<DOC>
[108th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:99674.wais]
HEALTH CARE INFORMATION TECHNOLOGY
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON WAYS AND MEANS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTH CONGRESS
SECOND SESSION
__________
JUNE 17, 2004
__________
Serial No. 108-55
__________
Printed for the use of the Committee on Ways and Means
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_________________________________________________________________
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COMMITTEE ON WAYS AND MEANS
BILL THOMAS, California, Chairman
PHILIP M. CRANE, Illinois CHARLES B. RANGEL, New York
E. CLAY SHAW, JR., Florida FORTNEY PETE STARK, California
NANCY L. JOHNSON, Connecticut ROBERT T. MATSUI, California
AMO HOUGHTON, New York SANDER M. LEVIN, Michigan
WALLY HERGER, California BENJAMIN L. CARDIN, Maryland
JIM MCCRERY, Louisiana JIM MCDERMOTT, Washington
DAVE CAMP, Michigan GERALD D. KLECZKA, Wisconsin
JIM RAMSTAD, Minnesota JOHN LEWIS, Georgia
JIM NUSSLE, Iowa RICHARD E. NEAL, Massachusetts
SAM JOHNSON, Texas MICHAEL R. MCNULTY, New York
JENNIFER DUNN, Washington WILLIAM J. JEFFERSON, Louisiana
MAC COLLINS, Georgia JOHN S. TANNER, Tennessee
ROB PORTMAN, Ohio XAVIER BECERRA, California
PHIL ENGLISH, Pennsylvania LLOYD DOGGETT, Texas
J.D. HAYWORTH, Arizona EARL POMEROY, North Dakota
JERRY WELLER, Illinois MAX SANDLIN, Texas
KENNY C. HULSHOF, Missouri STEPHANIE TUBBS JONES, Ohio
SCOTT MCINNIS, Colorado
RON LEWIS, Kentucky
MARK FOLEY, Florida
KEVIN BRADY, Texas
PAUL RYAN, Wisconsin
ERIC CANTOR, Virginia
Allison H. Giles, Chief of Staff
Janice Mays, Minority Chief Counsel
______
SUBCOMMITTEE ON HEALTH
NANCY L. JOHNSON, Connecticut, Chairman
JIM MCCRERY, Louisiana FORTNEY PETE STARK, California
PHILIP M. CRANE, Illinois GERALD D. KLECZKA, Wisconsin
SAM JOHNSON, Texas JOHN LEWIS, Georgia
DAVE CAMP, Michigan JIM MCDERMOTT, Washington
JIM RAMSTAD, Minnesota LLOYD DOGGETT, Texas
PHIL ENGLISH, Pennsylvania
JENNIFER DUNN, Washington
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Ways and Means are also published
in electronic form. The printed hearing record remains the official
version. Because electronic submissions are used to prepare both
printed and electronic versions of the hearing record, the process of
converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
Page
Advisory of June 10, 2004, announcing the hearing................ 2
WITNESSES
U.S. Department of Health and Human Services, Office of the
National Coordinator for Health Information Technology, David
Brailer National Coordinator for Health Information Technology. 6
U.S. Department of Veterans Affairs, Veterans Health
Administration, Dr. Robert M. Kolodner, M.D., Acting Chief
Information Officer............................................ 12
______
American Medical Informatics Association, Charles Safran......... 27
eHealth Initiative, Janet Marchibroda............................ 31
Indiana University School of Medicine, Regenstreif Institute, J.
Marc Overhage.................................................. 41
Permanente Federation, Andrew M. Wiesenthal...................... 50
SUBMISSIONS FOR THE RECORD
American Academy of Family Physicians, statement................. 63
American Clinical Laboratory Association, statement.............. 66
American College of Physicians, statement........................ 66
American Health Quality Association, David G. Schulke, statement. 72
Broadlane, Inc., San Francisco, CA, F. Lee Marston, statement.... 74
Guidant Corp., statement......................................... 76
Healthcare Information and Management Systems Society Advocacy
and Public Policy Steering Committee, Chicago, IL, Mary
Griskewicz, statement.......................................... 78
Kryptiq Corp., Beaverton, OR, Luis Machuca, letter and attachment 79
Kun, Luis G., Washington, DC, statement and attachment........... 81
MediStore, Houston, TX, Glenn R. Breed, letter................... 84
MedMined, Burlington, AL, statement.............................. 87
National Association of Chain Drug Stores, Alexandria, VA,
statement...................................................... 96
National Electronic Attachment, Inc., Atlanta, GA, Thomas W.
Hughes, statement.............................................. 98
National Initiative for Children's Healthcare Quality, Boston,
MA, Charles Homer, statement................................... 99
National Quality Forum, Kenneth W. Kizer, statement.............. 101
Patient's Healthcare Card, statement............................. 103
Weed, Lawrence L., Burlington, VT, statement..................... 107
Wu, Hon. David, a Representative in Congress from the State of
Oregon, statement.............................................. 110
HEALTH CARE INFORMATION TECHNOLOGY
----------
THURSDAY, JUNE 17, 2004
U.S. House of Representatives,
Committee on Ways and Means,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 2:45 p.m., in
room 1100, Longworth House Office Building, Hon. Nancy L.
Johnson (Chairman of the Subcommittee) presiding.
[The advisory announcing the hearing follows:]
ADVISORY
FROM
THE
COMMITTEE
ON WAYS
AND
MEANS
SUBCOMMITTEE ON HEALTHFOR IMMEDIATE RELEASE June 10, 2004
CONTACT: (202) 225-3943
FOR IMMEDIATE RELEASE
June 10, 2004
Johnson Announces Hearing on Health Care Information Technology
Congresswoman Nancy L. Johnson (R-CT), Chairman, Subcommittee on
Health of the Committee on Ways and Means, today announced that the
Subcommittee will hold a hearing on health care information technology
(IT). The hearing will take place on Thursday, June 17, 2004, in the
main Committee hearing room, 1100 Longworth House Office Building,
beginning at 2:00 p.m.
In view of the limited time available to hear witnesses, oral
testimony at this hearing will be from invited witnesses only.
Witnesses will include representatives from the public and private
sectors to discuss the use of IT in the health care sector to reduce
costs and improve patient outcomes. However, any individual or
organization not scheduled for an oral appearance may submit a written
statement for consideration by the Committee and for inclusion in the
printed record of the hearing.
BACKGROUND:
Greater use of IT in the health care field has the potential to
reduce medical errors and improve patient care. Many innovative IT
projects are underway in both the public and private sectors. Yet
widespread adoption of IT in the health care sector has been anemic.
The Medicare Modernization Act (P.L. 108-173) made some important
advances in the use of IT for health through provisions on e-
prescribing and the establishment of the Commission on Systemic
Interoperability to implement health IT standards. On April 27, 2004,
President Bush issued an Executive Order establishing the Office of the
National Health Information Technology Coordinator and announced the
goal of providing most Americans with an Electronic Health Record (EHR)
within the next 10 years. The Health IT Coordinator is charged with
developing a nationwide interoperable health information technology
infrastructure that improves health care quality, reduces medical
errors, and advances the delivery of appropriate, cost-effective,
evidence-based medical care.
In announcing the hearing, Chairman Johnson stated, ``Greater use
of information technology has the proven ability to dramatically
improve the safety and quality of our health care system while reducing
costs. I am encouraged HHS is moving forward quickly on adopting the IT
provisions included in MMA. I applaud the creation of the Office of the
National Coordinator for Health IT as a critical step in furthering the
public-private partnership that is required to bring our health care
system into the 21st Century.''
FOCUS OF THE HEARING:
The hearing will focus on the projects currently underway in both
the public and private sectors and will explore what further
initiatives are needed to increase the use of information technology
throughout the health care sector.
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<F-dash>
Chairman JOHNSON. Good afternoon. My apologies for the
hearing having to start belatedly, but I believed it was better
to allow us all to focus continuously on what I consider to be
a very important issue. I am pleased to chair this hearing on
the use of information technology (IT) in the health care
sector. Greater use of IT has the proven ability to
dramatically improve the safety and quality of health care for
Americans while at the same time lowering costs, reductions in
clinical errors, and elimination of redundant procedures.
Yet despite these clear benefits, widespread adoption of IT
in the health field has been disappointingly slow. Our goal
today is to understand the current state of the health IT
industry in both the public and private sectors and to promote
discussion as to how we can encourage greater use of technology
throughout this industry. I have long supported efforts to
increase the use of IT in health, which is why I introduced
H.R. 2915, the National Health Information Infrastructure Act
of 2003, last year. In addition, the Medicare Prescription
Drug, Improvement, and Modernization Act of 2003 (MMA) (P.L.
108-173) made some important advances in the use of IT for
health through provisions on electronic-prescribing (e-
prescribing) and the establishment of the Commission on
Systemic Interoperability to implement health IT standards.
I am encouraged that U.S. Department of Health and Human
Services (HHS), under the leadership of Secretary Tommy
Thompson and Administrator McClellan, is moving forward quickly
to implement the IT provisions included in the MMA. Another
important step was taken on April 27 of this year when
President Bush, by Executive order, established the Office of
the National Coordinator for Health Information Technology
(ONCHIT) and announced the goal of providing most Americans
with an electronic health record (EHR) within the next 10
years. I applaud the President's leadership and foresight in
issuing an Executive order that will further the public-private
partnership required to bring our health care system into the
21st century.
Today, I welcome leaders from both the public and private
sectors to further our efforts to promote greater use of health
IT. First, I am happy to welcome Dr. David Brailer who has been
appointed as the National Health Information Technology
Coordinator under the President's Executive order. In his
capacity, Dr. Brailer is charged with developing a nationwide
health IT infrastructure that improves health care quality,
reduces medical errors, and advances the delivery of
appropriate cost-effective, evidence-based medical care.
I look forward to hearing from Dr. Brailer about his vision
for making a national health infrastructure a reality. We will
then hear from Dr. Robert Kolodner, Acting Chief Information
Officer (CIO) for the Veterans Health Administration (VHA),
about the work that the U.S. Department of Veterans Affairs
(VA) has done over the years in implementing IT in its health
care system. The VA has long been recognized as a leader in the
use of IT. I understand that Dr. Kolodner will provide us with
a demonstration of the VA system.
Our second panel of witnesses consists of leaders in the
private sector who are working to increase adoption of health
IT. First, we will hear from Dr. Charles Safran, President of
the American Medical Informatics Association. He is an
Associate Professor of Clinical Medicine at Harvard Medical
School and chief executive officer (CEO) of Clinician Support
Technology, a health IT application provider. These very roles
provide Dr. Safran with a unique view of the opportunities and
challenges of health IT implementation.
We will also hear from Janet Marchibroda, CEO of the
eHealth Initiative, an organization which brings together key
stakeholders with a common goal of improving health care
through implementation of IT systems. We will then turn to two
witnesses who can provide us with specific examples of how they
are using IT to improve health care delivery and outcomes, Dr.
Mark Overhage, Associate Professor of Medicine at the Indiana
University School of Medicine will discuss the Indiana Network
for Patient Care which has electronically linked all 5 major
Indianapolis hospital systems operating a total of 11
geographically separated hospitals, thus creating a community-
wide electronic medical record system.
Finally, Dr. Andrew Wiesenthal, Associate Executive
Director of Kaiser Permanente Clinical Information Systems will
discuss the $3 billion health IT initiative that Kaiser is
currently implementing to bring electronic medical records to
its members. I believe we have a very distinguished set of
witnesses before us today. I look forward to hearing all of
their testimony. These are exciting times for those of us
interested in health IT. I look forward to working with all of
you as we move forward to improve the safety and quality of our
health care system and as we seek to press ever forward the day
in which Americans across the age spectrum can benefit from e-
prescribed and electronic-health records throughout the health
care delivery system in our country. I thank you all for being
here. Mr. Stark.
Mr. STARK. Madam Chair, I want to thank you for bringing us
here today to talk about the use of IT in our medical delivery
system. The appropriate and wide-spread use of IT, I think,
offers just enormous potential, whether it is in patient care,
reducing cost, safety, you name it. The congressional debate,
it seems to me, has moved off questioning the role of IT and
patient care and medical care delivery. I think that is perhaps
accepted broadly. So, the current debate has shifted to the
fact that we have a bunch of operating or operable systems, and
how can we make them interoperable and therefore, I suspect,
much more valuable to everyone?
I suppose we get right to the crux of why we are here, and
it is, is there anything that government can do to facilitate a
universal seamless system? Or should we just stay out of it? My
experience, I hate to date myself, but I was there at the
beginning of Visa and MasterCard and Bank of America went their
own way for a while. Those cards didn't talk to each other for
a lot of the same reasons that I suspect that medical systems
don't talk to each other. They find out secrets about other's
customers.
Well, lo and behold, or for whatever reason, maybe the Fed
saying, ``We won't clear these items unless you all agree to a
uniform protocol and so forth,'' it is a system now whereby I
guess I could go to Germany or Baghdad and stick my Visa card
in an automated teller machine, and it would quickly decide
that I am worthless and spit the cards back at me and probably
call the police and/or certainly they would call my wife and
say, ``What is he doing here?``
I see no reason why we can't, therefore, do that here. I
guess it is this we have before us. We have all the players,
every instrument in the orchestra is out there and they are all
first chair. The question is, does the government wave our arms
and make it sound like Shazala or Spike Jones? This is what I
hope the witnesses can tell us through the day. Thank you very
much. I look forward to hearing their testimony.
Chairman JOHNSON. Thank you, Mr. Stark. Dr. Brailer.
STATEMENT OF DAVID BRAILER, M.D., PH.D., NATIONAL HEALTH
INFORMATION TECHNOLOGY COORDINATOR, U.S. DEPARTMENT OF HEALTH
AND HUMAN SERVICES
Dr. BRAILER. Chairman Johnson, Representative Stark, thank
you. Other Members of the Committee, thank you for having me
here today on my first formal testimony on Capitol Hill to
discuss the Administration's efforts to increase the use of IT
and to address the issues that you have raised. As you know,
this is a high priority for the President and for Secretary
Thompson. The President has called for an EHR infrastructure to
be available to most Americans in the next 10 years and created
my position as one way to help achieve that goal. Your
leadership and that of the Subcommittee on this issue, through
e-prescribing and other health IT-related provisions in the MMA
of 2003, are also greatly important and appreciated.
This spring, as you know, the President reiterated his
strong commitment to this issue by creating the ONCHIT. This
was done by Executive order. I was appointed on May. In this
roll, I am working to bring together the resources and talent
in both the private and public sectors to drive adoption of IT.
There is unprecedented enthusiasm and commitment for changing
the day-to-day world for health care, and my goal is to focus
this into a well-developed plan in a set of coordinated actions
to accelerate the widespread adoption of EHRs.
The Administration has historically made significant
progress in this area. Last year, we licensed Systematized
Nomenclature of Medicine (SNOMED), a comprehensive set of
clinical terminologies, to make it available without charge for
care anywhere in the United States. We also adopted 20 sets of
clinical terminology standards across Federal agencies through
the Consolidated Health Informatics Initiative. These standards
will make it easier for information to be shared across
agencies and could serve as a model for the private sector.
The Executive order of April 27 not only created the new
office, but it also required the departments and agencies of
the executive branch of the Federal government to work together
to achieve our common goal of using health IT to improve
safety, quality, and efficiency of health care in every area of
the United States.
Specifically, we will work with every other executive
branch department and agency, including the VA, who are here
today, the U.S. Department of Defense (DOD), and the Office of
Personnel Management (OPM) as well as the private sector to
develop and implement the strategic plan to accelerate IT
adoption in both the public and private sectors.
This plan will be guided in key guiding principles that
include personalization of care, market-based solutions, shared
public and private investment, and individually controlled
information as a common good for public health and research.
Given the importance of this topic, we must work with both the
internal and external stakeholders so that we can move forward
quickly.
The President envisions a nationwide health IT
infrastructure that ensures that appropriate information will
be available at the time and place of care, resulting in
improved quality, fewer errors, and perhaps even lower health
care costs. This new infrastructure will help connect
physicians, hospitals, and consumers. This would give consumers
and clinicians secure and controlled access to important
information that is needed to make informed decisions about
health care and their health while ensuring individual
information--individually identifiable information--is both
confidential and protected. If designed and implemented
correctly, health information-exchange networks could promote a
more efficient delivery system.
It will also help to improve coordination of care among
hospitals, labs, physician offices, and other health care
providers. For example, the national availability of patient
health information could allow a Medicare beneficiary with
multiple chronic diseases to receive the same high-quality care
at home or while traveling without needing to carry their
information. Many patients take multiple drugs or have
histories of drug reactions, but decentralized and paper-based
records often don't reveal this fully when needed. Regardless
of where a beneficiary is receiving care, health information-
exchange networks would allow for their information, medical
history, potentially serious drug interactions and other things
to be available in real time along with out-of-pocket costs and
therapeutic alternatives all before the physician transmits a
prescription to a pharmacy.
The national availability of de-identified patient health
information will also enable research on health outcomes that
can more rapidly identify the most effective diagnostic and
treatment options for clinicians and patients and will
accelerate the translation of new research findings into
clinical practice. I will highlight, today, HHS initiatives
that are critical in meeting our goal of making EHRs available
for all Americans. These initiatives relate to, first,
automating clinical practice; two, interconnecting care; and
three, improving population health.
Our efforts to automate practice have been focused on
identifying and implementing tools to accelerate the adoption
and use of EHRs and e-prescribing. At President Bush's
direction in the Executive order, HHS is preparing a report on
options to create incentives in Medicare for other HHS programs
that encourage the adoption of interoperable EHRs and e-
prescribe. Also the OPM is identifying similar options through
the Federal Employees Health Benefit Program. The VA and DOD
are also identifying ways to transfer technology into the
private sector, particularly for rural and underserved care
delivery areas.
The HHS is also working to implement the provisions of the
recently enacted MMA, including those to encourage e-
prescribing by physicians participating in Medicare through the
use of standards and incentives. This year, the Agency For
Health Care Research and Quality (AHRQ) will spend $50 million
on health IT research and demonstration projects that are aimed
at improving safety, quality, and efficiency. The AHRQ is also
taking significant steps to facilitate interconnecting care
through the support of five State-level health information-
exchange networks which will be announced in a few months.
Beyond improving health care delivery, improved health
information-exchange will allow new bio-surveillance
initiatives to tap ITs to improve the Nation's capabilities of
detecting and quantifying public health outbreaks in
bioterrorism. BioSense is one example of a new IT-enabled
program which will allow the Centers for Disease Control and
Prevention to collect and analyze existing health care data
quickly to identify potential outbreaks or health hazards and
to respond accordingly. The Secretary and the President are
committed to improving the safety and efficiency of health care
by increasing the use of IT. The Administration has made
significant progress in this area, and we will continue to work
diligently to meet the President's goal of EHRs within 10
years.
On July 21st of this year, we will hold the Secretary's
second Health IT Summit where we will report on the progress of
the Health IT Strategic Plan ordered by the President and will
obtain input from those in the private sector who will actually
develop and use these systems. Leaders from the government and
from the health care and IT industries will convene and work
together to identify specific actions that will lead to rapid
progress. We have an unprecedented opportunity to improve both
the delivery of health care and population health through the
effective use of IT.
Members of the Committee, I am committed to helping you and
others make and maintain our health care industry as a national
treasure. I thank you again for the opportunity to address you,
and I would be happy to answer any questions you have. Thank
you.
[The prepared statement of Dr. Brailer follows:]
Statement of David Brailer, M.D., Ph.D., National Health Information
Technology Coordinator, U.S. Department of Health and Human Services
Chairwoman Johnson, Representative Stark, distinguished members of
the Committee: I 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 is a highpriority
for the President and Secretary Thompson. The priority has been further
accelerated by the President's call to make electronic health records
(EHR) available to most Americans in the next 10 years and by the
creation of my position to achieve this goal. Your thoughtful
leadership and that of your subcommittee toward achieving this goal has
been widely recognized and demonstrated through the e-prescribing and
other health information technology (HIT) related provisions in
Medicare Prescription Drug, Improvement and Modernization Act of 2003.
