movement that is inexpensive and secure. Standards
defining a national health information network that can provide
low-cost and secure data movement are needed.
<bullet> Coordinate federal health information systems--There is a need for
federal health information systems to be interoperable and to
exchange data so that federal care delivery, reimbursement, and
oversight are more efficient and cost-effective. Through FDA
and CHI, these efforts are currently underway.
Personalize Care
To fully complete interoperability, the ability to use information
at the consumer level is essential. Consumer-centered information helps
individuals take responsibility for their own health and more fully
participate in making health care decisions regarding their health and
well-being. Strategies to realize this goal include:
<bullet> Encourage use of Personal Health Records (PHRs)--Consumers are
increasingly seeking information about their care as a means of
getting better control over their health care experience, and
PHRs that provide customized facts and guidance to them are
needed.
<bullet> Enhance informed consumer choice--Consumers should have the ability
to select clinicians and institutions based on what they value
and the information to guide their choice, including the
quality of care providers deliver.
<bullet> Promote use of telehealth--The use of telehealth can provide access
to health services for consumers and clinicians in rural and
underserved areas.
Improve Population Health
Population health improvement requires the collection of timely,
accurate and detailed clinical information to allow for the evaluation
of health care delivery and the reporting of critical findings. This
information is important to the future of care delivery and the
standard of living in America. Strategies to realize this goal include:
<bullet> Unify public health surveillance architectures--An interoperable
public health surveillance system is needed that will allow
exchange of information, consistent with HIPAA and other laws,
to identify public health threats and better protect against
disease. Currently, the PHIN is working in conjunction with the
Department of Homeland Security on the President's
Biosurveillance Initiative, to develop public health
surveillance systems that are not only interoperable within the
public health arena, but also with law enforcement and other
federal agencies.
<bullet> Streamline quality and health status monitoring--Many different state
and local organizations collect subsets of data for specific
purposes and use it in different ways. A streamlined quality-
monitoring infrastructure that will allow for a complete look
at quality and other issues in real-time and at the point of
care is needed.
<bullet> Accelerate research and dissemination--Information tools and
standards are needed that can broaden the availability of
health data to researchers and accelerate the development of
scientific discoveries and their translation into clinically
useful products, applications, and knowledge.
KEY ACTIONS
Enormous utility will be realized once a national infrastructure is
in place. This is necessary to realize the President's vision. A range
of actions was announced at yesterday's Summit covering initiatives
already underway or soon to be launched. These key actions will advance
the strategic elements of the framework.
Establishing a Health Information Technology Leadership Panel
I will soon appoint a panel of executives and leaders to assess the
costs and benefits of health information technology to industry and
society, and develop options for immediate steps by both the public and
private sector, based on their individual business experience. The
Health Information Technology Leadership Panel will deliver a report on
these options to me no later than Fall 2004.
Private sector certification of health information technology products
EHRs and even specific components such as decision support software
are unique among clinical tools in that they are not required to meet a
set of minimal standards to be used to deliver care. To increase uptake
of EHRs and reduce the risk of product implementation failure, the
federal government is exploring ways to work with the private sector to
develop minimal product standards for EHR functionality,
interoperability, and security. A private sector ambulatory EHR
certification task force is determining the feasibility of
certification of EHR products based on functionality, security, and
interoperability.
Funding community health information exchange demonstrations
A health information exchange program through the Health Resources
and Services Administration, Office of the Advancement of Telehealth
(HRSA/OAT), has a cooperative agreement with the Foundation for e-
Health Initiative to administer contracts to support the Connecting
Communities for Better Health (CCBH) Program totaling $2.3 million.
This program is providing seed funds and support to multi-stakeholder
collaborations within communities (both geographic and non-geographic)
to implement health information exchanges, including the formation of
regional health information organizations (RHIOs) to drive improvements
in health care quality, safety, and efficiency. The specific
communities that will receive the funding through this program were
announced and recognized during the Summit on July 21.
Requiring standards to facilitate electronic prescribing
CMS will be proposing a regulation to adopt the first set of widely
used e-prescribing standards in preparation for the implementation of
the new Medicare drug benefit in 2006. When the final standards are
adopted, the Medicare Prescription Drug Plan (PDP) sponsors will be
required to support e-prescribing, which will significantly drive
adoption across the United States. Health plans and pharmacy benefit
managers that are PDP sponsors could work with RHIOs, including
physician offices, to implement private industry-certified
interoperable e-prescribing tools and to train and support clinicians.
Establishing a Medicare beneficiary portal
An immediate step in improving consumer access to personal and
customized health information is CMS's Medicare Beneficiary Portal,
which provides secure health information via the Internet. This portal
will be hosted by a private company under contract with CMS, and will
enable authorized Medicare beneficiaries to have access to their
information online or by calling 1-800-MEDICARE. Initially the portal
will provide access to fee-for-service claims information, which
includes claims type, dates of service, and procedures. The pilot test
for the portal will be conducted for the residents of Indiana. In the
near term, CMS plans to expand the portal to include prevention
information in the form of reminders to beneficiaries to schedule their
Medicare-covered preventive health care services.
Adopting standards to automate clinical research
FDA and NIH, together with the Clinical Data Interchange Standards
Consortium (CDISC), a consortium of over 40 pharmaceutical companies
and clinical research organizations, have developed a standard for
representing observations made in clinical trials called the Study Data
Tabulation Model (SDTM). This model will facilitate the automation of
the largely paper-based clinical research process, which will lead to
greater efficiencies in industry and government-sponsored clinical
research. The first release of the model and associated implementation
guide was finalized prior to the July 21 Summit and represents an
important step by government, academia, and industry in working
together to accelerate research through the use of standards and HIT.
Commitment to standards
A key component of progress in interoperable health information is
the development of technically sound and robustly specified
interoperability standards and policies. As discussed previously, there
have been considerable efforts by HHS, DoD, and VA to adopt health
information standards for use by all federal health agencies as part of
the FHA and CHI initiatives. The agencies have agreed to endorse 20
sets of standards to make it easier for information to be shared across
agencies and to serve as a model for the private sector. Additionally,
the Public Health Information Network (PHIN) and the National
Electronic Disease Surveillance System (NEDSS), under the leadership of
the Centers for Disease Control and Prevention (CDC), have made notable
progress in development of shared data models, data standards, and
controlled vocabularies for electronic laboratory reporting and health
information exchange. With HHS support, Health Level 7 (HL7) has also
created a functional model and standards for the EHR. We hope that
these efforts will stimulate the industry to adopt the standards agreed
upon by these large federal health care providers and payors.
PUBLIC-PRIVATE PARTNERSHIP
Leaders across the public and private sector recognize that the
adoption and effective use of HIT requires a joint effort between
federal, state, and local governments and the private sector. The value
of HIT will be best realized under the conditions of a competitive
technology industry, privately operated support services, choice among
clinicians and provider organizations, and payers who reward clinicians
based on quality. The Federal government has already played an active
role in the evolution and use of HIT. In FY04, total federal spending
on HIT was more than $900 million. Initiatives range from supporting
research in advanced HIT to the development and use of EHR systems.
Much of this work demonstrates that HIT can be used effectively in
supporting health care delivery and improving quality and patient
safety.
role of the national coordinator for health information technology
Executive Order 13335 directed the appointment of the National
Coordinator for Health Information Technology to coordinate programs
and policies regarding HIT across the federal government. The National
Coordinator is charged with directing HIT programs within HHS and
coordinating them with those of other relevant Executive Branch
agencies. In fulfillment of this, the National Coordinator has taken
responsibility for the National Health Information Infrastructure
Initiative (NHII), the FHA, and the Consolidated Health Informatics
Initiative (CHI), and is currently assessing other health information
technology programs and efforts. In addition, the National Coordinator
is charged with coordinating outreach and consultation between the
federal government and the private sector. As part of this, the
National Coordinator will coordinate with the National Committee on
Vital Health Statistics (NCVHS) and other advisory committees.
CONCLUSION
Transforming health care through health IT will result in better
care--care that is higher in quality, safer, and more consumer-
responsive--and at the same time more efficient. Our national strategy
for HIT is needed to achieve transformation. Interconnecting
clinicians, consumer-centric customized health information and care,
more treatment options and choices will be realized. HIT will improve
population health so that public health risks, and clinical research
can be enhanced.
The time is now to meet this challenge, however the changes
necessary are inevitable, needed and beneficial. The Administration has
put forth the framework, we look forward to the actions that will be
taken over the next decade to ensure Americans they will be the
beneficiaries of the best health care that can be delivered.
Your thoughtful leadership and that of your subcommittee toward
achieving this goal are widely recognized. I look forward to your
continued support and leadership that will further enable the Executive
Branch and private sector leadership to transform our paper based
health care system into an electronic, quality-based system that we all
can count on. I look forward to your questions.
Mr. Bilirakis. Thank you very much, Mr. Secretary. As
usual, you waste no words, and your passion is----
Mr. Thompson. I don't have much time left, Mr. Chairman. I
want to get this done.
Mr. Bilirakis. Well, Mr. Secretary, I guess that goes
really to my generic generally type question, and that is why
don't we do it? What is keeping us from doing it?
Mr. Thompson. What has happened----
Mr. Bilirakis. It is a no-brainer.
Mr. Thompson. What has happened in the past, Mr. Chairman,
is that there haven't been any standards, any standards in
hospitals and clinics, so why invest--because technology is
moving so rapidly, why should I invest in this system? Will it
in fact be the kind of technology that is going to be used in
the past?
No. 2, we haven't at the Department or in Congress or the
administration, we haven't demanded, we haven't pushed it. And,
No. 3, they haven't seen, insurance companies haven't demanded
it, and clinics haven't seen where it's in their best interest
to do so. Doctors are also very independent. Doctors have to
have straight As in order to get into any medical school in
America except for one course. The one course is handwriting,
and they still can't write legibly and so it is the one area
that there still are a lot of mistakes. So it is important for
us to do it.
So what we have done? We have required bar coding. No. 2,
we have now had a group of individuals come together and it has
been unanimously agreed to--20 out of the 24 domains and we
have reached unanimous consent on the standards.
No. 3, the pathologists have come up with a way called
SNOMED, synchronized medical terms, because some doctors use
head, some use brain, some use skull. We put this all together,
and it is called SNOMED. We have licensed that, and now that is
being given out free of charge. And the technology companies
and the software companies are going to use SNOMED as the
common language, as the common vernacular.
So now we are at the tipping point. We have done all this.
We have got the standards; we have got bar coding; we have got
the vocabulary. Now all we have to do is also say that for
those 12 percent that are still sending paper claims into
Medicare, you are not going to get paid as much compared to if
you send it on the computer. So it is moving. All we have to do
is get Congress to start helping to push it and I think we can
accomplish it.
Mr. Bilirakis. How would Congress do that?
Mr. Thompson. Well, there is several ways Congress can do
it. For instance, Congressman Stupak mentioned dollars.
Everybody is looking for dollars. First off, let me respond by
saying that other sectors of the economy have done it without
the government giving them money to do so. I mean the news
media have changed over all to high technology, banking has,
all the grocery stores in America--grocery stores are much more
technologically advanced than our hospitals and clinics. That
is sad to say but they are. And they have all done it. So you
can make the argument, ``Well, why do you have to do it?''
Well, sometimes you have to prime the pump, and we are putting
in demonstration dollars in order to do that.
There is another idea that I have had that I will throw
out, and I think that--you know, I have got ideas, I don't know
if you want to take them up or not, but we take in fraud and
abuse dollars of $1 billion--we took in $1.2 billion this year
and people say, ``You can't use that money because it is used
for other things.'' Well, fine. Give me a cap at $1 billion and
any fraud and abuse we get from fraudulent providers of
services above that allow that money to go into the mini-
Bilirakis fund to be used on a one-to-one match or two-to-one
match for people to go into high technology.
Or number three, there is a thing that we did at the State
level. We put up revenue bonds. The Federal Government would
put in a small amount of money like on Fannie Mae or Freddie
Mac or something like this, put in a small amount of money and
then allow revenue bonds to be issued and have it like a
revolving bank for people to use that as capital. That is one
way that Congress could look at it. Other ways Congress could
say in 5 years there is going to be no more payments on
Medicare, or 3 years, no more payments on Medicare on paper.
That is going to drive the system faster than anything.
Number three, Congress could force the Department of
Defense, Department of Veterans Affairs and Department of
Health and Human Services all together. We are doing it on a
voluntary basis, but Congress could step in and demand that we
all have unanimity and high technology, and that is going to
drive the system. So there are many ways Congress could help.
Mr. Bilirakis. Well, you certainly make a good case for it,
sir. I know our information is from the administration that
there would be something like $140 billion per year savings. In
your statement, you mentioned 130, 131. Bart made the comment
that the private sector would indicate that probably as much as
maybe 25 percent savings. My God, we are talking about big
money here now. Obviously, there would be some costs incurred
and we would have to have some information for our great CBO to
try to give us some credit for those savings somewhere along
the line, and that, as you know, is not an easy thing to do.
Mr. Thompson. The Federal Government spends $780 billion a
year on medical care. The total budget is $1.5 trillion for
health care. If you just took 1 percent, it would be $7.8
billion to put into technology and save the money, but, you
know, CBO probably would not score it that way, and OMB will
probably--I will probably get a nasty letter when I get back
that I even suggested that, but I am telling you that those are
the kinds of things--if you want to think out of the box, if
you want to make health care more competitive, better quality
and less expensive, these are the kinds of things that we have
to do as a country.
Mr. Bilirakis. Sure. I should think that we all are
agreeable, and I should think we could have some sort of a task
force that maybe we can add people from your office and from
the private sector too and work up a way to do this. Shame on
us. Shame on us. That is the kind of impression you have made
on me, put it that way.
Mr. Thompson. I didn't want to ever say that about you, Mr.
Bilirakis. Other people in Congress I might, but not you, my
friend.
Mr. Bilirakis. Mr. Stupak to inquire.
Mr. Thompson. Not anybody in this committee, I want to add.
Mr. Stupak. Let me ask my questions, then you might
reconsider that. You talk about this health care technology,
and I agree it can be very important, I think it could improve
the quality of health care, but I have got to go back to the
Medicare debate we had on the Medicare drug discount card. We
tried to put in there mandatory that doctors had to
electronically fill out their prescriptions, and doctors
objected, ``No, we can't do it. We don't have the money. We
can't get up to speed,'' so it is voluntary. So the docs really
aren't doing it in the Medicare prescription discount card that
we have out there.
So as we push this thing and as the chairman said, why
don't we just go ahead and do it, you indicated that the
insurance companies are concerned about it, there aren't enough
standards, you have got 20 of the 24 domains out there, but it
certainly looks like to me from listening to your testimony
that they are waiting for the government to do it, to really
say, ``These are the standards, they are not going to change,
so once we get these things up and running we know what we can
count on and we can rely upon on.''
So I still have some hesitancy here, and I think the
government is going to have to step up and do it. And in the
plan that was released yesterday, I think you only had $2.3
million in seed money. So if the docs aren't going to do it
underneath the Medicare discount card, that is voluntary, and
if the insurance companies are waiting, and the standards
aren't uniform throughout the industry, how do we do it with
only $2.3 million in seed money then, other than just say, ``Do
it and you are going to have to eat the cost.''
Mr. Thompson. Well, first off, I happen to like you, you
are from Michigan, Upper Peninsula, which you stole from
Wisconsin some time ago.
Mr. Stupak. That was Toledo, that was Ohio.
Mr. Thompson. The standards were created by our Department,
Congressman Stupak, and I set up a committee and we worked on
it with the private sector and they are unanimous agreed to, 20
out of the 24. So the standards are there.
Mr. Stupak. Okay.
Mr. Thompson. We have got the uniform vocabulary called
SNOMED. That is there right now. We have got the bar coding. So
the government has stepped in here, and we have done it without
any orders from Congress. The Department has just gone out and
done that. We have set up a coordinating committee with the
Department of Veterans Affairs, and one of the--Congresswoman
Wilson said it best, the Veterans Affairs Department is ahead
of us. They are doing a much better job than anybody else as
far as technology. And we have just got to follow those kind of
leads and get it done, and we can do it.
The $2 million to $3 million was just for HRSA. There is an
additional $50 million in AHRQ, which has got grants and
setting up demonstration programs. In our budget, we are asking
for an additional $100 million, Congressman Stupak, in order
for demonstration plans to get these things started.
Indianapolis clinics and Santa Barbara clinics are doing the
best job as far as technology and connecting different clinics
within the communities to do it. We need to take that and then
we need to get regional things and then we need to get a
national system. And that is what we are--we set up a task
force yesterday to do it, and I have said I am going to be
appointing those individuals and we are expecting to get a
report back by October on how we can set up a national system.
So we are starting at the national level through the
Department of Health and Human Services, Veterans Affairs and
Department of Defense and the local level with these regional
things, these regional embryonic things in Indianapolis, and
now we have got to drive both ends together.
Mr. Stupak. In the prescription drug bill, doctors won't do
it, it is voluntary. If you take a look at this----
Mr. Thompson. I would have supported you on that.
Mr. Stupak. Would you support us on doing an FSS, Federal
Supply Service, for Veterans Administration as opposed to a
Medicare bill, because that will drive down the cost of the
prescriptions by 40 percent?
Mr. Thompson. Well, that is a big difference between what
you first said and what you are just asking me now, sir.
Mr. Stupak. Well, since you were agreeing with me, I
thought we could go one more.
Mr. Thompson. Well, you don't want to push me too far.
Mr. Stupak. Well, let me ask you this, going back to the
financing. In my opening, I said Mayo Clinic spent over $100
million just in 1 year to do it, and I still see small
physicians practices are going to come up--they are not going
to be able to come up with these big monies to do this. Even
with free technology, they still need training and integration
to make this work, and this all costs money.
So while the system may be there, to actually get the docs
to use it and small clinics, especially in rural areas, to do
it, when you look at Mayo Clinic, which, as you know, is in
Rochester, Minnesota, not necessarily the biggest place in the
world, but they spent over $100 million just in 1 year to try
to implement something like this. How do the rest of the
clinics around the Nation do it? And the Mayo Clinic just in
Rochester alone is pretty big to have 25,000 employees up there
but they still spent $100 million in 1 year. So how do you get
the rest of them to do it?
Mr. Thompson. Well, Congressman Stupak, let me just
respond. Every other sector of the economy has done it without
the government's help. I mean every other sector, the
groceries, financial, manufacturing, they have all done it.
And, second, how expensive is it to that clinic and doctor and
hospital to have a mistake. There are 98,000 people died last
year, according to the Institute of Medicine, because a mistake
is made. It is an extremely expensive thing for clinics and
hospitals to have mistakes. Technology will prevent at least 50
percent of that.
I know that people say it has got to be money, but I look
at the other side of it and say--and on the other side you are
going to save money by having technology. If you invest in
technology, you are going to save money. You are going to be
faster, more efficient, more productive and safer and more
profitable.
Mr. Stupak. And I agree, it probably works in profit-driven
industries like groceries, things like that. I don't see it
working so well in service industries.
Mr. Thompson. But even saying that, maybe you should take
my idea about taking a cap on fraud and abuse and make the
mini-Bilirakis law or the mini-Stupak law.
Mr. Bilirakis. The point is there is more than one way to
skin a cat, and I think we should open up our thinking in this
regard, and I am sure Mr. Stupak----
Mr. Thompson. I have got many ideas if you ever want to sit
down and talk to me about them.
Mr. Bilirakis. Mrs. Wilson to inquire.
Mrs. Wilson. Thank you, Mr. Chairman. Thank you, Mr.
Secretary, for being here again. Have you done any thinking
about how do you handle the issue of privacy as we implement a
more electronic and more interoperable systems, because I hear
that as a major, and it is, as a major concern of how do you
ensure that--it is a lot easier to make sure that only the doc
has access to the documents when they are stuck in his office
and he can't find them anyway. When they become electronic,
there is greater accessibility and the potential for
inappropriate use is there.
Mr. Thompson. Congress has passed a law, the HIPAA law, and
we have implemented it, and I think we have done a pretty darn
good job of implementing it in the Department. And we certainly
want to protect privacy. Number two, your bank accounts are
very private. I mean banks can do it, insurance companies do
it. Why can a bank have privacy on your bank account, which is
very private, and we can't do it for technology.
Yesterday, we had the--2,300 people from all over America
showed up. Every State was represented. Every technology
company was represented. They just don't think the privacy
thing is that problematic. We have got to demand and ensure
that it is private, but the technology is there to continue to
make it private. And my rejoinder to you is, isn't it less
problematic to have it in a private number or a private
identification of a patient in a computer than it is in a
manila folder putting out there where everybody walks through
and looks at it or something like this in the library? I think
your privacy--your records are probably much more easily
distributed or misplaced or somebody else has got a better
chance to see in a manila folder than it does with technology.
Mrs. Wilson. I don't disagree with you on the fact that
this is a soluble problem, but it is one that we are concerned
about----
Mr. Thompson. Yes, I know it is. It is one I am concerned
about too.
Mrs. Wilson. [continuing] because you have bigger access to
the system. I wondered if you would expand a little on the
summit. We all know there is a summit going on on health
information technology, and I wondered if you would expand
about what some of the major outcomes were of that summit and
what you saw.
Mr. Thompson. Well, first off, we put out this strategic
framework, and we are going to have, first, informed clinical
practice, how we can encourage clinicals to start setting up
systems. Second, interconnect the clinicians so that clinics in
all of New York or all of Boston are able to communicate with
one another and pass the thing. Third one, personalized care,
how you develop a personal health record. And, fourth, how you
are going to be able to improve population health. And this is
what I was talking about where all of the statistics come in to
CDC. You know how many forms and reports are filed with CDC? A
lot of them are different, they are not interoperable. What we
want to do is develop that system. We also want to develop in
public health how we are able to get the therapies and
treatment out of NIH faster from the laboratory to the bedside
so much quicker. Some people say it takes 17 years. That is
ridiculous in this modern age to develop a cure for a malady
over 14 or 17 years if we could do it much faster. And so these
are the kind of things we laid out.