As a result of the President and the Secretary's strong commitment
to this issue, the Office of the National Coordinator for Health
Information Technology has been established to meet the goals of the
Executive Order announced earlier this spring. In my new role as
National Coordinator for Health Information Technology, I will be
working with the Administration, Congress and the private sector to
bring together the resources and talent to drive the adoption of HIT in
the health care system. There is unprecedented enthusiasm and
commitment for changing the day-to-day world of health care with HIT
from leadership across sectors, and my goal in the next year is to
focus this into a well-developed plan and a set of coordinated actions
to accelerate the widespread adoption of electronic health records and
e-prescribing.
The Administration has already made significant progress in this
area. Specifically,
<bullet> Last year, we licensed SNOMED (Systematized Nomenclature
of Medicine, a comprehensive set of clinical terminologies) to make it
available without charge to everyone in the United States.
<bullet> As part of the Federal Health Architecture, we adopted
clinical terminology standards across federal agencies through the
Consolidated Health Informatics (CHI) initiative. The Department of
Health and Human Services (HHS), Department of Defense (DoD),
Department of Veterans Affairs (VA), and other Executive Branch
agencies have endorsed 20 sets of standards, such as standards for
medications, labs, and immunizations. These standards will make it
easier for information to be shared across agencies and could serve as
a model for the private sector.
<bullet> The Secretary created the Council on the Application of
Health Information Technology (CAHIT), which has been the coordinating
and internal advisory body for HHS. CAHIT has served as the primary
forum for identifying and evaluating activities and investments that
promote and/or complement evolving private sector initiatives and
strategies.
The Executive Order of April 27th not only created my position
within the new Office, but it also required the Departments and
agencies of the Executive Branch of the federal government to work
together to develop and align policies and programs that will achieve
our common goal of using HIT to improve the safety, quality and
efficiency of health care in every area of this country. I have also
been given the responsibility to direct the HHS HIT programs, and to
coordinate these with those of other Executive Branch Departments and
agencies. Specifically, HHS will coordinate with other Executive Branch
Departments and agencies to develop and implement a strategic plan for
and to use resources to accelerate HIT adoption in the private sector.
Both the DoD and VA have surpassed the private sector in successfully
incorporating HIT into the delivery of health care, and will play a
central role in adoption efforts. The Office of Personnel Management
(OPM), as the purchaser of healthcare for federal employees, has a
unique role and the ability to encourage the use of electronic health
records through the Federal Employee Health Benefits Program. It can
join other purchasers who are developing programs that support adoption
of HIT by physicians and hospitals, and its use in improving and
rewarding quality. In addition to collaboration with federal agencies
and Departments, I will also coordinate outreach and consultation by
the federal government with interested public and private
organizations, groups, and companies. We will coordinate with the
National Committee on Vital and Health Statistics and other advisory
committees to do this, and will enhance relationships with public-
private collaboratives that are advancing HIT adoption.
The President's vision is to develop a nationwide HIT
infrastructure that ensures appropriate information is available at the
time and place of care, resulting in improved health care quality,
fewer medical errors and may even reduce health care costs. This new
infrastructure will help to connect physicians, hospitals and consumers
in every location of our country. This would give consumers and
clinicians secure and controlled access to all the important
information they need to make informed decisions about their health and
health care, while ensuring individually identifiable information is
confidential and protected. Designed and implemented correctly, health
information exchange organizations could promote a more efficient
health care delivery system. They will also help to improve
coordination of care through the secure exchange of information among
hospitals, labs, physician offices, and other health care providers.
Health information exchange networks could be privately operated
and governed by many State, regional or community level health
information exchange authorities. These authorities would have
responsibility for protecting information and ensuring that data is
used to advance the public interest, and used in compliance with
applicable State and federal laws. Regional health information exchange
networks could keep indexes of where patients were treated and could
intercommunicate, but not create a national database. 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 to where needed,
immediately and securely. Information would only be accessible to
authorized users and aggregated at the individual patient level for the
time that it is needed, without being stored in a database. The purpose
of this information exchange would be to personalize care in such a way
that each patient could be diagnosed and treated as an individual
rather than a disease type. For example, the national availability of
patient health information could allow a Medicare beneficiary with
multiple chronic conditions to receive the same high quality care at
home or while traveling, without needing to carry their information or
fear that new findings or treatments may not be known to all possible
health care providers. Many patients take multiple drugs or have
histories of drug reactions, but decentralized paper records often do
not reveal this fully. 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.
The national availability of de-identified patient health
information will also enable research on health outcomes that could
more rapidly identify the most effective diagnostic and treatment
options for clinicians and patients and will accelerate the translation
of new research into clinical practice. Across HHS, there are several
inter-related HIT programs that are aimed at improving the delivery of
health care and enhancing public health surveillance. I will highlight
the key initiatives that are critical to meeting our goal of making
electronic health records available for all Americans. These
initiatives fall into three categories: 1) automating clinical
practice, 2) interconnecting care, and 3) improving population health.
Clinical Practice
Our efforts to automate practice have been focused on identifying
and implementing tools to accelerate the adoption and use of electronic
health records and e-prescribing. At President Bush's direction, in the
Executive Order, HHS is preparing a report on options to create
incentives in Medicare or other HHS programs to encourage the adoption
of interoperable electronic health records and e-prescribing, and OPM
will report on similar options for encouraging the adoption of such
technology through the Federal Employee Health Benefit Program. As you
know, HHS isalso implementing the provisions in the recently enacted
Medicare Modernization Act to encourage electronic prescribing by
physicians participating in Medicare through the use of standards and
incentives. The National Committee on Vital and Health Statistics has
already conducted two hearings and is expected to provide
recommendations on standards to the Secretary before September 2005,
the date specified in the new law. The Food and Drug Administration's
recently promulgated requirement for bar coding will also enable e-
prescribing in hospitals and will reduce the incidence of some forms of
medication delivery errors. Additional provisions of the Medicare
Modernization Act support demonstrations providing incentives for
physician practices to improve the quality and safety of care for
Medicare beneficiaries through effective implementation of selected HIT
systems, in up to four States.
In addition, HHS' Indian Health Service (IHS), with the help of
other HHS agencies, is developing an enhanced EHR system, a version of
the VA's VistA product, which can be used in IHS and tribal health care
facilities. The enhanced system will improve care for patients by
allowing appropriate information to be available whenever and wherever
they seek care within the IHS system.
This year, the Agency for Healthcare Research and Quality (AHRQ)
will spend $50 million on health information technology research and
demonstration projects aimed at improving the safety, quality,
efficiency and effectiveness of care. Using a portion of these
resources, AHRQ will establish a Health Information Technology Resource
Center, a much-needed resource that will provide technical assistance,
expert health information technology support, educational services and
other services to HHS grantees to support the implementation of HIT
into clinical practice. President Bush's fiscal year 2005 budget
request includes an additional $50 million to expand health information
technology demonstration projects, particularly targeted to health data
exchange by providers. This request would double federal investments in
this area.
We are also examining how to address regulatory barriers to HIT
adoption. HHS recently created a new regulatory exception to the
physician self-referral (``Stark'') prohibition, Section 1877 of the
Social Security Act, which will allow provider organizations to furnish
health information technology items or services to physicians if
certain criteria are satisfied. This new exception will facilitate
adoption of HIT and participation in local health information exchange
networks by assuring hospitals and doctors that they can work together
to finance the acquisition of community-wide health information systems
Interconnecting Care
Beyond fostering the adoption of electronic health records, it is
critical for HHS to support the appropriate exchange of health
information across settings of care as needed. Fundamental to
information sharing in nearly every form is the use of standards to
allow caregivers to easily share and use patient information. At HHS'
request, the international standards-setting organization known as
Health Level 7 (HL-7) has established a draft standard defining the set
of functions of an electronic medical record. HHS will continue to work
with HL-7 and others to define standards for transmitting complete
electronic health records.
HHS has already adopted strong national privacy and security
standards for health plans, health care providers and others covered by
the Health Insurance Portability and Accountability Act of 1996
(HIPAA). These standards, which are carefully balanced to ensure
individuals' access to quality care, will guide the development of a
national health information infrastructure and form the basis of the
safeguards to protect the privacy and confidentiality of personal
health information. As both the President and Secretary Thompson have
made clear, maintaining privacy and security protections for
individually identifiable health information is a primary concern as
health information exchange organizations are developed across the
country.
In addition to the important work and progress we have made in the
development and adoption of clinical and technical standards, we have
also taken significant steps recently to facilitate interconnecting
care through the support of health information exchange networks. Over
the next few months, AHRQ will fund five State-level HIT projects. This
project will build on nascent health information exchange networks and
current State-level planning activities by providing crucial funding,
technical assistance and coordination. In fiscal year 2005, HHS and
AHRQ will continue to complement and expand these initiatives with up
to $50 million to support the development of health information
exchange networks.
Improving Population Health
HHS has new HIT programs underway to advance the use of electronic
medical records nationally. This effort should also benefit population
health activities and improve preparedness. President Bush's fiscal
year 2005 budget proposes $130 million at CDC for a new biosurveillance
initiative to tap information technology to improve the nation's
capabilities to detect and quantify public health outbreaks and
bioterrorism, as part of a coordinated multi-departmental effort. Key
to this effort is BioSense, which will allow CDC to collect and analyze
existing health-care data quickly to identify potential outbreaks or
health hazards and respond accordingly. Information then could be
shared quickly with other federal agencies and State and local health
officials to promote more effective coordination. CDC also supports the
National Electronic Disease Surveillance System, which promotes the use
of standards to advance development of efficient, integrated and
interoperable surveillance systems at federal, State, and local levels.
In addition to these activities, HHS is taking a leadership role in
promoting and supporting the widespread adoption of HIT through: (a)
providing a national vision; (b) leading by example; (c) developing a
framework for strategic action; and (d) planning initiatives to promote
competition and innovation. The strategic plan that HHS will develop in
collaboration with DoD, VA, and OPM, to accelerate HIT adoption in the
private sector, will be grounded in key guiding principles including:
1) personalization of care, 2) market-based solutions, 3) shared public
and private investment, and 4) individually controlled information as a
common good for public health and research.
We will coordinate with the private sector to develop market
institutions that will enable the widespread use of EHRs and
sustainable health information exchange networks to improve delivery of
care and health outcomes. For example, we are exploring how to support
physicians and other purchasers of HIT so that they can choose
technology that meets their needs and assess costs and benefits. Also,
we are looking at how the private sector can measure and report the
conformance of specific products to a defined set of benchmarks. These
and other market institutions will make our national investment in HIT
effective and sustainable and will ensure ongoing investment in product
research and development.
We are aware that every day, Americans are dying of medical errors
and are not always getting the best treatments. We need results that
will change care delivery and that will last. The Secretary and the
President are firmly committed to improving the safety and efficacy of
health care by increasing the use of information technology throughout
the health care industry. The Administration has already made
significant progress in this area, and we will continue to work
diligently to meet the President's goal for most Americans to have
electronic health records within 10 years.
On July 21, 2004, we will hold the Secretary's Second HIT Summit,
where we will report on the progress of the HIT Strategic Plan ordered
by the President and obtain input from those in the private sector who
will actually develop and use the HIT systems. Leaders from the
government and the health care and information technology industries
will convene and work together to identify specific actions that will
lead to rapid progress. Overwhelming support from leaders in the public
and the private sector presents an unprecedented opportunity to improve
both the delivery of health care and population health through
effective use of HIT.
Members of the Committee, I am firmly committed to contributing
what I can to helping you and others make our health care industry a
national treasure. I thank you again for the opportunity to address you
on this important health care matter. 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.
<F-dash>
Chairman JOHNSON. Thank you very much, Dr. Brailer. Dr.
Kolodner.
STATEMENT OF ROBERT M. KOLODNER, M.D., ACTING CHIEF HEALTH
INFORMATICS OFFICER AND DEPUTY CHIEF INFORMATION OFFICER FOR
HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS
Dr. KOLODNER. Thank you very much, Madam Chair and Members
of the Subcommittee. Good afternoon. I am pleased to be here to
share VA's experience with the development, implementation, and
clinical acceptance of our EHR, VistA. The VHA encompasses
about 1,300 sites of care, including 158 hospitals and over 850
community-based outpatient clinics as well as long-term care
facilities. The VA treats almost 5 million veterans each year
among our 7.5 million veteran enrollees. Our veterans tend to
be older, sicker, and poorer than age-matched individuals.
VistA supports all of this. The VA is a leader in the world
of EHRs. The very prestigious Institute of Medicine recognized
that leadership by stating that VHA's integrated health
information system, including its framework for using
performance measures to improve quality, is considered one of
the best in the Nation.
The VA has implemented health IT extensively to improve the
quality and safety of its medical care while protecting the
privacy of our veterans. VistA began as the decentralized
hospital computer program and became today's VistA in the mid-
nineties. Our next generation VistA will be HealtheVet-VistA.
Our publicly available version of VistA is HealthePeople-VistA.
The VA's VistA is a comprehensive EHRs system installed
nationwide and supporting patient-centered care. Let me
describe a few key components. First, the Computerized Patient
Records System (CPRS) is recognized as one of the most
sophisticated clinical applications in the world, providing
immediate access to shared information and eliminating
duplicate orders. The CPRS has been implemented in all VA
medical centers, nursing homes, and clinics, giving providers
access to patient information across multiple sites and
clinical disciplines.
The CPRS virtually eliminates errors caused by ineligible
handwriting and misinterpretation of dosages and strengths or
medication needs because 93 percent of all VA medication orders
are entered directly by the ordering provider in all care
settings. Moreover, physicians are immediately alerted to
potentially dangerous drug combinations or to a patient's
allergy to a drug before they can key the order because of
built-in automated drug checks.
Second, the Bar Code Medication Administration system
ensures that each patient receive the correct medication in the
correct dose at the correct time. Third, CPRS is further
enhanced by VistA imaging, which is also in use at all VA
medical centers and provides the means to capture and display a
wide variety of images to the physician. Fourth, VA has
developed My HealtheVet, a secure web-based personal health
records system designed to provide veterans key parts of their
medical record and access to medical information.
What benefit has the EHR helped bring? Decision support
tools have facilitated the treatment of chronic disease and
delivery of preventative care. Comparing VA patient care
quality data from 2003 with Medicare data from 2003 and with
the best reported performance of any other health care system
in the United States, VA care sets the benchmark for every 1 of
18 clinical performance indicators.
VistA has helped to make this happen and provide the
confirming data. At VA, we know that the support and input of
clinicians is essential to the successful deployment of EHRs
systems. This involvement increases user acceptance and enables
us to meet the needs of the providers, teams, clinics, wards,
and medical facilities.
Over the past 20 years, VA has developed an effective,
repeatable process for successful use of clinical applications.
The VA is now working with the Centers for Medicare and
Medicaid Services (CMS) to stimulate the broader adoption and
effective use of EHRs in the United States. We both strongly
encourage the use of high-quality private vendor EHRs.
Further, CMS and VHA are collaborating on making available
a VistA-Lite version of VA's VistA system. VistA, that is owned
by the American taxpayer and has been freely available via the
Freedom of Information Act (P.L. 104-231)--the Indian Health
Service is using it. For anyone who wants to use it, VA will
continue to make available its public version, HealthePeople
VistA.
Secretary Principi has clearly stated that will continue to
be VA's position. This position is strongly supported by
congressional Members on both sides of the aisle and by the
President and Secretary Thompson. In VA, the EHR is essential
to effectively caring for our veterans. Today, we are working
hard on improving data quality and standardization. In 2001, to
ensure our future, we began building our next generation
system, HealtheVet-VistA.
[The prepared statement of Dr. Kolodner follows:]
Statement of Robert M. Kolodner, M.D., Acting Chief Health Informatics
Officer and Deputy Chief Information Officer for Health, U.S.
Department of Veterans Affairs
Madam 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 clinical disciplines. CPRS provides a
single interface through which providers can update a patient's medical
history, submit orders, and review test results and drug prescriptions.
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 latest 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, and faster and more reliable for finding items of information
providers are seeking, such as the results of a specific type of
laboratory test over a period of time.
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,
national infrastructure 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.
Without data standards, we might be able to exchange health
information, as we do now when we copy and send paper records, but we
won't be able to use it as effectively 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 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.
A 2001 article in the Journal of the American Medical Informatics
Association described VHA's efforts to speed retrieval of clinical
information, by creating a controlled terminology for indexing the
information stored in CPRS.\1\ This collaborative effort among
clinicians, informaticists, and health information management
professionals will improve document selection, and support the ability
to transfer and incorporate documents from other facilities.
---------------------------------------------------------------------------
\1\ Brown, Steven H., MS, MD, et. al. ``Derivation and Evaluation
of a Document-naming Nomenclature.'' Journal of the American Medical
Informatics Association 8, no. 4 (2001): 379-389.
---------------------------------------------------------------------------
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,
including the Privacy Act, the HIPAA Privacy Rule, and several agency-
specific authorities, safeguards have been implemented to ensure that
the privacy of individuals is protected throughout these collaborative
projects.
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 global 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.
The EHR Plan will guide VA and DoD in the joint development of a
``virtual'' health record accessible by authorized users throughout DoD
and VA. This virtual health record 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.
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 the
virtual health record. 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. These data include
DoD admission/discharge/transfer (ADT) information, laboratory
information, radiology, discharge summary and cytology reports, allergy
information, consultation reports, prescription data from government
and retail pharmacies from the DoD Pharmacy Data Transaction Service
(PDTS), and outpatient associated medical codes extracted from the DoD
Standard Ambulatory Data Record (SADR). 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.
This project, known as ``CHDR'', will demonstrate the bi-directional
capability to exchange pharmacy and demographic data in a prototype in
2004, and will achieve interoperability by 2005. 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 are currently developing a final architecture for the
electronic interface between the agencies' health information systems.
We also have implemented a joint project management structure that
includes a single Program Manager from VA and a single Deputy Program
Manager from DoD. This structure ensures joint accountability and day-
to-day responsibility for project implementation. Developing the
technology to support the exchange patient health care data and the
creation of an electronic medical record for both veterans and active
duty personnel is a priority for VA. We believe that the plan being
pursued, although challenging and complex, will provide the necessary
flexibility while achieving the desired interface between VA and DOD.
VA and DoD are optimistic that as a result of the improved
collaboration between the two departments in these joint IT
initiatives, both 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-Lite
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, 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-Lite'' version of VA's VistA system. VistA-
Lite will be designed specifically for use in clinics and physician
offices. In developing VistA-Lite, 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-Lite 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-Lite 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-Lite project and the
response has been favorable.
The VistA-Lite 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-Lite 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>a.3</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>a.3</SUP> EHR Special Interest
Group, which manages this initiative.
The HL7<SUP>a.3</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>a.3</SUP>
EHR model will enable HHS and others to qualify EHR systems in terms of
completeness and readiness for adoption.
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.
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 herbs, 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 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.
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 physicians and patients
that is at the core of the art of medicine.
The President recognized America's medical 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.
<F-dash>
Madam Chair, this completes my statement at this time. I
would like to give a brief demonstration of the VA EHR. On the
lap top next to me, I actually have a copy of the complete
VistA system running on the laptop.
[Demonstration.]
It is not only the operating system and the complete
medical record but also the imaging record, as you will see
very shortly. We would log on to the system. In a normal
system, we would have password protection. We then have, on the
front sheet, any alerts that are specific for patients that I
am responsible for. I can choose a patient, and then a cover
sheet is opened which provides me a quick summary of a patient
with lots of information where I can drilldown, for example,
for information on their medications or allergies or other
items.
I can also look at vital signs and very quickly can go
ahead and see a graph of their blood pressure over time, and
very often, we go ahead and turn the terminal to the patient
and talk with them about either changes in their blood pressure
or in their weight. Now, the information that I have here is
actually real patient data. We have scrambled the identifying
information to protect privacy, but the data that you will see
here is real clinical data.
Mr. Madliff is a patient who came to see us. One other
thing that I want to show is that we use this chart so you have
tabs across the bottom of the screen, so it looks like the
chart doctors are used to using within the medical center. Many
of our medical centers already are essentially paperless
because they don't need to pull the paper chart because all the
information is at the finger tips of the providers.
In this case, I am going to look at the laboratory results
from Mr. Madliff. In looking at a complete blood count, we will
open that up, get all the results, and then go ahead and grab
his results. What I want to look at in particular is Mr.
Madliff's hematocrit or his red blood count. What you see here
are some dramatic drops in a very short period of time. What
these represent are severe bleeding episodes. If we look very
carefully, we can go ahead and expand this area and see that,
in fact, there are a lot of results in a short time that
probably occurred with an inpatient hospitalization. We see a
gradual drop followed by a rapid rise. Those represent
transfusions of blood cells because of the anemia that Mr.
Madliff had.
In order to find out what was going on and how we could
help him, we took Mr. Madliff to have a colonoscopy because,
very often, a gastro-intestinal (GI) bleed is a very common
cause, and in fact, we can capture the picture that shows that
Mr. Madliff had diverticulitis. On another particular image
that was captured during the colonoscopy, we actually see there
is actual bleeding in the colon. So, this gentleman did, in
fact, have a GI bleed. In order to diagnosis where that bleed
was, we often do bleeding studies or bleeding scans. So, this
is an example where the patient was injected with some dye, and
then we looked to see where bleeding is.
This was done several years ago, and this was a film that
was taken. Our providers put it up to the light box, couldn't
find where the bleeding was, so an industrious physicians
assistant took it over and scanned it to what was then a new
imaging system. Brought it up. Once they had it up, they were
able to go ahead and zoom in on it and change some of the
backgrounds so they could look at different parts of the x-ray.
Out here in the periphery, they saw something that looked a
little bit suspicious. By reversing it, they were able to see
an area out here that was a fuzzy area and that represented the
area of the bleed. So, they were able to locate very quickly,
using this automated system, where the bleed was.
Let me go ahead and show you one other patient so I will
change to a different patient, in this case Mr. Green. Mr.
Green has a different problem, which is to be expected. If we
look at the progress notes, we see that there is a cardiology
note that was made. We can open up that cardiology note, and
there is the text note but, along with that, a number of images
are open. In this case, it represents cardiac catheterizations,
and we can in fact see the cardiac catheterization of Mr.
Green. We can show him here is an area that represents why you
are having chest pain, this narrowing of the coronary artery.
Following that, we can actually continue with the procedure
and, using a coronary angiography, can actually show the
balloon in his coronary artery, but more importantly, when it
is all done, we can go ahead and look at what was the result of
the procedure, including that the area that was once
constricted is wide open. Obviously, showing this to the
patient, being able to turn and say, ``Here it is, you did have
this problem, here is how we treated it, now we have taken care
of the acute problem, now we need you to take your medicine and
to follow a better diet and we will be working closely with
you.''
This then, as you can see, is an alternative to what we
normally have which is a set of charts. In this case, we have
five charts. The average in VA is 2.5 charts. Some of the
patients with chronic conditions can actually have a ton of
charts. Trying to find a particular blood count in this is
almost impossible. Trying to see a pattern so you can see the
two or three episodes of bleeds is obviously impossible, except
for the way we usually do it in medicine which is we get a
medical student to go through the chart and by hand manually
graph the results. So, that ends my demonstration. I will be
available now for any questions that you might have.
Chairman JOHNSON. Certainly is dramatic to see how you can
track information from year to year and visit to visit in a way
that you simply couldn't if you had to go back and pull that
all out of a paper record. When you are able to show a patient
such a change in their status, do they take their medicine more
regularly thereafter? Do you have any research that shows
greater compliance because they understand the problem better
and what was done?
Dr. KOLODNER. We have a number of things that we are doing.
In particular, rather than being able to isolate whether the
patient is more compliant by showing them their data, we have
the decision support and the reminders that are part of helping
us to practice better care. The table that I showed a little
bit earlier, has that result on these various indicators having
to do with beta blockers after heart attacks, the rate of
pneumo vacs, or vaccine. In fact, for the pneumo vacs vaccine,
our rate now is 90 percent. That sounds pretty good until you
then also add we have about a 9-percent refusal rate. So, we
have essentially either immunized or gotten a refusal from all
the patients who should be receiving pneumo vacs in the VA. By
using the reminders and getting them even more engaged with
personal health records, we think that that will make it an
even more beneficial factor for our veterans.
Chairman JOHNSON. Thank you. That was very interesting. Dr.
Brailer, I wanted to pursue this issue of the national
perspective on this issue, what is meant by a national health
information infrastructure, just kind of as a starting point.
The witnesses on our second panel, they will attest to the fact
that, currently, there are a number of very innovative projects
going on in the private sector that expand the use of IT, in
one case in Indianapolis, in another case in a system, Kaiser.
As entities are developing such systems independently and
demonstrating the power of them, what is your role and what is
the relationship between these independent actions and the
development of a national health information infrastructure?
Dr. BRAILER. Thanks for the question. I think we have
multiple roles to play. First, you are seeing the early
adopters, communities, States, regions, who, for reasons of
their own leadership, the market that they have, various other
factors are moving ahead of many other regions. I think our
role with them is to be supportive and, honestly, to learn from
them so we can take the lessons that they have, incorporate
them into policy and do research and advice for other regions.
As we think about the mainstream of America, I think we
can't rely on this early adopter effect to take us where we
need to go. Therefore, I see really three types of roles that
we need to play: first, to provide the Federal actions that can
support these local communities, and that could include looking
at our rules, our regulations, our other policies to ensure
that they are able to do what they are doing. An example is the
change that was released in the MMA that created the waiver to
the Stark amendment that allowed community organizations to
support investment. There are many other things like that.
Two, these regions need to have seed money, startup funds
to be able to work through very complicated business technical
privacy issues and to derive many of the factors of support
that are needed locally. The grants and other things, money
that will be available in the 2005 budget and beyond that,
clearly are supportive of that.
Thirdly, there are technologies, there are pieces that are
necessary to support regions. Some are local, and some are
national. Some of the technologies are available now; some are
not. Some are available, but they are not very cost-effective.
I see a national role in helping bring together some of the key
technologies that are needed to allow a State or a regional
area to be able to develop their own infrastructure.
So, in the end, we may not have as clean of a model as
Britain, where it is a very hierarchical regionalized system,
but I think we will have a Federal role that consists of laws
and rules, technology support, and if you would, some of the
financial underpinnings and then regions that could vary how
they deploy this within some boundaries that have governance in
oversight in what they are doing, have technology deployment,
and the real human components of helping physicians and other
components of the industry, consumers being able to actually
make use of these technologies to deliver the results that we
want.
Chairman JOHNSON. In some of the areas of the country, the
private sector initiatives are very dramatic. They are big.
They are comprehensive. Do you have any concern that they will
develop solutions that then are not interoperable?
Dr. BRAILER. Oh, I am very concerned about solutions being
developed that are not interoperable. I think, in many ways,
today a regional enterprise or a hospital system faces a choice
between, do we move forward without complete interoperability,
or do we wait on all the ingredients? One of the key factors we
have to do is complete the efforts the Secretary started around
the Consolidated Healthcare Informatics Initiative efforts to
promulgate standards. The effect of any movers waiting on us to
promulgate standards is a very negative factor in adoption.
Beyond that, these regions have many other barriers that we
face, some of which are out of our control to be able to move
that forward.
Chairman JOHNSON. Let me just pursue one other question,
and we will go back and forth here. To what extent are the
pieces out there, like SNOMED and things like that, beginning
to build a national structure? What is the timeframe for you
and whoever else to come to a conclusion about standards so
that we can guarantee that what happens will be interoperable?
Dr. BRAILER. I think we have three stages of standards. We
are very late in the first phase. That is to agree on what the
standards are. This is standards that exist in paper that we
agree on. There is still a large variation in the
implementation of those standards. The second phase is to have
common references for actual implementations. The companies
that build these products actually incorporate software into
their product that reference these. Third, is to create the
work flow and the actual human factor changes. We have SNOMED
as a standard, but if we are not able to incorporate that into
the daily work of a physician, we won't capture data that is
SNOMED compatible.
I think we are crossing over the last phase with a few more
standards and very much approaching the phase of reference
implementation and then the phase of adoption into standard
practices. I think this can be done, the next phase, in the
next year or two at the outside and then overlapping another
year or two into the other. So, I would think, in a short
number of years, we should be able to be through this standards
phase into a very mature, very fully deployed and highly
referenced standards effort.
Chairman JOHNSON. Thank you very much. Mr. Stark.
Mr. STARK. I thank the witnesses very much. Let my just
start out, this will sound more negative than I hope where we'd
end up. In 30 years, I have seen and heard suggested a variety
of standardized ideas in terms of either prescribing drugs or
hospitals having standardized accounting systems or physicians
having standardized patient records. Guess what? We have no
agreement 30 years later in how these things should be done.
My guess is that, if I was going to be around here 30 years
from now, if we let people just fuss around with that--it seems
to me, the last time CMS and the Health Care Financing
Administration decided to redesign so we would have a uniform
reporting for all the intermediaries, because we had 70 or 80
different computer systems, and guess what, they went out and
left contracts with 8 different contractors and none of the new
systems could interface with the others. So, what, we went from
70 systems that couldn't talk to each other to 8 that couldn't
talk to each other. That is where my sense is that we are
today. I can't quote that, quarrel with that. In many cases,
there is a sense of professional pride, I suppose, among
individual providers, physicians. There is a sense of
entrepreneurial intellectual property, in terms of people who
may have certain procedures or ways of operating their
businesses or developing their drugs that they don't want
anybody else to find out. Many of those things would be
reasonable excuses.
I don't think there is any disagreement that, if we don't
get some kind of reasonable database outcomes research, we
aren't going to make much progress in the ever more technical
field of delivering medical care. So, with that, as a
background and because we are dealing now in a governmental
forum and recognizing that this may prejudice the free market,
free enterprise, we did it in physician reimbursement, for
better or for worse. The government pays about a third,
probably a little more of all the medical care that is
delivered in this country. Pretty much directly. I am not
including what the States do, but Federal government pays about
a third.
When this Committee determined how we would reimburse
physicians under Medicare, again, guess what, most of the major
insurance companies in the private sector followed suit,
applied their own index to it, and it has become, for better or
for worse, a standard among major payers. I don't know how
much. So, my instinct is to say, this isn't ever going to get
any better unless we give Dr. Brailer some legislative
authority, which I don't think he has at all, and say, ``Doc,
in 6 months, you have got to come up with a standardized
patient records form.''
Then I would follow the question--I would ask my colleague,
Dr. Gingrey, if he would get in on this as well--``Is there any
reason that any of you physicians couldn't practice medicine
based on Dr. Kolodner's system? Maybe you would like it a
different way, but is there anything there that would effect
the practice of medicine as we know it?``
If we just said that is what it is going to be, there may
be better systems but in an effort to get there, to get moving
on it, and it may be somebody else's system--we will hear from
Kaiser and others today who are trying to do it. If we pick the
system and said, now the only way we enforce it is say, ``This
is how the Federal government intends to pay for Medicaid and
Medicare,'' we can't tell Blue Cross and we can't tell Aetna
what to do, but my guess is we would move people toward a
standard version. Please, we have some people who are
professionals at this. I would ask the two witnesses. Could we
do that?
Mr. GINGREY. Representative Stark, you asked me to respond.
I appreciate that. I think the answer is, I can't think of any
reason why we shouldn't, couldn't do that. I think it would
make the practice of medicine much safer, much more efficient.
You have already discussed the reasons why and what Dr.
Kolodner presented to us here, what they are doing in the VA
and, as you pointed out, at the very outset, the MasterCard and
Visa card, why you couldn't actually take that information and
put it on a little wallet-size card like that so that, not only
would it be on a hard drive somewhere or from State to State,
but the patient actually could carry it with them. Clearly, I
think Representative Stark is correct, that we not only could
do it, but we should do it. I hope it doesn't take 10 years to
get there.
Chairman JOHNSON. We opened it up. Mr. Camp.
Mr. STARK. I was going to ask Dr. Brailer how long it has
been since you may have practiced, but could you practice with
that kind of a gizmo or whatever it is?
Dr. BRAILER. Well, first, it has been 2 years since my last
patient contact, but as the father of a 3-year-old, I have
patient care for my son frequently.
Mr. STARK. I know the problem.
Dr. BRAILER. I actually used my first electronic medical
record when I was a resident and rotated through the VA. It was
not a system quite this elegant. I want to say, thanks for
improving it, Rob, because the one I used was great but not
this good. I think we need to recognize, Congressmen, that the
market exists on a broad spectrum. Today, there are physicians
who are adopting these tools and using them. There are some who
are sitting at the press of this, others who are being more
studied and, in the end, others who will go to their deaths
without knowing this.
They are doing that for a variety of reasons, many of the
ones you described. They are cultural factors. There is fear of
technology, although I find that to be really remarkably less
than constantly stated. There is something that I think is true
with all of this, and that is that one solution that works for
those that are sitting on the edge--they really need a little
bit of a nudge and some help--is not the solution for those
that are sitting with some recalcitrants.
My concern with having kind of a big program that pushes
this is we could be quite inefficient with resources for those
that don't need a lot of help, and it could be ineffective for
the others. That is kind of the core of this. Many physicians
who have tried to do this have failed. The failure rate of
implementation is quite high. I would be concerned if we pushed
or reimbursed our way to physicians doing this that we might
increase the failure rate. It is not because of bad technology.
It is because this is so intrusive to the workload. My
particular concerns are one-man and two-man practices----
Mr. STARK. Take old geezers like me, who come to technology
slow, but my kids, who may be doing fourth grade work on the
computer, you will get to that point, can learn. It seems to me
that, if the system is there, in a way, I guess you could make
exceptions for those who choose not to participate at all, but
for those who do want to learn, if we allow a multiplicity of
systems without any common language and coordination, we won't
ever make the change. So, in medical schools, if they all
started using the system, and those like you youngsters who
like this stuff, and understand it, the nerds of the medical
profession, as it were, you guys could pick up on it. Your
parents would just have to miss the fun of practicing medicine
on the Internet. I don't know. I will give up.
Chairman JOHNSON. Dr. Brailer, I will give you a yes-or-no
answer. We have one more person to question. There is the next
panel. There is another Subcommittee that starts meeting at
4:00. So, I want everyone to at least hear the testimony. You
want to respond briefly.
Dr. BRAILER. I don't know if I can say yes or no to such a
detailed and thoughtful question. I would argue this: that
there are factors of readiness in practices and in the market
that need to be put in place as investment flows. Those factors
that might include helping reduce the failure rate of
implementation by helping physicians purchase systems that meet
their needs, being able to evaluate and certify that products
meet the claims that are made so we will be able to know what
kinds of products they are, being able to help physicians with
implementation, actually changing the way their practice
operates so that those tools which tip off these changes don't
tip off calamities in terms of negative results. I think these
readiness factors need to exist in the milieu where investment
from private sector and others is made--that is where we are
concentrating on this--that make sure we have multiple
pathways.
Mr. CAMP. Thank you Madam Chairman. Dr. Brailer, I
appreciate both of your testimony, but my question is,
expanding technology for technology's sake is fine, but I am
very interested in, obviously, the increase in quality and
attempt with that increase in quality to also keep costs down.
Obviously, I have seen a lot of the advantages of the new
technologies in the medical field because, obviously, with
three children, I probably am a three-time user of the health
services. It just seems to me that simply technology for
technology's sake is not the goal. The goal really ought to be,
how does technology increase quality of care and, at the same
time, keep costs down. If you could just briefly comment, I
would appreciate it.
Dr. BRAILER. Thanks for the question. I think that is one
of the core issues. We are leaving a phase where there has been
an enlightenment with technology but forgetfulness about why it
is important. Just to summarize a few key points. There is very
good evidence that IT, when used in hospitals and physicians
offices can deliver the kinds of results that Dr. Kolodner
described consistently. Those results include reducing errors,
being able to comply with evidence that is stated and accepted
as the normal practice, being able to improve preventative
care. That evidence, I think, is overwhelming to the point
where I would take the view that we usually think of IT as a
form of therapy, that it is not different than perhaps giving
drugs or doing other things because it does consistently lead
to that result when used correctly. The issue is how to make
sure that it is used correctly.
Its ability to save money comes from the evidence that it
can reduce inappropriate care or non-value-added care or change
the overall environment of chronic care management in the
industry where each physician in their practice or each
hospital is not able to render longitudinal services. So, I am
quite optimistic about that and think the record is relatively
strong in both academic science and in field experience, which
is why I think we are here at the fore, being able to push this
forward.
Chairman JOHNSON. Thank you. Thank you both. This
discussion was very useful because I think, as you say, Dr.
Brailer, this completely changes the way an office works and
also the way it thinks about its work. So, it is very important
that we provide assistance, and as the two of you leave,
because we really want to get on to the other panel--and thank
you, Dr. Kolodner, for that excellent--I had no idea actually
that it could integrate the information from so many years of
charting and allow to you go deeper into x-rays like that. That
is excellent.
I think this so profoundly changes the way an office looks
at health information and its relationship to the patient. It
is very important that, not only we look at this issue, what is
it costing, where do we get the money, because so far, some of
the change is being funded by either health plans who could
afford to invest or the government. I think we have to take
seriously, what does it cost?
The thing that hasn't been discussed that I think is just
as serious is what kind of support do you give two--or three-
man practices or two--or three-women practices to help them
learn how to use this and be there periodically when they are
having trouble. Because we see, over and over again, those
difficulties in our own offices as we have to make systems
change.
Thank you very much for being with us. I will move on to
the other panel so that all Members will be able to hear all
the testimony. Then we will move on to questions in the second
panel. Dr. Safran; Janet Marchibroda of eHealth Initiative;
Marc Overhage; and Andrew Weisenthal, Dr. Weisenthal of Kaiser
Permanente. We will start with Dr. Safran, the President of
American Medical Informatics Association of Bethesda, Maryland.
Dr. Safran.
STATEMENT OF CHARLES SAFRAN, M.D., PRESIDENT, AMERICAN MEDICAL
INFORMATICS ASSOCIATION, BETHESDA, MARYLAND
Dr. SAFRAN. Chairman Johnson, Ranking Member Stark, Members
of the Subcommittee on Health, thank you for your leadership
and for the opportunity to appear before you today. These are
very promising times for the widespread application of IT to
improve the quality of health care while also reducing costs.
In my comments, I especially want to note the importance of the
resource that is most often underutilized in our approach to
information systems: our patients.
My name is Charles Safran, I address you today as the
President of the American Medical Informatics Association, the
association of physicians and nurses and health professionals
that has long been the primary force in the innovative use of
IT in health care. We are focused on linking the fields of
health IT with its users, health care professionals and its
ultimate beneficiaries, our patients. I am a primary care
physician on the faculty of Harvard Medical School. I am also
CEO of Clinician Support Technology (CST), a small business
developing Internet-based collaborative health care to empower
consumers to be more effective participants in their own care.
Health care is information-intensive, and billions of
dollars have already been spent on health information systems.
All too often, the result has been digital islands of data that
have not provided real benefit for clinicians and their
patients. By contrast to the usual fragmented department-by-
department approach to information management, a few
integrated, highly functional clinical computing systems have
emerged.
In 1993, the American Medical Informatics Association
termed these systems patient-centered. What distinguishes these
systems was that patient care, not cost accounting or billing,
was the mission. The systems were designed for clinicians by
clinicians. These systems, in Boston, Indianapolis, Salt Lake
City, New York City, Nashville, and elsewhere, are national
models for patient safety, e-prescribing, EHRs and community
information systems.
There is no question that EHRs improve patient care. There
are many studies to prove this, but why has adoption been slow?
Why do we rely too much on sneaker wear, asking patients and
their families to carry medical records and reports across the
boundaries of our fragmented health system? The answers to
these questions are complex and include significant constraints
of managed care and misaligned physician incentives, but in
large measure, it is people and policies that have created the
barriers, not technology. I would argue, informed people,
especially informed patients, and enlightened policies can
overcome these barriers.
CST Baby Care Link, which I helped to develop, is an
Internet technology that empowers parents to participate in the
care of a sick child which, in turn, improves care and lowers
costs. Baby Care Link is designed for parents who may never
have used the Internet. It delivers just-in-time information to
help patients navigate complex health care systems.
In a recent report to the State of Colorado, which funds
Baby Care Link through a public-private partnership with the
generous support of Johnson & Johnson, parents who frequently
use Baby Care Link took their infants home from the neonatal
intensive care units 2 weeks sooner than families who were less
frequent users. The benefit from Medicaid's parents was even
greater. At Stroger Cook County Hospital, Baby Care Link has
literally stepped over the digital divide, providing new tools
for clinicians and their parents to communicate, collaborate,
and coordinate the care of fragile newborns.
I want to bring up four areas of focus where I think this
Committee and our government can have some impact. First, we
need to train a new generation of physicians, nurses, and
health professionals to lead the development, selection, and
implementation of patient-centered health information-systems.