On top of that we are going to set up a Technology
Committee that is going to report back to me in 60 days how we
are going to implement this. And the second thing was is we are
going to set up a Certification Committee, mostly in the
private sector with some people from the Department of Veterans
and Defense and Health and Human Services that is going to be
able to certify the kind of equipment that is going to have the
functionality plus the interoperability, because we want to
make sure that the equipment that is being sold to software
would have sort of a certificate in the private sector that
this machine, this software will do what it is supposed to be
able to do.
And the third thing we want to do is we set up a portal and
we are going to try something with Medicare and with the
clinics in Indianapolis, and we are going to set it up so that
somebody on Medicare is going to go in and be able to get their
own records from Medicare, be able to use the web page, the
Internet, to be able to get their own records, their own
information, something that is badly needed. The technology is
there, and I think it would help the person if you are able to
get your own records, be able to determine what your illnesses
are and get some treatments and so on and so forth. So it is an
increase in information sharing with the individual patient
with Medicare.
Mrs. Wilson. One final question, and that is has the
Department done any studies quantifying the savings or benefits
to information technologies applies to Medicaid or Medicare?
Mr. Thompson. We haven't done it specifically for Medicaid
and Medicare, although I know it--being a governor, I know it
would be tremendous if you had the technology, up-to-date
modern technology on Medicaid. I know there would be huge
savings. It is just bound to. But we haven't quantified it for
Medicaid or Medicare. What we have tried to do through AHRQ,
through our research arm at the Department of Health and Human
Services. We tried to quantify what the savings would be for
the total health care dollar, and that is about $131 billion to
$140 billion. It is about 10 percent of the total health care
dollars we think could be saved by having technology utilized
fully.
Mrs. Wilson. Thank you.
Mr. Bilirakis. The gentlelady from California, Ms. Capps,
for 8 minutes.
Ms. Capps. Thank you, Mr. Chairman. Once again, thank you,
Secretary Thompson, for making yourself available to this
committee. I have been impressed with the number of times you
have done that, and because I don't know how many more times
there will be this occasion in this session of Congress, I
wanted to thank you for your leadership and I think especially
of my interest and yours in the shortage of nurses and how you
have really demonstrated leadership in the country on that
topic.
Mr. Thompson. You have been a giant in that field, and I
thank you.
Ms. Capps. Well, the work isn't done yet, but your
leadership has been enormous in that area. Particularly, I want
to thank you for almost single-handedly but with a great team
making obesity a national issue, calling it what it is--an
epidemic. And I think we are beginning to see the fruits of
that, and we owe you a great deal for that leadership. I
remember visiting the Counter Bioterrorism Center you have
developed, so you have been very busy and active during your
time and always with such passion that it is infectious
whenever you come in the room. It is like we have to hurry up
and get these things done.
All right. I want to take advantage--and also I want to
thank you for recognizing the health initiative in Santa
Barbara County. They came and got an award yesterday, and that
is something that can be a model for other communities. They
did it kind of on their own ideas, many of them, and I am a big
champion of what they have accomplished as well.
I want to take advantage of our subtitle and I want to use
this time I have, if I may, to address some concerns that I
have, because I value so much your response in helping us. Mr.
Secretary, as you know, in May, the Food and Drug
Administration rejected over-the-counter status for emergency
contraception, known as Plan B. As you know, Plan B is not an
abortion, it is not the same as methophrestone or RU-486. It is
simply a highly concentrated dose of contraceptives. And
experts estimate that over-the-counter availability would
result in 150,000 fewer abortions every year.
Over-the-counter sales would particularly help victims of
sexual assault. In the United States, every year, about 25,000
women become pregnant as the result of rape. An estimated 88
percent could be prevented if sexual assault victims had timely
access to emergency contraception. This is what I want to get
to with you: This decision was made over the recommendation of
the Agency's own Advisory Committee, it is my understanding, at
least, and that this committee or committees voted 23 to 4 to
allow over-the-counter sales and 27 to 0 that it was medically
safe.
But in spite of this consensus among scientific and medical
staff at the FDA, the Agency rejected this, and some have said
that this decision politicized the whole process, and that is
my concern. These accusations and the controversy surrounding
the decision for some people put into the question the
reliability and reputation of the Food and Drug Administration
over which you have responsibility. And so I want to take some
time--I didn't have my opening statement so I could get your
response to some questions I have about this.
In the past several years, for example, or under your
watch, how many times and for what drugs has the Director of
Acting Director of the Center for Drug Evaluation and Research,
CDER, rejected the recommendation of Advisory Committees of the
FDA staff for over-the-counter drugs?
Mr. Thompson. I don't know.
Ms. Capps. Is it possible to find that out?
Mr. Thompson. Sure. Absolutely. I don't know.
Ms. Capps. I would appreciate it. And I wondered what role
you, if any, you played or any other political appointees at
FDA, the Department of Health and Human Services or elsewhere,
have a role? How was this decision arrived at that you can
share with me?
Mr. Thompson. The decision is scientifically based,
scientifically reviewed by peer review. I have nothing to do
with any decisions dealing with medicines at FDA or any kind of
treatments. That is completely outside of my bailiwick. In
regards to this one, as I understand it, the committee and the
individuals that are responsible for this are waiting for
continuing scientific information as to how this would affect
teens. So that process is continuing, as I understand it.
Ms. Capps. So it isn't a done deal?
Mr. Thompson. It is my understanding that they are waiting
for some more scientific evidence from the company as to how
this would impact on teens.
Ms. Capps. But you nodded when I mentioned the votes.
Mr. Thompson. Yes.
Ms. Capps. That the Advisory Committee did make this
recommendation. And I guess you are going to get back to us.
Because it is customary, isn't it, for the Advisory Committee's
recommendations to stand?
Mr. Thompson. Yes. I think there have been examples, but I
don't know how many, Congresswoman, but I will get that
information to you. You should have it--it should be readily
available, so you should have it next week.
Ms. Capps. Okay. I appreciate that, because I would like
to----
Mr. Bilirakis. I would hope, Lois, that we could stick to
the subject. I am not saying that what you are asking is
insignificant, but----
Ms. Capps. I know.
Mr. Bilirakis. [continuing] certainly, it is not the
subject matter. And on the floor debates are required to be
germane to the subject. And I am not sure, really, what the
committee rules are here. Ordinarily I would be leading it in
any case, but, come on, let's go back to the subject.
Ms. Capps. I know. Well, I appreciate it but I also have
not been able to get answers to some of these concerns. I am
representing now many people in my district who were quite
upset about this, and I don't like to see the reliability of
the Agency tarnished in any way. I think it is important that
we have a process, and I know it is a vulnerable to
politicization, and I just really want us to focus on----
Mr. Thompson. I disagree with that.
Ms. Capps. Okay.
Mr. Thompson. It is possible, but there was no politics
played in this at all. They are waiting for some more evidence
on this. I am confident no political operative was involved.
Ms. Capps. Okay. And also then you are saying that it is
not a completely decided yet.
Mr. Thompson. It is my understanding that it was turned
down waiting more scientific evidence, how this would impact on
teens.
Ms. Capps. Well, I look forward to seeing----
Mr. Thompson. That is my understanding, Congresswoman.
Ms. Capps. Well, maybe when you respond as to the number of
times in the past that you will also give us some direction as
to where this stands.
Mr. Thompson. Absolutely.
Ms. Capps. And I can inquire more directly of you
personally.
Mr. Thompson. I just turned to my legislative person,
Jennifer Young, and she will have an answer to you next week.
Ms. Capps. Thank you. I want to touch on another topic, and
I know my chairman is going to say I am stretching it, but this
is another huge concern that I have, I only have a minute and a
half left. This is a big topic. Among the provisions included
in the Medicare bill last year was a change in the payments for
cancer care. The old system was clearly broken, I will be the
first--all of us would acknowledge that. Medicare and its
beneficiaries paid too much for oncology medications. We had
hearings on that right in this committee. We agreed that it
needed to be fixed. But Medicare also paid oncologists, cancer
centers and oncology nurses nothing, too little----
Mr. Thompson. That is true.
Ms. Capps. [continuing] for the care, the comprehensive
care that cancer patients receive. The overpayment for cancer
drugs was used to pay, and maybe it was vulnerable, but it was
used to pay for treatments that cancer doctors provided to
cancer patients through these auxiliary cancer center services.
As a result of the changes in the bill, overall reimbursements
for 2004 remained the same as in past years, but starting in
2005, drug payments go down as payment shifts from AWP to
average sales prices, and this will be a huge decrease in
payments to doctors. Transitional payments designed to prevent
disruption of cancer care are going to be cut by 29 percent in
2005. The terror and the fear out in the community of cancer
patients is enormous and to the oncologists as well.
In May, Dr. Norwood and I and 68 of our colleagues on both
sides of the aisle wrote to Administrator McClellan asking for
release of the CMS planned payment rates for 2005. This is
critical to ensure that the cancer community can be aware of
what they are facing and how to avoid disruption. We haven't
received a response yet. That is why I stretch the title of
this hearing and ask you to see where we can find information
that I could take back to our constituents.
Mr. Bilirakis. Mr. Secretary, would you give us a date when
you might respond to those questions rather than to do it here
now?
Mr. Thompson. Absolutely.
Mr. Bilirakis. All right. Give us a date. When might you
she receive it?
Mr. Thompson. The first question she will have an answer
next week.
Mr. Bilirakis. All right.
Mr. Thompson. On the cancer one, Dr. McClellan is working
on that, so I am not sure. I can't give you a date on that,
because he is working on that.
Mr. Bilirakis. All right. Ms. Capps is concerned that she
hasn't received responses in the past. I want to allay her
fears there, but at the same time I want to keep going on the
subject matter of the hearing.
Mr. Thompson. We have got proposed rules all the time
coming out on Medicare. I will get Dr. McClellan to call you.
Ms. Capps. Thank you.
Mr. Bilirakis. All right.
Ms. Capps. Thank you. And thank you, Mr. Chairman.
Mr. Bilirakis. Let's see, Mr. Shimkus, for 8 minutes.
Mr. Shimkus. Thank you, Mr. Chairman. Mr. Secretary, it is
great to be here. Mr. Stupak looks slender and more healthy,
and if he stands up he can probably show you his pedometer that
probably--you got it, Bart, today? How many steps today?
Mr. Thompson. How many do you have?
Mr. Shimkus. Forty-eight thirty-eight? Not bad.
Mr. Thompson. I have only got 28.
Mr. Shimkus. I am going to double him on the basketball
court in about 45 minutes when we get down there. But that is a
critical thing, leadership, and you have brought excitement and
passion to this debate, and I just want to thank you. It is not
an easy one. I am a part-time partner on this committee, and I
try to shy away from this because it is so bureaucratic,
paperwork, payment systems, line items. It just drives you
crazy. You never hear anything positive. It is always negative.
So I just want to continue to applaud you.
The Health Care Leadership Council, I have gone to their
little event they have here on the Hill and they show
technology. They did it just yesterday, and if you didn't go
by, you really should, because this really, with all due
respect, it is probably more important that we see the
technologies out there in the private sector in this than hear
your testimony, because it is there. Bar coding of drugs,
patient access to records online, nurse access on dosage to
make sure that the proper dosage isn't being applied at the
time, at the bedside of the patient. So we are not talking
about Star Wars here, we are just talking about technology that
is out there to move it into our governmental system for
providing health care to Medicare and Medicaid individuals.
I was a county treasurer my first assignment in a very
famous country called Madison County, Illinois. Two hundred
fifty thousand people when I took office. We collected property
taxes. Two billings a year, we had 30 employees, and it was all
hand ledger. This was only 15 years ago. We went to
spreadsheets, we went to bank statements with microcodes, we
went to a P.O. Box for the banks to do some of the billings, we
electronically transferred payments back to the property tax
districts, the school districts instead of cutting them a
check. We saved the taxpayers thousands of dollars, and we
decreased the office staff by 10 employees. We did a better
job, we were more efficient. So it can be done. And if can't be
done anywhere--the private sector is doing it, because they
know they have to save money by becoming efficient. It is
government that needs the prodding and the pushing, because we
are not looking at the bottom line, as the private sector does.
You mentioned some comments before, and I know the VA's
here. We have also been successful in getting dollars to a
telemedicine clinic in Springfield, Illinois that is now
working with the VA hospital in Marion so that patients on just
general views with technology and digital cameras and to be
able to transfer records, a guy can stay home or a guy can go
to the local clinic and be received, in essence, by a doctor
through telemedicine, thus saving time, effort and energy. And
for rural America, and Wisconsin has got some rural areas, 150,
200 miles of driving at a time.
So I would just give you an opportunity to say how else do
you think that we can be helpful through the authorization
process that we do or the spending? How can we help you push
this change in the Federal bureaucracy?
Mr. Thompson. The best thing you can do is just what you
got done saying, Congressman, is the fact that there are many
examples out there. The VA has got examples, our Department has
got many examples that we have done on standards. The fact that
you are holding this hearing is an absolute vital one because
it is right after the technology summit yesterday. It shows
that momentum is there.
Number three, when you are looking at the Medicare
reimbursement formulas, you can put in a provision that says
that within 3 years, 4 years or 5 years, that all claims have
got to be submitted by technology, not in writing anymore.
Number four, you can be contacting your own individual
hospitals and clinics and inform them of the importance of
this, of getting into technology.
Number five, the examples you were saying in Marion,
Illinois, which is a good one. It needs now, of course, the
national interoperability so that a veteran that is in your
hometown, is it Marion or Madison or wherever it is, is going
to be able to order drugs if he or she is on vacation or if he
or she has an accident in Florida, that their records can be
immediately reviewed by somebody in the emergency room so that
they are able to treat you or that patient properly.
These are the kind of things that are out there, and every
other sector of the economy is there except the health policy
and the health fields.
Mr. Shimkus. And we have helped facilitate that, even in
the years that I have been here, through this committee----
Mr. Thompson. Yes.
Mr. Shimkus. [continuing] through the Telecommunications
Subcommittee when we passed legislation to allow the electronic
receipt of signatures. I mean how many people now do
refinancing--you can refinance your mortgage through faxes and
electronically without ever going into a building anymore.
Mr. Thompson. Isn't that great?
Mr. Shimkus. Thank heavens, it is wonderful.
Mr. Thompson. Yes.
Mr. Shimkus. Especially with the busy schedule that people
have. So thank you. Keep up the good work.
Mr. Thompson. And what you have done as county treasurer in
Madison County, what did you do, reduce the employees by 10?
Mr. Shimkus. We went from 30 to 20 employees.
Mr. Thompson. Yes, by technology. And people say, ``Where
are we going to get the money?'' Look at the savings. Look at
the savings. Invest in the savings.
Mr. Shimkus. And that is always suspect if the work product
was less, but the work product was better, because the taxing--
the school districts, the municipalities got their money faster
because we didn't have employees writing checks, putting them
in the mail, sending them to the taxing districts, they just
did it electronically.
Mr. Thompson. Can you imagine the cost to America and to
Americans when you realize that--if the Institute of Medicine
study is correct that 98,000 people died from medical mistakes
last year, and a good share of those can be prevented by
technology. Imagine what the savings would be just in that
category alone.
Mr. Shimkus. Well, we had the debates on medical liability,
and of course that is why Madison County, Illinois is very
infamous, but this whole debate a lot of times hinges around
medical errors, and a lot of medical errors occur because of--
and I am one of those that have terrible handwriting--when you
use technology and you have to keystroke entries on what is
there, you will bypass a lot of those errors. The technology I
viewed yesterday, if the doctor wanted a 20 milligram dosage
and they----
Mr. Thompson. Or a microgram, that is a 1,000----
Mr. Shimkus. Yes. And it looks like an eight and then the
nurse puts in eight and the screen pops up and says, ``Hey,
this is 10 times more than what the doctor had prescribed.''
Blaring lights, sirens, and if it can save one life, it is
worth the effort.
So thank you for the time. I will give you back my five
seconds, Mr. Chairman. I yield back.
Mr. Bilirakis. Mr. Rush for 8 minutes.
Mr. Rush. Thank you also, Mr. Secretary, and I want to join
with others who have welcomed you here and who have applauded
you for your leadership and for your position on various issues
as it relates to health care. You are the governor of a
neighboring State of my State, and it is good to know that you
have come to Chicago on many occasions and helped us
tremendously there, and I appreciate your eloquence and your
passion on IT issues and how it vastly--and I agree with you,
how it would vastly improve health care in the future.
I want to discuss the issue right now of something that is
presently before us. It is not in the future, it is right here,
right now, and that is the issue of information technology and
how it affects the 340-B Drug Pricing Program. Again, it is an
immediate issue. And the Inspector General, in June, issued a
report on overcharging of prescription drugs under the 340-B
Program. The report is entitled, ``The Appropriateness of the
340-B Drug Prices.'' In the report, the Office of the Inspector
General recommends that HHS' Health Resources and Services
Administration create and maintain a secure web-based system so
providers can verify that the prices they are charged with in
fact comply with 340-B, and this system would be accessible
only by password.
As you know, right now drug manufacturers are not really
accountable to anyone and have been consistently and illegally
charging 340-B public hospitals and community health centers
more than they are allowed to under the law. And I wanted to
get your response and ask you what do you think of the OIG's
suggestion for a secure web site that would create
accountability? And are you in the process of implementing such
a system, and what is you overall view of that, of the system?
Mr. Thompson. Well, first off, thank you very much for the
question, Congressman Rush, and thank you also for your passion
in your district. I have followed you from afar and also gotten
to know you since I have been out here, and I have always been
very impressed by you, and I thank you.
In regards to 340-B, you know that anything dealing with
community health clinics it is near and dear to me. I am very
passionate about them. I believe so much in them. And anything
that detracts from them I get very irritated. And so I have
asked HRSA, which is responsible for community clinics, to do
some research on it, to make recommendations to me. They are in
the process of that. I just turned to my staff to find out when
those recommendations are going to be. They don't know yet, but
they are coming soon.
In regards to the OIG report, I will receive suggestions
they have to improve the system and any that I am in favor of--
I will look at that, and before I leave I will do everything I
possibly can to implement it.
Mr. Rush. Mr. Secretary, I really appreciate your comments,
and I know your passion for community health centers. And since
my question was pretty direct and you gave me a pretty direct
answer and I have got some additional time, would you comment,
please, on the status of school-based health clinics? Mr.
Chairman, we are going a little bit far away from the subject
matter, but the Secretary and I agree on so much and I just
wanted to know that we agree of the importance of the school-
based health clinics, and what do you see the role in the
future--how do you see the role in the future of school-based
health clinics?
Mr. Thompson. Well, I think school-based clinics are badly
needed. I think any way that we can deliver health care to our
children in an effective way it is important. That may be the
only health care that that child or children is able to get.
And I happen to be one of those believers that children need as
much good quality health care as they possibly can receive. And
if that is where they are going to get it, then I am in favor
of it.
Mr. Rush. Mr. Chairman, I yield back.
Mr. Bilirakis. The Chair thanks the gentleman. Mr. Buyer to
inquire.
Mr. Buyer. Thank you, Mr. Secretary. Given the liberty that
members are taking and the latitude of the chairman, I need to
take mine. You have done a great job with regard to the drug
discount card in signing up a lot of people----
Mr. Thompson. Thank you.
Mr. Buyer. [continuing] but a lot of those cards aren't
getting in people's hands. And I know Dr. McClellan's working
on that, but I just want you to know you can talk to any Member
of Congress and they are having some problems even getting the
cards and lag times. And I think you know that, but I just
wanted to reinforce it. Thank you, Mr. Chairman, for the
latitude.
On the--gosh, I have to go back. In the late 1990's, I
Chaired the Personnel Committee on Armed Services, so I had the
military health delivery system working on IT. Now I Chair O&I
on VA working on IT, and I get to be here with my colleagues
here and we work on IT. The great thing is we have got all
three, I have got experience with all three. The downside of
that is I also have experienced great pains over the years,
because the initiatives that we are talking about today aren't
new initiatives.
These things have been there from 1997. There have been
discussions about VA, your departments and DOD and seamless
interoperable, bi-directional, multidirectional, standards-
based, and we haven't done a very good job, I don't think, at
the beginning. GAO, you can pull up any imaginable GAO report
with regard to the exchange of health data and they have been
very critical of a lot of the IT. So I was a good listener to
your opening statement, especially in your response to Mr.
Bilirakis' question on what can Congress can do.
A lot of this can and should be done through the executive
function. Coming off of a hearing yesterday on this, I just
want you to know where I think we can be really helpful. I
think we are going to have to change structure. In this town,
those who have the money have the power, and if you want to
break the bureaucracies, you give--whoever is in charge of
information management give him the money. And that is what I
am about prepared to do with the VA.
And so I will take the Assistant Secretary, who is Bob
McFarland, out at Dell Computer, who has come to help the
country and he is getting pretty frustrated by the
bureaucracies and the three stovepipes that we have, and I am
prepared to change structure for the VA. And I am going to give
him the money, and I am going to stop having the IT having to
go beg. And I just am curious about your comment if we begin to
change structure and give the money and let's turn the table
here on IT. A lot of projects out there. We have funded
billions of dollars, and there is a huge graveyard out there
with IT projects.
Mr. Thompson. Congressman Buyer, first, let me thank you
for your advocacy for the cards. You have done an outstanding
job, and I know of your passion for it and what you have done,
and I appreciate it, and I am in your debt.
Mr. Buyer. Thank you.
Mr. Thompson. In regards to the mistakes being made, any
time you start a program as large and as monumental as this,
you are going to make some mistakes along the way. We have
tried to fix them as soon as we see them. If you have got any
suggestions, please give them to us. Dr. McClellan and
everybody in the Secretary's office is very concerned, and we
are working on all of these problems as fast as we possibly can
and coming up, I think, with good results.
In regards to--I sort of like your idea. Somebody suggested
that there should be somebody over in OMB or in each one of the
departments that is in the technology field that has the veto
power over any budget increases in any divisions if it doesn't
meet the technological standards, and it certainly would change
the thinking processes, and it would certainly change the
outcomes a great deal. And so your idea of changing the
structures I have no difficulty with it at all and think that
you would accomplish a great deal when you do it.
Mr. Buyer. When Dr. Kaiser decentralized within the VA and
we have gone to so many outpatient clinics and given more power
to visions and we say if you get collect money, you get to keep
money. What that has also done is create a lot of little
kingdoms out there----
Mr. Thompson. Yes. Right.
Mr. Buyer. [continuing] and we don't have standardizations,
and we have really a lot of problems, and as you try to work
with NIH.
Anyway, this isn't just to steambull your idea, the Marine
Corps said, ``We're going to take control here of ourselves,''
and they put all the power in one person. And it has worked
very, very well, but we don't have that across the board in our
departments.
Mr. Thompson. No, we don't.
Mr. Buyer. And I just wanted to let you know that is what
I'm thinking, and I appreciate your counsel. Thank you.
Mr. Thompson. I would--well----
Mr. Buyer. Go ahead.
Mr. Thompson. I would think that the more power that you
could give to a secretary to run his or her department,
Congress would be much better served and the people would be--
the secretary.
Mr. Bilirakis. Enough said. Ms. Eshoo to inquire.
Ms. Eshoo. Thank you, Mr. Chairman. Welcome, Mr.
Secretary----
Mr. Thompson. It is always a pleasure.
Ms. Eshoo. [continuing] and thank you for your service to
our country. It shows that you have, as everyone here has said,
you have a passion about it, you care about it, and I think
that whenever you decide that your tenure ends, your
contributions----
Mr. Thompson. In January.
Ms. Eshoo. [continuing] will be lasting.
Mr. Thompson. Thank you very much.
Ms. Eshoo. Well, we all have parentheses around what we do,
so thank you. And, Mr. Chairman, thank you for holding what I
think is really a very important hearing. The other night I
found myself, there must be something wrong with me that I have
C-SPAN on even when I get back to my apartment, but I am not so
inclined to listen to the National Governors Association
meeting but the headline of it was, ``Health Care in the
Digital Age.'' And the keynote speakers were Newt Gingrich, the
former Speaker of the House, Leon Panetta, the former Chief of
Staff at the White House, and I don't remember the gentleman's
name but he was outstanding, the man that heads up Starbucks.
And so much of what we have talked about here today, about the
number of lives that are lost due to medical errors and how we
improve our health care system so that there is a jointness, a
sharing, an integration of technology is absolutely front and
center in the 21st century. We are facing it across the board
in the Federal Government. The 9/11 Commission came out with
its report today, talked about smokestacks and within the
intelligence community that they had a need to know but not a
need to share.
And I think that there are two ways to maybe draw a line
and to two columns. One of it is private. I mean we have
hospitals, obviously, that are public hospitals, we have
district hospitals, we have private hospitals. And it seems to
me that with those hospitals we have got to strike a
partnership with them. The reason they are not doing it--why so
many are not doing it, there is not an incentive, and there has
to be a little bit of a carrot in this. Do I think we have
enough money to incent all of them to pay for or do their
systems? Of course we don't, and I don't think we are the ones
that should be doing that. But I think that with, first of all,
leadership from the Federal level where we say, ``This is a
priority,'' and then they follow some kind of model.
I think the idea, Mr. Chairman, and we can do this, is your
idea, Mr. Secretary, about over a certain number in the abuse
or the fraud dollars that are secured by the Department, that
that be dedicated to this. I also think that we should be
looking at mechanisms for very low interest loans. They will be
able to do that. You know, in California, after the big
earthquake, the legislature told the hospitals that they had to
retrofit by such and such a date. Well, they never came up with
a mechanism for this, you see, and they didn't have the money
to retrofit. For many of them, retrofitting was tearing the
place down and building a new hospital.
So we have mechanisms where we can help make that happen,
and I think that we shouldn't think of this thing as being so
massive that it can't be done. The technologies are already out
there. Congress doesn't have to invest this stuff.
Now, in terms of Federal operations, we have to come up
with some standard and how we are going to do that, but you can
take care of that, we can take care of it in the various
committees. It is reaching the other hospitals, the rest of the
hospital community across the country. In my district--I mean
we always need success stories, someone was saying so much is
negative--El Camino Hospital in Mountain View, California--and
before you leave if you find yourself in California, I would
love to accompany you there.
Mr. Thompson. I would love to go. Thank you.
Ms. Eshoo. Exactly. They have made an investment in their
patients, and it is the first hospital in the world to become
paperless. They have 97 percent of all their orders by 200 of
their doctors are done electronically. Now, they set it as a
priority, so we can do this, and I welcome your leadership.
This committee should pick up on these ideas and get them into
legislative language. Again, we can incent them. We can set
some money aside, you have got something there, but this is
from the Secretary's Office got to bring some of the private
hospitals together and the country hospitals, the public
hospitals. Let them participate in it too.
You are local, State government, and so you think in a very
solution-oriented way, and I welcome it. I come from country
government, so I am trying to think that way. I think we have
the ingredients here.
Mr. Thompson. We do.
Ms. Eshoo. And I would be happy to work with the chairman,
with you, with your office, with all of my colleagues. You can
tell that you have a real bipartisan spirit here because of the
way you have worked and conducted yourself, Mr. Secretary. So
those are two things that I think we can do.
Mr. Thompson. Thank you very much.
Mr. Bilirakis. Any response?
Mr. Thompson. Thank you for your invitation. I would be
more than happy to come out.
Ms. Eshoo. Yes. I would love it if you would. We would be
thrilled.
Mr. Thompson. And I am looking for that example where it is
completely paperless. I am not sure it is completely paperless.
I bet you still have a manila folder or an application come in.
Ms. Eshoo. Maybe. This is what they told me, and when
people talk about----
Mr. Thompson. I want to see that hospital where you can go
onto your computer, make your appointments, go in and go
through all the departments, end up having your medical care,
have your bill when you walk out and never see any paper. That
is what I want.
Ms. Eshoo. Absolutely.
Mr. Bilirakis. Well, I think----
Ms. Eshoo. Their x-rays are digital.
Mr. Thompson. That is great.
Ms. Eshoo. Yes. So come and see.
Mr. Bilirakis. Mr. Secretary, again, thank you. I mean
everybody has thanked you, and we really mean it. You have been
here before us so many times, and you have got to be one of the
busiest people in the world, and yet you find time for it, and
we appreciate it so much. Thank you----
Mr. Thompson. You are wonderful people. Thank you.
Mr. Bilirakis. [continuing] for encouraging us and spurring
us on on this subject.
Mr. Thompson. Thank you very much.
Mr. Bilirakis. Thank you very much. The next panel will
consist of Robert M. Robert M. Kolodner, Acting Chief Health
Informatics, Officer and Deputy Chief Information Officer for
Health, for the U.S. Department Of Veterans Affairs; Dr. David
Blumenthal, director for the Institute for Health Policy,
Massachusetts General Hospital/Partners with the Health Care
System; Dr. Carol Diamond, managing director of the Markle
Foundation, Rockefeller Plaza, New York; and Dr. Edward H.
Shortliffe, professor and chair of the Department Of Biomedical
Informatics, also professor of medicine and of computer science
and deputy vice president for Strategic Information Resources--
pretty busy person--Columbia University Medical Center.
Welcome, Doctors, here. You have been in the room. I think
you see a real interest and hopefully a real fire in us as far
as this subject is concerned, and we look forward to your
testimony. Your written statement is already a part of the
record. We would hope in the 5 minutes that we allot you that
you would complement it, supplement it somewhat. Hopefully, you
can stay within about 5 minutes. If you are a minute or 2 over,
I am not going to shut you off. But in the interest of time--
hopefully we can get through before we have to run for further
votes.
Dr. Kolodner--is that correct?
Mr. Kolodner. Kolodner, sir.
Mr. Bilirakis. Good. Kolodner. Kolodner. Dr. Kolodner,
please proceed.
STATEMENTS OF ROBERT M. KOLODNER, ACTING CHIEF HEALTH
INFORMATICS OFFICER AND DEPUTY CHIEF INFORMATION OFFICER FOR
HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS; DAVID BLUMENTHAL,
DIRECTOR, INSTITUTE FOR HEALTH POLICY, MASSACHUSETTS GENERAL
HOSPITAL/PARTNERS HEALTH CARE SYSTEM; CAROL DIAMOND, MANAGING
DIRECTOR, MARKLE FOUNDATION; AND EDWARD H. SHORTLIFFE,
PROFESSOR AND CHAIR, DEPARTMENT OF BIOMEDICAL INFORMATICS,
PROFESSOR OF MEDICINE AND OF COMPUTER SCIENCE, DEPUTY VICE
PRESIDENT FOR STRATEGIC INFORMATION RESOURCES, COLUMBIA
UNIVERSITY MEDICAL CENTER, DIRECTOR, MEDICAL INFORMATICS
SERVICES, NEW YORK PRESBYTERIAN HOSPITAL
Mr. Kolodner. Thank you. And, Mr. Chairman, I just wanted
to confirm I will be doing a statement and then a demo. I
believe that was what the staff agreed to.
Mr. Bilirakis. Is your mic on?
Mr. Kolodner. Is that--that works, okay. Very good. Mr.
Chairman and members of the subcommittee, good afternoon. I am
Rob Kolodner, a physician in the Department of Veterans
Affairs. I currently serve in two related roles as both the
Acting Deputy Chief Information Officer for Health for VA and
as the Acting Chief Health Informatics Officer within the
Veterans Health Administration. I am pleased to be here today
to discuss the importance of benefits of health IT and to
underscore VA's commitment to the strategic framework released
yesterday.
Over the past several years, VA, through its HealthePeople
strategy, had initiated or joined in efforts to stimulate the
use of information technologies in health care by working with
Federal, State and industry partners. This strategy addresses
four key health IT components: The electronic health records,
or EHRs, personal health records and two critical pieces
necessary to exchange health information among them, the
National Health Data and Communication Standards and an
information exchange infrastructure.
Even by themselves, EHRs can help us provide better, safer
and more consistent care to all patients, and that better
quality care actually costs less. VA is a recognized leader in
the development and use of health IT to the benefit of our
Nation's veterans. VA's VistA System is a comprehensive EHR
system, and let me describe a few key components. VA's
Computerized Patient Records System, or CPRS, provides a single
integrated application used by health care providers in all VA
medical centers, nursing homes and clinics, and I will be
demonstrating that shortly. CPRS virtually eliminates
medication errors caused by illegible handwriting and through
automated allergy and alerts prevents potentially dangerous
treatments from being ordered.
VA's Bar Code Medication Administration System, or BCMA,
uses bar code technology on all medications and on the
patient's wristband to ensure that each patient receives the
correct medication, in the correct dose, at the correct time.
Shortly, I will also show you the VistA Imaging, which provides
the ability to capture and display a wide variety of medical
images.
You may be thinking this sounds great but is it really
being used by doctors, nurses and other health professionals.
VA's VistA Systems now contains more than 1.1 billion orders as
well as half a billion notes and reports, and these numbers are
growing quickly. Daily, in VA facilities, more than 865,000
orders and over half a million progress notes will be entered
electronically by VA providers, and 585,000 medications will be
administered safely using BCMA.
Does this technology really make a difference in health
care. As a physician, I have seen firsthand the benefits of
EHRs in VA, including immediate access to information,
elimination of duplicate orders and increased patient safety.
CPRS has helped VA become one of the best performing health
systems in the U.S. VA sets the benchmark for clinical
performance indicators proven to save lives, such as higher use
of beta blockers after a heart attack and higher screenings for
cancer.
And we have already begun to build our next generation
standards-based interoperable EHR system to move us from being
facility-centric to person-centric. Earlier I mentioned
personal health records. VA's My HealtheVet is a web-based
personal health record for all veterans. This type of
capability will transform the way veterans participate in their
health care experience and get information about their wellness
and care. Version 1 contains health information resources, and
by next year veterans will be able to have a secure copy of key
portions of their health record from VA's VistA Systems.
In the area of standards, VA was instrumental in the
formation of the interagency consolidated health informatics
initiative to foster the adoption of Federal interoperability
health standards. In the area of information exchange
infrastructure, VA and DOD developed a HealthePeople Federal
Plan to ensure the development of an interoperable electronic
virtual health record by 2005 to better serve our Nation's
veterans.
The Federal Health Information Exchange Phase I project
deployed in June 2002, makes health records over 2 million
unique veterans and servicemembers makes their DOD electronic
records available to VA providers. Phase II, starting in late
2005, will provide for the joint development and implementation
of interoperability between VA's health data repository and
DOD's clinical data repository.
As Dr. Jon Perlin, VA's Acting Undersecretary for Health,
announced yesterday at the Health IT Summit, VA is working with
Centers for Medicare and Medicaid Services to release early
next year a VistA Office EHR. And it is a version of VA's VistA
system configured to meet the needs of community health clinics
and office-based practices in rural and underserved areas. We
look forward to sharing our knowledge, expertise and where
desired our systems with our partners throughout the health
care community to support the strategic framework for
transforming health care to improve patient safety and quality
of care.
Dr. Perlin has asked me to convey an invitation to all of
you to see VA's Electronic Health Record in action at the VA
Medical Center just a mile away in Washington. In the interim,
I would like to provide a brief demonstration of VA's
Electronic Health Record so you can better appreciate the
capabilities we think are critical for every health provider
nationwide to have available in order to provide better, safer
care to all patients.
At this time, let me turn on the screens and hopefully they
will show, and you will see on the screens up above you I will
be opening up what we call CPRS. This is the clinicians
interface. And by the way, the entire VistA system, that which
can run large tertiary care hospitals in Houston or west L.A.,
all of that software is running on my laptop here in addition
to the imaging software.
So I click on the icon and normally in a regular system I
would be asked for a security password and access code, and
then I would see this screen. This is an opening screen where I
can choose which patient I want to see. It also gives me a
variety of alerts for patients that are mine about notes that
are unsigned or orders that have come in, abnormal orders. By
the way, the information you will see here is real patient
data, but it has been scrubbed so there is no identifying data,
but it is not made up data in terms of what you will be seeing.
So at this point, let me select a patient, Mr. Madliff, and
Mr. Madliff, when we select him, we get his cover sheet. At
this time, I am also going to open up the VistA Imaging and
have that available on the screen. This portion here that I am
pointing to in the center is CPRS. It basically uses the
metaphor of a chart and so you see tabs along here that look
just like a chart that clinicians would normally be using and
are familiar with. It also has brief summaries of the various
diagnoses or medications. If I want to look at the person's
blood pressure or weight, I can do that. And not only can I
look at that, but I can also graph it. And very often in the
examining room we actually have the terminal so we can turn it
to the patient and show, in this case, ``Mr. Madliff, we
noticed that your weight has been increasing recently,'' and we
can discuss with him what has been happening as far as the diet
or exercise and can actually engage him by having him see the
data that we see as well.
Now, Mr. Madliff is somebody who has a particular problem.
He came in and we looked at his laboratories, and in fact we
can open those here and quickly graph them. I will pull up his
hematocrit, which is the count of his red blood cells, and we
will take a look at all the results. And we see here that on a
number of occasions Mr. Madliff had a very steep drop in his
blood count. Actually, if we look very carefully, we can see
that during these times, as we expand that data, that not only
was there a drop, but in this case there was a sharp rise
twice. You don't normally develop red cells that fast. That
meant that he actually got a transfusion because of his anemia.
So when he came in then the issue is what is cause of his
anemia? We did a colonoscopy and fortunately we are well past
lunch here. This is actually a picture captured from the
colonoscopy, and so this picture would be available to all of
his providers. It shows here that he has these structures here.
This is diverticulosis that he has, but, more importantly, we
actually saw during that occasion here bright red blood, so he
was bleeding, and he had some sort of a bleed in his colon.
Now, the question is where did that come from, and so we
actually did something called a bleeding scan where we inject
some dye and take an x-ray. And this particular one was done
about 1992. It was before we had the digital systems, so this
was done on film. The patient was in the ICU, and when they
went to look at this film on the light box, the normal way of
looking at an x-ray, they were simply not able to find where
the bleeding was. So a physician's assistant took it over
because the imaging system had just been installed there. He
actually scanned in the x-ray and then brought it up, and this
allowed us to use some of the digital techniques that you can
use on x-rays to look at them. And, one of the advantages of
this is that we can actually adjust the x-ray, and this was
from a standard x-ray, to be able to see different parts of the
x-ray better.
And what we did was we looked out in this area and you will
see right here a little hazy area, and actually, if we invert
it, we can see a little bit better here. And this area, where
it is not sharp but it is very hazy, is in fact where the
bleeding was, and we were able to locate it, and they were able
to then pass a catheter and actually stop the bleeding by
closing off that clot. So that is Mr. Madliff. You can see
right at the fingertips you have got all of the data. It is
available at any place in the hospital. The images are
available any place in the hospital.
Let me now take you to another patient. We are going to
select----
Mr. Bilirakis. Doctor, forgive me for interrupting you, but
we have three votes on the floor. The buzzing you may have
heard was not bees, it was an indication of votes on the floor.
So we are going to have to break, and I apologize to you, but I
was hoping we could maybe get through before that. But as soon
as we finish up with these three votes, we will be back, and
hopefully we can get a few more people back here. Very
fascinating, I might add. Thank you very much. We are going to
recess for a few minutes. That is all I can tell you.
[Brief recess.]
Mr. Bilirakis. Mr. Kolodner, you weren't finished yet,
right? You had another example for us?
Mr. Kolodner. One more example, sir, and then I will be
finished, so my colleagues can----
Mr. Bilirakis. Okay. Please proceed.
Mr. Kolodner. Thank you. This is Mr. Green, and Mr. Green
has a cardiology problem. There is a cardiology note, as you
see here, with a little icon next to it, so when you click on
that it actually opens up the appropriate images. In this case,
he had a cardiac cath, and so we see here the image itself, and
we can in fact see why Mr. Green has been having some chest
pain. This is coronary artery in the narrowing. In this case,
we can show that to the individual and indicate why he is
having the pain.
Now, normally what we would do is during that cath we would
actually go ahead and take care of the problem, so a little bit
later on here we actually have the balloon in place so that it
is opening up the area, and we can finally follow it with a
follow-up film that we can actually show to the person to show
that in fact that area is now wide open, and so we have taken
care of the problem.
And, obviously, in terms of working with somebody and
educating them and helping them understand what their problem
was, in this case, why it is important for him to take his
follow-up medications, why he has to follow a diet so that this
doesn't happen again, it is a very powerful way of engaging the
veteran in improving their collaboration in participation in
care.
So at that point, I am finished my demo, Mr. Chairman.
[The prepared statement of Robert M. Kolodner follows:]
Prepared Statement of Robert M. Kolodner, Acting Chief Health
Infomatics Officer and Deputy Chief Information Officer for Health,
Department of Veterans Affairs
Mr. Chairman and Members of the Subcommittee: I am pleased to be
here today to discuss the importance of electronic health records and
the role of the Department of Veterans Affairs (VA) in the development,
use, and sharing of this valuable technology.
Recently, President Bush outlined an ambitious plan to ensure that
most Americans have electronic health records within 10 years. The
President noted a range of benefits possible with the expanded use of
information technology, including improved health care quality; reduced
frequency of medical errors; advancements in the delivery of
appropriate, evidence-based medical care; greater coordination of care
among different providers; and increased privacy and security
protections for personal health information.
In addition to these benefits, the transition from a paper-based
medical record to an electronic health record (EHR) brings with it
cost-saving efficiencies in how information is managed. In a paper-
based environment, a lot of time is spent simply handling paper. Entire
jobs are devoted to filing, retrieving, copying, distributing, and
tracking paper records and radiology films. The implementation of an
EHR does not eliminate these activities altogether, but it does
drastically reduce clinicians' dependence on hard-copy information.
Clinicians are able to access the information they need without
requesting it from the file room or searching through stacks of files
in their offices. Medical records and radiology films can be accessed
on-line, so that there is no need to repeat studies when test results
or films cannot be located. With an EHR, most VA sites have been able
to decrease the space devoted to file rooms, retrain staff members to
perform data management tasks, and reduce the costs associated with
printing, duplicating, and maintaining hard-copy records and films.
For decades, VA has developed innovative IT solutions to support
health care for veterans. Over the past several years, VA has worked
with federal, state, and industry partners to broaden the use of
information technology in health care. VA strives to continue the
development of the EHR while protecting the privacy of our veteran
population and maintaining the integrity of our systems. These efforts
have laid the groundwork for the President's health IT initiative.
With one of the most comprehensive electronic health record (EHR)
systems in use today, VA is a recognized leader in the development and
use of EHRs and other information technology tools. Beginning in the
late 1970's--before such tools were commercially available--Veterans
Health Administration (VHA) developed software applications for a
variety of care settings, including inpatient, outpatient, and long-
term care. These applications form the foundation of VistA--the
Veterans Health Information Systems and Technology Architecture, the
automated health information system used throughout VHA.
In the mid-1990's, VHA embarked on an ambitious effort to improve
the coordination of care by providing integrated access to these
applications through implementation of an electronic health record,
known as the Computerized Patient Record System or CPRS.