We should require accreditation of informatics training
programs just as we required the accreditation of other
clinical specialties. Second, government can help foster a more
open and efficient marketplace by funding an independent
national resource containing research evaluations and business
outcomes related to health IT. Simply, it is a database of what
works and what doesn't work. Third, we need to make the
availability of IT a priority for underserved populations to
improve communication and coordination of their care needs. We
should not use the digital divide as an excuse for avoiding the
hardest health care problems.
Last, we should turn our focus from the hospital and the
physicians office toward the home. While good hospital
information systems and EHRs are a necessity, I believe that
the personal health record, a lifelong electronic repository of
health information controlled by the patient, will make a key
evolutionary step toward a new health paradigm that is truly
patient-centered.
In our country, patients are the most underutilized
resource, and they have the most at stake. They want to be
involved, and they can be involved. Their participation will
lead to better medical outcomes at lower cost with dramatically
higher patient and customer satisfaction. We should remember
that the real goal of improved health information systems is
not better hospitals or better physician practices but better
quality of care and healthier citizens. Thank you for allowing
me to speak today. I will be happy to answer questions.
[The prepared statement of Dr. Safran follows:]
Statement of Charles Safran, M.D., President, American Medical
Informatics Association, Bethesda, Maryland
Chairman Johnson, Ranking Member Stark, members of the Health
subcommittee: thank you for the opportunity to appear before you today.
These are exciting and very promising times for the widespread
application of information technology to improve the quality of
healthcare delivery, while also reducing costs, but there is much yet
to do, and in my comments I want to note especially the importance of
the resource that is most often under-utilized in our information
systems--our patients.
My name is Charles Safran. I address you today as President of the
American Medical Informatics Association--AMIA--the association of
physicians, nurses and health professionals that has long been a
primary force in the innovative use of information technology in
healthcare. We are especially focused on linking the field of health
information technology with its users--health care professionals--and
its ultimate beneficiaries, our patients. I am a primary care physician
on the faculty of Harvard Medical School and on the staff of the Beth
Israel Deaconess Medical Center. I am also CEO of Clinician Support
Technology, a small business developing Internet-based Collaborative
Healthware to empower consumers to be more effective participants in
their own care.
Healthcare is information intensive, and hospitals in the United
States have spent billions of dollars to computerize everything from
the billing office to the laboratory, pharmacy and radiology
departments. But too often the result has been hospitals with digital
islands of data. Today when a health system announces a $100 million 5-
year information technology implementation plan all too often it is
talking about replacing data systems that can't talk to each other--and
that have not provided real benefits to clinicians or their patients.
Let me mention one example of the impact of information systems
that keep clinical data in separate silos. A well-known hospital
implemented a physician order-entry system with considerable fanfare--
which within weeks resulted in a physician revolt and the firing of the
CIO. The order-entry system was state-of-the-art, but it failed at one
high volume, clinically critical moment--when a patient was admitted
from the emergency room. It turns out that the ER departmental system
did not talk to the hospital admitting system. Patients needed to be
re-registered in the hospital system, a process that could take 30
minutes to one hour. To a clinician, an hour delay in writing a
critical care order was simply unacceptable.
By contrast to the usually fragmented department by department
approach to information management, some hospitals, like the Beth
Israel Deaconess Medical Center in Boston, LDS Hospital in Salt Lake
City, Columbia Presbyterian Hospital in NYC, and Vanderbilt Hospital in
Nashville, have had highly integrated and functional clinical computing
systems for decades. In 1993, the American Medical Informatics
Association termed these systems Patient-Centered. What distinguished
these information systems was that patient care--not cost accounting or
billing--was the primary mission, and the systems were designed by
clinicians for clinicians. In a Patient-Centered system, data is
entered once and shared many times. When a patient is admitted to the
hospital from the ER in one of these health systems, a single keystroke
moves his or her clinical information to the caregivers who need to
have it, when they need to have it. The National Library of Medicine
supported the specialized training of the physicians, nurses, and
health professionals who run these systems, and the Agency for
Healthcare Research and Quality (and its predecessors) have supported
their evolution and unbiased evaluation. Today these systems provide
replicable models for the effective use of information technologies for
patient safety, e-prescribing, electronic health records, and community
information networks.
There is no question that electronic health records improve patient
care. There are numerous scientific studies that prove it. But most
physicians do not have electronic health records (EHR) in their private
offices--Why? Even in a city like Boston where most of the hospitals
have Patient-Centered information systems and many physicians do have
EHRs, citywide connectivity and interoperability are the exception
rather than the rule. These hospitals and physician offices could
securely exchange patient data across the street or across town (or
across the world for that matter), but they don't--Why? Why do we still
rely far too much on ``sneakerware'', asking patients and their
families to carry medical records and reports across the boundaries of
our fragmented health system? The answers to these questions are
complex--and are influenced by factors ranging from the significant
time constraints of managed care to misaligned financial incentives
that reward episodic care rather than the quality of care delivered--
but in large measure it is people and policies that have created the
barriers, not technology. And, I would argue, informed people--
especially, informed patients--and enlightened policies can overcome
the barriers.
For each of us, healthcare is a local experience. Healthcare well
delivered is not about procedures or sophisticated technologies; it is
about communication, coordination and collaboration between a patient,
their family, and their care team. This circle of care revolves around
the home and community, not the hospital. Most physicians practice
outside the hospital and most of your constituents spend very little
time in the hospital. The decision to seek medical care is made in the
home and hence we need to provide healthcare in the home. Telemedicine,
literally ``care at a distance'', is not a futuristic idea, but is
routinely practiced by Dr. Michael Kienzle and his team in Iowa as they
care for elderly throughout their state with the ``Clinic in Every
Home.'' In Wisconsin, Dr. Patricia Brennan and her team routinely link
with post hospitalization patient with the Internet-based HeartCare
program. Similar programs of eHealth or ``cybermedicine'' as Professor
Warner Slack at Harvard likes to call it are underway in many states.
CST<SUP>'</SUP> Baby CareLink, which I helped develop, is Internet
technology that empowers parents to participate the care of the sick
child--which in turn improves care and lowers costs. Baby CareLink, now
running in eight states in 13 different health systems, is specifically
designed for a parent who may never have used a computer or the
Internet before. Written at a 6th grade reading level in English and
Spanish, Baby CareLink delivers just-in-time information to help a
parent navigate our complex healthcare system. In a recent report to
the State of Colorado, which funds Baby CareLink through a public-
private partnership with the very generous support of Johnson &
Johnson, parents who frequently used the Baby CareLink took their
infants home from neonatal intensive care units two weeks sooner than
families who were less frequent users. The benefit for Medicaid parents
was even greater, with even earlier discharges and greater potential
costs savings. At Stroger Cook County Hospital, Baby CareLink has
literally stepped over the digital divide, providing new tools for
clinicians and their patients to communicate, collaborate and
coordinate the care of fragile newborns. We had been told repeatedly
that poor people will not use the Internet, but what we discovered is
that motivated parents, regardless of economic status, eagerly use
interactive tools that are appropriately written and presented. In
fact, interactive tools written with low reading and health literacy in
mind are clearly better educational investments than printed materials.
Wouldn't the millions of dollars a year we spend on printing brochures
that we know are ineffective be better spent on innovative children's
health related information technology?
Consumerism is coming to healthcare, as it has to almost every
other industry. A huge sea-change is beginning in healthcare. The
Internet has unleashed information and health-related online
communities are flourishing. But, Americans and their physicians and
nurses remain largely disconnected. Over 40% of families that we
surveyed at the Jimmy Fund clinic in Boston found the phone method of
communicating with their care team inadequate; over 40% of your
constituents say they want to email their physicians. Yet, only 5 to
10% of American physicians agree to respond to email from their
patients. Why hasn't consumer demand forced change in the healthcare
market? Part of the problem is that at the ATM machine the transaction
is easy to quantify and understand, but in the physician's office the
outcomes of good (and bad) communications are intensely personal.
Let me conclude with four areas that I think government can focus
on and support to help promote innovative uses of information
technologies, and the long-term health of our citizens.
First, we need to train a new generation of physicians, nurses, and
health professionals to lead the development, selection and
implementation of patient-centered health information systems. These
professionals, trained at the university level in applied clinical
informatics, will transform the clinical IT landscape. In Boston, the
CIO's of the two largest health systems, John Glaser, PhD at Partners
Healthcare and John Halamka, MD at CareGroup, as well as Daniel Nigrin,
MD at the Children's Hospital, are all products of NLM funded post
doctoral training programs in informatics. We should require the
accreditation of informatics training programs, just as we require the
accreditation of any other clinical specialty.
Second, we need an unbiased and up-to-date clearinghouse of
products and implementation strategies to inform health systems and
physicians about health IT options. Even as Dr. Brailer, in his role as
National Health Information Technology Coordinator, and the Commission
on Systemic Interoperability chartered under the Medicare Modernization
Act are facilitating the absolutely critical development and
dissemination of agreed-upon standards for health IT systems,
government--through the AHRQ, the NLM or another mechanism--can help
foster a more open and efficient marketplace by funding an independent
national resource containing research, evaluations and business
outcomes relating to the wide range of health IT choices available
today. Simply, a database of what `works' and doesn't work would be
invaluable in helping direct future health care IT investments by
hospitals and physicians, and someday even consumers.
Third, we need to make the availability of information technology a
priority for underserved populations to improve communication and
coordination of their health care needs. We should not use the digital
divide as an excuse for avoiding the hardest health care problems. Our
experience with Baby CareLink suggests that even modest support of
appropriately designed Internet-based information systems that can
provide the information that patients and their families really need
can result in significant improvements in health care quality, even as
it reduces costs.
Lastly, we should turn our focus from the hospital and physician
office into the home. While good hospital information systems and
electronic health records are a necessity, I believe that the personal
health record, a lifelong electronic repository of health information
controlled by the patient, will be the key evolutionary step towards a
new health paradigm that is truly Patient Centered.
In our country, patients are the most under-utilized resource, and
they have the most at stake. They want to be involved and they can be
involved. Their participation will lead to better medical outcomes at
lower costs with dramatically higher patient/customer satisfaction. We
should remember that the real goal of improved health information
systems is not better hospitals or better physician practices, but
better quality of health care and healthier consumers.
Thank you for allowing me to speak with you today. I will be happy
to answer any questions.
<F-dash>
Chairman JOHNSON. Thank you very much. Ms. Marchibroda.
STATEMENT OF JANET MARCHIBRODA, CHIEF EXECUTIVE OFFICER,
EHEALTH INITIATIVE
Ms. MARCHIBRODA. Madam Chairman Johnson, Congressman Stark,
distinguished Members of the Subcommittee, I am honored to be
here today to testify before you on the role of IT in improving
quality, safety, and efficiency in health care. My name is
Janet Marchibroda. I am testifying today on behalf of the
eHealth Initiative and serve as its CEO. I am also Executive
Director of the Foundation for eHealth Initiative. Both are
Washington, D.C.-based, national nonprofit organizations whose
missions are the same: to improve the quality, safety, and
efficiency of health care through information and IT. I also
serve as the Executive Director of Connecting for Health, a
public-private sector collaborative funded and led by the
Markle and Robert Wood Johnson Foundations that is designed to
address the barriers to the development of an interconnected
electronic health information infrastructure.
There is a looming health care crisis in our country. As
Americans, we are faced with, as we know, an aging population,
health care cost increases, dissatisfied clinicians abandoning
the practice of medicine, a shortage of nurses, rising numbers
of uninsured, and baby boomers demanding greater
accountability. We are at a place where there is a crisis
requiring a new kind of thinking about how we should manage and
deliver health care. The evidence is clear and compelling that
the way we delivered care before will not fit the world as it
is now, and we have to become more efficient and effective, and
IT can play a critical role in addressing these challenges.
Right now, as we have heard from the other folks that have
testified, the health care system is highly fragmented, with
information stored in a variety of formats which in most cases
are not connected. In an electronic information age when vital
data can be transferred electronically at the speed of light,
only a fraction of health care data is accessed and transferred
digitally. More than 90 percent of our estimated 30 billion
health care transactions in the United States each year are
still conducted by phone, fax, or mail. As a result, the
information that is needed to support the care of patients is
not available when it is needed and where it is needed to
support both clinical decisionmaking and patients as they
navigate our health care system.
There is now clear and compelling evidence that IT will
indeed help to improve quality, safety, and efficiency, and
those statistics are outlined in detail in my written
testimony. Despite evidence of the quality, safety, and
efficiency improvements that can be achieved through the use of
IT, adoption rates continue to be low. In our discussions with
many hospitals, clinicians, plans, employers in the health care
system, the following have emerged as the key barriers to
adoption.
First of all, the lack of standards and interoperable
systems. While some gains could be achieved by putting EHRs in
every clinician's office, we won't truly recognize the value
unless they are interoperable and interconnected. Number two.
The need for up front funding for those who really need help,
and a misalignment of incentives. That was number two. Number
three. Organizational change within the clinician's office.
Four, the need for leadership both within government and in the
private sector.
There is a great deal of work that is going on across both
the public and private sectors to tackle each of these
barriers. Many groups have made great strides including in the
Federal government, the Consolidated Health Informatics
Initiative, and the National Committee on Vital and Health
Statistics in the standards arena. In the MMA in particular,
the standards requirements in the electronic prescription
program, and also the standards requirements in the Medicare
management performance demonstrations will help to spur
adoption of data standards.
In addition, in order to buildupon the current momentum,
activities should continue on the current trajectory, and the
Federal Government should continue to play its strong role in
data standards. In addition, demonstration projects should be
constructed ideally through public-private sector partnerships
to test and evaluate standards related to data, technical
architecture, and security so that lessons learned and various
tools and resources can be shared with other communities across
the country who are adopting IT and emerging health information
exchange.
Second, with regard to misalignment of incentives and
funding, our 50 million health IT grant program received an
unprecedented amount of interest from hundreds and hundreds of
health care stakeholders interested in technology-related
projects. The eHealth Initiatives Connecting Communities for
Better Health program conducted in cooperation with Health
Resources and Services Administration (HRSA), which is
providing seed funding to multi-stakeholder collaboratives
within communities revealed that 134 communities across America
in 42 States and the District of Columbia had pulled together
stakeholders from at least 3 stakeholder groups, and they have
matched funding already and they were seeking additional
funding. I think there is a real opportunity for the public and
private sectors to work together to facilitate this change
across our country.
Finally, as it relates to alignment of incentives, I think
that the MMA and the chronic care provisions related thereto
offer an excellent opportunity to support movement toward an
electronic health care system by leveraging and rewarding those
applications that, at the same time, build a health information
infrastructure.
In conclusion, health care IT holds great promise for
helping our Nation address its health care challenges, but
there are many barriers to adoption, including those related to
leadership, financing, standards, and organizational change. We
at the eHealth Initiative are committed to working with the
public and private sectors to tackle these barriers.
Madam Chairman Johnson, Congressman Stark, distinguished
Members of the Subcommittee, thank you for inviting me to
discuss our perspectives on the role of IT. We commend you and
your Committee for the work that you have done to improve the
quality, safety, and efficiency of health care for patients
through IT for all Americans. Thank you.
[The prepared statement of Ms. Marchibroda follows:]
Statement of Janet Marchibroda, Chief Executive Officer, eHealth
Initiative
Madame Chairwoman Johnson, Congressman Stark, distinguished members
of the Subcommittee, I am honored to be here today to testify before
you on the role of information technology in improving quality, safety
and efficiency in healthcare. My name is Janet Marchibroda. I am
testifying today on behalf of the eHealth Initiative and serve as its
Chief Executive Officer. I am also Executive Director of the Foundation
for eHealth Initiative. Both are Washington, D.C.-based national non-
profit organizations whose missions are the same: to improve the
quality, safety and efficiency of health and healthcare through
information and information technology. The eHealth Initiative's
membership includes clinicians, employers, health plans, healthcare IT
suppliers, hospitals and other healthcare providers, consumer groups,
pharmaceutical and medical device manufacturers, public health
organizations, standards bodies, and academic institutions that have
interests in improving healthcare through information technology. I
also serve as the Executive Director of Connecting for Health, a
public-private sector collaborative established by the Markle
Foundation which receives additional funding and support from the
Robert Wood Johnson Foundation that is designed to address the barriers
to development of an interconnected health information infrastructure.
In my remarks today, I will share some information and observations
about what we believe are the key challenges to improving healthcare in
America, information technology's role in addressing those challenges,
the current state of the healthcare system as it relates to information
technology adoption, the key barriers the system is facing in achieving
progress, and strategies that both the public and private sectors can
employ to promote the usage of information technology to support better
health and healthcare.
Challenges Within the U.S. Healthcare System
There is a looming healthcare crisis in our country. As Americans
we are faced with an aging population, healthcare cost increases,
dissatisfied clinicians abandoning the practice of medicine, a shortage
of nurses, access problems created by lack of health insurance
coverage, and baby boomers demanding greater accountability.
By 2030, one in five Americans will be over 65 years of age,
consuming a larger portion of our healthcare resources. And with rising
healthcare costs continuing to drive up health insurance premiums (2002
premium increases averaged 12.7 percent), healthcare purchasers are
finding themselves choosing between wage increases or higher subsidies
for health insurance. The rate of healthcare inflation is at an all-
time 12-year high, at eight times the general inflation rate.
Clinicians also are facing rising insurance premiums, but of
another sort: malpractice rates. Many are leaving medical practice due
to escalating premiums and the increasing challenges of an overly
complicated healthcare system. And clinicians are not the only ones in
the healthcare sector facing challenges. Nurses are becoming scarcer,
with a current shortfall of approximately 400,000 nurses nationwide.
Thirty states had a shortage of registered nurses in 2000, and 44
states and the District of Columbia are expected to have a shortage in
2020.
Access problems are further complicated by those lacking
appropriate healthcare coverage. Today, 15.8 percent of the U.S.
population is not covered by health insurance. This leaves close to 44
million Americans without financial coverage for major medical
emergencies and access to needed medical care on an ongoing basis.
The Institute of Medicine (IOM) and other highly regarded
organizations have published a great deal of information regarding the
patient safety challenges currently experienced in our healthcare
system. According to the IOM, medical errors in hospitals kill an
estimated 44,000 to 98,000 people per year--more than those that die in
motor vehicle accidents (43,458), or from breast cancer (42,297).
Adverse events occur in up to 3.7 percent of hospitalizations, with up
to 13.6 percent of them leading to death.\1\ Studies show that adverse
drug events occur in 5 to 18 percent of ambulatory patients.\2\ In a
2001 Robert Wood Johnson survey, 95 percent of doctors, 89 percent of
nurses and 82 percent of healthcare executives said that they have
witnessed serious medical errors. Forty-seven percent of patients
surveyed in 2000 by AHRQ and the Kaiser Family Foundation say they are
concerned about experiencing a medical error. In many cases, physicians
do not know what drugs a patient is currently taking because of the
lack of information technology and connectivity.
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\1\ To Err Is Human: Building a Safer Health System, Institute of
Medicine, 2000.
\2\ Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan
T, et al. Systems analysis of adverse drug events. ADE Prevention Study
Group. JAMA. 1995;274: 35-43.
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There are also opportunities for improvement in the quality of care
that is delivered. A June 26, 2003 report in the New England Journal of
Medicine documents the appropriateness of treatment for 7,528 adults.
Their research revealed that American adults, on average, receive only
a little more than half (54.9 percent) of the healthcare measures
recommended for their conditions--and the lead author pointed to the
need for ``a major overhaul of our current health information systems''
as a key step to fix the problem.\3\
---------------------------------------------------------------------------
\3\ From a June 26, 2003 report in USA Today, ``50/50 chance of
proper health care,'' by Rita Rubin.
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Finally, in addition to challenges in the healthcare delivery
system, the U.S. is experiencing challenges in the public health
system. Recent threats including those related to SARS and West Nile
Virus, as well as the terrorist acts of September 11, 2001 underscore
the vital significance of disease surveillance in protecting the public
from natural and unnatural outbreaks.
As Americans we are at a place where there is a real social,
political and economic crisis requiring a new kind of thinking about
how we should manage and deliver healthcare. The evidence is clear and
compelling that the way we delivered care before will not fit the way
the world is now. We have to become more efficient and effective, and
information technology can play a critical role in addressing these
challenges.