With CPRS, providers can access patient information at the point of
care, across multiple sites and for all clinical disciplines. CPRS
provides a single interface through which providers can update a
patient's medical history, submit orders, review test results, review
drug prescriptions, and perform other functions to support clinical
care delivery and the promotion of wellness. The system has been
implemented at all VA medical centers nationwide and at VA outpatient
clinics, nursing homes, and other sites of care.
The Benefits of Electronic Health Records
Electronic health records are appealing for a number of reasons.
The most compelling reason to use information technology in health care
is that it helps us provide better, safer, more consistent care to all
patients. The President referred to a 1999 report in which the
Institute of Medicine (IOM) estimated that between 44,000 and 98,000
Americans die each year due to medical errors. Many more die or suffer
permanent disabilities because of inappropriate or missed treatments in
ambulatory care settings. IOM cited the development of an electronic
health record as essential for reducing these numbers and improving the
safety of health care. In its 2002 publication Leadership by Example,
IOM noted that ``[c]omputerized order entry and electronic medical
records have been found to result in measurably improved health care
and better outcomes for patients.''
How can EHRs improve patient safety and quality of care? First,
with an EHR, all relevant information is available--and legible. A
provider can quickly review information from previous visits, have
ready access to clinical guidelines, and survey research results to
find the most appropriate treatments and medications. All of this
information is available wherever patients are seen--in acute settings,
clinics, examining rooms, nursing stations, and offices. With CPRS,
providers can quickly flip through electronic ``pages'' of a patient's
record to review or add information. All components of a patient's
medical record--including progress notes, referrals, orders, test
results, images, medications, advance directives, future appointments,
and demographic data--are readily accessible at the point of care.
Many of us see different doctors for different medical conditions.
How many of these physicians have access to all of the information that
has been collected over the course of these visits? In VHA, patient
records from multiple sites and different providers can be viewed at
the same time at the point of care. This is simply not possible with
paper records. Additionally, most clinicians find EHRs more convenient
to use than traditional paper records. They are less cluttered, easier
to read, faster and more reliable for finding items of information that
the providers are seeking. In addition, the EHR supports enhanced views
to help provide more information than that of a single test result, for
example, presenting a graph of a specific type of laboratory test over
a period of time for a single patient or for multiple patients.
In addition to making medical records more accessible, EHRs can
help clinicians better document the reasons a patient sought care and
the treatment that was provided. Given the time constraints they face,
many physicians resort to writing brief, sometimes cryptic notes in a
patient's chart, and then write more complete documentation when they
have time. EHRs enable clinicians to document care quickly and
thoroughly, and provide reminders to complete any documentation that is
overdue.
CPRS, for example, allows clinicians to enter progress notes,
diagnoses, and treatments for each encounter, as well as discharge
summaries for hospitalizations. Clinicians can order lab tests,
medications, diets, radiology tests, and procedures electronically;
record a patient's allergies or adverse reactions to medications; or
request and track consults with other providers.
More information isn't always better if we can't use it. Even if we
could transfer paper records quickly and reliably from one provider to
another, and make sure that the information in records was complete,
many hard-copy patient records simply contain too much information for
a clinician to sift through effectively. There is always the
possibility that something crucial could be missed. When health
information is stored electronically, however, we can make use of
software tools to analyze that information in real-time. We can target
relevant information quickly, compare results, and use built-in order
checks and reminders to support clinical decision-making. These
capabilities promote safer, more complete, more systematic care.
Consider the benefits we have seen in VHA in the area of medication
ordering. When orders for medications are handwritten or given
verbally, errors and mistakes inevitably occur. However, when
physicians use computerized order-entry systems to enter medication
orders electronically, errors caused by illegible handwriting or
misinterpretation of dosages, strengths, or medication names are
virtually eliminated. CPRS includes automated checks for drug-drug or
drug-allergy interactions, alerting the prescribing physician when
potentially dangerous combinations occur. Currently, 93% of all VHA
medication orders are entered directly by the ordering provider.
Information technology can also serve to reduce the number of
errors that occur when medications are given to a patient. VHA's Bar
Code Medication Administration system (BCMA) is designed to ensure that
each patient receives the correct medication, in the correct dose, at
the correct time. In addition, the system reduces reliance on human
short-term memory by providing real-time access to medication order
information at the patient's bedside.
BCMA provides visual alerts--prior to administration of a
medication--when the correct conditions are not met. For example,
alerts signal the nurse when the software detects a wrong patient,
wrong time, wrong medication, wrong dose, or no active medication
order. These alerts require the nurse to review and correct the reason
for the alert before actually administering the drug to the patient.
Order changes are communicated instantaneously to the nurse
administering medications eliminating the dependence on verbal or
handwritten communication of order changes. Time delays are avoided and
administration accuracy is improved.
BCMA also provides a system of reports to remind clinical staff
when medications need to be administered or have been overlooked, or
when the effectiveness of administered doses should be assessed. The
system also alerts staff to potential allergies, adverse reactions, and
special instructions concerning a medication order, and order changes
that require action.
The Importance of Standards
The use of electronic health records and other information
technology tools in a single medical office can improve health care
quality, reduce medical errors, improve efficiency, and reduce costs
for the patients treated there. However, as the President noted, the
full benefits of IT will be realized when we have a coordinated
approach to accelerate the broader adoption of health information
technology.
The National Health Information Infrastructure (NHII) initiative
recognizes the importance of data and communications standards in
developing a comprehensive network of interoperable health information
systems across the public and private sectors. Interoperability is
dependent, in large part, upon the adoption of common standards. With
data standards, health information exchange will allow for more cross
comparability and speed retrieval of ``like'' clinical information to
deliver safer, higher quality care using clinical alerts and reminders.
VA was instrumental in the formation of the interagency
Consolidated Health Informatics (CHI) initiative, and works closely
with the Department of Defense (DoD) and the Department of Health and
Human Services (DHHS) on CHI and related projects. CHI, which is part
of the President's eGov initiative, was established to foster the
adoption of federal interoperability standards related to health care
as part of a joint strategy for developing an electronic health record.
To date, CHI has endorsed 20 communications and data standards, in
areas such as laboratory, radiology, pharmacy, encounters, diagnoses,
and nursing information.
We have seen the value of data and communications standards within
VHA. Like other EHRs, CPRS allows users to search for specific medical
terms, dates of care, diagnoses, and other information quickly, without
having to review multiple documents. Although this search feature is a
handy tool, information retrieval can be hampered by a lack of standard
naming conventions. Virtually all clinical documents throughout VHA are
stored in CPRS; as a result, patient records containing hundreds, or
even thousands, of notes are becoming common. As the volume of online
information increases, the task of finding a specific note or report
among them can be difficult, particularly when different clinicians and
sites assign different names to similar documents.
The ability to aggregate and compare information from multiple care
sites has reinforced the importance of standardization for computable
data as well. VHA is developing a Health Data Repository to store
clinical information transmitted from VHA sites across the country. The
repository will provide a central source of data for analysis,
management reporting, performance monitoring, and research. Yet, the
ability to aggregate these data from different sites will depend on the
degree to which data fields are standardized.
Data Standards and Interoperability
Our data standardization efforts have also improved our ability to
share information with other agencies. In accordance with the various
confidentiality statutes and regulations governing these records,
safeguards have been implemented to ensure that the privacy of
individuals is protected throughout these collaborative projects. These
confidentiality statutes and regulations include the Privacy Act, the
HIPAA Privacy Rule (which are uniform federal privacy standards
protecting individuals' protected health information in the possession
of covered health care providers and entities), and several agency-
specific authorities.
I'd like to highlight our work with the Department of Defense. To
support the transition of individuals from active-duty to veteran
status, the optimal use of health resources through sharing agreements,
and VA-DoD collaborations on deployment health issues and health
conditions, we need to exchange clinically relevant health data between
the departments--and we need to exchange it electronically.
To this end, VA and DoD have developed a joint strategy to ensure
the development of an interoperable electronic health record by 2005.
The approach is described in the Joint VA/DoD Electronic Health Records
(EHR) Plan--HealthePeople (Federal) strategy and includes three
components: 1) joint adoption of health information standards, 2)
collaborative software application development/acquisition, and 3)
development of interoperable data repositories. The EHR Plan provides
for the exchange of health data by the departments and for the
development of a health information infrastructure and architecture
supported by common data, communications, security, and software
standards and high-performance health information systems.
In May 2004, GAO reviewed the Plan and recommended that VA and DoD
document a comprehensive joint project management plan and project
management structure. In response to GAO recommendations, VA and DoD
clarified the existing project management structure that provides
executive oversight by the chief information officers of the Military
Health System and the Veterans Health Administration. This project-
management structure ensures day-to-day joint accountability and
decision-making authority. Additional oversight comes through the VA/
DoD Health Executive Council, co-chaired by the Assistant Secretary of
Defense for Health Affairs and VA's Under Secretary for Health. The two
Departments are finalizing an updated joint project management plan.
The EHR Plan will guide VA and DoD in the joint development of
interoperable electronic health records to enable access to health
information by authorized users throughout DoD and VA. This will be
achieved through the transparent interaction of health systems or
applications between DoD and VA. Providers of care in both departments
will be able to access relevant medical information to aid them in
patient care for shared patients.
In support of the President's Management Agenda, the President's
Task Force (PTF) to Improve Health Care Delivery For Our Nation's
Veterans provided recommendations for the departments' goals to provide
a seamless transition from military to veteran status, including inter-
operable, bi-directional, and standards-based health records. Primary
governance of these joint efforts is the responsibility of the
Congressionally-mandated VA/DoD Health Executive Council (HEC) and
Joint Executive Council (JEC).
The first phase of the plan, the Federal Health Information
Exchange (FHIE), was deployed July 2002. FHIE provides historical data
on separated and retired military personnel and beneficiaries from
DoD's Composite Health Care System (CHCS) to the FHIE framework; the
information is then accessible in VA through CPRS. Currently, there are
over two million unique DoD electronic records available for retrieval
from the FHIE repository, and the volume of information available
through FHIE continues to grow as individuals are discharged to veteran
status.
The next phase of the EHR Plan is the joint development and
acquisition of interoperable data repositories by the departments. The
departments have formed an active working integrated project team to
implement the exchange of clinical data between the VA Health Data
Repository (HDR) and the DoD Clinical Data Repository (CDR). By linking
these two systems, the departments will achieve interoperability of
health information between DoD's CHCS II and VA's HealtheVet-VistA.
Using clinical decision support applications, providers in both
departments will be able to access and use relevant health information
to aid them in making medication decisions for their patients,
regardless of whether that information resides in VA's or DoD's
information systems.
Other examples of VA-DoD work include the DoD/VA Interagency
Virtual Private Network (VPN), which allows for the secure exchange of
clinical data between the two departments, and the Laboratory Data
Sharing and Interoperability Project (LDSI), which allows DoD to act as
a reference lab for chemistry tests performed for the VA. VA orders are
entered electronically in CPRS and are transferred to CHCS via a secure
VPN connection; results are returned electronically to VA. Turnaround
times are much quicker and patient safety is enhanced because manual
entry of the results into CPRS is eliminated. The LDSI application is
currently uni-directional and is being enhanced to support the bi-
directional exchange of orders and results between VA and DoD, so that
each agency can serve as a reference lab for the other.
Another collaborative project is the DoD/VA Consolidated Mail-out
Pharmacy (CMOP) Interface. In this project, military beneficiaries
treated at Naval Base Coronado, Naval Air Station, San Diego,
California, and Kirtland Air Force Base, Albuquerque, New Mexico, can
choose to have their outpatient prescriptions filled by the CMOP at
Fort Leavenworth, Kansas, and mailed to them rather than having to wait
and pick up prescriptions at the pharmacies in the military treatment
facility. The VA fills an average of 8,000 orders and 10,000
prescriptions per week for the two military treatment facilities.
VA and DoD will be better positioned to evaluate health problems
among service members after they leave military service, veterans, and
shared beneficiary patients; to address short- and long-term post-
deployment health questions; and to document any changes in health
status that may be relevant for determining disability.
VistA-Office EHR
As a physician, I have seen first-hand the benefits of electronic
health records in VHA: immediate access to information, elimination of
duplicate orders, increased patient safety, improved information-
sharing, more advanced tracking and reporting tools, and reduced costs.
CPRS has been enhanced and refined continuously since its initial
implementation, and has been recognized by IOM and in the mainstream
press as one of the most sophisticated EHR systems in the world.
Although VistA and CPRS were developed specifically to support the VA
model of care, they were designed with flexibility and adaptability in
mind. As VA has shifted its focus from inpatient, institutional care to
an ambulatory, primary care model in recent years, we have updated and
enhanced our information systems to support different care settings,
adding new ``smart'' software features, incorporating new technologies,
and developing better methods of coordinating data from multiple sites.
In fact, an early version of VA's EHR was altered for use in both DoD
and Indian Health Service. By the mid 1990's the three largest federal
systems providing direct health care were using derivatives of VA's
EHR, although only VA was using the current and more robust version
including CPRS.
VistA and CPRS are in the public domain. They have been adopted for
use in the District of Columbia's Department of Health, American Samoa,
and several state health departments and state veterans homes. A number
of countries, including Germany, Finland, Great Britain, Mexico, and
Ireland, have either implemented VistA or expressed an interest in
acquiring the technology.
VHA is now working with the Centers for Medicare and Medicaid
Services (CMS) to make the benefits of electronic health records
available to other providers. VA and CMS are collaborating on the
development of a ``VistA-Office EHR'' version of VA's VistA system.
VistA-Office EHR will be designed specifically for use in clinics and
physician offices. In developing VistA-Office EHR, VHA and CMS hope to
stimulate the broader adoption and effective use of electronic health
records by making a robust, flexible EHR product available in the
public domain.
VistA-Office EHR will be based on VistA, but will be streamlined
and enhanced to make it appropriate and affordable for use outside VA.
For example, patient registration features of VistA will be modified to
reflect the requirements of smaller medical practices. Specialty
components, such as OB/GYN and Pediatrics, will be enhanced. The VistA
operating environment will be streamlined so that installation and
maintenance are simplified. VistA-Office EHR can be adopted directly by
physician offices, used by vendors who provide administrative support
services to physician offices, or used by commercial software
developers to make competitively priced products with similar
functionality. Private developers, physician organizations, and health
care purchasers have been made aware of the VistA-Office EHR project
and the response has been favorable.
The VistA-Office EHR project is co-managed by CMS and VHA, and is
coordinated with other federal agencies, including the Indian Health
Service, Health Resources and Services Administration, the Centers for
Disease Control (CDC), and the Food and Drug Administration (FDA). The
project is funded by CMS. The first version of the VistA-Office EHR
system is expected to be available in November. Subsequent releases
will reflect changes and improvements made to the core VistA system and
will be developed in conjunction with participating agencies.
Many providers and communities are eager to use EHR technology, but
don't know where to start. For providers who have not used an EHR
before, it is difficult to determine which capabilities are needed in a
particular setting. To assist health organizations in the comparison
and selection of EHRs, Health Level Seven (HL7 <SUP>'</SUP>), an
international standards development organization, has established an
industry-wide initiative to define a set of standard functions for
electronic health records, and to recommend the high-level, care-
related functions appropriate for different care settings. VHA worked
with HHS to commission the development of the standard, and a VHA nurse
informaticist co-chairs the HL7 <SUP>'</SUP> EHR Technical Committee,
which manages this initiative.
The HL7 <SUP>'</SUP> EHR standard is intended to set the benchmark
for electronic health records, through broad public- and private-sector
participation and consensus on required EHR functionality. This
approach promotes a common industry EHR focus, but allows sufficient
latitude for commercial product differentiation, fostering competition
and innovation among developers of EHR systems. The HL7 <SUP>'</SUP>
EHR model will enable HHS and others to qualify EHR systems in terms of
completeness and readiness for adoption.
EHR Availability to Rural and Medically Underserved Communities
By Executive Order, the President directed that the Secretaries of
the Departments of Veterans Affairs (VA) and Defense (DoD) develop a
joint approach to work with the private sector to make their health
information systems available as an affordable option for providers in
rural and medically underserved communities. This approach provides
coordinated VA/DoD recommendations that focus on the capture of
lessons-learned, technology and knowledge transfers from data exchange
initiatives, the adoption of common standards and terminologies, and
the development of telehealth technologies.
In cooperation with HHS, and as also mandated by the President's
Executive Order, VA contributed to the development of a national
Strategic Plan that will address a coordinated strategy to improve the
delivery of health care by evaluating and recommending technologies
that are available across the federal government. VA is providing input
on collaborative approaches, public and private, being taken to
transform clinical practice and health care delivery using the EHR.
Emphasis for collaboration has focused on these areas:
Knowledge Transfer of Information
VA already has realized the target benefits of adopting EHRs and is
ready to share our experience to expand the use of the EHR, and related
information technologies, to the larger health community. Much of VA's
VistA system was developed by VA government resources and therefore,
the software exists in the public domain. Through on-going and active
collaborations with a number of government and private-sector
resources, VA encourages the proliferation of public domain
technologies based on VistA code. This approach reduces expensive
development costs associated with software and human capital
requirements, and makes proven EHR technology an affordable and direct-
transfer option to rural and medically underserved communities.
Adoption of Common Standards and Terminologies
VA and DoD have achieved the common adoption of an initial set of
standards through the Consolidated Health Informatics (CHI) initiative.
In partnership with HHS, VA and DoD are lead partners in the CHI
project, one of the 24 eGov initiatives supporting the President's
Management Agenda. The goal of the CHI initiative is to establish
federal health information interoperability standards as the basis for
electronic health data transfer in federal health activities and
projects.
TeleHealth Technologies Used for Long Distance Consultations
Telehealth makes up a significant component in how VA intends to
fulfill its mission to care for veteran patients. Telehealth involves
the provision of health care services when patient and provider are
separated in time and/or place, and take place using electronic media.
Telemedicine is included within the broader rubric of telehealth.
Within VA, telehealth transactions most often involve care between all
professional groups and patients, not just physicians. The expansion of
telehealth is an important part of the mission of VA, and directly
supports coordinated delivery of care.
The computerized medical record is a critical component to VA's
strategy for the expansion of telehealth. For example, using
videoconferencing to connect a patient with a provider situated many
hundreds of miles away could not take place safely and effectively
without having the patient's health record, laboratory results and
clinical images available. VA is working to expand the concept of the
multi-media record into the home using home-telehealth technologies and
My HealtheVet. In VA, technology is not the driver; rather, technology
is supportive of the way in which VA meets the changing nature of the
health needs of veteran patients.
Personal Health Records and My HealtheVet
The development of personal health records is another area of focus
in health information technology. Personal health records are an
adjunct to the electronic health records used in a clinical setting,
providing patients a secure means of maintaining copies of their
medical records and other personal health information they deem
important. Information in a personal health record is the property of
the patient; it is the patient who controls what information is stored
and what information is accessible by others. Personal health records
enable patients to consolidate information from multiple providers
without having to track down, compile, and carry around copies of paper
records. By simplifying the collection and maintenance of health
information, personal health records encourage patients to become more
involved in the health care decisions that affect them. VA maintains
the integrity and security of the systems containing protected health
information while simplifying the collection and maintenance of health
information. Systems are fully compliant with both the Privacy Act and
HIPPA rules.
Last year, VHA responded to more than 1 million requests from
veterans for paper copies of their health information. Such requests
are processed through Release of Information offices at VA Medical
Centers. As the use of personal computers among veterans has increased,
so has the interest in electronic access to medical information.
The VHA My HealtheVet project was conceived as a way to help
veterans manage their personal health data. My HealtheVet is a secure,
web-based personal health record system designed to provide veterans
key parts of their VHA health record and to let them enter, view, and
update their own health information. Patients who take over-the-counter
medications or dietary supplements, or who monitor their own blood
pressure, blood glucose, or weight, for example, can enter this
information in their personal health records.
The implications of My HealtheVet are far-reaching. Clinicians will
be able to communicate and collaborate with veterans much more easily.
With My HealtheVet, veterans are able to consolidate and monitor their
own health records and share this information with non-VA clinicians
and others involved in their care. Patients who take a more active role
in their health care have been found to have improved clinical outcomes
and treatment adherence, as well as increased satisfaction with their
care.
The first version of the national My HealtheVet, released last
fall, includes a library of information on medical conditions,
medications, health news, and preventive health. Veterans will be able
to use the system to explore health topics, research diseases and
conditions, learn about veteran-specific conditions, understand
medication and treatment options, assess and improve their wellness,
view seasonal health reminders, and more. Subsequent releases will
provide additional capabilities, enabling veterans to request
prescription refills on-line, view upcoming appointments, and see co-
payment balances. The My HealtheVet pilot, which includes personal
health data, has been piloted at 9 VA medical centers for nearly two
years. Protecting patient health data has been a key focus in
developing the system. The pilot guarantees that all patient data is
encrypted for storage, not directly readable, and not identifiable by
name. A security penetration study conducted by an independent
contractor was very positive. The system also meets all the
requirements for security as established by the VA Office of Cyber
Security.
In the future, veterans will be able to request and maintain a copy
of key portions of their health records from VistA and to grant
authority to view that information to family members, veterans' service
officers, and VA and non-VA clinicians involved in their care. VA is
also working with DoD and other partner organizations to develop a
longitudinal health record that will incorporate information from DoD,
VA, and private-sector health providers from whom the veteran has
sought care.
Summary
In announcing his plan to transform health care through the use of
information technology, the President noted our country's long and
distinguished history of innovation--as well as our failure to use
health information technology consistently as an integral part of
medical care in America. Health care is often compared unfavorably to
other professions and industries in its use of information technology.
Grocery stores, for example, are frequently mentioned as being ``more
automated'' than hospitals. At first, this seems outrageous, yet it is
not really surprising--treating patients is far more complex than
grocery shopping.
We clearly have a long way to go in optimizing our use of
information technology in health care; yet, we are not starting from
scratch. Electronic health records, personal health records, data and
communication standards, and sophisticated analytical tools--the
building blocks of a comprehensive, national health information
infrastructure--have already been implemented in some communities and
settings and are maturing quickly. Our challenge is to create a
technology infrastructure that will revolutionize health care without
interfering with the human interaction between providers and patients
that is at the core of the art of medicine.
The President recognized America's health care professionals and
the skill they have shown in providing high-quality health care despite
our reliance on an outdated, paper-based system. At VHA, we know that
the support of clinicians is essential to the successful implementation
of electronic health records and new IT tools. Clinicians, while often
the greatest proponents of health information technology, can also be
the greatest critics. At VHA, physicians, nurses, and other providers
are actively involved in defining requirements and business rules for
systems, prioritizing enhancements, and conducting end-user testing.
This involvement increases user acceptance, minimizes disruption during
upgrades, and most importantly, enables us to tailor systems to the
needs of the health care community.
In VHA, the electronic health record is no longer a novelty--it is
accepted as a standard tool in the provision of health care. Our focus
is now moving from technical implementation issues to those involving
data quality, content, standardization, and greater interaction with
other providers and systems. As VHA refines and expands its use of
information technology, we look forward to sharing our systems and
expertise with our partners throughout the health care community to
support the President's plan for transforming health care--and the
health of our veterans.
Mr. Chairman, this completes my statement. I will now be happy to
answer any questions that you or other members of the Subcommittee
might have.
Mr. Bilirakis. Thank you so very much, Doctor. Fascinating,
really.
Dr. Blumenthal, please proceed, sir.
STATEMENT OF DAVID BLUMENTHAL
Mr. Blumenthal. Thank you, Mr. Chairman, for inviting me to
participate here today. My name is David Blumenthal, and I am a
professor of Medicine and Health Policy at Harvard Medical
School, also a practicing primary care physician. And just for
the record, I would love to have that medical record, that
electronic technology to work with. I do work with an
electronic health record, but it doesn't have nearly the power
that the VA system does.
It is difficult, I think, for experts in this field to make
concrete the power of this set of technologies, and I think two
analogies may be useful, although they are not perfect, in
trying to think about the importance of health IT. And the
first is a really powerful intervention that we know by the
name antibiotics, and the second is our Nation's transportation
system. I think that health IT has every bit as much capacity
to improve the health of our population, perhaps more, than
antibiotics do, and in fact health IT would enable us to use
antibiotics more effectively by making sure that we use them
when they were appropriate, use them in the right does, use
them at the right time.
If we had antibiotics sitting around on the shelves unused
and waiting to be used, the protests from the American public
would shake the roofs of this great body and every legislature
around the country, yet that is exactly the situation in which
we find ourselves.
The other point I wanted to make is about the
transportation system. Our means of transportation are largely
privately owned, and people decide what kind of transportation
they want to take. The cars that they use and the buses are
privately owned, the airplanes are privately owned. But they
wouldn't be very useful if we didn't have superhighways to let
them travel from State to State, and they wouldn't be very
useful if we didn't have air traffic controllers to keep them
moving in an orderly way and in a safe way. And to some degree,
the lack of a transportation system, lack of information
superstructure is what makes us--one of the things that
prevents health IT from being used as efficiently as it could
be.
There is enormous bipartisan support obviously for health
IT. I think the difficulty will come when we get to talking
about precisely what to do. I think we need to do four kinds of
things, all of which were discussed to some degree this
afternoon already. The first is that the Federal Government
needs to lead in the development of standards for
communication, that information highway that I mentioned. I
think that is what interoperability through uniform standards
really comes down to. The second is that we need financial
support and incentives to hasten the adoption of health IT and
especially to hasten it for cash-strapped small providers of
care and for rural and for providers and hospitals that serve
indigent and rural populations.
We need a lot of research and development to continue the
progress that we have seen in the development of health IT, and
we shouldn't forget that we have a lot to learn still to
improve how it is used and to improve the products that are out
there and understand its positive and its negative effects. And
then I think we need the relaxation of certain fraud and abuse
statutes that inhibit the development of health IT.
Let me just say a little bit more about a couple of these
points. First, the provision of financial support or
incentives. The Secretary referred, I think, to the use of
Medicare as a lever or Medicare payment, and I think that it is
not unreasonable to think in the future, not right away, but in
the future of requiring as a condition of participation in
Medicare that hospitals and doctors have access to and use
electronic health records. That is not something you would want
to do tomorrow, but with due warning I think it is possible.
The second point I would like to make is that there are in
fact very important financial disincentives to adopt health
information technology, especially for individual physicians
and small groups. There is good evidence that the process of
adoption reduces productivity for physicians by 10 to 20
percent, which means that they get a 10 to 20 percent loss of
income in the short term associated with the--and that is on
top of the cost of purchasing the equipment. And that is a lot
to take in a time of constrained incomes, and we need to find
some way to get them over that hump. And 60 percent of American
physicians still practice in groups of less than 5.
The other point I would like to make is that institutions
in poor and rural areas have trouble accumulating capital to
expend the kind of money that we have been talking about, and
they will need help to get access to that capital.
The options for providing this kind of--in addition to
conditions of Medicare payment, you have heard discussed some
of the options for providing the support. It could include
loans or grants or increased payments through reimbursement
mechanisms under Medicare or Medicaid. All I think should be on
the table and looked at closely.
We clearly need a multifaceted, comprehensive approach with
multiple points of attack in order to get this antibiotic
equivalent out to the American people at this point, and I am
sure that all of us here today look forward to working with you
on that project. And I want to thank you again for giving me
the opportunity to appear before you today.
[The prepared statement of David Blumenthal follows:]
Prepared Statement of David Blumenthal, Director, Institute for Health
Policy, Massachusetts General Hospital and Partners HealthCare System
Mr. Chairman, members of the Committee, thank you for the
opportunity to appear before you today to discuss our nation's approach
to realizing the benefits of health care information systems. My name
is David Blumenthal. I am a primary care physician practicing medicine
in Boston, Massachusetts. I am also Director of the Institute for
Health Policy at Massachusetts General Hospital and Partners HealthCare
System in Boston, and Samuel O. Thier Professor of Medicine and
Professor of Health Care Policy at Harvard Medical. My responsibilities
further include directing the Harvard Program on Health Systems
Improvement, which is a university-wide program designed to develop and
encourage innovative approaches to delivering health care to the
American people.
Though I am not personally as expert on clinical information
systems as the other distinguished members of this panel, it is
impossible for anyone who studies our health care system today to avoid
the issue of health information technology or HIT as it is commonly
known. The reason is that the set of technologies and capabilities
embodied in HIT is so powerful and so important that they must be
factored into any decisions facing public officials and private
managers who desire to improve the health of the American people or to
improve the quality and efficiency of health service delivery.
It is difficult sometimes, even for experts, to make concrete the
potential value of IT systems in health care, so let me use two
analogies--admittedly imperfect--to try to capture the importance of
health IT. The first is to antibiotics. The second to our nation-wide
transportation system.
If a discovery with the life-saving potential of antibiotics were
sitting unused on warehouse shelves around America, while thousands
upon thousands of Americans were suffering and dying untreated, there
would be an outcry that would shake the roof of this great legislative
body, and every other legislature throughout the U.S. I believe that
clinical IT has the power to save as many or more lives than
antibiotics--indeed, clinical IT has the power to make sure that
antibiotics themselves are used more effectively, to save more lives
and prevent more suffering. But clinical IT systems are sitting unused,
and will not be employed to their full potential unless we act
collectively to assure this will happen.
The analogy to the nation's transportation system speaks to a
slightly different issue: the importance of coordinated public and
private action to unleash the power of clinical IT. The means of
transportation in our country are, for the most part, privately owned
and operated. Airlines, trucks, most railroads, and millions upon
millions of automobiles are owned and operated by private companies and
individuals who decide what equipment to use, where to go and when, the
color of the seats and whether they should be leather or vinyl. That is
clearly the way the American people want it.
But how useful would our private means of transportation be if we
didn't have highways to travel on, or air traffic controllers to assure
that airplanes can move safely and securely from one city to another
and land in an orderly (if not always timely) manner? Even if every
doctor, hospital and nursing home in the country had the best available
computers and software to manage clinical information, it would still
be essential to have a means of moving that information from one place
to another in a reliable, secure fashion, so that patients and their
doctors could take advantage of it wherever they go. In other words, we
need a secure, modern national information superhighway that criss-
crosses our country, just as we have a national transportation
infrastructure. To get that information highway will require public-
private partnerships in which government plays a leadership role.
In recent months, a remarkable consensus, bridging partisan,
ideological and professional divides, has emerged in support of the
propagation of health information technology in the U.S. The question
is what precisely government should do and over what time frame. I
think a consensus is emerging in this regard as well, though I suspect
much hard work remains to reach agreement on the specifics. The core
required elements are captured in the excellent document released today
by Secretary Thompson, but their details need to be rapidly defined and
put into policy. I would personally emphasize the following particular
actions as critical:
1. Federal leadership in the development of standards for communication
between IT systems that will enable interoperability.
2. The provision of some financial support and/or incentives to hasten
the adoption of IT and its life-saving potential, especially
for small, cash strapped providers of care, like small
physician groups, and for hospitals that serve indigent and
rural populations.
3. Continued research and development to refine the uses of IT, and
especially, to demonstrate and disseminate approaches to
creating seamless community wide information networks.
4. Relaxation of certain fraud and abuse restrictions that inhibit
collaboration between doctors and hospitals in the development
of IT systems.
The first, third and fourth of these proposals are critical to
creating the information superhighway of which I spoke earlier. They
are equivalent to designing the interstates and the air traffic grid,
demonstrating how they work, and clearing away critical obstacles.
The second policy direction, the provision of financial support, is
likely to be particularly difficult to agree upon during a time when
federal deficits are skyrocketing and health care spending is also
about to balloon as the new Medicare prescription drug benefit comes on
line. It is also clear that there are many health care providers in
this country, including large integrated health care systems and
powerful, prestigious hospitals, that do not need any external
financial support to plug into the modern world of health IT.
Nevertheless, help is needed for the following specific groups:
1. Physicians in solo practice and small groups who still constitute 60
percent of practicing physicians in the U.S. These doctors
often do not have the expertise or the money to purchase,
learn, maintain and trouble-shoot new health IT systems.
Furthermore, even in organized health systems such as HMOs, the
adoption of IT systems reduces productivity in the short term
by 10 to 20 percent or more. For physicians in fee-for-service
practice, a 10 percent reduction in revenue is a high price to
pay for health IT at a time when their incomes are often
falling.
2. Many health care institutions serving disproportionate numbers of
indigent patients lack the capital to maintain their physical
plants, much less spend tens of millions of dollars to put in
place new IT systems. If we are not careful, populations served
by these institutions will fall further behind mainstream
America in the care that is available to them. Not only that,
but these institutions will fail to realize the efficiencies
that IT can bring in the long term.
The options for providing financial assistance to providers who
need it are several. They include revolving loans, grants, and
increased payments to providers who adopt IT systems with basic
capabilities. Whatever particular approach we take, we should be
prepared to invest significant resources over a long period of time.
The cost of implementing a 21st century health IT system in the U.S.
will be measured in billions of dollars, not millions. But I, for one,
believe it will pay off handsomely for patients, doctors, employers,
insurers and all the other key stakeholders in the American health care
system.
Mr. Chairman, thank you again for the opportunity to appear before
you today. I am happy to answer any questions you may have.
Mr. Bilirakis. Thank you so very much, Dr. Blumenthal.
Dr. Diamond?
STATEMENT OF CAROL DIAMOND
Ms. Diamond. Thank you, Mr. Chairman and other
distinguished--well, there are no other distinguished members
here. Thank you for having me here today. For the last few
years, I have had the privilege of Chairing the committee, the
Connecting for Health initiative, which is an initiative of the
Markle Foundation. We operate and fund Connecting for Health
and receive additional support from the Robert Wood Johnson
Foundation. Connecting for Health is really a truly unique
public-private collaborative. It involves over 100 leaders from
health care. They are broad-based and multi-stakeholder-based.
They include physicians, consumer organizations, privacy
advocates, the vendors of systems, hospital representatives,
employers, payers, accreditors and government agencies.
For the last few years, we have rallied around tackling
some of the barriers that stand in the way of information
technology being more widely adopted, and as we have heard many
times today, this is a vital agenda to improve health care
quality, reduce medical error and lower the costs, as well as
empower patients.
I am delighted to inform you on some of the progress that
we have made most recently. As you heard, momentum is growing,
and much good work is underway, but while progress has been
made, we have a lot to still accomplish. It is important to
keep in mind that the real difficulties that patients face
every day in an uncoordinated paper-based system are very
significant.
As our report describes, there is no more compelling
description of the gaps in information than the stories as
described by the patients themselves and their families who use
the health care system. Patients and families who know how
important their medical information is to receiving the best
possible care often feel like human medical records, carrying
around records for their children each time information for
life-changing decisions are made and each time treatment
decisions are being decided upon. They, of course, cannot be
expected to carry around their medical records, and we must do
better.
As I am sure the committee knows, modernizing the health
care system is fraught with challenges. They are technical,
financial and policy related. Many of these challenges do not
have easy answers, and the industry has grappled with many of
them for more than a decade. And I want to emphasize that
grappling with some of the challenges in IT is really the
reason, I think we heard multiple times today, that this has
been a very slow agenda. The call to action and the call for
the adoption of IT is at least a decade old, maybe more, and
yet it hasn't happened, and I think it has forced us to look
very carefully at what the barriers are.
Last week, we released a report, which we submitted here
too, called, ``A preliminary Road Map for Achieving Electronic
Connectivity.'' And the report grew from the impatience and the
desire of some of the Nation's most foremost health care
leaders to chart a path forward. Our report offers clarity
about how to efficiently create a decentralized standards-based
network that is effective for health care and effective for
patients. I want to emphasize that the path forward did not
start with agreement. We worked hard in the process to come out
with a series of recommendations and next steps that are near
term and specific.
The key recommendations represent agreement by our group as
well as the input of some of the best minds in the country on
health care and information technology. And they fall into
three categories. The first is creating a technical framework
for connectivity. We do not want silo'd information systems. In
order to provide a majority of their benefits, electronic
records must connect with other clinical systems--pharmacies,
laboratories, hospitals and other doctors. The potential to
avoid medical errors and drug interactions and to deliver real-
time prompts and reminders, both to patients and physicians,
depends on having a highly connected network that exchanges
data between clinical systems, such as personal health records.
Unless we pay attention to the requirements at the local,
regional and national level, it is unlikely that piecemeal
technology adoption will result in the connected network
necessary to realize the quality gains in health care, and it
has not to date.
This network requires connectivity that will arise from
trust, safeguards for privacy and security, a strategy that
minimizes risks of patient data misuse. We believe the approach
has to be built on the premise of patient control and
authorization. It must conform to a common set of open
standards for information flow and consist of a decentralized
network of networks that is built on the Internet. And we also
believe it can and should be done without a national health ID.
Second, we have some recommendations in the area of
financial barriers. As has just been stated, the current system
does not provide incentives for the investment in high-quality
health care that would be achieved through interoperable
information systems, and therefore incentives need to be
realigned. We think that the realignment of these incentives to
promote health care quality can only be achieved through the
adoption of applications that are capable of exchanging
information based on standards. Incentives should include IT
adoption with supportive interoperability among data sources
outside of the physician's office and with an emphasis on
interoperability. We think without this we will not achieve the
quality gains in health care.
I do want to emphasize that in the earlier discussion the
comment was made that IT can produce a better product, yet the
system we have is piecemeal and volume-based in its incentive
model, and therefore investing in systems that allow us to
reduce unnecessary doctor visits or that require us to spend a
lot of time looking for medical records are not in the interest
of the way the current incentive model works, and I think that
they do go unattended.
Finally, our recommendations are in the area of engaging
the American public. Our own research has found that members of
the public do not fully understand this problem that we are
trying to solve. While they understand the inefficiencies in
the system, they are not aware that information technology can
help to solve it. However, they are very interested in having
access to their medical record and being able to email their
physicians and being able to see their own medical records and
their laboratory tests online, from home. So we encourage the
path forward to include a set of strategies that engages the
public in this agenda. The electronic personal health record is
an essential tool for integrating the delivery of care and
putting each patient at the center of this model.
So while we do not offer a prescription for which
innovations will be most effective, we do know that most of
them cannot be realized without the rapid, accurate and secure
exchange of personal health information among authorized users.
And we believe that the greatest improvements in health care
leading to the most profound opportunities will occur when
Americans can access and control and see their medical records
in partnership with their care team. Thank you.
[The prepared statement of Carol Diamond follows:]
Prepared Statement of Carold Diamond, Managing Director, Markle
Foundation; Chair, Connecting for Health
Chairman Bilirakis, Congressman Brown and distinguished members of
the Subcommittee on Health, thank you for inviting me to meet with you
today.
For the last two years, I have had the privilege of chairing
Connecting for Health (see www.connectingforhealth.org), an initiative
established and operated by the Markle Foundation, with additional
funding and support from the Robert Wood Johnson Foundation. Connecting
for Health is committed to accelerating actions on a national basis to
tackle the barriers that prevent us from bringing healthcare into the
information age to improve the quality of healthcare, reduce medical
errors, lower costs and empower patients.
Connecting for Health is based on the belief that the development
of an interconnected health information infrastructure will depend upon
close cooperation between the public and private sectors in a way that
maximizes the benefits of their complementary expertise and experience.
Today, Connecting for Health is a truly unique public-private sector
initiative, consisting of over 100 broad-based stakeholders
representing providers, patients, payers, accreditors, government
agencies, researchers and healthcare information systems manufacturers
and vendors (see the appendix for the list of current Steering and
Working Group members). I am delighted to have this opportunity to
inform this Committee on progress made within the context of Connecting
for Health and on what we believe the conditions to be to accelerate
the adoption and use of Information Technology to improve the quality
of health care in the United States.
Momentum is growing . . .
Last year, this Committee showed true leadership by introducing
groundbreaking and innovative Health Information Technology initiatives
in the Medicare Modernization Act including a process to create
standards for electronic prescribing that physicians and pharmacists
can use; the development of a safe harbor in the Stark and Anti-
Kickback Acts that would allow hospitals to disseminate technology to
physicians; the authorization of various grants to accelerate e-
prescribing; the development of a chronic care improvement program that
will test disease management strategies and the call for the use of
monitoring technologies to exchange clinical information (among other
things).
In addition to the work in this Committee, other notable recent
developments include: the President's call for the creation of
electronic health records for all Americans in ten years; the
establishment by the Department of Health and Human Services of the
National Health Information Technology Coordinator and the appointment
of Dr. David Brailer to the position; the release announced by Dr.
Brailer of the report on the nation's first strategic framework to
develop electronic health records; the various legislative bills
proposed and introduced by Senator Ted Kennedy, Senator Hilary Rodham
Clinton and Representative Nancy Johnson, Senator Judd Gregg, among
others; and the creation of a ``21st Century Healthcare Caucus'' within
the House of Representatives focused on IT and Healthcare (of which
some members of this Committee are part of), all showing a bipartisan
recognition of the importance of addressing these issues promptly.
Furthermore, the Defense Department and the Veterans Administration
have been building and implementing very sophisticated health IT
systems. HHS agencies, including the CDC, CMS, AHRQ, the Health
Resources and Services Administration and others are conducting
demonstration projects, grant programs and other developmental
activities.
This momentum is a result of the growing understanding and
evidence, produced by various studies, groups and pilot projects, that
smart investments in health care information technology can rein in
costs, eliminate waste and improve patient safety and health care
quality
However, while progress has been made, we have not yet accomplished
all that we need to. It is important to keep in mind the real and
constant difficulties patients face in today's uncoordinated, paper-
based system. Every one of us is touched by the U.S. health system--
from before birth until death. During our lives, we experience both
predictable and unpredictable needs for health care assistance. Every
time we encounter the healthcare system, information about our
background, medical history, health status, and insurance are
immediately required. And every medical encounter produces its own
trail of documentation.
The stakes are high . . .
There are hundreds of millions of doctor office visits alone every
year in the United States. A complex patchwork of healthcare
practitioners and payers process information for each one of those
visits. The records are either on paper or in separate computer systems
that typically have limited, if any, ability to exchange data
electronically (except for purposes of reimbursement). In all those
files of paper and streams of data, no one has a bigger stake in the
information from a particular clinical encounter than the patient who
needed it. And, in nearly all circumstances, no one in the system can
know more about the patient's life than that patient. Health
professionals have no way of accessing all of the important information
about our health, and we have no way of compiling and managing the
information about ourselves.
In our fragmented and pluralistic delivery system, the electronic
personal health record is an essential tool for integrating the
delivery of health care and putting each patient at the center of their
care. It can support the shift from episodic and acute care toward
continuous healing relationships with physicians and healthcare
professionals. It represents a transition from a patient record that is
physician-centered, retrospective and incomplete to one that is
patient-centered, prospective, interactive and complete.
Throughout the course of our work a number of individuals have
agreed to share their stories with us, and in our attempt to bring the
private and public sectors together we have explored the deficiencies
of our paper-based healthcare system through these real-life stories (a
selection of testimonies is available at our website,
www.connectingforhealth.org). For instance, a Michigan father and his
young daughter, who has a rare and complicated leukemia, told us about
the pile of files he has to carry every time he joins his daughter to
see a specialist, fearing that she would not get the best care without
every clinician understanding the complexities of her disease or
knowing what worked best for her in the past. His story is supplemented
by the stories of other patients who went out of their way to have
access to their medical information, and use it to receive the best
possible care for themselves and their families. These stories remind
us how patients and their families struggle to overcome preventable
information gaps in healthcare each and every day. They have made us
even more determined to break open the logjam blocking the flow of
vital healthcare information, which is required to improve healthcare
quality, safety, and efficiency.