The Role of Information Technology in Addressing Healthcare Challenges
According to the IOM's report--Crossing the Quality Chasm, ``If we
want safer, higher quality care, we will need to have redesigned
systems of care, including the use of information technology to support
clinical and administrative processes--the current care systems cannot
do the job. Trying harder will not work. Changing systems of care
will.''
The U.S. healthcare system, representing approximately $1.4
trillion or 14 percent of the nation's gross domestic product, is
highly fragmented, with information stored in a variety of formats
(often paper-based) which in most cases are not connected. Each
healthcare entity, public and private--clinicians, hospitals, insurers,
researchers--gathers and holds its own information, most often in paper
form. In an electronic information age when vital data can be
transferred electronically at the speed of light, only a fraction of
healthcare data is accessed and transferred digitally. More than 90
percent of the estimated 30 billion healthcare transactions in the
United States each year are still conducted by phone, fax or mail.\4\
---------------------------------------------------------------------------
\4\ Michael Menduno, ``apothecary.now,'' Hospitals and Health
Networks, July 1999, 35-36.
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As a result, the information that is needed to support the care of
patients is not available when it is needed and where it is needed to
support both clinical decision-making and patients as they navigate our
complicated healthcare system. The absence of readily available,
comprehensive, patient-centric health information and ready access to
clinical knowledge negatively affects healthcare at every level.
Clinicians sometimes are forced to approach patient care with
incomplete information about a patient and without point-of-care access
to the multitude of clinical decision support guidelines that are
available to guide them. The volume and complexity of these guidelines
is growing so fast that they cannot be accessed effectively without the
use of information technology. As a result, clinicians may
unnecessarily repeat tests, call for unnecessary hospital stays, or
advise ineffective (or sometimes dangerous) treatments. Research shows
that physicians spend and estimated 20% to 30% of their time searching
and organizing information. And in fact, today, 10 to 81 percent of the
time, physicians do not find patient information they need in a paper-
based medical record.\5\ This can lead to duplication of lab tests and
other medical services, delays in treatment, and the increased risk of
medication errors.
---------------------------------------------------------------------------
\5\ Clinical Information: Achieving the Vision, 2002; Kaiser
Permanente.
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In addition, researchers and public health officials do not have
ready access to aggregate data to track diseases or measure the
effectiveness of treatments. Patients cannot easily view their own
health records or transfer their own health information from clinician
to clinician. Businesses cannot measure the effectiveness of clinicians
or health systems in delivering safe, quality care.
There is now clear and compelling evidence that information
technology will indeed help to improve the quality, safety and
efficiency of our Nation's healthcare system.
A recent study from the Center for Information Technology
Leadership indicates that we can achieve $44 billion in savings
annually in reduced medication, radiology, laboratory, and
hospitalization expenditures from 100 percent adoption of Computerized
Provider Order Entry (CPOE) in the ambulatory care environment. A more
recent study indicates that standardized healthcare information
exchange among healthcare IT systems would deliver national savings of
$86.8 billion annually after full implementation and would result in
significant direct financial benefits for providers and other
stakeholders.
According to the CITL CPOE data, more than two million adverse drug
events and 190,000 hospitalizations per year could be prevented using
IT.\6\ Further, evidence from Brigham & Women's Hospital concluded that
through use of CPOE, error rates were reduced by 55 percent, from 10.7
to 4.9 per 1,000 patient days.\7\ A recent study of intensive care
patients by Kaiser Permanente found that when physicians used a CPOE
system, incidents of allergic drug reactions and excessive drug dosages
dropped by 75 percent, and the average time spent in the intensive care
unit dropped from 4.9 days to 2.7 days, reducing costs by 25
percent.\8\
---------------------------------------------------------------------------
\6\ The Value of Computerized Provider Order Entry in Ambulatory
Settings, Center for Information Technology Leadership, 2003.
\7\ Bates et al., JAMA, October 1998.
\8\ Clinical Information: Achieving the Vision, 2002; Kaiser
Permanente.
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Current Levels of Information Technology Adoption
Despite evidence of the quality, safety and efficiency improvements
that can be achieved through the use of information technology,
adoption rates continue to be low. More than 90 percent of the
estimated 30 billion health transactions each year are conducted by
phone, fax or mail.\9\ Forty percent of surveyed healthcare
organizations planned to spend 1.5 percent or less of their total
operating budgets last year on IT, and 36 percent set spending at 2 to
4 percent.\10\ This compares to an average IT investment of 8.5 percent
in other industries.\11\
---------------------------------------------------------------------------
\9\ Michael Menduno, ``apothecary.now,'' Hospitals and Health
Networks, July 1999, 35-36.
\10\ An info-tech disconnect, Modern Healthcare, February 10, 2003.
\11\ InformationWeek Research's Evolving IT Priorities 2002 and
2003.
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It appears that the organizations and individuals who are taking
the lead in the adoption of information technology are the ones who
truly believe that healthcare information technology can save money and
improve healthcare quality, safety and efficiency as well as those who
have been able to offset those investments through grant programs.
Those who have been the slowest adopters are those who have had limited
access to capital, and those who have not had ongoing financial
incentives to support their adoption.
On the individual practitioner level, only 5 to 10 percent of
physicians use electronic medical records in their practices. And in
the electronic prescribing area--some research shows that less than 5
percent of U.S. physicians currently ``write'' prescriptions
electronically.\12\
---------------------------------------------------------------------------
\12\ ``A call to Action: Eliminate Handwritten Prescriptions Within
3 Years!'' Institute for Safe Medical Practices. http://www.ismp.org/
msaarticles/whitepaper.html.
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At the facility level, while 13 to 15 percent of hospitals have
implemented some form of computerized medication order entry,
physicians in these organizations enter less than 25 percent of their
orders using the system.\13\
---------------------------------------------------------------------------
\13\ American Society of Health-System Pharmacists Study.
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Demand is Emerging from Clinicians and Consumers
It is clear that demand for information technology adoption is now
emerging from clinicians and consumers. Recent activities related to
information technology by groups such as the American Academy of Family
Physicians, the American College of Physicians, and the American
Medical Association serve as a signal of this increased interest. In
fact, a recent Medical Group Management Association (MGMA) study
indicates that 22.8 percent of respondents thought that use of the
electronic medical record (EMR) would result in decreased costs, and 31
percent believed it would increase patient satisfaction.
There is also increasing consumer demand for electronic tools that
will support navigation of the healthcare system. A study by Jupiter
Media Metrix showed that 54 percent of consumers were willing to
``switch'' to a physician who would use e-mail to schedule
appointments, renew prescriptions, answer treatment questions and check
lab reports. A 2003 Foundation for Accountability (FACCT) survey
conducted as part of Connecting for Health found that over 70 percent
of consumers surveyed believed a personal health record would improve
quality of care. When respondents were asked about having health
information online, 71 percent said it would clarify doctor
instructions, 65 percent said it would prevent medical mistakes, 60
percent said it would change the way they manage their health and 54
percent said it would improve quality of care.\14\
---------------------------------------------------------------------------
\14\ Connecting for Health. The Personal Health Working Group Final
Report: July 2003, p. 5.
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Barriers to Information Technology Adoption
In discussions with stakeholders across the healthcare system,
including clinicians, hospitals, health plans, employers and healthcare
information technology suppliers--the following have emerged as the key
barriers to adoption:
<bullet> Lack of Standards and Interoperable Systems. The lack of
interoperable systems and data standards has often been cited as a key
barrier to adoption. According to a 2002 survey conducted by the
Medical Records Institute, clinicians across a variety of settings
identified ``difficulty in finding an electronic medical record
solution that is not fragmented over several vendors or IT platforms''
as a top barrier.\15\ While some gains could be achieved through the
adoption of electronic health records across the healthcare system, the
real value--particularly within clinician offices--expressed in terms
of quality, safety, and efficiency will only be achieved if such
systems are interoperable and electronic connectivity is achieved, so
that clinicians have key information--such as that related to
laboratory tests and prescriptions--when and where it is needed--at the
point of care.
---------------------------------------------------------------------------
\15\ The Medical Records Institute and SNOMED. Fourth Annual MRI
Survey of Electronic Health Record Trends and Usage. 2002.
---------------------------------------------------------------------------
<bullet> Lack of Upfront Funding and Misalignment of Incentives.
Practicing clinicians, hospitals and other healthcare providers often
cite the lack of upfront funding and business models to support ongoing
usage as key barriers to adoption. In addition, emerging research
indicates that there is a misalignment between those who pay for the
implementation and ongoing usage of information technology and those
who benefit from its usage. Under the current healthcare system,
benefits related to the gains in quality, safety, and efficiency are
spread across all stakeholders while the real costs are borne by only a
few. Incentives must be realigned to facilitate the exchange and
sharing of data and information across and between organization,
institutions, providers, and payers. In a survey of provider CEOs, 25
percent cited lack of financial support as a barrier, while 17 percent
cited the need to provide quantifiable benefits or return on investment
as the greatest barrier.\16\ A recent survey of 5,000 family physicians
conducted by the American Academy of Family Physicians found that 60.5
percent cited affordability as a barrier to adopting electronic medical
records.
---------------------------------------------------------------------------
\16\ Healthcare Information and Management Systems Society and
Superior Consultant Company, 14th Annual HIMSS Leadership Survey. 2003.
---------------------------------------------------------------------------
<bullet> Organizational Change Issues. A recent survey of 5,000
family physicians conducted by the American Academy of Family
Physicians found that 54.2 percent cited worries about slower workflow
or lower productivity.\17\ This has been confirmed through several
meetings and discussions with practicing clinicians across the country.
---------------------------------------------------------------------------
\17\ Ibid.
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<bullet> Need for Leadership. In order to drive transformational
change, leadership is needed from both the public sector--both at the
federal and state level--and every segment of the private sector--
including clinicians, hospitals, laboratories, payers, employers and
other healthcare purchasers, manufacturers of pharmaceutical and
medical devices, public health agencies, and those who build and
implement information technology.
Public and Private Sector Strategies for Addressing Barriers
There is a great deal of work going on in both the public and
private sectors to overcome the barriers identified above to drive
improvements in the quality, safety and efficiency through the use of
information technology but clearly more work still needs to be done.
The eHealth Initiative and its Foundation and key initiatives such
as Connecting for Health, have taken an active role in advancing the
development and implementation of policies and practical strategies by
key stakeholders across the healthcare system to promote a healthcare
system that mobilizes information to support patients through
electronic connectivity and the use of standards-based, interoperable
information systems. The following summarizes key steps taken by our
organization, the public sector and several other private sector
organizations that are moving us towards an interoperable, electronic
healthcare system.
Standards and Interoperable Systems
Many influential groups have made great strides in both the
development and adoption of standards to support a higher quality,
safer and more efficient healthcare system enabled by information
technology. Within government, the Consolidated Health Informatics
Initiative has played an integral role in gaining consensus on the data
standards that the Federal government will use in its own operations.
The National Committee on Vital and Health Statistics has played a
critical role by providing ongoing advice and counsel to the Secretary
of the Department of Health and Human Services regarding the standards
that should be adopted to promote an interoperable, electronic
healthcare system.
Through Connecting for Health, a public-private sector
collaborative in which the Foundation for eHealth Initiative is
involved, leaders across every sector of healthcare achieved consensus
on a first set of data standards that should be adopted by our
healthcare system, which played a considerable role in moving this work
forward. Connecting for Health is extending this work further in its
second phase, through the development of recommendations which address
technical architecture, applications and standards to support
electronic connectivity and IT adoption.
The eHealth Initiative and its Foundation have played an integral
role in promoting standards adoption. Through our Public-Private Sector
Collaborative for Public Health, we developed strategies and practices
for transmitting data electronically--using standards--to support
public health surveillance processes. Our Connecting Communities for
Better Health Program, conducted in cooperation with with the U.S.
Health Resources and Services Administration (HRSA) is providing seed
funding to nine multi-stakeholder collaboratives within communities
across the country who are using IT and mobilizing information across
institutions to support quality, safety, efficiency and public health
goals within their regions. One of the key criteria for selection was
the usage of standards in electronic data transmission conducted as
part of the project. These projects will be announced to the public
over the next month.
The Medicare Prescription Drug, Improvement and Modernization Act
of 2003 (MMA) provides critical provisions that will promote the
adoption of data standards, including the standards requirements
included in both the electronic prescription program and the ``Medicare
Care Management Performance Demonstration'' as well as the creation of
the Commission on System Interoperability which will develop a
comprehensive strategy, timelines and priorities for the adoption and
implementation of healthcare information technology standards. In
addition to the MMA, H.R. 2915, the National Health Information
Infrastructure Act of 2003 also provides critical provisions that will
facilitate the adoption of standards to promote interoperability. The
eHealth Initiative supports this bill and commends Chairwoman Johnson
for her leadership.
In order to build upon the current momentum for standards
development and more importantly--adoption of existing standards,
activity should continue on the current trajectory. The Federal
Government should continue to play a strong role in the development and
adoption of standards within its own programs. It should provide
incentives to the private sector to promote the usage of such
standards, and it should work closely with the private sector in
establishing consensus on the standards that should be adopted.
To accelerate the adoption of information technology adoption and
an interoperable healthcare system, demonstration projects should be
conducted--ideally through public-private sector partnerships--to test
and evaluate standards and specifications related to data, technical
architecture, applications and security--so that lessons learned and
various tools and resources can be shared with other communities across
the country who are adopting information technology and engaging in
health information exchange activities.
Lack of Upfront Funding and Misalignment of Incentives
Progress on addressing the second key barrier--financing--has
lagged behind the significant work around data standards and
interoperable systems, despite the demand from both healthcare
communities and stakeholders across the country.
The Agency for Healthcare Research and Quality's $50 million Health
Information Technology grant program received an unprecedented amount
of interest from hundreds and hundreds of providers and other
healthcare stakeholders interested in grant funding to support both
planning and implementation of information technology-related projects.
In response to a request for proposal sent out by the Foundation for
eHealth Initiative as part of its Connecting Communities for Better
Health program conducted in cooperation with HRSA, proposals came in
from 134 communities representing 42 states plus the District of
Columbia, who were interested in implementing information technology
and sharing clinical data electronically across at least three
stakeholder groups, and who had secured matched funding to support this
work. The response from both of these programs indicates that
communities across America, and the healthcare leaders who reside
within them, are ready to move towards an interoperable, electronic
healthcare system, but will need help in getting there. Our dialogue
with several of these communities indicates that, while the creation of
these programs has stimulated a great deal of interest and in many
cases, has created the impetus for a multi-stakeholder consortium of
leaders to take this work forward--that efforts will be hampered by the
lack of capital required to get this work off the ground.
A small number of pilot projects are emerging that are driven by
both employer-purchasers and health plans that provide incentives to
clinicians, hospitals and other healthcare providers who are using
information technology to deliver higher quality healthcare. The
Bridges to Excellence Program is one example of an initiative that is
developing and evaluating reimbursement models that encourage the
recognition of healthcare providers who demonstrate that they have
implemented comprehensive solutions in the management of patients and
deliver safe, timely, effective, efficient, equitable and patient-
centered care which is based on adherence to quality guidelines and
outcomes achievement. Adoption of health information technology, with
special emphasis on fully functional electronic medical record systems,
equipped with electronic prescribing modules and robust clinical
decision support, is being targeted for rewards. Physician practices
will be able to earn up to $20,000 per physician per practice for
adopting these systems.
In addition, the MMA provisions related to a ``Medicare Care
Management Performance Demonstration'' in Section 649, offer a valuable
set of learning laboratories for testing and evaluating the impact of
providing information technology to physicians on quality, safety and
efficiency. It is imperative that these demonstrations be closely
coordinated with private sector initiatives such as Bridges to
Excellence, where possible, to coordinate market experiments.
Finally, the chronic care provisions included in the MMA offer an
excellent opportunity to support movement towards an electronic
healthcare system by rewarding those applications that leverage
integrative information infrastructures, new applications of
information and communication technologies, expert clinical systems
that incorporate evidence-based guidelines for multiple conditions, and
predictive modeling capabilities to support their operations.
In order to continue to move towards an electronic health
information infrastructure and the adoption of health information
technology, it is critical that policy options that both align
incentives and provide federal investment be developed and implemented.
These activities will not only accelerate movement, they will also
serve to stimulate private sector innovation and investment in these
activities. Current and emerging Federal programs should be leveraged
to test and evaluate these policy options.
Organizational Change
A number of initiatives have emerged--primarily in the private
sector--to address organizational change issues and facilitate the
migration towards an interoperable, electronic healthcare system.
Successful adoption of electronic application depends upon the ease and
speed with which the clinician can use it, as much as the value that it
provides for quality, safety, and cost. It is affected by a number of
factors including how well the system supports the specific workflows
present within a clinician's office, and the specific features that the
system provides to improve speed and efficiency. While the effective
implementation of information technology ultimately improves outcomes
and results in efficiency gains, migrating to a new system takes time
and resources, and achieving full return on investment takes time.
Because of the changes in care delivery and clinical care processes
that are necessary in order to migrate towards the use of electronic
systems, the provision of financial and other incentives designed to
promote their usage are critical.
To provide support to providers who are undergoing this transition,
organizations such as AMIA and HIMSS are developing resources and
educational materials that will help clinicians, hospitals and other
healthcare providers effectively implement information systems. In
addition, the eHealth Initiative and its Foundation have contributed to
the field in two key areas. Through our Electronic Prescribing
Initiative, the eHealth Initiative engaged more than 70 national
experts and key stakeholders across every sector of healthcare and the
prescribing chain to develop design, implementation and incentives
recommendations that will facilitate the effective and rapid adoption
of electronic prescribing in the ambulatory environment.
Representatives from hospitals, clinician groups, healthcare IT
suppliers, patient and consumer organizations, federal and state
agencies, pharmaceutical manufacturing organizations, pharmacy benefits
management organizations, health plans, pharmacies, and connectivity
providers reached consensus on a set of recommendations related to the
levels of electronic prescribing and the benefits that accrue at each
level as well as detailed recommendations related usability, clinical
decision support, communication, standards and vocabularies,
implementation, and incentives.
Through the Connecting Communities for Better Health Program the
Foundation for eHealth Initiative is obtaining critical input from
experts, ``on-the-ground'' implementers, and other key stakeholders to
develop resources and tools related to technical, financial,
organizational, and clinical challenge areas related to health
information technology adoption and the mobilization of information
across organizations. These resources and tools are being disseminated
through our Community Learning Network and Resource Center and meetings
such as the June 2004 Connecting Communities Learning Forum and
Resource Exhibition, both of which provide both a learning network and
a resource to enable communities and healthcare stakeholders to learn
from national experts and each other, strategies for addressing the
challenges related to implementation of IT and a health information
infrastructure.
Private sector organizations will and should continue to emerge to
assist healthcare stakeholders as they migrate towards an electronic
healthcare system. The Federal government can play a critical role by
leveraging the work being conducted by private sector organizations and
collaborations in this area. This is also an area that would benefit
from public-private sector collaboration.
Leadership
A number of key actions taken by both the public and private
sectors have signaled a significant increase in the level of leadership
around healthcare information technology issues.
President Bush's recent executive order, which establishes the
National Health Information Technology Coordinator position and calls
on Federal leaders--within ninety days--to provide options to provide
incentives to promote adoption of interoperable health information
technology will play a critical role in helping to spur adoption of
information technology within the healthcare system. The work of Dr.
David Brailer--the new National Health Information Technology
Coordinator--including that which is related to developing and
implementing a strategic plan; advancing standards through
collaboration with the private sector and evaluating benefits and costs
of IT--will also be very important to stimulate cooperation within the
public sector and collaboration related to these issues across both the
public and private sectors.
Connecting for Health, a public-private sector collaborative has
also taken several steps to move us towards an interoperable healthcare
system, including gaining consensus among diverse stakeholders across
both the public and private sectors on an initial set of ``adoption-
ready'' data standards; developing a high-level value proposition for
interoperability and a framework for migration; and identifying the
high-level characteristics of the personal health record and survey on
consumer attitudes. Over the next month, an incremental Roadmap for
achieving electronic connectivity will be released by Connecting for
Health which is designed to articulate the near-term actions that
should be undertaken by both the public and private sectors to get to
an electronic health information infrastructure. In addition, over the
next few months, several recommendations which have been vetted by both
the public and private sectors, which address a wide range of issues
related to adoption of interoperable information systems will be
released.