Connecting for Health's Preliminary Roadmap
Since its creation, Connecting for Health has demonstrated that
blending together the knowledge and experience of the public and
private sectors can provide a highly effective formula for progress.
Early in its inception, Connecting for Health led the national debate
on electronic clinical data standards. The group drove consensus on the
adoption of an initial set of standards, developed case studies on
privacy and security, and helped define the electronic personal health
record.
While we do not offer a prescription for which innovations in care
will be most effective in improving healthcare quality or reducing
medical error, we do know that most of them cannot be realized without
the rapid, accurate, and secure exchange of personal health information
among authorized users. And we believe that the greatest improvements
in healthcare--leading to the most profound opportunities for better
health--will occur when each American can access, control, and make use
of their own health information in partnership with their care team.
Just last week, Connecting for Health released its second report: a
Preliminary Roadmap for Achieving Electronic Connectivity in Healthcare
(available at http://www.connectingforhealth.org/resources/
cfh_roadmap_final_0714.pdf). The report aims to facilitate broad
agreement on a set of immediate actions that can be taken by all
healthcare stakeholders over the next several years in order to
efficiently create a decentralized and standards-based network that is
effective for healthcare and patients.
Our report is meant to build a realistic path forward and we do not
call for whole-scale revision to the current system. Such an approach
would be dangerously disruptive and prohibitively expensive. Instead we
have brought a diverse group of stakeholders together to offer an
incremental path forward that builds on two important concepts.
First, we accept, with appreciation, the good work already done in
developing specific electronic health record (EHR) and personal health
record (PHR) applications. Medication management tools are offered by
pharmacies and pharmacy benefit managers; chronic disease tools are
optimized for congestive heart failure or diabetes sufferers; secure e-
mail and results reporting systems are being integrated with both
hospital and ambulatory EHRs. Connecting for Health does not say that
one approach is right and another wrong, but that the national
infrastructure must support and accommodate connectivity among all of
these--and that they must all conform to a small set of common
principles, including use of an agreed upon set of standards. This goal
manifests in our recommendation for creating a technical framework that
is required to take our fragmented healthcare system and make
investments that can lead to a more integrated, high quality patient
care experience.
Second, the model we envision allows individuals and their
authorized health professionals to construct the health record
appropriate to their needs exactly when and how it is needed. The most
innovative aspect the Preliminary Roadmap is the recommendations on how
to develop a national health infrastructure through the creation of a
``network of networks,'' based on open standards, which can be created
without a central database of health records or a National Health ID--
both long-time barriers that have prevented bringing the benefits of
information technology to the field of healthcare.
In order to be accepted by patients and providers, the network must
safeguard the privacy of health information. Among the important
implications of our proposed system for a network of networks, is that
personal health information would continue to reside where it does now,
primarily with hospitals and healthcare providers. According to the
patient's preferences, relevant health data could be assembled from
numerous sources at the point of care, enabling decision making to be
informed by past treatment successes and failures and medication
history. Both the patient and the clinician could have direct access to
this vital information.
The secure and confidential treatment of patient information is a
fundamental design criterion of the health information infrastructure
we endorse. We recommend the inclusion of architectural, technical, and
policy safeguards within the ``Common Framework,'' to safeguard the
privacy and security of patient data while at the same time permitting
the rapid and accurate exchange of information among authorized users.
Proposed steps for safeguarding privacy and security are embedded in
the fabric of all of the Preliminary Roadmap recommendation areas.
Information about an individual's health is usually stored in many
different places by a variety of healthcare providers. According to the
system we propose, information would be accessible only to authorized
users and aggregated at the individual patient level when and where it
is needed. This would preclude the need to create large central stores
of information.
Regardless, a set of standards and secure networks would allow
information such as lab results, x-rays and medical history as well as
clinical guidelines, drug labeling and current research findings to
move where it is needed, immediately and securely. Regardless of where
a beneficiary is receiving care, health information exchange networks
would allow for information about medication history and potentially
serious drug interactions to be available in real-time, along with out
of pocket costs and therapeutic alternatives, before the physician
transmits a prescription to a pharmacy.
Key Recommendations
The key recommendations fall into three broad categories:
<bullet> Creating a Technical Framework for Connectivity: A non-proprietary
``network of networks'' built on the Internet is essential to
support the rapid acceleration of electronic connectivity that
will enable the flow of information to support patient care.
Such a network should be based on a ``Common Framework.'' Only
by conforming to a ``Common Framework'' can we ensure that data
exchange pilots, personal health records, and regional systems
will be able to interoperate across and with other regional
systems. The network should be decentralized, based on
interoperable standards, define standards for secure Internet
transport, safeguard patient privacy and be built
incrementally, without the use of a unique National Health ID
or a centralized database of records.
<bullet> Addressing Financial Barriers: The current system does not provide
incentives for the investment in high-quality healthcare
achieved through interoperable information systems, and
therefore incentives need to be redirected. Financial and other
incentives and related processes must be designed to promote
improvements in healthcare quality through the adoption of
clinical applications and information exchange based on
standards.
<bullet> Engaging the American Public: The public must be informed with a
consistent set of messages to be used by government,
healthcare, and consumer leaders to promote how patients can
improve their own health and healthcare through the benefits of
electronic connectivity and to encourage patients and consumers
to access their own health information.
1. Creating a Technical Framework for Connectivity
In order to provide a majority of their benefits, clinical
applications must interconnect with other clinical systems. The
potential to avoid medical errors and drug interactions, to deliver
real-time prompts and reminders at the point of care and directly to
the patient or caregiver, and to improve the ability to conduct
clinical research depend on a highly connected network of regional
healthcare communities that exchange data between effectively used
clinical systems such as personal health records.
Unless there is purposeful attention paid to infrastructure
requirements at the local, regional and national level, it is unlikely
that piecemeal technology adoption will result in the connected
infrastructure necessary to realize the quality of care and economic
efficiency gains promised by IT. The network requires a high degree of
connectivity that arises from trust, safeguards for privacy and
security and a strategy that minimizes risks of patient data misuse.
With that said, the approach must be voluntary and built on the premise
of patient control and authorization.
In order to accelerate electronic connectivity, a non-proprietary
``network of networks'' built on the Internet that is based on
standards and a decentralized and federated architecture should be
developed, building upon local and regional networks. In addition, our
proposed network is designed to be flexible to accommodate the various
electronic health record (EHR) and personal health record (PHR) models
that are already being developed. And in order to support the creation
of the network where national standards are implemented locally and
regionally, we have determined that a ``Common Framework'' is needed.
This ``Common Framework'' is comprised of standards, policies and
methodologies that can be replicated quickly to ensure connectivity,
reliable authentication; it would also include a minimum suite of
standards that work together to support information exchange. We
recommend that the common framework be tested and evaluated through a
``reference implementation or pilot project'' within the next 12
months. Because our incremental approach is designed to leverage
existing infrastructure, it dictates that secure connectivity be built
on the Internet and its communication protocols.
2. Addressing Financial Barriers
Among the most often cited barriers to the adoption of information
technology in healthcare are misaligned financial incentives. Because
of the way the payment system is structured, for many providers,
especially in the small practice primary care setting, the acquisition
or use of IT results in a net financial loss. Ambulatory care practices
are on the front line for the treatment of patients in the United
States today, specifically the chronically ill, yet have the lowest
adoption rates of healthcare IT. One of the main reasons physicians and
hospitals are not adopting clinical information technology at a rapid
rate is due to the poor financial case. Despite these financial
barriers, however, the promise of EHRs and other clinical information
technology remain formidable. As several studies have shown, EHRs can
advance the quality and efficiency of care, resulting in reduced
medical errors, reduced utilization, and improved ability to manage
chronic disease, the improved longevity and health status, among other
potential benefits.
This gap between the potential of clinical information technology
and the willingness to adopt these technologies raises the question of
whether the market appropriately supports technology purchasers in
society's efforts to realize value.
We recommend that incentives for IT--including applications,
electronic connectivity and information exchange--include the
requirement of use of standards and interoperability, since the
majority of the benefits of IT accrue only when systems can talk to
each other. Failure to encourage interoperability could lead to the
growth of technologically sophisticated islands or silos of
information, which would decrease the potential value of the investment
in IT dramatically.
Our recommendations include the results of our insights regarding
the level of incentives that would require ``tilt'' or cause
significant change in the number of small and ambulatory private
practices that begin to adopt electronic health records as a result.
3. Engaging the American Public
Our own research found that most members of the public do not fully
understand the problem we are trying to solve. Many are unaware, except
for a general perception that costs are high, of the inadequacy of our
healthcare system, and the high volume of medical errors. In addition,
the majority of Americans assume that their doctors use information
technology far more than is actually the case. In fact, according to
our own survey, more than half believe their own doctors are far more
``wired'' than is actually the case. Given these gaps in knowledge, it
is not surprising that most people have not thought about how better
use of technology within the system might improve healthcare quality.
Our research further shows that most patients or consumers have not
fully conceived how they could benefit from their own access to and
control of personal health information. This is in part because
patients are in general used to being somewhat peripheral players in
the traditional pattern of care. Many assume that their care is
primarily the responsibility of the professionals. However, our
research indicates that the vast majority of patients, when presented
with a description of services that would enable them to participate
more fully and conveniently in self-care, such as the ability to view
test results or e-mail doctors directly, show a significant level of
interest. We believe that it is essential to increase public awareness
of the avoidable problems with healthcare delivery and of the potential
of technology, and therefore recommend a large public education effort
towards that end.
In order to support implementation of its recommendations,
Connecting for Health will release a final version of the Roadmap and
detailed reports by individual Working Groups that contributed to it by
September. The final Roadmap will provide additional detailed
recommendations for action and commitments from Connecting for Health's
Steering Group members, and I would be delighted to share these with
the members of this Committee in due course.
Finally: Robert Frost famously finished his poem, ``The Road Not
Taken,'' by writing that he chose the road ``less traveled by,/And that
has made all the difference.'' We believe that the Connecting for
Health Collaborative is, in its own way, also on a journey. We invite
all stakeholders in healthcare to examine the choices presented in this
Preliminary Roadmap and then join with us, on behalf of those whose
lives and health are at stake, in finding those paths that will make
the greatest positive difference.
The steps forward described in the Connecting for Health
Preliminary Roadmap will permit such innovations in care and patient
engagement to occur. We believe that they will allow clinicians,
entrepreneurs, and families to develop new and better ways to deliver
services, to monitor health, and to manage care. They will also enhance
the quality of research and public health. A system that provides an
abundance of complete, reliable information to the point of care--and
to the home--can reduce waste, error, and frustration while improving
diagnostic accuracy, the quality of communications, and even the
ability of family members to care for each other.
Thank you. I will be pleased to try to answer any questions members
may wish to ask.
Appendix : Connecting for Health, Steering Group Participants
steering group leaders
Carol Diamond, MD, MPH, Managing Director, Health, Markle
Foundation; Daniel Garrett, Vice President and Managing Director of
Computer Sciences Corporation's Global Health Solutions Practice; John
R. Lumpkin, MD, MPH, Senior Vice President, Robert Wood Johnson
Foundation and Chair, National Committee on Vital and Health
Statistics; Janet M. Marchibroda, Executive Officer of the eHealth
Initiative and the Foundation for eHealth Initiative; and Herbert
Pardes, MD, President and CEO, New York-Presbyterian Hospital
steering group members
James Bradley, Chief Executive Officer, RxHub; Claire Broome, MD,
Sr. Advisor, Integrated Health Information Systems, Centers for Disease
Control and Prevention; Gwendolyn A. Brown, Director, Healthcare
Policy, EDS, Global Government Affairs; Nancy Brown, Senior Vice
President of Strategic Planning, McKesson Corporation; Garry Carneal,
President and Chief Executive Officer, URAC; Gary Christopherson,
Senior Advisor to the Under Secretary, Veterans Health Administration,
Department of Veterans Affairs; Carolyn Clancy, MD, Director, Agency
for Healthcare Research and Quality; Nathaniel Clarke, MD, Medical
Director, American Diabetes Association; Richard A. Correll, President,
College of Healthcare Information Management Executives; Janet
Corrigan, PhD, Division Director, Institute of Medicine; Molly J. Coye,
MD, MPH, Chief Executive Officer and Founder, Health Technology Center;
Kelly Cronin, Executive Director, Council on the Application of Health
Information Technology, Department of Health and Human Services; Mike
Cummins, Chief Information Officer, VHA Inc.; Francois de Brantes,
Program Leader, Healthcare Initiatives, General Electric Corporation;
Mary Jo Deering, PhD, Special Expert for Informatics Dissemination and
Coordination, U. S. Department of Health and Human Services; Carol
Diamond, MD, MPH, Managing Director, Health, Markle Foundation; Robert
Dickler, Sr. VP Division of Healthcare Affairs, Association of American
Medical Colleges; Craig Fuller, Chief Executive Officer, National
Association Of Chain Drug Stores; Daniel Garrett, Vice President,
Managing Partner, Global Healthcare Leader, Computer Sciences
Corporation; Peter Geerlofs, MD, Chief Medical Officer, Allscripts
Healthcare Solutions; John Glaser, PhD, Vice President and Chief
Information Officer, Partners Healthcare System, Chair, Working Group
on Financial, Organizational and Legal Sustainability; Paul Gorup, Vice
President and Co-Founder, Cerner Corporation; John Halamka, MD, Chief
Information Officer, CareGroup Healthcare System; Chief Information
Officer, Harvard Medical School; W. Edward Hammond, PhD, Professor,
Community and Family Medicine Duke University; Linda Harris, PhD,
Senior Health Communication Scientist, National Cancer Institute; C.
Martin Harris, MD, Chief Information Officer, Cleveland Clinic; Douglas
Henley, MD, Executive Vice President, American Academy of Family
Physicians; Joseph Heyman, MD, Trustee, American Medical Association,
American Medical Association; Yin Ho, MD, Director eBusiness, Pfizer,
Inc; Kevin Hutchinson, Chief Executive Officer, SureScripts; Michael
Jackman, Chief Technology Officer Health Imaging Group, Eastman Kodak
Company; William F. Jessee, MD, President and Chief Executive Officer
Medical Group Management Association; Brian Keaton, MD, FACEP,
Attending Physician/EM Informatics Director and Summa Health System,
Board Member, American College of Emergency Physicians; Kenneth W.
Kizer, MD, MPH, President and Chief Executive Officer, National Quality
Forum; Linda Kloss, Executive Vice President and Chief Executive
Officer American Health Information Management Association; David
Lansky, PhD, President, Foundation for Accountability; Chair, Working
Group on Policies for Electronic Information Sharing Between Doctors
and Patients; Mark Leavitt, MD, PhD, FHIMSS, Medical Director and
Director of Ambulatory Care, Health Care Information and Management
Systems Society; Randy Levin, MD, Associate Director for Electronic
Submissions Food and Drug Administration; Jack Lewin, MD, President,
California Medical Association; Stephen Lieber, President, Healthcare
Information and Management Systems Society; Donald Lindberg, MD,
Director, National Library of Medicine; John R. Lumpkin, MD, MPH, Sr.
Vice President, Director, Healthcare Group, Robert Wood Johnson
Foundation and Chair, National Committee Vital and Health Statistics;
Janet M. Marchibroda, Executive Director, Foundation for eHealth
Initiative; Chief Executive Officer, eHealth Initiative; Clement
McDonald, MD, Director of Regenstrief Institute; Distinguished
Professor of Medicine, Indiana University School of Medicine; Arnold
Milstein, MD, MPH, Medical Director, Pacific Business Group on Health,
The Leapfrog Group; Thomas Murray, PhD, President, The Hastings Center;
Margaret O'Kane, President, National Committee for Quality Assurance;
Dennis S. O'Leary, MD, President, Joint Commission on Accreditation of
Healthcare Organizations; J. Marc Overhage, MD, PhD, Associate
Professor of Medicine, Indiana University of Medicine Senior
Investigator, Regenstrief Institute; Herbert Pardes, MD, Chief
Executive Officer, New York-Presbyterian Hospitals, University
Hospitals of Columbia and Cornell; James Reardon, Chief Information
Officer, Tricare Management Activity, Department of Defense; Russell J.
Ricci, MD, Chief Medical and Strategy Officer, HealthSTAR
Communications; Craig Richardson, Vice President Health Care
Connectivity and Alliances, Johnson & Johnson Pharmaceutical Services;
Wes Rishel, Vice President, Gartner Research; William Rollow, MD,
Deputy Director, Quality Improvement Group Office of Clinical Standards
and Quality Centers for Medicare and Medicaid Services; James Schuping,
Vice President, Workgroup for Electronic Data Interchange; Clay Shirky,
Adjunct Professor, NYU Interactive Telecommunications Program, Chair,
Working Group on Accurately Linking Health Information; Steve Skerry ,
Vice President Interoperability, IDX Systems Corporation; Steve Sleigh,
PhD, Director Strategic Resources, International Association of Machine
and Aerospace Workers; Ellen Stovall, President, National Coalition for
Cancer Survivorship; Thomas Sullivan, MD, Past President, Massachusetts
Medical Society, Women's Health Center Cardiology; Paul Tang, MD, Chief
Medical Information Officer, Palo Alto Medical Foundation; Robin
Thomashauer, Executive Director, Council for Affordable Quality
Healthcare; John Tooker, MD, MBA, FACP, Executive Vice President
American College of Physicians; Scott Wallace, President and Chief
Executive Officer, The National Alliance for Health Information
Technology; Andrew Wiesenthal, MD, Associate Executive Director, The
Permanente Federation; Robert B. Williams, MD, MIS, Partner Healthcare,
IBM Business Consulting Services; William Yasnoff, MD, PhD, Senior
Advisor, National Health Information Infrastructure Department of
Health and Human Services, Office of Assistant Secretary for Planning
and Evaluation; and Jon Zimmerman, Vice President, Health Connections,
Siemens Health Services
Mr. Bilirakis. Thank you, Doctor. Doctor Shortliffe,
please. Is that correct? Am I----
Mr. Shortliffe. Yes.
Mr. Bilirakis. Shortliffe.
STATEMENT OF EDWARD H. SHORTLIFFE
Mr. Shortliffe. Thank you very much. I come to you both as
a physician who has taught and practiced in academic hospitals
and clinics and as a biomedical computer scientist with
extensive experience in the design and the development and the
implementation of clinical information systems. So I really do
bridge these two fields we are talking about today, as does Dr.
Kolodner.
Those of us who have worked with health care information
technology are really pleased by the recent attention, such as
today's hearings, that have been directed at this topic, and
Secretary Thompson's enthusiasm. The unfulfilled promise of
information technology in support of health and health care has
been really clear to some of us for many years, more years,
maybe even more than 10 that Dr. Diamond mentioned. Some of us
have been doing this 30 years and have felt strongly about this
subject that long. And we have been dismayed to see a widening
gap, if anything, between the implementation of information
technology solutions to pressing problems in other segments of
society when you contrast that with their limited penetration
in health care settings.
On the other hand, a variety of factors have recently
combined to heighten our awareness of what is possible and of
the need for active intervention and promotion of solutions.
And I know I speak for others in the health care computing
community when I say that we are grateful for the recognition
recently and we are eager to help in any way that we can.
Seldom have I seen more consensus on the need for action and
the promise that awaits us if we do this right. But, as always,
the devil is in the details, and that is the challenge faced by
all groups with a stake in enhancing the use of information
technology in health care, including the Congress as it
considers the role that it might play.
Now, there are so many things one could talk about, and in
my brief time I guessed what my colleagues would say since I
knew I was coming last and we in this small community do know
each other well. So I decided that I would highlight for you
the perspective of the individual physician who practices in
this country. I recognize that they are an important element in
any solution that we propose but that their ability to
participate effectively is highly constrained. So I am going to
put on a physician's hat for a moment, set aside my activist
interests as a health computing professional, and I believe
that there are a variety of important issues that really need
to be understood and considered in formulating any incentive
programs or implementation plans for health care IT.
And by way of anecdote, I, as a health computer scientist
working on a medical school faculty, scratched my head for many
years trying to understand how it was that I could be working
on the cutting edge of research on health care computing for 70
or 80 percent of my time and then for the other 20 percent
enjoined to the clinic or to the in-patient hospital wards of
one of the best hospitals in the United States where the
computing support was vastly different from what I knew was
possible and what I had available to me in my research
laboratory, trying to understand this disconnect and why it was
so hard to bring what was possible into settings such as that.
Well, first, bear in the mind that the vast majority of
health care in this country is provided by physicians in
ambulatory settings and most commonly in relatively small
offices, not in medical schools and VA hospitals. Our view of
what is needed cannot be overly skewed by the perspectives of
those who practice in large multispecialty practices or in
clinics associated with academic medical centers. Although
well-implemented IT in a single institution can provide major
quality and cost benefits for that entity, as it has for the VA
as a whole, it is in the integrated penetration of health care
IT throughout essentially all practice settings that the
Nation's health stands to gain the most.
And this means creating an infrastructure, both regional
and national, into which all practice settings can tie, but
also helping the individual practices that need to tie into
that infrastructure to make wise decisions and investments.
Now, I believe it is really too easy to simply say that
physicians are resistant to change or overly committed to
antiquated approaches to data management. We see many examples,
in fact, where clinicians have embraced new technologies rather
quickly. But information technology presents some special
problems for practitioners.
It is not their way of expertise, and they are really
uncertain how to evaluate the options that are provided to
them. It is not a part of their education. That is something we
could address. And it seems foreign to the major thrust of
their professional interests. System implementations are often
disruptive to operations, at least in transition, and too often
the physicians find that major investments have resulted in
inadequate system solutions that fail to meet their
expectations, they integrate poorly with the other systems they
happen to have in their offices, they are difficult to adapt to
the special needs of a particular practice.
Many physicians tell me that they have no innate objection
to electronic medical records, the decision support software or
other aspects of office automation, but they don't know where
to start and they are not sure they can justify the expense
with the benefits that are gained by them. There is no
certification process, for example, although the Secretary
addressed this issue, that allows them to be sure that a
product that is offered is compliant with the emerging national
standards for connectivity, for data storage and exchange, for
privacy and for security. Indeed, such standards are still
evolving, and there is as yet no coherent and well accepted
process for bringing such standards to a broad consensus that
allows all stakeholders to adopt and comply with them.
Consultants often seem as confused, frankly, by the options
as the physicians are. This is not an area where you can just
get a consultant and expect to have a good result. There are
expensive failures of recommended systems that are legendary,
and it is small wonder that clinicians are looking elsewhere
for assistance.
In addition, the arguments for implementation of health
care IT are too often viewed by clinicians as being primarily
directed at health systems and payers and patients with much
less direct benefit appreciated by the physicians themselves.
They understandably ask why in a financial environment that is
characterized by significant regulatory and reimbursement
challenges for physicians in practice that doctors should be
asked to invest in medical records systems whose primary
systemic beneficiaries are elsewhere than in their offices.
This misalignment of fiscal incentives is often cited as a
major barrier to widespread dissemination of information
technology in the practice settings where, ironically, the
primary data are being gathered and where decision support
capabilities could most beneficially be utilized.
Solutions need to recognize that physician offices are not
only sources of key information that we want centrally--the
payers, the health policy makers, the researchers, the large
institutions--but that those offices are vitally important
users of information, that a robust information infrastructure
could be delivering back to them directly to their practice
settings rural, suburban, inner city, academic, across all that
spectrum. When physicians experience clear benefits from their
IT investments and see efficiencies and cost savings as well as
enhancements to information access, then a major barrier to
suitable investments will have been overcome.
The problems being discussed today and the exciting
opportunities that will accompany their solution are clearly
much broader than the single issue of how best to distribute
information technologies in individual practices. I mean
hospitals and other topics are equally as important. Yet when
we focus on physicians, I believe there are several steps that
Federal agencies could take in facilitating solutions to the
issues I have identified, and many of these in fact were
addressed in Secretary Thompson's remarks.
First, there has to be a suitable alignment of the
financial incentives so that those who most benefit from the
investment in health care IT are the ones who are expected to
invest most heavily in its dissemination and implementation.
Second, federally facilitated programs to enhance the process
for setting and adopting standards, which needs to be a shared
public-private effort, are sorely needed. And this too was
addressed in yesterday's summit. Third, a mechanism for
assuring rigorous certification of vendor-provided solutions is
required so that the individual purchasers, these doctors in
offices, for example, can be assured that a given product is
compliant with the emerging requirements of a national health
information infrastructure. And, fourth, we have to recognize
that expertise in health care information technology is more
than expertise in information technology itself. And many of
the people who build the systems that are used by doctors today
are experts in information technology but know nothing about
the culture and the practice of medicine or are brought to it
as a secondary activity much later in their careers.
So there is an important unique discipline at the
intersection of health care and computer systems, and we need
to nurture the training of experts who can be the researchers
and the designers and the developers and the implementers and
the evaluators of health information technology in the future.
So I am pleased to have had an opportunity to share some of
these thoughts with you today, and I am sure I and all the
others on the panel would be happy to answer any questions you
have.
[The prepared statement of Edward H. Shortliffe follows:]
Prepared Statement of Edward H. Shortliffe, Deputy Vice President for
Strategic Information Resources, Professor and Chair, Department of
Biomedical Informatics, Professor of Medicine and of Computer Science,
Director of Medical Informatics Services, NewYork-Presbyterian
Hospital, Columbia University Medical Center
I would like to thank Chairman Bilirakis, Representatives Barton
and Dingell, and the other members of the Subcommittee on Health for
this opportunity to address you regarding Health Information Technology
and the role that the federal government can play in facilitating its
efficient and effective deployment in this country. I come to you both
as a physician who has taught and practiced in academic hospitals and
clinics and as a biomedical computer scientist with extensive
experience in the design, development, and implementation of clinical
information systems. A fellow of the American College of Medical
Informatics, I have served on the Board of Regents of the American
College of Physicians and on a variety of government advisory groups,
including the President's Information Technology Advisory Committee and
the National Committee for Vital and Health Statistics. After spending
30 years at Stanford University, I currently am at Columbia
University's medical school where I chair a department of biomedical
informatics. Our faculty members have built, and continue to be
responsible for, the management of a variety of successful and heavily
used clinical systems at the NewYork Presbyterian Hospital.
Those of us who have worked with health care information technology
are pleased by the recent attention that has been directed at this
topic, both within government and in the private sector. The
unfulfilled promise of information technology in support of health and
health care has been clear to some of us for many years, and those in
the field have often been dismayed to see a widening gap between the
implementation of information technology solutions to pressing problems
in other segments of society contrasted with their limited penetration
into health care settings. On the other hand, a variety of factors have
recently combined to heighten our awareness of what is possible and of
the need for active intervention and promotion of solutions. I know I
speak for others in the health care computing community when I say that
we are grateful for that recognition and eager to help in any way that
we can.
As I reflect on the past five years, I see a number of forces that
have come together to create the current enthusiasm for health
information technology solutions. Simply stated, these are safety and
quality, costs, and privacy. Although the health care community has
long been concerned with all three of these issues, certain recent
landmarks events greatly broadened our awareness of their dependence on
information technology solutions:
<bullet> A series of three influential reports from the Institute of Medicine
(``To Err is Human,'' ``Crossing the Quality Chasm,'' and
``Patient Safety: Achieving a New Standard of Care''), all of
which made strong cases for the role of IT in addressing
problems with medical errors and enhancing patient safety
<bullet> Federal advisory activities, including seminal contributions from the
Workgroup on the Health Information Infrastructure from the
National Committee on Vital and Health Statistics (NCVHS) and
two important sets of recommendations (first in 2001, then
again this year) from the subcommittees on health within the
President's Information Technology Advisory Committee (PITAC)
<bullet> Employer concerns regarding the burgeoning costs of health care,
leading to the creation of the Leapfrog Group and its active
promotion of more effective implementation and use of
information technology in health care settings
<bullet> The privacy, security, and transaction rules that were announced by
DHHS in response to the requirements of the 1996 Health
Insurance Portability and Accountability Act (HIPAA) and that
in many respects require informed technological solutions in
order to be compliant
<bullet> The influence of the Internet and the World Wide Web, which has
greatly increased the access to health information by the
public and transformed their familiarity with, and expectations
of, health information technology in the settings where they
seek care.
The list could be much longer, and would certainly include the
large number of recent reports, from a variety of public and private
sources, that reiterate and refine the recommendations that have come
before. Seldom have I seen more consensus on the need for action and
the promise that awaits us if we do this right.
But, as always, the devil is in the details, and that is the
challenge faced by all groups with a stake in enhancing the use of
information technology in health care: Dr. Brailer in his new role as
National Health Information Technology Coordinator, hospitals and other
provider organizations, payers, and individual health professionals. I
realize that the Congress is particularly concerned with what role the
federal government can and should play in encouraging more effective
and efficient implementation and use of the technologies that we
discuss today. My colleagues on this panel will have addressed this
issue in some detail, illuminating for you both the promise and the
challenges that face us and the opportunities for effective federal and
other governmental action.
I would like to highlight the perspective of the individual
physician who practices in this country, recognizing that they are an
important element in any solution that we propose but that their
ability to participate effectively is highly constrained. If I may,
then, don my physician's hat for a moment, setting aside my activist
interests as a health computing professional, I believe that there a
variety of important issues that need to be understood and considered
in formulating any incentive programs or implementation plans for
health care IT. Recommendations for federal action follow in part from
these observations.
First bear in mind that the vast majority of health care in this
country is provided by physicians in ambulatory settings, and most
commonly in relatively small offices. Our view of what is needed cannot
be overly skewed by the perspectives of those who practice in large,
multispecialty practices or in clinics associated with academic medical
centers. Although well implemented IT in a single institution can
provide major quality and cost benefits for that entity, it is in the
integrated penetration of health care IT throughout essentially all
practice settings that the nation's health stands to gain the most.
This means creating an infrastructure, both regional and national, into
which all practice settings can tie, but also helping the individual
practices to make wise decisions and investments.
Viewed from the perspective of a clinician in a small office, the
issues we discuss today are overwhelming in many respects. It is too
easy to say that physicians are simply resistant to change or overly
committed to antiquated approaches to data management. We see many
examples, in fact, where clinicians have embraced new technologies
rather quickly. But information technology presents some special
problems for practitioners. It is not their area of expertise, and they
are uncertain how to evaluate the options that are provided to them. It
is not a part of their education, and seems foreign to the major
thrusts of their professional interests. System implementations are
often disruptive to office operations, at least in transition, and too
often physicians find that major investments have resulted in
inadequate systems solutions that fail to meet expectations, integrate
poorly with other systems, or are difficult to adapt to the special
needs of a particular practice.
Physicians need help in making informed choices and in dealing with
the logistical and financial hurdles that have until now often made it
unattractive for them to invest in IT solutions. Many physicians tell
me that they have no innate objection to electronic medical records,
decision support technologies, or other aspects of office automation,
but they do not know where to start and are not sure that they can
justify the expense for the benefits gained. There is no certification
process that allows them to be sure that a product that is offered is
compliant with emerging national standards for connectivity, data
storage and exchange, privacy, and security. Indeed, such standards are
still evolving and there is as yet no coherent and well-accepted
process for bringing such standards to a broad consensus that allows
all stakeholders to adopt and comply with them. Consultants often seem
as confused by the options as the physicians are, and the expensive
failures of ``recommended systems'' are legendary. It is small wonder
that clinicians are looking elsewhere for assistance.
In addition, the arguments for implementation of health care IT are
too often viewed by clinicians as being primarily directed at health
systems, payers, and patients, with much less direct benefit
appreciated by the physicians themselves. They understandably ask why,
in a financial environment characterized by significant regulatory and
reimbursement challenges for physicians in practice, the doctor should
be asked to invest in medical record systems whose primary systemic
beneficiaries are elsewhere. This misalignment of fiscal incentives is
often cited as a major barrier to widespread dissemination of
information technology into the practice settings where, ironically,
the primary data are gathered and where decision-support capabilities
could most beneficially be utilized. Solutions need to recognize that
physician offices are not only sources of key information (required by
payers, health policy makers, researchers, and large institutions), but
also vitally important users of information that a robust information
infrastructure could be delivering directly to their practice
settings--rural, suburban, inner-city, or academic. When physicians
experience clear benefits from their IT investments, and see
efficiencies and cost savings as well as enhancements to information
access, a major barrier to suitable investments will have been
overcome.
The problems being discussed today, and the exciting opportunities
that will accompany their solution, are clearly much broader than the
single issue of how best to distribute information technologies into
individual practice settings. Yet there are several steps that federal
agencies could take in facilitating solutions to the issues I have
identified.
First, there must be a suitable alignment of financial incentives
so that those who most benefit from the investment in health care IT
are the ones who are expected to invest most heavily in its
dissemination and implementation.
Second, federally facilitated programs to enhance the process for
setting and adopting standards (a shared public-private effort) are
sorely needed.
Third, a mechanism for assuring rigorous certification of vendor-
provided solutions is required so that individual purchasers can be
assured that a given product is compliant with the emerging
requirements of a National Health Information Infrastructure.
Fourth, we must recognize that expertise in health care information
technology is more than expertise in information technology itself.
There is an important, unique discipline at the intersection of health
care and computer systems, and we need to nurture the training of
experts who can be the researchers, designers, developers,
implementers, and evaluators of health information technology in the
future. Short-term programs to enhance the production of such
individuals are needed, as well as increased support for academic
training programs and well-defined career pathways. The National
Library of Medicine has been a leader in this area, but its resources
for training are limited and the nation's need far exceeds the ability
of current NLM programs to produce the people who can provide the
leadership we need in this burgeoning area.
Members of the subcommittee, I am pleased to have had a chance to
share some of these thoughts with you today and welcome the opportunity
to answer any questions you may have regarding my testimony.
Mr. Bilirakis. Thank you very much, Doctor. We have been
joined by Joe Barton, the chairman of the full committee. He
has to cover all of the committee hearings and what not, as
well as other things, so it is a real compliment to this
subject, quite frankly, that he is even willing to sit in on a
few minutes of it. Joe, I am going to yield to you at this
point and see----
Chairman Barton. Mr. Chairman, I am not going to have any
formal questions. I have actually read the testimony, I read
the staff memo. I appreciate the Secretary of HHS appearing on
the panel before these gentlemen. I appreciate all you folks
are doing. It is obvious that there is a lot to be done and a
lot of money that can be saved, and while it is not in the
testimony, it is obvious that there is quite a bit of
institutional opposition to it by groups out in the country
that for whatever reason oppose some of the initiatives that
are being put forward.
So this is something that we are going to work on certainly
in the next Congress. I doubt we will be able to implement much
in this Congress, but Chairman Bilirakis has got a passion for
this, and it is a passion that is going to be rewarded
hopefully in the next Congress. So I appreciate you all being
here.
Mr. Bilirakis. Thank you.
Chairman Barton. With that, Mr. Chairman, I am going to
yield back.
Mr. Bilirakis. Well, thank you, Mr. Chairman. You know, we
have found out that there is a lot of money that can be saved,
but I think we have also found out that with better
incentives--with better efficiency that would be available as a
result of doing something like this, we would save an awful lot
of lives. I guess that also translates into money in a way. But
someone, I think it was the Secretary, made the comment about--
someone made the comment of 98,000 lives lost a year as a
result of medical errors. And if you can cut that down into
maybe even half of that, for crying out loud, as a result of
this, that is enough of a reason for us--I mean after all we
are here representing the public regarding quality of medicine,
medical care and what not, and hopefully that will, if nothing
else--and then when you add the money to it too, I think that
should give us enough incentive.
Dr. Blumenthal, you said you are a primary care physician?
Do you have a practice?
Mr. Blumenthal. Yes, a small practice, sir.
Mr. Bilirakis. And you are an internist?
Mr. Blumenthal. I am an internist.
Mr. Bilirakis. An internist.
Mr. Blumenthal. Practice in the out-patient department of a
large hospital in Boston.
Mr. Bilirakis. In Boston. My oldest son is an internist,
and I haven't talked with him about this, but I will. I will.
Probably this weekend. What is going to be his reaction?
Mr. Blumenthal. Well, I think that most physicians favor
this in principle but are concerned about its impact on their
daily lives. I think that Dr. Shortliffe began to get at that,
and one of the things that I think does occur when you
introduce these systems is that in the short term they take
time. There is time required to put in patient information
before it is in the computer, available to be accessed. There
is time--every time a patient comes into my office, I go
through the medications and make sure that they are the right
medications and the right dosage, and I have to enter that data
manually. That adds to the length of a patient visit at a time
when there is a lot of pressure on patient visits to make them
shorter. And, therefore, it has fairly reliably been
demonstrated, I think, that you see fewer patients because your
visits get longer at the introduction point of the electronic
health record.
Mr. Bilirakis. Which is what period of time, would you say?
Mr. Blumenthal. Well, a couple years, I would say.
Mr. Bilirakis. A couple years?
Mr. Blumenthal. And likelihood is that you save a lot of
money elsewhere in your practice. You may need fewer people to
file records, you may need fewer receptionists, your time may
be saved on other things. But in the short term, there is this
hit to your bottom line that I think constitutes one of the
most compelling reasons for a loan or some kind of assistance
program to the average physician so that when you ask your son
what he thinks about it, if he doesn't have one already and if
he is in independent practice, he will likely say----
Mr. Bilirakis. He is by himself.
Mr. Blumenthal. He will say, ``Dad, that is a great idea.''
Mr. Bilirakis. Some people say it is impossible for
particularly a family doctor, primarily care physician to be
able to make it being alone. Well, so far, so good, but it is
killing him, I think.
Mr. Blumenthal. So imagine if his income were down 20
percent in a year. How would he feel about something----
Mr. Bilirakis. Do you all agree there that there is that
period of time there, transition period, that is going to
cost--so when we talk about incentives, you are not really
talking about a reward for doing this, you are talking about
basically making the physician whole, the office whole, the
expenses, the additional equipment, et cetera, and then the
time that you indicate that would be taking additional time.
Mr. Blumenthal. There is an ongoing thing as well, and I
practice in a big system, and when I don't know what--when
something goes wrong with my software, I can pick up a phone
and call the help desk that is run by my health care system.
And if you are in private practice and you suddenly find that
your software has a glitch and you have to get the information
out of it in order to be useful to your patients, well, you
need help right away. You can't wait three or four days. So
finding a way to make sure the physicians can weather that
challenge is also, I think, a big issue that needs some
attention.
Mr. Bilirakis. Anything you would like to add, any of you?
Mr. Shortliffe. I would be surprised if you showed your son
in solo practice the VA demo that we just saw or one of the
many other fine, more solo practice oriented systems that do
exist, that he wouldn't see the advantages of having that at
the end point. If it only could like appear and be working
perfectly overnight. It is the ``how do I get from here to
there'' question that is the dominant one that I think prevents
people from making that move.
Too often they have heard about failed experiments by
colleagues and others that haven't worked well. They don't
really have the expertise to make that decision, and so it is,
``Help me to make sure that I don't make a mistake, that I
don't lose a fortune doing this, and then at the end of the day
I can really then take advantage of these kinds of
facilities.'' And they just don't know how to do it.
Ms. Diamond. I just wanted to add that I think the
incentives you need to be thought about is something to get
them over that period of adoption and acquisition of the
system, but I also think one thing that we know is that those
systems don't deliver all the benefits they could deliver if
they connect to other systems. In other words, just having
something in your practice that doesn't talk to the pharmacy or
to the laboratory or to other physicians doesn't have the
ability to, as you said, save lives and reduce medical errors.
And I think that is something we need to think carefully about,
because if we only incent the adoption of the technology and we
don't incent that technologies need to talk to other things and
improve the outcomes of care, which the current model does not
do, we will end up with silos, and I don't think it will return
the investment we are hoping for.
Mr. Bilirakis. Sure. You want to add anything, VA?
Mr. Kolodner. The connectivity really magnifies the
benefits by orders of magnitude. The equivalent would be if you
think about the PCs that you had 15 years ago before the
Internet and you could do word processing, you could do some
spreadsheets, you could do some taxes, rudimentary then, and it
was of some use. But the connectivity that the Internet has
provided and the availability of information now is just
tremendous, and I think that is the kind of leverage you get
when you----
Mr. Bilirakis. Well, that is what kind of really gets to me
is the availability and we are just not taking advantage of it.
The entire profession is just not taking advantage of it. The
government is not taking advantage--although we should be able
to do it, for crying out loud, in so far as tying in HHS with
the Veterans Administration, with CDC, et cetera, et cetera,
NIH and whatnot. It would sure be an awful lot of easier, and
yet we are not doing it. So shame on us in that regard.
Dr. Kolodner showed us the videos, the slides, whatever,
and they were really, I think, impacting, but I can see a
veteran coming into a facility, let's say--I should use Bay
Pines with the problems that they have had with their
computers--I will use James Haley in Tampa. There is a
snowbird, lovingingly we call them, coming down from Michigan--
but not from Texas, they don't come from Texas to Florida or
vice versa--coming down from Michigan in the winter and being a
patient in one of the medical facilities up there, the VA
facilities. So it is easy enough to interact. But you go into
the private sector, now that is more of a problem, isn't it?
Mr. Blumenthal. Mr. Chairman, I have lots of patients who
are snowbirds, and I have one I am thinking of right now who
has had a heart transplant who goes to Florida in the winters,
and he usually comes back on different medicines and with
different regimens, and I never know why. And if I could find
out why, it would certainly help me care for him better. And
that is a very common experience. You don't have to go to
Florida to have that disconnect. You can go right across town
to one of the other excellent hospitals in my community, and I
am dependent on getting letters from specialists from around
town, which often arrive but not always, to find out what their
care consisted of or I am dependent on their information, what
they can recall.
Mr. Bilirakis. Well, yes. That brings up the point really
that, again, the emphasis on Dr. Kolodner's exhibition was the
x-rays and whatnot that took place and how they were being
used, even how they took place. Now, when you get into the
private sector and considering the litigious society that we
are in, medical malpractice and everything of that nature,
would a doctor in Michigan, and I am not talking about VA now
but private practice, a doctor in Michigan basically depend
upon an x-ray that was taken in Tampa, Florida before he
would--would he do that or is there--you think he would? Okay.
I mean that could be a big savings right there in terms of----
Mr. Blumenthal. In my situation, I would probably want one
of our radiologists to bring it up on the screen and look at
it, look at the technical quality, but the likelihood is, given
the proficiency of the technologies that we have available,
that that technical quality would be good.
Mr. Bilirakis. Well, that is good to hear that. How do we
compare on this with the rest of the world?
Mr. Shortliffe. I think it is clear that we are struggling
to keep up with the rest of the world in this area largely
because in many other countries health care systems are more
like the VA. They have centralized single pair environments
where the decisions about how to handle this technology and how
to instill into practices and the like are determined centrally
and without the kind of fragmentation.
So here we are very dependent right now on will a
grassroots activity--that is what I have been watching for 30
years--will a grassroots activity create something that is
truly national and comprehensive and standardized? And
increasingly I think we are aware that the answer is no, that
the organizations that manage to pull this off are those that
have more central authority and decision making, and the VA has
I think proven that in this country. So we have examples in
other countries of much more consistent and standardized
exchange of data simply because there is a national health
service or other standardized approach.
Mr. Bilirakis. Yes, something like the VA, in other words,
which makes it a little less complex. Should this be a part of
their education, their being the providers?