Conclusion
In conclusion, healthcare information technology holds great
promise for helping our Nation address its healthcare challenges.
Evidence has shown that the effective implementation of information
technology and the mobilization of information across organizations can
result in significant improvements in healthcare quality, safety and
efficiency and can also serve to protect and improve public health.
But there are many barriers to the adoption of information
technology and electronic connectivity, including those related to
leadership, financing, standards and organizational change. It is
imperative that we build upon the work being conducted by both the
public and private sectors and the public-private sector partnerships
that have emerged--to continue to drive the change that it necessary to
help us achieve our vision of an electronic healthcare system that will
lead to better health and healthcare for all Americans.
Madame Chairwoman Johnson, Congressman Stark, distinguished members
of the Subcommittee, thank you again for inviting me to discuss our
perspectives on the role of information technology in addressing our
healthcare challenges, the barriers that impede its adoption, and the
strategies that can be employed to overcome these barriers. We at the
eHealth Initiative are committed to working with both the public and
private sectors to make our vision of an improved healthcare system
enabled by information technology and electronic connectivity a
reality. We commend you and your Committee for the work that you have
done to improve the quality, safety and efficiency of healthcare for
patients through information technology. Your introduction of H.R.
2915, to accelerate the creation of a National Health Information
Infrastructure, along with the inclusion of several important
information technology provisions in the Medicare Prescription Drug,
Improvement and Modernization Act of 2003 (MMA), and of course this
hearing today all serve to improve our nation's healthcare system
through information technology. Again, thank you for this opportunity
and I look forward to answering any questions you may have.
<F-dash>
Chairman JOHNSON. Thank you very much. Dr. Overhage.
STATEMENT OF J. MARC OVERHAGE, M.D., PH.D., ASSOCIATE PROFESSOR
OF MEDICINE, REGENSTREIF INSTITUTE, INDIANA UNIVERSITY, SCHOOL
OF MEDICINE, INDIANAPOLIS, INDIANA
Dr. OVERHAGE. Good afternoon. My name is J. Marc Overhage,
and I am an Associate Professor of Medicine at the Indiana
University School of Medicine, and a Senior Investigator at the
Regenstrief Institute. I also serve on the Board of Directors
of the American Medical Informatics Association and the
leadership governance of the eHealth Initiative. Primarily, I
am a practicing general internist, a doctor for adults.
I am here today to testify regarding our experience in
developing a regional health information exchange in order to
help the Committee understand how we created our exchange, and
then to suggest ways in which the government may be able to
help other communities do the same. The region where we have
developed our health information exchange is central Indiana
which, with a population of 1.6 million, is representative of
other urban centers, and the health care delivery system there
faces all of the challenges of which you are all acutely aware.
The Regenstrief Institute is a not-for-profit medical
research organization created in 1969, and is dedicated to the
improvement of health through research that enhances the
quality and cost effectiveness of health care. Thirty years
ago, Clem McDonald began creating the Regenstrief Medical
Records System, with three simple goals: first, to eliminate
the logistical problems associated with the paper record;
second, to standardize the care process to deliver information
in a more organized and useful way; and, third, to analyze and
understand the data to improve the health of populations.
Beginning a decade ago with grant funding from the National
Library of Medicine and the AHRQ, Dr. McDonald and I began to
create and evaluate a regional health information exchange. We
extended the functionality of the Regenstrief medical records
system to include methods for matching patients without
requiring a common identifying number, for standardizing how
the systems represent the clinical information regardless of
which organization generated the data, for combining the
standardized clinical data into useful and acceptable fashions
for care delivery, along with appropriate access controls and
auditing to protect the privacy of the patients' data. In a
pilot study, we showed very promising results, and on the
strength of those results we were able to convince a larger
number of organizations to participate in the collaboration
that emerged and we now call the Indiana Network for Patient
Care (INPC).
This system allows providers, in compliance with the Health
Insurance Portability and Accountability Act 1996 (P.L. 104-
191) privacy and security regulations, to obtain essential
clinical data almost instantly from participating
organizations. We have built a technology that supports the
INPC on established clinical information standards, including
the HL7 messages that define the format for exchanging data and
Logical Observation Identifiers Names and Codes (LOINC) that
identify laboratory tests. While standards continue to evolve,
the INPC is proof that current standards are sufficient to move
forward.
We use a common web-based interface and single sign-on to
simplify access for physicians. However, as you are well aware,
today, only a small proportion of physician practices use any
type of electronic health information systems in their
practice. In order to address this problem, we have created an
innovative tool called DOCS4DOCS to introduce a basic level of
clinical information system utilization into physician
practices.
Perhaps most importantly, the DOCS4DOCS system provides
services built around the health information and exchange that
are sufficiently valuable that participants are willing to pay
for them. The clinical messaging service which delivers results
from hospitals, radiology centers, and other providers to
physicians' offices in Indianapolis provides operating
efficiencies to those organizations and allows the providers to
receive the results in a reliable and efficient and uniform
fashion.
The ultimate measure of our success will be the creation of
a sustainable funding model for the health information
exchange. We have made substantial progress by creating the
Indiana Health Information Exchange, which is a not-for-profit
509(A)3 corporation that supports the first commercial services
built on the health information exchange. Hospitals and other
data providers who utilize the clinical messaging service pay
for this service, receive a good return on their investment,
and help underwrite and support the costs of the infrastructure
for the other services.
We have recently completed a multi-year study in which all
of these hospitals sharing data with each other, and will be
able to share the results of that study soon. When we asked
care providers, though, how the health information exchange has
helped them, they readily recall anecdotes. For example, one
woman who was waiting to be seen in her provider's office
suddenly collapsed. Her provider was able to identify her and
retrieve her medical records within a few moments, and this
allowed them to view her past medical history, medications, and
allergies, providing them with information when the patient
could not. It changed the decisions they were planning to make,
and helped to take better care of this patient. In this case,
the INPC acted as the patient's voice, speaking for her when
she could not.
As another example, a patient came to the emergency
department with chest pain, and his providers thought that he
was probably having a heart attack. As they were preparing to
administer blood thinning medications that would help relieve
his symptoms, they discovered through the INPC that the patient
had had a head injury within the last 2 weeks, a
contraindication of that medication, and perhaps prevented the
patient from dying. There are a number of things I think that
the government can do to help advance this cause that are
detailed in my written testimony. Thank you very much.
[The prepared statement of Dr. Overhage follows:]
Statement of Marc Overhage, M.D., Ph.D., Associate Professor of
Medicine, Regenstreif Institute, Indiana University, Indianapolis,
Indiana
Good afternoon Mr. Chairman and Members of the Committee. My name
is J. Marc Overhage and I am an Associate Professor of medicine at the
Indiana University School of Medicine and a Senior Investigator at the
Regenstrief Institute but I am also a practicing general internist, a
doctor for adults. I am testifying today to share our experience
developing a regional health information exchange in order to help the
Committee understand how we created our health information exchange and
then to suggest some ways in which the government can help other
communities create their own health information exchanges.
The Indianapolis MSA which includes 9 counties in central Indiana
with a population of 1,607,486 is the 29th largest in the US. Afro-
Americans or blacks account for 13.9% of the population, Asians 1.2%
and Hispanics (any race) 2.7%.
There is a long history of successful public--private
collaborations in central Indiana. The most recent example is
Biocrossroads (www.biocrossroads.com) which is an economic development
activity focused on growing Indiana's already formidable life sciences
industrial base. We believe that a sustainable health information
exchange will be such a public-private collaborative and that the
communities familiarity and success with this model will facilitate the
process.
Five major hospital systems--Community Hospitals Indianapolis, St.
Vincent Hospitals and Health Services, St. Francis Hospital and Health
Centers, Clarian Health and Wishard Health Services serve Indianapolis.
These five hospital systems operate a total of 11 different hospital
facilities and more than 100 geographically distributed clinics and day
surgery facilities. Collectively, these systems admit 165,878 patients,
and serve more than 390,000 emergency room visits and 2.7 million
clinic visits per years.
Regenstrief Medical Record System
The Regenstrief Institute, Inc., (www.regenstrief.org) an
internationally recognized informatics and healthcare research
organization, is dedicated to the improvement of health through
research that enhances the quality and cost-effectiveness of health
care. Established in Indianapolis by philanthropist Sam Regenstrief in
1969 on the campus of the Indiana University School of Medicine, the
Institute is supported by the Regenstrief Foundation and closely
affiliated with the I.U. School of Medicine and the Health and Hospital
Corporation of Marion County, Indiana.
Regenstrief Institute investigators have more than 30 years of
experience with the capture, maintenance, and retrieval of electronic
medical record information. The long-term Regenstrief Medical Record
System (RMRS) <SUP>i</SUP> captures patient information from three
hospitals on the Indiana University Medical Center campus and from 30
clinics scattered around the inner city of Indianapolis. At Wishard,
where it has been in operation since 1972, the RMRS captures all
diagnostic studies (labs, EKGs, cardiac echoes, cytology, surgical
pathology, bone marrow biopsies, obstetric ultrasounds, EMG, EEG,
radiology studies, etc.) and all orders (including prescriptions) in a
coded form. It also captures encounter information and the full text of
all dictated reports (operative notes, discharge summaries, visit
notes, radiology). The RMRS carries every EKG tracing produced at
Wishard for the last 13 years, and every digital radiology image
produced at IU/Riley and Wishard since August of 1999, and from
Methodist hospital since January 2002. As JPEG compressed (10:1) files,
the radiology images from these institutions consume 80 gigabytes per
month.
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\i\ McDonald CJ, Overhage JM, Tierney WM, et. al. The Regenstrief
Medical Record System: a quarter century experience. International
Journal of Medical Informatics 1999;54:225-253.
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The RMRS also captures clinical data from 8 primary care
neighborhood health centers and 27 public health clinics supported by
the Marion County Health Department and all four homeless clinics in
Indianapolis. In addition, the community and public health clinics can
use the RMRS to schedule patients and capture all drugs prescribed and
diagnostic tests performed. In each setting, the RMRS augments patient
care and facilitates clinical research.
Additional information is added to the RMRS from other sources.
From the hospital case abstract tapes the system stores admission and
discharge diagnoses, dates, and lengths of stay, and death date for
patients who die in the hospital. Death information for all registered
patients is obtained from hospital death summaries, autopsy reports,
and the Indiana State Department of Health death certificate tapes.
The long-term RMRS at Clarian Health Partnerscontains more than 3
million patients and 420 million computer understandable clinical
observations. This information is instantly available for patient
management from over 2000 terminals and workstations around the medical
center campus. The RMRS is one of the few systems that have captured
large amounts of coded patient information from all patient care
locations (inpatient, hospital and emergency room). It is also one of
the oldest continuously maintained computer medical record systems in
the country. Though we have changed programming and file structures
three times over 30 years, we have always translated and carried
forward the patient data from the old version of the system into the
new system. So, we have all clinical data we collected since 1972 in
one consistent electronic medical record format. No other EMR system
can make that claim.
These data are used heavily for research and management purpose.
The Regenstrief Institute employs eight full-time data analysts to
answer research and management requests related to this data for a
large number of research projects. A recent example of the research
value of the database is the report by Marc Rosenman, M.D. who found
that IV erythromycin given to newborns was associated with a 10-fold
increased risk of pyloric stenosis.<SUP>ii</SUP>
---------------------------------------------------------------------------
\ii\ Mahon BE, Rosenman MB, Kleiman MB. Maternal and infant use of
erythromycin and other macrolide antibiotics as risk factors for
infantile hypertrophic pyloric stenosis. J Pediatr. 2001
Sep;139(3):380-4.
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How we got started
The first across hospital data sharing for clinical care began in
Indianapolis in 1993. In that project Wishard Memorial Hospital
provided access to its electronic medical record data to emergency
department physicians caring for patients in the Community Hospital
East and Methodist Hospital emergency rooms in Indianapolis. Building
on this experience, all five of the major Indianapolis hospital systems
and two large primary care groups joined in the Indiana (previously
Indianapolis) Network for Patient Care (``INPC'' or ``Network'') in
1997. All five hospital systems agreed to allow the exchange of patient
data for access and use by various Indianapolis health care providers
to render emergency and primary care. The primary goals of the INPC
are: (1) reduction of the costs of care inefficiencies such as
unnecessary repeat testing; (2) increased accuracy of medical diagnoses
through common and rapid access to patient information through
electronic means; and (3) utilization of the broad-based and ever-
growing collection of information on the Network for research purposes
related to, among other things, studying the efficacy and cost-reducing
effects of broad-based access to patient information and reviewing the
information to learn about specific diseases and their treatment.
The National Library of Medicine and the Agency for Healthcare
Research and Quality supported the initial development of the INPC
through their intramural grant program. The system currently includes
data from 13 hospitals in five different hospital systems, the Marion
County Health Department (MCHD) and a growing number of physician
practices. These hospitals account for over 95% of all beds and ED
visits in the Indianapolis MSA. The data collected include
demographics, laboratory results, ED, inpatient and outpatient
encounter data including free-text chief complaint, coded diagnoses and
procedures, vital signs and other data, but not all these data elements
are available for every participant. The core set of data currently
received from all participants includes demographics, laboratory data,
ED and inpatient encounter data including chief complaint, coded
diagnoses and coded procedures. The system currently utilizes the real-
time laboratory result data for active surveillance of reportable
conditions.
The network provides e-mail services, Web access, electronic
medical record access, medical library services and numerous special
purpose functions (variously) at each institution. It also delivers
clinical data to the central RMRS medical record system from a host of
different departmental and administrative systems and provides care
providers and researchers access to the data. The network provides
pathways for interfaces to seven laboratory systems, seven hospital
registration systems, four dictation transcription systems, four
radiology systems, three pharmacy systems, three different EKG cart
systems, two surgery scheduling system, and more than 20 other systems.
Most of the larger interface use standard based HL7 messages. We
have standardized the terminology at six organizations so that
laboratory tests, radiology results and other patient information are
described using the same terms no matter where the data comes from. We
use a common interface and one sign-on to link users to independent
clinical files at multiple institutions and to other services (such as
library knowledge bases). We have developed mechanisms for linking
patients registered independently in different institutions and for
linking physicians' master files to the state physician identifying
databases. Providers can enter clinical orders and visit notes or
upload transcribed notes from any device on the network and the system
will store them in the appropriate medical record file system.
All INPC participants now deliver registration records, all
laboratory tests, and all UB92 records (diagnosis, length of stay, and
procedures codes) for hospital admissions and emergency room visits to
separate electronic medical record vaults maintained on their behalf.
The computer system standardizes all clinical data as it arrives at the
INPC vault, laboratory test results are mapped to a set of common test
codes with standard units of measure, and patients with multiple
medical record numbers are linked.<SUP>iii, iv</SUP> Each institution
has the same file structure and shares the same term dictionary which
contain the codes, names (and other attributes) for tests, drugs, coded
answers, etc. When a patient is seen in any of the 13 emergency rooms
operated by participating hospitals, and the patient consents, the
information from all of these institutions about one patient can be
presented as one virtual medical record.
---------------------------------------------------------------------------
\iii\ Overhage JM, Tierney WM, McDonald CJ. Design and
implementation of the Indianapolis Network for Patient Care and
Research. Bull Med Libr Assoc. January 1995;83(1):48-56.
<SUP>iv</SUP> Overhage JM, Dexter PR, Perkins SM, Cordell WH,
McGoff J, McGrath R, McDonald CJ. A randomized controlled trial of
clinical information shared from another institution. Ann Emerg Med
39(1);14-23, 2002.
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Patient ID merging
There is no gold standard against which we can compare our patient
matching algorithm. We have carried out formal comparisons of matching
strategies that suggest our current algorithm has a 90-92% sensitivity
and 100% specificity using combinations of social security number,
gender, name, and birth date fields.<SUP>v</SUP> A less scientific but
very important measure of how well the matching algorithm works is that
we have never had a provider report an erroneous match providing
additional evidence that specificity is near 100%.
---------------------------------------------------------------------------
\v\ Grannis SJ, Overhage JM, McDonald CJ. Analysis of Identifier
Performance using a Deterministic Linkage Algorithm. Proc AMIA Symp.
2002; Submitted.
---------------------------------------------------------------------------
We certainly miss some matches (sensitivity is less than 100%) and
when we do we don't allow the clinician to see the data for the missed
match. An error in entering the social security number at one
participant, for example, will prevent that registration record from
matching with other registration records from the same or different
participants for that patient. If the patient is registered in an ED
with the correct social security number, the global patient registry
will not match the registration record with the erroneous social
security number even though all the other data match. The provider
caring for the patient has no way to see the ``close'' matches and
cannot access the data for that patient.
Shared Pathology Information Network (SPIN)
With funding from the National Cancer Institute, all of the INPC
participants, as well as two new participants (the Indiana State
Department of Public Health and their Indiana State Cancer Registry)
participate in the Shared Pathology Information Network (SPIN). The
hospital participants are adding surgical pathology reports, inpatient
pharmacy data, discharge summaries and radiology reports to the data
they already provide to INPC. The public health department will
contribute de-identified cancer registry data. Many of the hospitals
are willing to make this data available for treatment purposes, as long
as SPIN protects it well
This NCI project will provide a link from clinical data and
outcomes (pheno-
type) to tissue specimens (genotype), as paraffin blocks in pathology
departments.
This evolving regional, population-based medical record database
provides extraordinary opportunities for epidemiology i.e. clinical and
public health research. This project raises many interesting challenges
regarding the linking of de-identified records.<SUP>vi, vii</SUP>
---------------------------------------------------------------------------
\vi\ Grannis SJ, Overhage JM, McDonald CJ. Analysis of Identifier
Performance using a Deterministic Linkage Algorithm. 2002 AMIA Fall
Symposium (submitted).
<SUP>vii</SUP> Schadow G, McDonald CJ. Maintaining Patient Privacy
in a Large Scale Multi-Institutional Clinical Case Research Network.
2002 AMIA Fall Symposium (submitted).
---------------------------------------------------------------------------
Reports
The INPC system can generate a variety of patient specific and
population based reports that facilitate clinical care. There are a
variety of triggers for creating these reports including patient
encounters and the passage of time. One of the key patient specific
reports is the Clinical Abstract. The clinical abstract provides a
``one page'' summary of specialty appropriate clinical information. The
content is specialty specific: a pediatric oriented clinical abstract
would summarize growth data and immunization records, an obstetrical
abstract would contain data that reflects fetal well being and key
dates such as the last menstrual period (LMP) and estimated date of
confinement (EDC) and an HIV abstract would feature trends in key
laboratory results and details of treatment history.
DOCS4DOCS <SUP>'</SUP>
DOCS4DOCS is an innovative tool we have created to introduce a
basic level of clinical information system utilization in physician
practices. It provides clinical messaging functions--in its simplest
form, practices receive various kinds of clinical data and messages
from multiple sources; the system aggregates and sorts the data in
useful ways and provide printed versions of this data that a physician
can review and act on much as they do today. DOCS4DOCS can be used to
record when results have been reviewed, for inter and intra office
communications and for short to intermediate term storage of these
results.
We have deployed DOCS4DOCS to over 800 physicians today with
rollout to approximately 600 more planned for this year and 1,600 the
following year. The system uses a novel distributed approach to
provider identity maintenance. Providers link themselves to the various
identifiers used in various source systems (providers may have
different and even multiple identifiers in a single hospitals
laboratory, transcription and ADT systems for example). Not only does
this approach simplify maintenance but puts it in the hands of those
who stand to benefit by good maintenance and who know the mappings
best.
Perhaps most importantly, DOCS4DOCS provides services built around
the health information exchange, that are so valuable that participants
are willing to pay for them. The DOCS4DOCS clinical messaging service
is replacing, printing, faxing and other delivery methods for the
majority of hospitals in Indianapolis providing operating efficiencies
to the hospitals and improved functionality to the providers since they
receive all of their results in a reliable, timely and uniform manner.
Uniformity is very important to the providers because they often
receive reports from multiple laboratories and find it difficult to
quickly and appropriately interpret them since every hospitals' reports
look different. With a consistent format, they are more easily able to
identify abnormal results, normal ranges and even which patient the
report applies to.