Mr. Shortliffe. Well, this is what I do much of my time is
educate people in this area, and I must say I think the
difficulty we have in making traditional medical schools
believe that this is an important topic for medical education
is challenging for us.
Mr. Bilirakis. Is that right? That difficult.
Mr. Shortliffe. It is not part of medical education right
now. You could argue that maybe all people need to do is be
exposed to good systems while they are in training so that they
know how the other half can live and then they can hopefully
take some of those lessons into the practice settings that they
move on to when they are through with their house staff years,
but to be quite honest, I think there is more to this field
than just being an informed user. To be a good selector of
systems, you need to have some understanding of some of the
underlying concepts. So many of us feel that there is a body of
knowledge that goes beyond use that should be conveyed to
future physicians as well.
Mr. Bilirakis. Well, I have taken up----
Mr. Kolodner. Mr. Chairman?
Mr. Bilirakis. Oh, I'm sorry.
Mr. Kolodner. One thing about that, and I think Dr.
Shortliffe is correct, that it is more than just exposure,
although it is useful to at least have that experience. One of
the things about the VA is because it is so widespread and
affiliated with about 107 of the 127 medical schools, that
about 70 percent of the doctors and over 50 percent of other
allied health professionals do rotate through VA as some part
of their training. So they at least get to----
Mr. Bilirakis. So they pick that up then.
Mr. Kolodner. But still have the misalignment of the
incentives once they get out of that experience and go into
practice, and that still needs to be addressed.
Mr. Bilirakis. Okay.
Mr. Shortliffe. If I can make a quick comment about this
because Dr. Kolodner might not, I can tell you that in my own
experience in my former institution in California where our
medical students and house officers rotated both through an
academic medical center, private hospital environment and
through the VA, I watched this fascinating transformation over
the last 30 years where about 30 years ago you sort of dreaded
your VA rotations. Things were not well organized, they were
more backwards, and people then went off to the university
environment, and they would rotate between these two
environments and be exposed to both.
Today, it is very much the opposite at that institution.
People know that their lives are easier at the VA when they are
a house officer or an intern or a resident because of the
quality of the information technology that is available to
them, and they look forward to their VA rotations. It has
changed their perceptions a great deal just in the years I have
been observing medicine.
Mr. Bilirakis. That is quite a compliment. I have taken up
an awful lot of time. I am going to yield to Mr. Green,
gentleman from Texas, who has just come in to join us.
Mr. Green. Thank you, Mr. Chairman, and I apologize for not
being here earlier, because this is an important issue. And it
is just that we have different committees, in fact I would give
up the committee I was in, my Ethics Committee, for easily
sitting here because of the importance of the information IT
for health care.
I want to follow up on your questions about incentivize
because that is one of my concerns is how do we incentivize it
for the individual doctor. I know loans. One of the ways I was
thinking here because talking with a lot of my practitioners,
professional liability. I represent a very urban district in
Houston; in fact, our VA facility is really a great facility,
and having dealt with it in the private sector as an attorney
doing psychiatric work, I could tell the difference over the
last 20 years, and we have a new facility from the early
nineties, but, again, the professionalism at the VA is just so
much better than it was 15 or 20 years ago. In fact, a few
years ago, if you remember my neck brace, the same surgeon that
did my fifth and sixth at Baylor College of Medicine Methodist
Hospital in Houston did surgery at VA two days a week, and he
was a top neurosurgeon and a great guy. So the professionalism
is there and the quality is there, because I know I follow that
too with my constituents too.
And what I have seen at our local VA, and I know it is
elsewhere, that the technology and the use of the information
is so much better than a lot of my private hospitals, for-
profit and non-profit. But is there a way that we could
encourage--for example, I know businesses in my district have
to go through to get a lower workers' comp rate, they have to
do certain things. Is there a way that professional liability
could be lowered because you can actually show that the
insurance companies will pay less claims by using IT and
quality using it. I mean I know on the Federal level, because
most of that is State regulation, but I know using the
information it seems like it would--and the concern of the
chairman and all of us have, and I know you at that table do,
about the errors issue and if that would help. Has that been
explored by any of the private sector? I know VA doesn't have
that worry.
By the way, I have a daughter who has finished her second
year of residency at UTM in Galveston and there her and her
husband are at a huge facility, so they don't have to worry
about professional liability, but I have a lot of physicians
who do.
Mr. Blumenthal. Congressman, our medical malpractice system
is so broken that I am not sure reducing errors would result in
reducing premiums. And the reason I say that is because so many
times the people who are the victim of errors don't sue, and
people who aren't the victim of any errors do sue. And so it is
a very messy system. I don't know of any studies, but I haven't
looked at this literature, that show a relationship between the
adoption of electronic records and rates of malpractice claims,
which is different from rates of safety problems. And so I
think that there is not necessarily one-to-one feedback. I
think it is an interesting thing to pursue, but I think there
are probably many more direct positive feedback mechanisms that
flow than the malpractice.
Mr. Bilirakis. Could that be an incentive, some sort of
legislation that would tie the two in in some way?
Mr. Blumenthal. If you want to get in the business of
regulating malpractice premiums, I am sure that that would be a
good lever to use.
Mr. Green. Having served 20 years in the legislature, and I
know that is supposed to be done on the State level, I don't
know if we want to regulate medical malpractice on the Federal
level, but I would hope our States would do it, because I don't
want to regulate auto insurance either.
Next question I have is concerning both the SARS and
anthrax and the need for some type of integrated health
information system. Frankly, I think we dodged a big bullet
with SARS. I mean aggressively on both an international level,
in our own country, very lucky too. What is the story, I would
rather be lucky than good. But my concern is because of our
lack of that information sharing, even with CDC doing the best
they can, is there on the Federal, State and local levels,
using the electronic records and the information sharing--and,
again, if we can share it, then we ought to be able to do it
with our neighbor in Canada, which was the next concern. And I
know there was some coordination, but, again, I don't feel
comfortable with--I would rather be good than just lucky, and I
think we were lucky with SARS. Could anybody on the panel talk
about that?
Mr. Shortliffe. The issue of connectivity that Dr. Diamond
was mentioning a moment ago is at the heart of the use of
information technology to solve or at least help support
solutions to problems such as that kind of public health
threat. And you may have heard prior testimony before this
committee in the last few years about the problems of the
public health infrastructure, which, frankly, is the
infrastructure that supports all the things we are talking
about today. It is the same infrastructure. So that as we build
up a structure that supports public health and the connectivity
of public health departments into regional and national
networks, the ability to gather data from multiple sources and
so forth, we are building the same network that can also allow
medical records to move with a patient from one emergency room
to another, et cetera.
So these are highly linked issues, but I would totally
agree that those kinds of public health concerns, like SARS or
any kind of rapid detection of infectious threats, biological
threats in particular, is absolutely dependent upon getting in
place a national health information infrastructure that is more
effective than what we have now.
This has been an area where I would argue, because I know
people in the public health service, there has been abysmal
support financially for the development of the technology over
the years, and the public health departments until very
recently were sometimes dependent upon a 2,400 baud modem to
call into some local node with 1 computer shared by 5
operatives in a local area. And, fortunately, I think we are
seeing some improvement in that, but it was pretty dismal only
a decade ago.
Mr. Green. I have noticed in Houston, because we have an
immunization project, our office does every year, it comes up
in August, a couple weeks before school starts, and because of
it, our immunization rates are lower than some of our
neighboring cities and other urban areas. But dealing with the
groups that provide it, Mr. Chairman, I don't know if you have
this problem in Florida, but we have a city of Houston health
department and county, our Harris County, who will provide the
immunizations. And up until a couple of years ago, there wasn't
any communication. They actually used different systems to have
immunizations, and that is a State issue. In fact, we have
gotten money to our State health commissioner to be able to try
and coordinate that between these two local agencies. Again,
there is so much we can do, provide them resources to do it,
but that is just a symbol, I guess, of some of the problems we
are having.
Mr. Shortliffe. It is a really great example, though,
because you have tried to solve it by coming up with an
immunization solution, but if the infrastructure were in place,
you would have used that for this kind of connectivity in
sharing.
Ms. Diamond. I was just going to add that that is really at
the heart of, I think, prior testimony today of the importance
of standards and interoperability as we think about these
incentives, because short of that it is not just getting the
system in place in an office or public health department, it is
about getting a system that will talk to other things in place,
and that all has to be tied to together or we do end up with
stovepipes or silos or whatever you want to talk about that get
in the way of doing the job and improving quality and improving
public health.
Mr. Green. And to follow up one more time, Mr. Chairman, on
the effort, is there any Federal money available to deal with
that information sharing? Is there money that we have
authorized that would provide for that?
Mr. Bilirakis. Well, the Secretary told us that there are a
few million dollars out there, but he did refer to the
possibility of using a certain amount of the waste, fraud and
abuse savings and allocate it to something like this, so it
wouldn't be necessarily new money. The problem that we have,
Mr. Green knows very well and we all do up here, is the
Congressional Budget Office. And even if you could show, geez,
$140 billion savings every year, even if you can show much more
than that, Mr. Stupak indicated about 25 percent of health care
costs could be saved, the Congressional Budget Office wouldn't
give you any credit for it, and they would only hit you with
the expenses, these incentive expenses and whatnot, as we call
them. So that is the problem that we have, obviously.
But I feel we can work around it. And if we can work
together as a Congress, the majority and minority, and if we--
if, and I would like to say when, we create a task force or
whatever we want to call it, to work on this subject and feel
that we need to, as part of that group, the private sector, who
would represent--Dr. Diamond, who would represent the public?
Who would you suggest would----
Ms. Diamond. That is a very good question. We have been, as
you said, trying to pull together all the stakeholders from the
health care industry, and it is often difficult to find people
who represent the public. There are consumer groups out there
who try to represent public interests, and we work with several
of them in Connecting for Health. One of the reasons I like to
think that both of our foundations, both the Markle Foundation
and the Robert Wood Johnson Foundation, got into this is
because the public interest is our objective as well.
And I think there is an opportunity to represent the
public. How much of the public you represent, I imagine that
Congress' job, but I do think the public voice does need to be
in the dialogue and in the debate as this agenda moves forward.
Mr. Bilirakis. Yes, I agree.
Ms. Diamond. I think without that, we will miss a huge
opportunity.
Mr. Bilirakis. I agree. I didn't mean to take away from
you, Gene.
Mr. Green. Oh, no. I was just going to follow up, and one
of the other issues is that for an individual practitioner to
buy this to the standards so they don't just get sold something
that, like you said, is just worthless, and it has to have some
standards, maybe using Medicare, for example, because----
Mr. Bilirakis. Yes, the Secretary mentioned that.
Mr. Green. Yes, that we could use--that Medicare could have
certain standards for the informational health sharing. So a
physician, a solo practitioner who really doesn't have time to
go learn about the computers would have some kind of ability to
be able to say, ``Yes, I will make this investment to go with
it.'' Thank you, Mr. Chairman.
Mr. Bilirakis. The VA, do they somehow interact with the
private sector in terms of availability of software and
whatnot?
Mr. Kolodner. Yes, sir. First of all, VA participates in a
lot of public-private forums, so we are working very closely,
for example, with Connecting for Health and other activities.
With an estimated 40 percent of our veterans getting some care
in the private sector each year, it is very important for us to
see the private sector actually use these technologies so that
we can exchange back and forth and provide our data to the
providers who are caring for them in the community and vice
versa.
In terms of software, one of the things is that there are
some very good companies out there, some very good vendors,
though there are the incentive issues, as we have seen. And so
it is very important for us to focus in terms of our software
on the rural and underserved areas where with our initiative
with CMS the software is really being configured to try and
meet the needs of that particular community. But even before
that, we have had some entities, the D.C. Department of Health
and a couple of States, that have indicated that they are going
with the VistA software and have found some companies to
provide support to them. And, in fact, just last week, the
country of Mexico, in one of their public health systems, has
decided to go with VistA and have made a 3-year commitment to
start putting it up in three hospitals with the intent to go
very widespread, but that particular portion accounts for about
60 percent of all of the population of Mexico.
Mr. Bilirakis. You wanted to add----
Mr. Blumenthal. Mr. Chairman, if I could add a couple of
points to questions that have been raised in the past. One
concerns money, and it seems as though the Congress has not
been unwilling to add expenditures to the Medicare program
where it felt that they had a real return for the beneficiaries
of the program. It strikes me that this is one such area.
Whether CBO marks it as an additional expenditure or not, it
certainly marked the prescription drug benefit as an additional
expenditure, and yet the prescription drug benefit was passed.
The second point, I guess, has to do with----
Mr. Bilirakis. But there is not an unlimited pool out
there. Somewhere along the line----
Mr. Blumenthal. I understand that.
Mr. Green. Particularly in that pool you are not sure how
much it is.
Mr. Bilirakis. Well, since when have you even cared?
Mr. Green. I have only been here 6 terms. You are training
me.
Mr. Bilirakis. All of a sudden--who are the fiscal
conservatives--all of a sudden. But any case.
Mr. Green. I am good lawyer, I can argue either way.
Mr. Blumenthal. The other point I guess I wanted to make
was that it seems to me that these information technologies are
core to our national security when it comes to bioterrorism and
health care security. And there is no reason, I think, why some
of the funds that have been available for homeland security
couldn't and shouldn't be used for the shoring up of the
ability of front-line providers of care in emergency rooms
around the country, for example, to provide prompt information
on atypical disease patterns that could represent terrorist
activity.
Mr. Bilirakis. Well, you have been terrific, and you have
been patient, and I apologize for the delay. You know, you sit
there and you listen to our opening statements. Thank God there
weren't too many here today for that. If Gene had been here, it
would have added another----
Mr. Green. You only give me minutes, Mr. Chairman, and I
talk slow.
Mr. Bilirakis. But anyhow you are very patient, and we
appreciate that very much. I would say that the opening
statements of all members of the subcommittee are made a part
of the record, without objection. We will have additional
questions to you in writing, as we always do, and we appreciate
a timely response to those. And, additionally, I invite you to
furnish us whatever it is you please, anything that might be
helpful to us.
I am hopeful that in the fall that we can at least get
started talking about this. No, we are not going to come up
with anything until the next Congress and hopefully even then,
but hopefully we can start at least talking, maybe we can start
meeting.
But there are all kinds of obstacles out there. You have
mentioned them, Dr. Diamond. There is a lot that you haven't
even mentioned, but lots of those obstacles coming in our
minds, I think, and that is why these things don't get done.
But hopefully we will be open-minded enough to get together and
try to do something about this. It is a shame. What a resource
that is out there that--talk about malpractice. What a resource
we are not taking advantage of.
Well, thank you very much. Hearing is adjourned.
[Whereupon, at 5:07 p.m., the subcommittee was adjourned.]
[Additional material submitted for the record follows:]
Prepared Statement of American Clinical Laboratory Association
The American Clinical Laboratory Association (ACLA) congratulates
Chairman Bilirakis and the Subcommittee on Health for holding this
hearing on health care information technology (IT). ACLA is an
association representing independent clinical laboratories throughout
the United States including local, regional and national laboratories.
Increasingly, clinical laboratories are using IT innovations to
improve patient care, as well as to promote the highest level of
efficiency and affordability. Implemented properly, IT will provide
ready access to timely, relevant, reliable and secure information
through an interconnected infrastructure affording better health and
health care.
ACLA wants to make sure that the laboratory industry is an active
participant as IT becomes a more important part of health care
delivery. Specifically, we want to avoid the problems that the
laboratory industry experienced with the implementation of the HIPAA
standard transaction requirements in which requirements did always not
match the operational realities of providing laboratory services and
billing for these services. Accordingly, ACLA is taking a more active
role in the IT issue by joining the private sector coalition on health
care IT, the E-Health Initiative (E-Hi).
ACLA is currently working with various agencies within the Federal
Government on the issue of health information technology--including the
Centers for Disease Control and Prevention (CDC), the Agency for
Healthcare Research and Quality (AHRQ), and the Centers for Medicare
and Medicaid Services (CMS). Most notably, ACLA is working with CMS'
Office of Research, Development, and Information on the development of
standards for clinical laboratory data reporting. This demonstration
project seeks to investigate the potential benefit of linking existing
data streams including laboratory, pharmaceutical, and radiological
data through the Doctor's Office Quality--Information Technology (DOQ-
IT) project. ACLA is committed to helping the Administration move from
paper to electronic health records. ACLA is pleased CMS sought the
clinical expertise of the association and its members since
laboratories have been utilizing this means of information sharing for
many years.
Again, congratulations to Chairman Bilirakis and the entire
Subcommittee on Health for holding this hearing. ACLA looks forward to
working with the Committee to facilitate the adoption of IT throughout
the health care sector.
______
Response for the Record from the Department of Veterans Affairs to
Questions from Ranking Member John D. Dingell
Question: To help assess the type of financial commitment necessary
to implement a health information technology strategy, please itemize
the funding the Department of Veterans Affairs has spent on each VA
information technology advance such as electronic medical records,
imaging of patient labs, patient access to records, telehealth and
other aspects of VA's health information technology infrastructure
including maintenance and updates year by year over the past 10 years.
For each health information technology advance, can you state where the
funding originated?
Response:
VA's Health Information System
The Department of Veterans Affairs' (VA) Health Information System
is a compilation of more than 100 highly integrated clinical and
administrative applications that support care delivery. VA began to
develop component clinical applications such as laboratory, radiology,
pharmacy, imaging, etc. in the early 1980's. Subsequently, the same
development and operational infrastructure was used for administrative
and financial applications such as employee timekeeping, patient
accounts and VA's billing and accounts receivable financial systems.
These applications, initially known as the Decentralized Hospital
Computing Program (DHCP) and later as the Veterans Health Information
Systems and Technology Architecture (VistA), represent both VA's
Electronic Medical Record (EMR) and non-EMR applications needed to run
the VA hospital information system.
Funding for the development and maintenance of all information
technology efforts came from the Medical Care, Research and MAMOE
appropriations for FY 1995 through FY 2003 and from the Medical
Administration appropriation in FY 2004. This funding supports the
development, deployment, operations and maintenance of applications
software; acquisition and operation of commercial software;
acquisition, operation and maintenance of hardware in support of
healthcare delivery; acquisition of information technology (IT)
services; and salaries and benefits for VA IT employees.
VA does not break down its budget documentation by an EMR category.
Expenditures in support of health information technology/efforts such
as Medical Imaging (including cardiology, laboratory, pathology,
radiology, etc.), Blood Bank, Bar Code Medication Administration,
Laboratory and patient access to medical records are funded through the
health IT budget. Applications that comprise the EMR, as well as the
expenditures for infrastructure, support, and operating expenses are
contained in broader categories in VA's budget documentation. For
example, in FY 1997, IT projects included clinical EMR applications
such as pharmacy, clinical laboratory, radiology, nursing, surgery,
mental health, dietetics, medical records tracking, as well as,
administrative/financial applications, including enrollment,
telecommunications infrastructure, and universal billing. These
initiatives were mentioned in the budget narrative; however, the
historical specific cost information is not available.
The available historical or estimated obligation data are displayed
on Attachment A for FY 1995-FY 2004. The funds specified were and are
used to support development and operations of VA's EMR nationally.
Obligations for financial information systems, telecommunications
services, phone bills, web operations, desktop computing, and
administrative staffing support are also included in these totals.
Based on the FY 2003 health IT budget, the average annual cost of
operating and maintaining VA's EMR, VistA, was $62 dollars per enrollee
per year (based on 7.2 million enrollees). This figure included field
costs for hardware, software and support personnel.
The accounting processes for Information Technology (IT) spending
have changed significantly over the course of 10 years. Project-
specific information is available for the current fiscal year.
Implementation and training costs are also included in the figures
below: FY 2004 program spending for VA's; VistA Imaging, My HealtheVet,
etc., follows:
VistA (includes Computerized Patient Record System CPRS)--$353.6
million
My HealtheVet (including patient access to medical records)--$5.9
million
VistA Imaging (displays images from various VistA applications)--
$70.2 million
VHA Computing Infrastructure (required to run VistA systems)--$84.7
million
Telehealth
Telehealth development in the Veterans Health Administration (VHA)
began during the early 1990's. This work built on the VA's existing and
emerging information technology infrastructure, including network
connectivity, video conferencing, and use of clinical applications.
Early foundational work also involved testing the use of new
technologies, e.g., use of the Internet as a tool to communicate with
veterans, audio/ video streaming through the web, on-line submission of
forms, use of Public Key Infrastructure to securely identify
individuals, etc. Funding for this foundational work was part of VA's
health IT budget; however, it was displayed in the budget under capital
expenditures for infrastructure and/or development for clinical VistA
applications and not broken out specifically for Telehealth.
In 1997 a Telemedicine Strategic Health Care Group (SHG) was formed
in the Office of Patient Care Services in VHA to develop the clinical
processes necessary to develop and sustain Telehealth in VHA. The
expenditures presented below, and in the accompanying spreadsheet
(under Telehealth obligation data) therefore reflect the clinical
processes necessary to make Telehealth a part of mainstream healthcare
delivery in VHA. There are specific technologies e.g., teleradiology
that have been purchased for the direct provision of services at the
VISN and facility level, are contained within the medical equipment
budget, and have not been separately itemized to Telehealth. The direct
clinical consultation/care provided via Telehealth is not separately
itemized. These clinicians are employed to deliver care and the
proportion of time devoted to Telehealth is variable and not separately
itemized. In July 2004, the Telehealth SHG was incorporated into a new
Office of Care Coordination.
Attachment B provides VHA Telehealth expenditures and funding
sources for FY 1995-2004. Home Telehealth IT infrastructure support
funding in the amount of $2,098,000 for FY 2003-2004, is not included
in the total Telehealth program support expenditures.
[GRAPHIC] [TIFF OMITTED] T5460.001
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