Use of Accepted Medical Informatics Standards
Not only have we used the standards for clinical data exchange and
representation that have been endorsed by the federal government's
Consolidated Health Informatics Initiative and the Connecting for
Health project but we have been major forces in their development. In
1984, the Clem McDonald led an effort that culminated in 1988 with the
first clinical message standard. That work was carried into HL7 and
today, virtually all clinical system vendors support HL7, and most
North American, European, and Pacific Rim health care institutions use
the HL7 standard to exchange clinical results. The PI of this proposal
wrote most of the HL7 Order Entry and Observation Reporting chapters
since its inception in 1987. Gunther Schadow, another RI researcher,
has been the major force behind the HL7 Version 3 Reference Information
Model (RIM) and the Version 3 Data Types and is a co-chair of the
Orders and Observations Subcommittee and Marc Overhage is an HL7 editor
and author of several HL7 implementation guides for the CDC.
Regenstrief /IU investigators initiated the development of the
Logical Observation Identifier Names and Codes (LOINC<SUP>TM</SUP>)
database that now contains 31,000 standardized codes and names for
clinical observations ranging from diastolic blood pressure to serum
levels of Hepatitis B surface antigen. Large health care institutions
and HMOs (e.g. Partners of Boston, the Veterans Administration, Kaiser
Permanente, Aetna Insurance, and large commercial laboratories e.g.
Quest and Lab Corp) use LOINC widely. Several countries including
Australia, Canada, New Zealand, Switzerland, Germany, Korea, and Hong
Kong also use LOINC. The FDA is considering a proposal to require LOINC
codes as part of all new drug submissions. The Regenstrief Institute
now distributes the LOINC database and RELMA mapping program via a web
site at no cost for all commercial and research purposes (http://
www.regenstrief.org/loinc).
The Structure of the INPC Agreement
The flow and management of data in INPC is designed to ensure that
the use and disclosure of patient information by and among the member
providers complies with federal and state law. The participants'
agreement on the use and disclosure of patient data is codified in a
contract that I will call the INPC Agreement, which is a roadmap for
identifying the policy and practical issues that must addressed when
sharing health data in a context as large as the INPC. The INPC
AGreeement was drafted, reviewed, and approved by clinicians,
compliance officers, lawyers, risk managers, and information systems
personnel in a cooperative consensus-building process.
How Can the Network and Its Participants Share Health Data to Treat
Patients?
Both federal and state laws address the sharing of protected health
information (``PHI'') between health care providers to treat patients.
The Privacy Rule issued pursuant to the Health Insurance Portability
and Accountability Act and most state laws generally allow covered
entities (health care providers such as hospitals, practice groups, and
other organizations) to use and disclose PHI without a patient's
consent for ``treatment'' purposes.
The INPC Agreement is consistent with the permissible uses of PHI
for treatment set forth in the Privacy Rule.
The Network is simply a way for the participants to more easily
provide PHI to one another, through electronic means, for the treatment
of common patients. The INPC allows participants to access Network
information submitted by other participants for any treatment purpose
(in the HIPAA sense) of the accessing participant, regardless of the
care setting (e.g., emergency room, inpatient, outpatient surgery,
etc.). However, the Network will not release information unless there
is verification that a patient is actually in the care setting (such as
the exchange of registration information).
The Privacy Rule allows covered entities to engage business
associates to perform functions on their behalf that requires the use
or disclosure of PHI.
The Regenstrief Institute acts as a common business associate of
all of the participants for the purpose of storing and disclosing the
participants' PHI to other participants for treatment purposes. The
INPC Agreement contains appropriate Privacy Rule business associate
provisions.
The INPC Agreement does not require participating hospitals to
obtain a patient's consent prior to disclosing the patient's PHI
another participant or to Regenstrief for treatment purposes because
neither the Privacy Rule nor Indiana state law requires such consent.
Who May Have Access to PHI for Treatment Purposes?
The institutional provider participants must identify the
individuals in their organization who may access PHI on the Network.
Each institutional participant must certify and warrant that it has
taken certain steps to ensure that such individuals will protect the
confidentiality of the Network information. Each participant must also
ensure that Regenstrief receives regular updates to the institution's
authorized personnel list. Participants are also encouraged to identify
affiliated physician practice groups who might benefit from access to
the Network for patient treatment purposes. However, the institutional
participant with whom the physician group is affiliated is responsible
for ensuring that the physicians abide by the confidentiality
restrictions described in the prior paragraph.
What Information Is To Be Stored on the Network?
The INPC Agreement identifies the information that participants
agree to submit to the Network. Without a common agreement that the
participants will store minimum categories of information, the Network
will not become populated and will not be useful.
The participants agree to make good faith efforts to store, at a
minimum, the following kinds of data:
(1) hospitalizations and the emergency room encounter information;
and (2) patient demographic information, reason for visit, treating
health care provider(s), date of visit, place of visit, diagnoses,
procedures, vital signs, all laboratory reports, pathology reports,
radiology studies and reports, discharge summaries, operative notes,
inpatient medications, cardiology studies, and other diagnostic tests
to the extent that participants have the capability to submit such
information electronically. Participants are encouraged to make any
other clinical information they wish available to the Network.
Consideration must be given to whether a network will accept PHI
that is provided extra protection under the law.
Specifically, alcohol and drug abuse treatment records are afforded
stringent protection under federal law, and the Privacy Rule gives
psychotherapy notes enhanced protection. Accepting such information on
a common network will increase the administrative burdens and security
measures required to protect such information. The INPC Agreement
discourages the submission of drug and alcohol abuse treatment
information and prohibits the submission of psychotherapy notes.
How May the PHI Be Used and Disclosed for Research Purposes?
The Regenstrief Insittute and the participants recognize the
important opportunities for scientific research provided by the large
repository of patient information housed on the Network. Therefore, the
Agreement provides for methods of using and disclosing the Network
information for research purposes. In all cases, the research
provisions of the Privacy Rule are followed. The Agreement sets forth a
hierarchy of research uses and disclosures. Use of deidentified health
data for research purposes requires minimal approval from the
participants whose data will be used. Research that requires the use of
identifiable PHI is subject to several approvals, including
institutional review board approvals. Given the Privacy Rule's detailed
provisions governing the use of PHI for research, the research sections
of a network's governing agreement must be carefully drafted so that
all parties are comfortable that their data will be used properly. This
is a sensitive and complicated area for discussion. In no event does
Regenstrief allow information to be disclosed for research projects
that has the effect of comparing the participants with one another
(such as individual participant outcomes or participant financial
information) without the affected participant's approval. This was a
particular concern of participants in the highly competitive
Indianapolis health care market.
What Are Other Considerations?
Consistency of Data.
Consideration must be given to the format of the information
submitted to the Network so that the information is accessible to all
participants in a common form. Will the network require the submission
of data in a common form, or will the network translate the information
into a common form after submission? Under the INPC Agreement,
Regenstrief assists participants with the mapping of test results and
physicians codes into standard forms that are accessible and
understandable by all participants.
Other Uses of Information.
Will other uses of information be allowed. For example, under the
INPC, the institutional participants use Regenstrief as their business
associate for purposes of screening their health data for communicable
disease information that must be reported to the Indiana State
Department of Health. Future uses of the information may include
screening the information for indicators of bioterrorism activity.
Indemnification.
Given the availability of PHI through the Network that is beyond
the physical control of individual participants, the participants
required an indemnification provision that protects them in the event
that Regenstrief or another participant wrongfully uses or discloses
PHI.
Governance.
The Network is governed by a Management Committee. While the INPC
Agreement sets forth the structure of the Network, the Management
Committee is empowered to make day-to-day operational and policy
decisions that are consistent with the structure set forth in the
Agreement. Issues addressed include technical issues, confidentiality,
the scope of information stored and accessed by participants, and the
use of the information. The Management Committee is comprised of
representatives of the institutional participants and Regenstrief.
Disposition of Information Upon Termination.
Consideration must be given to the disposition of PHI upon
termination of the Agreement or if a participant withdraws. For
example, research that relies on the continued availability of the
information could be impeded if a participant withdrew and removed its
information from the Network. In addition, if information is removed
from the Network, the ability of a participant to have access to
information to defend itself in malpractice suits could be compromised.
Thus, the INPC Agreement makes provision for the extended storage of
the information after the termination of the Agreement and after the
withdrawal of a participant.
Models of the potential savings from HIE between organizations
provide some estimates. One study estimated that uniform data-sharing
application nationwide providing easy access to view patients' clinical
information would save more than $39 billion--or $11.57 per patient per
month. The California Health Care Foundation didn't calculate savings
at a national level but estimated net benefits of over $5M annually for
large communities with high penetration of HIE. In a study I
participated in the Center for Information Technology Leadership at
Partner's Healthcare used a rigorous analytical approach to assess
clinical information technologies and disseminates its findings to help
provider organizations maximize the value of their IT investments, help
technology firms understand how to improve the value proposition of
their healthcare products, and inform national healthcare IT policy
discussions. They created a financial model that examined the direct
value of four levels of interoperability, but the conclusions focused
on the financial value of moving to non-standardized, machine-
organizable data and standardized, machine-interpretable data (http://
www.citl.org/news/HIEI--Findings.pdf). The model did not include any
benefits from improved quality or safety of care. CITL found that the
value of standardized HIE far exceeds the value of non-standardized
HIE. CITL based its model on literature reviews, expert assessments,
and market research. To supplement published studies, CITL relies on
the informed judgment of its Expert Panel and interviews with IT users,
developers, and vendors. The provider centric model included 1,238
nodes. HIEI produces two principal types of benefits: administrative
savings and reduced utilization. Administrative savings included the
financial value of time saved by transitioning from manual to
electronic data exchange Reduced utilization (elimination of
redundancy) resulted in economic benefit by eliminating unnecessary lab
and radiology tests and improved interoperability between providers and
labs, and providers and radiology centers. On a national basis, the
model projects $87 billion annual savings with $34 billion value to
providers.
In order to explore the implications of the model locally, we reran
the model with parameters chosen to represent the Indianapolis MSA.
With these parameters, the model predicts net benefits of $3.6 billion
over 10 years and an annual net benefit of $500 million in year 10 with
providers' net benefits of $1.4 billion over 10 years and an annual net
benefit of almost $250 million. These are preliminary findings and
require careful review and verification but suggest the order of
magnitude of the value of HIE in the Indianapolis MSA. Provider to
provider exchange accounted for the largest proportion of the benefit
with payor, laboratory and radiology being the next largest.
The ultimate measure of our success will be creation of a
sustainable funding model for HIE in central Indiana. We have made
substantial progress by creating the Indiana Health Information
Exchange (IHIE), a not for profit 509(A)3 not for profit support
organization that supports the first commercial service built on the
HIE. Hospitals and other data providers in the region are paying fees
to deliver clinical results (e.g. laboratory test results, transcribed
reports and admission notices) to providers. The IHIE can provide these
services at a savings through economies of scale, by eliminating
duplicative efforts and by moving results delivery to an electronic
platform. If we successfully demonstrate savings from HIE in the
ambulatory setting we would create a service through IHIE supported by
fees from those who benefit from the exchange.
Benefits to the community
We are still formally evaluating the benefits of health information
exchange. We have demonstrated a $26 reduction in charges for each
emergency department visit even when only one hospital is sharing data
with others. We have completed a much larger study in which all of the
hospitals shared data with each other but we have not finished
analyzing the results. When we ask care providers how the health
information exchange has helped them, they readily recall anecdotes. In
one case an ambulance brought a young women to the emergency department
unresponsive and data from the INPC allowed her providers to avoid
extensive neurological testing and deliver appropriate psychiatric
treatment. In another recent episode, a woman was checking into a
hospital outpatient clinics when she collapsed. Her providers were able
to identify her and bring up her medical record within minutes of her
arrival to the department. This allowed them to view her past medical
history, medications, allergies--providing us with information when the
patient could not. It changed the decisions we were planning to make
and helped us take better care of this patient. In this case, the INPC
acted as the patient's voice--speaking for her when she could not. A
few weeks ago, a colleague of mine, was taking care of a patient with
an upper respiratory infection. He had a fever, and cough--but denied
any medications or health problems. When the doctor reviewed the
patients records, she recognized the patient had HIV and required a
different course of treatment. In this case a condition that could
normally be treated as an outpatient, required hospitalization and more
aggressive treatment. As a final example, a patient came to the ED with
chest pain. He was very ill, and not able to tell the doctors his
medical history. The physicians were concerned that he was having
trouble with his heart, and possibly having a heart attack. A standard
treatment for this condition is give medicine that will thin the blood
and allow blood flow back to the injured area of the heart. When the
physicians reviewed the data from the INPC they found that a CT scan
done at another hospital three weeks previously indicated the patient
was recovering from a recent head injury, where giving a blood thinner
would have caused increased bleeding and would have injured the
patient--possibly resulting in death. These examples illustrate the
types of direct patient benefits that health information exchange can
provide.
What should the government do
<bullet> Development will require a simultaneous top down and
bottom up approach. The top down part defines the common approaches;
the bottom up builds the collaboration, trust and value proposition.
<bullet> Government can facilitate definition of a ``path'' or
``stake in the ground'' so that vendors can develop with confidence and
providers can purchase with confidence. This ``stake in the ground''
includes profiles or collections of standards like those endorsed by
the government's Consolidated Health Informatics Initiative and the
Markle Foundation's Connecting For Health program, definitions of
``good enough'' security measures and a common approach to
authentication.
<bullet> Government can encourage use of standard at all levels
through, for example, the FDA establishing LOINC <SUP>'</SUP> codes for
laboratory tests when they are approved and requiring these codes to be
included with all printed materials related to the test. Finally,
government should participate with other payors in creating mechanisms
that use savings generated by health information exchange to offset the
costs of infrastructure and the losses that providers suffer as a
consequence of improved information flows
I sincerely thank the Committee for this opportunity and would welcome
any or all of them to come to Indianapolis and see what we have
accomplished first hand.
<F-dash>
Chairman JOHNSON. Thank you very much, Dr. Overhage. Dr.
Wiesenthal.
STATEMENT OF ANDREW M. WIESENTHAL, M.D., ASSOCIATE EXECUTIVE
DIRECTOR, KAISER PERMANENTE
Dr. WIESENTHAL. Madam Chairman, Representative Stark,
Members of the Subcommittee, I am honored to be here today to
testify before you on health care IT. My name is Dr. Andy
Wiesenthal, and I am speaking today on behalf of Kaiser
Permanente. I am a pediatric infectious disease specialist by
training, and the Associate Executive Director of the
Permanente Federation, the National Organization of the
Permanente Medical Groups. In this capacity, I co-lead the 10-
year, $3 billion effort to implement the comprehensive health
care information system throughout Kaiser Permanente.
Seventeen years ago, I was asked to lead the quality
improvement program in Kaiser Permanente's Colorado region. I
believe then and I believe now that, in order to improve the
care that physicians and nurses deliver, they need better and
more accessible information. Patients need more ways to relate
to the health care system so their needs are effectively
addressed.
Finally, if we are to truly assess the quality of care, it
is essential to have detailed, automated information about the
interactions between practitioners and their patients. All of
this requires new ways of collecting, storing, and retrieving
health care information. Seventeen years ago, there was really
nothing off the shelf that could meet those needs. After trying
in my basement to write the software for an electronic medical
record myself, I quickly recognized that the scale and
complexity of this work required a more organized, sustained
effort. Kaiser Permanente in Colorado eventually invested $55
million in this effort, and implemented its clinical
information system in 1998. Fortunately, the state of the art
has progressed considerably since I began my effort in 1987.
Five years ago, Kaiser Permanente decided to implement a
comprehensive electronic medical record nationally. The term
electronic medical record, however, does not capture the broad
range of capabilities that Permanente physicians and other
Permanente clinicians will have once the system is fully
implemented. Kaiser Permanente HealthConnect, as we refer to
it, will include a unified electronic medical record for each
patient that crosses the spectrum of care from the clinic
through the emergency department to the inpatient setting and
ultimately the home; inpatient and outpatient clinical decision
support, including built-in guidelines and care pathways; a
patient billing function, scheduling for patients, physicians,
and equipment; broad web-based access, and many other
capabilities.
Why did we decide to implement a comprehensive electronic
medical record at this time? It was a strategic imperative. To
make a major leap forward in terms of quality improvement,
service, patient safety, care coordination, efficiency,
effectiveness, and job satisfaction, we needed to take the
risk. The overriding goal of Kaiser Permanente HealthConnect is
quality improvement. Once fully implemented, patient medical
information and clinical decision support will be available on
a 24 hours-a-day, 7 days-a-week, 365 days-a-year basis, and
more than one clinician will be able to use a single patient's
information simultaneously. Having the complete medical record
available makes it possible for physicians to be aware
immediately of all patient issues, test results, history, and
concerns, as well as recommendations the patient has received
from other clinicians. Clinicians will always be able to work
with the most current information and provide the best care and
service possible.
Here is a real life example from a Kaiser Permanente
Northwest physician: a surgical colleague called me about a
patient referred to him with a large mass that he noted on
imaging studies. I was able to pull up and look at the Computed
Axial Tomography (CAT) scan on my desktop within a minute, and
agreed with him that the mass was thyroid-related. I was able
to review the patient's symptoms, medical history, and
laboratory test results within a minute, and concluded that I
should see her to do a thyroid biopsy.
I was able to check my schedule, and because of a recent
cancelation, I was able to invite the patient straight over. I
saw her within half an hour of being contacted. All of the
information I needed was on hand, and a definitive diagnostic
test, a fine needle biopsy of the thyroid, was done there and
then. In the old days, it would have taken 6 to 24 hours or
longer for me to receive the x-ray jacket to look at the hard
copy of the CAT scan. I would have needed to gather copies of
all labs, prior clinicians' notes, and so forth, from the paper
chart. Many times, with urgent consult requests, we did not get
the chart in time to review before seeing the patient. This
would lead to duplication of testing or, worse, potential
failure to recognize important clinical elements that are easy
to see with our electronic medical records system.
Now, when a colleague calls with a question, just about the
only information they need to provide is the patient name or
number, and I can pull up his or her data just about faster
than they can tell it to me over the phone. Receiving care for
patients should be more convenient. Patients will be able to
make the most of care or advice or information via telephone,
web, and e-mail, whatever means they choose to fit their needs.
Web-based access to results and e-mail messaging will allow
each patient to attain greater autonomy in accessing
information, and can make it easier for them to send a question
or request to their care giver. In the end, benefits to
patients in terms of quality, convenience, service,
personalized care, costs, and better science are considerable.
While it is still unclear whether in the long run overall
spending will decline as a result of implementing Kaiser
Permanente HealthConnect, if it just breaks even, the new
benefits for patients by any measure are quite considerable. We
are pleased that Congress has begun to think about the ways it
can enable health plans and health care providers across the
spectrum to bring the benefits of health care IT to all
patients. The two most prominent ideas being developed relate
to standards setting and financial incentives. In my written
testimony I discuss in more detail what Congress could do in
this area. In closing, I want to congratulate the Subcommittee
Chair and the Ranking Member for this timely and important
hearing. I would be pleased to answer any questions.
[The prepared statement of Dr. Wiesenthal follows:]
Statement of Andrew M. Wiesenthal, M.D., Associate Executive Director,
Kaiser Permanente
Madame Chairwoman, Representative Stark, members of the
Subcommittee, I am honored to be here today to testify before you on
health care information technology and the promise it has for improving
health care quality and patient safety, lowering health care costs, and
expanding important research opportunities. My name is Dr. Andrew M.
Wiesenthal. I am the Associate Executive Director of the Permanente
Federation, the national organization of the Permanente Medical Groups.
In this capacity, I co-lead the 10-year, $3 billion effort to put in
place, operate and maintain a comprehensive health care information
system throughout Kaiser Permanente, one of the nation's leading health
plans and its largest private-sector health care delivery system.
Kaiser Permanente provides health care coverage and medical care to
more than 8.3 million members in nine states and the District of
Columbia. The Permanente Medical Groups include more than 12,000
physicians, who are supported by approximately 130,000 professional,
clinical, and administrative employees.
In my remarks today, I want to share with you what Kaiser
Permanente is doing in the area of health care information technology.
I also want to explain why we are doing this--what value we hope this
will bring to our members. I will conclude with some suggested actions
the Subcommittee may want to consider to speed the adoption of
electronic medical records throughout the health care system.
Why Kaiser Permanente is Investing Significantly in an Electronic
Medical Record
Seventeen years ago, I was asked to lead the Quality Improvement
Program in Kaiser Permanente's Colorado Region. I believed then and I
believe now that in order to improve the care that physicians and other
clinicians provide, they need better and more accessible information.
They need better information on the patients they see, at the time they
see them. They need up-to-date information about clinical issues when
they make medical decisions. They need better, faster ways to get more
reliable feedback on the care they deliver. And patients need more ways
to relate to the health care system so that their needs are effectively
addressed. Finally, if we are to truly assess the quality of care, it
is essential to have detailed, automated information about the
interactions between the health care team and the people for whom they
are responsible. All of this requires new ways of collecting, storing
and retrieving information.
Seventeen years ago, there was no widely available comprehensive
electronic medical record, one containing all the clinical information
about a patient recorded over several years by many different
physicians, pharmacists, clinical laboratory technicians and others and
that can be retrieved instantaneously by any attending clinician with
the proper authority to do so. There were crude, general database
programs and some rudimentary programs specifically designed for the
purpose. But there really was nothing at the time that could meet these
straightforward needs.
After trying to write the software for an electronic medical record
myself, I quickly recognized that the scale and complexity of this kind
of work required a more organized, sustained effort. Kaiser Permanente
in Colorado eventually invested $55 million in this effort and
implemented its Clinical Information System in 1998. Fortunately, the
state of the art has progressed considerably since I began my effort in
1987.
Working to deliver better health care through information
technology is a Kaiser Permanente tradition. More than 40 years ago,
Dr. Morrie Collen, director of Kaiser Permanente's first research
center returned from a national congress on medical electronics
convinced that there were ways to use computers to improve health care.
Dr. Collen's work eventually led to a 1961 grant from the Public Health
Service to study the automation of multiphasic health testing. As a
result of this project, KP patients were among the first to see
internists armed with computer printouts of pertinent medical data.
Since then, several generations of systems connecting physicians
electronically with their patients' medical information have been
tested and implemented in different Kaiser Permanente regions. Each
regional effort has had its merits. But a more powerful system that
would allow seamless communication between physicians regardless of
location was needed.
Five years ago, Kaiser Permanente decided to implement a
comprehensive electronic medical record throughout its entire system.
After several stages of internal development work, we decided one year
ago that software developed by Epic Systems of Madison, Wisconsin had
evolved to the point that it could handle our size and complexity. Why
did we make these decisions? Frankly, we saw them as a strategic
imperative. We believed that if we were going to make a major leap in
terms of quality improvement, service, patient safety, care
coordination, efficiency, effectiveness, and job satisfaction, we
needed to take the risk. While we have developed some components of the
system ourselves, and others come from an array of vendors, the core of
the system we are implementing is from Epic Systems. Similar Epic
software has been implemented in many of the nation's largest health
care systems. It's my job to direct the implementation at Kaiser
Permanente.
Kaiser Permanente's Electronic Medical Record
The term ``electronic medical record'' does not really capture the
broad range of capabilities that Permanente physicians and other Kaiser
Permanente clinicians will have available once the system is fully
implemented. That's why we have created a more encompassing name to
refer to the system--KP HealthConnect. The full range of functions
includes:
<bullet> A unified electronic medical record for each patient
crossing the spectrum of care from the outpatient arena, through the
emergency department, to the inpatient setting and ultimately the home.
<bullet> Inpatient and outpatient clinical decision support
<bullet> Patient billing function
<bullet> Patient, physician, and equipment scheduling
<bullet> Web-based access for patients and providers (both KP and
non-KP)
<bullet> Inpatient pharmacy support and reporting
<bullet> Clinical laboratory support and reporting
<bullet> Emergency department management
<bullet> Interfaces to a wide variety of other systems like PACS
(picture archiving systems) and population care management systems
The Benefits Kaiser Permanente Expects from KP HealthConnect
The overriding goal of KP HealthConnect is quality improvement.
Once fully implemented, patient medical information and clinical
decision support will be available on a 24/7/365 basis and more than
one clinician will be able to use a single patient's information
simultaneously. Internal research from our Colorado Region, where
Kaiser Permanente has 420,000 members, shows that electronic medical
records are being accessed on average about 1 million times each month.
This compares quite remarkably with 90,000 monthly paper chart
deliveries before the system was implemented. Having the complete
medical record available makes it possible for physicians to be aware
immediately of co-morbidities, past visits and patient concerns, as
well as recommendations the patient has received from other clinicians.
In addition, test results will be immediately available electronically.
This means clinicians will always be able to work with the most current
information and provide the best service possible.
Nothing illustrates the kind of quality improvement made possible
by the implementation of KP HealthConnect than a real-life example. As
one physician in Kaiser Permanente's Northwest Region explained:
A surgical colleague called me about a patient referred to him
with a large mass that was noted on imaging studies. I was able
to pull up and look at the CT scan on my desktop within a
minute and agreed with him that the mass was thyroid related. I
was able to review the patient's symptoms, medical history and
laboratory test results within a minute, and concluded that I
should see her to do a thyroid biopsy. I was able to check my
schedule and, because of a recent cancellation, I was able to
invite the patient straight over. I saw her within half an hour
of being contacted. All of the information I needed was on
hand, and the definitive diagnostic test (fine needle biopsy)
was done there and then. In the ``old days,'' it would have
taken 6-24 hours or longer for me to receive the X-ray jacket
to look at the hard copy of the CT scan. I would have needed to
gather copies of old labs, prior clinicians' notes, etc. from a
paper chart. Many times, with urgent consult requests, we did
not get the chart in time to review before seeing the patient.
This would lead to duplication of testing, or worse, potential
failure to recognize important clinical elements that are easy
to see with our electronic medical record system. Now, when a
colleague calls with a question, just about the only
information they need to provide is the patient name or number,
and I can pull up his or her data just about faster than they
can tell it to me over the phone.
Other benefits that have been noted by clinicians include the
increased likelihood of resolving patient concerns in the first visit,
the ability to deliver more services in a single visit, and addressing
prevention and other ancillary needs when patients make visits to
address health problems. Respondents to an internal survey also
indicated that use of an electronic medical record reduced unnecessary
clinical laboratory, radiology, and emergency department utilization
and increased the effectiveness of scheduled and unscheduled telephone
contacts.
Much of the appeal of electronic medical records is the opportunity
to improve quality by having patient information immediately available.
Equally important and often as prominent when discussing electronic
medical records is the availability of on-line, real-time decision
support information. With KP HealthConnect, the latest clinical
information will be available to physicians in the examining room to
provide point-of-care recommendations for a wide variety of clinical
conditions. We are building our practice guidelines and treatment
pathways into the system. Permanente physicians already have access to
the complete range of on-line medical journals from their desktops and
in the examining room.
We also expect that KP HealthConnect, by allowing more personalized
care, will significantly increase patient satisfaction. For example,
staff will be able to use up-to-date clinical, social and patient
preference information when caring for patients. Patients will have
greater access to their own information and be full partners in
decision-making. An after-visit summary will be printed for patients at
the end of each appointment and will be available permanently online.
Team care will be more patient centered. Since all information about a
patient will be available, even a physician who has never seen a
patient will immediately know his/her history and preferences. This
should make each patient encounter more personal, individualized, and
ultimately responsive.
Receiving care should be more convenient as well. Patients will be
able to make the most of care/advice/information via telephone, web,
and e-mail. Telephone wait times will be reduced and the need for
callbacks to find medical records eliminated, allowing office personnel
to rapidly retrieve essential information when the patient needs it.
Web-based access to test results and e-mail messaging will allow each
patient to attain greater autonomy in accessing information and can
make it easier for them to send a question or request to their
caregiver. Web-based availability of one's medical record on a 24/7/365
basis will allow patients to make decisions when it is convenient for
them. Making personal and technical information available to patients
over the Internet should make it possible for patients to conduct a
variety of transactions with their doctor without having to interrupt
their own lives to go to the office or spend time on the phone.
We expect that KP HealthConnect will create efficiencies for Kaiser
Permanente and our members. There is already strong evidence from the
regions where we have had an electronic medical record for some years
that, as each appointment meets more of a patient's needs, the demand
for appointments declines. Two years after our Colorado Region
implemented an electronic medical record, we saw a 9 percent decline in
age-adjusted annual office visits per member. Primary care visits
declined by 11 percent; specialty care visits declined by 5 percent.
Our Northwest Region experienced a similar 9 percent overall decline in
the demand for office visits, and the breakdown for primary care and
specialty visits was almost identical. It is worth noting that these
two regions had implemented different electronic medical records
systems, although their capabilities were very similar. Neither region
intended to reduce outpatient visit rates--it appears to have resulted
from more efficient use of appointments overall.
As we noted above, we expected visits to become more efficient.
More than one issue will be able to be handled in a single visit. Since
prescriptions and lab requests are immediately placed in the system,
wait times will be reduced as will overall time spent at the doctor's
office. There will also be lower pharmacy and laboratory costs than
there would be with paper medical records. Copying costs are reduced.
Resources and time dedicated to maintaining and transporting paper
records will be reduced or eliminated. Administration of benefits and
new products will be more efficient and accurate. Benefits information
and information related to new products will be continuously available
online, allowing for more accurate administration of services.
Finally, clinical research to support evidence-based care will be
greatly enhanced. Comprehensive patient data will be available for
larger populations and more accessible than ever before, allowing for
significantly more robust research than previously possible, for a
fraction of the cost, and taking relatively much less time. Some
research that would benefit from very large populations may be possible
for the first time. For example, the recently reported RAND Corporation
ACOVE studies examined the extent to which physicians complied with an
agreed upon set of standards in caring for an aged population. It
included a sample of 400 patients and required thousands of hours of
medical records extraction. The study cost hundreds of thousands of
dollars. With systems like KP HealthConnect, the information would be
available almost instantaneously, ultimately on an aged population of
about 1.5 million people with considerably greater reliability given
that abstraction can be eliminated. The research potential is almost
beyond imagination.
In sum, the benefits to patients in terms of quality, convenience,
service, personalized care, costs, and better science are considerable.
While it is still unclear whether, in the long run, overall spending
will decline as a result of implementing KP HealthConnect, if it breaks
even, the new benefits for patients by any measure are quite
considerable.
Making Electronic Medical Records Broadly Available
Kaiser Permanente has been working to implement an electronic
medical record for many years. The promises of a single-system, user-
friendly, comprehensive, electronic medical record for all of Kaiser
Permanente are still a few years away. While we have begun broad
implementation of our system, the federal government has begun to think
about the ways it can enable health plans and health care providers
across the spectrum to bring the benefits of health care information
technology to all patients. The two most prominent ideas being
developed relate to standard setting and financial incentives.
Standard Setting
The lack of widely accepted standards for health care information
technology has had profound consequences for the development and
dispersion of electronic medical records. First, it has increased the
risk any company would face if it chooses to develop health care
information technology products. Very few developers could afford to
build a product using proprietary technology only to find that it is
made obsolete by the subsequent adoption of standards with which it is
incompatible. Similarly, few providers or health plans will make an
investment in a costly system if they run the risk of having a suddenly
outmoded system, unable to communicate with other systems. This
explains why we have worked so hard to help the industry develop the
tools that are the foundation of many systems now in use or in
development. We worked closely with the College of American
Pathologists in the development of SNOMED-CT, the recently adopted
standard for medical terminology that the government is making
available to everyone. We also actively participate in HL7 and other
broad-based standard setting organizations. This allows us to
contribute our expertise to these groups and has helped us to
anticipate emerging developments.
As the government moves to adopt an increasingly complete set of
standards for health care information technology,
<bullet> The federal government should move quickly to adopt
standards for interoperability. Priority should be given to:
-- identification of data standards appropriate for national
adoption and gaps in existing standards,
-- provision of targeted financial support for public-private
partnerships to develop and/or endorse such standards, and
-- leading public-private efforts to promulgate and maintain
standards
The Consolidated Health Informatics Initiative is an effective
model--where the government, in collaboration with the private
sector, identifies standards for the federal health care sector
that will serve as a model for the private sector. This is an
example of both federal leadership and the power of public-
private partnerships. For this kind of effort to succeed,
sufficient federal resources are essential.
<bullet> Efforts should be made to ensure that pioneers in the
deployment of electronic medical records can easily comply with newly
adopted standards.
Financial Incentives
We are convinced that widespread adoption of health care
information technology like KP HealthConnect is essential for sustained
quality improvement. We also believe that this technology is essential
to the development and application of quality measures. However, as
MedPAC noted in its ``Report to Congress: New Approaches in Medicare''
released on Tuesday,
``many barriers slow physician adoption of information
technology. The costs of investing in information technology
can be significant, the financial return is not certain, and
any financial benefits will not necessarily accrue to the
physician practice bearing the costs.''
If we are correct that adoption of health care information
technology is essential for sustained quality improvement, then support
for health care information technology is needed.
Both public and private purchasers of health care are introducing
quality-related financial incentives into the payment for health care.
The Leapfrog Group has been a leader in the introduction of payment-
related quality standards, especially for hospitals. Several large
employers, including General Electric, Ford, and Proctor and Gamble,
are supporting the development and implementation of approaches to
linking payment to quality for physician care. And, some States have
developed Medicaid payment methods that depend in part on quality.
Discussions are now beginning about how payment incentives can improve
care and outcomes for Medicare beneficiaries. Ultimately, for payment
incentives to have real influence on quality, they should be directly
tied to the care delivered during a specific time period. The kind of
information needed to do this can only be made available through
sophisticated electronic medical record systems.
<bullet> We urge the Congress to ensure that the federal
government participates in the investment needed to implement
electronic medical records. The Medicare and Medicaid programs are far
and away the largest third-party purchasers of health care. As a
general rule, providers and health plans care for beneficiaries of
these programs on an administered pricing basis. They have no
independent ability to set payment rates at a level that includes
sufficient resources for investment in health care information
technology. Moreover, there are few existing financial incentives for
providers to pay up front for these systems. Even small increases in
Medicare and Medicaid provider and health plan payments would help
create momentum toward broad adoption. At the same time, providers and
private health plans should be expected to work with other purchasers
to ensure adequate private-sector investment in a health care
information technology that helps everyone.
In closing, I want to congratulate the Subcommittee Chair and
Ranking Member for this timely and important hearing. I would be
pleased to answer any of the Committee members' questions.
<F-dash>
Chairman JOHNSON. Thank you very much, all of you, for
being here and for your thoughtful testimony, and for the
extraordinary work you are doing and have done over many years.
It is sort of startling to hear how much money has been
invested, how far you have come, how deep you are into systems
that are quite encompassing of both lives and institutions.
You heard Dr. Brailer's testimony. Now, you are doing it.
How hard is this standard setting? Remember, we put in our
original bill that came out of this Committee e-prescribing at
the same year that we are going to bring all the seniors into
the prescription drug access. It makes absolute sense, and you
can hear it through your testimony, that these things should be
coordinated from the point of view of quality health care and
eliminating problems; but in the process of the Conference
Committee, that 2 years became 8. So, there is a lot of
resistance out there.
Now, what is the standards issue? How hard is it going to
be for Dr. Brailer to set standards? You already know a lot
about how different are your standards. Could you figure out
interoperability if you needed to between your systems? How far
do we have to go before we can at least complete this first
step of what are the standards so then we can begin to address
the other issues of money, of absorption, of integration, of
implantation, of training? Yes, Dr. Wiesenthal.
Dr. WIESENTHAL. Well, I think certainly Dr. Overhage will
also speak to this. Both of our organizations and others have
actually invested very heavily in helping to contribute to the
national standards. I don't think at this point that the
standard setting is the hard part. It is the use of the
standards and the software. We have gone to great lengths to
incorporate, to actually develop many hundreds of thousands of
terms for SNOMED Clinical Terms (CT) and to incorporate that
into the work that we are doing. We use the LOINC laboratory
standards that the Regenstrief Institute has developed and many
others that are national. I don't think it is the standard
setting that is the issue; I think it is encouraging
institutions like ours and vendors to incorporate those
standards in a rigorous, reproducible way so that the
information can move back and forth.
Dr. OVERHAGE. If I may go just a step further. I think
that, in order to do that implementation as was referenced,
some of the important steps are certification, creating a
capability to ensure that a plug and play capability--that may
be a bad word with the computers they serve, are not quite that
good. To ensure that standards truly are able to interoperate,
and that we do not need to develop a mass of new standards but
rather to utilize properly the ones that are there. We may need
a reference implementation. I think Dr. Brailer mentioned that,
a vehicle for testing against to make sure that those standards
are implemented in a consistent fashion.
Ms. MARCHIBRODA. The government can rapidly accelerate
adoption using carrots, not sticks, by just building it into
their Federal government programs, whether it is--ultimately
when electronic data is transmitted, to support currently
required accountability measures for quality that CMS uses, or
whether it is the public health surveillance that is conducted
by local, State, and public health agencies, when transmitted
electronically, asking that it be transmitted using standards.
There are a number of ways through its programs that standards
adoption could be accelerated.
Chairman JOHNSON. Dr. Safran?
Dr. SAFRAN. Well, I think at the local level, the problem
isn't standards, it is incentive for anybody to use them. So,
when I am practicing in my own office, I keep my own chart. I
may have it completely electronic, but there is nothing broken
from my perspective. The thing that is broken is that when you
are a patient and you have to go from my office to a
specialist's office, and you have to retell the story, you have
to send the medical records, you have got to request them, and
you have got to retell the medications. There is no incentive
for me to purchase a system or to--me, as a physician in my own
office, to have--I may have a completely good electronic record
that solves my problem. The problem is really a patient's
problem, our citizen's problems, and so there is no--it is the
incentives.
So, in Kaiser, we have sort of an interesting unified
incentive of the physicians and the hospitals where--and the
health system. For most of us, the practice outside of any sort
of unified system, we need better incentives for this kind of
collaboration and health care. My belief is that we need to
empower our citizens, the consumers, to demand that their
physicians use e-mail and electronically transfer their
records.
Chairman JOHNSON. Mr. Stark.
Mr. STARK. Well, I had in mind a modest incentive, Madam
Chair, like we wouldn't pay you until you did it. I know that
would not be a popular solution, but at some level, I am afraid
that--it might be only for part of your practice, but it seems
to me that convenience--and as you point out, why should you go
through the inconvenience. I appreciate that.
I think you are quite right there, because somebody is
going to go off to a radiologist or somebody else who needs
information from you and that is, your office probably says,
look, we give out that information from 3:30 to 4:00, and you
call in on this number, because we don't have time to be
answering the phone off and on all day. Possibly that would be
eliminated, and then one of the underlying things, that you all
would be more efficient in, as you described, Dr. Wiesenthal,
you could get the answer more quickly because you wouldn't have
to spend 24 hours or 36 hours waiting for hard copies to get
transmitted by United Parcel Service of America or something.
That is hard to sell somebody when you are looking at them
and say, look, you have got to spend $100,000 to train, new
software, input people, and buy a new system for your office.
To some extent, Madam Chair, I think our witnesses make the
case for us to move more quickly rather than later, because the
more this gets ingrained and the longer it goes without--even
if it isn't enforced, as long as you know what is out there--I
still use--nobody knows what MYM is, and I should use whatever
this new system is to keep my checking account. The MYM, you
can't buy it anymore. I know it is going to crash. As sure as I
sit here, I know it. Then I am going to spend a month typing
into one of these new ones. The new one, you know what? I can
get my bank account downloaded automatically; I can't in my old
one.
If I took the time--but I know what it is going to be when
the system crashes. There is no doubt in my mind what I am
going to have to do. I hope we can--I leave it up to the
Chairman; she is going to have to take the flack as to who is
going to be mad at her. You are not going to make everybody
happy, but I think you are going to have to do it.
Chairman JOHNSON. One of the reasons we are having these
hearings is that we lost in conference because we hadn't laid
the base of understanding.
Mr. STARK. I think you are going to have to pick a system,
Madam Chair, and are just going to have to say, that will be
it, we agree with you, let us go.
Chairman JOHNSON. Well, we do want your input under those
kinds of issues.
Mr. STARK. Good luck.
Chairman JOHNSON. Mr. McCrery.
Mr. MCCRERY. Ms. Marchibroda, you seem to disagree about
the necessity of setting standards. You seem to indicate in
your testimony that you thought that was one of the barriers to
getting more people or more entities to adopt IT, but there is
not a set of uniformed standards out there. Did I misinterpret
your----
Ms. MARCHIBRODA. Absolutely. We are very enthusiastically
supportive of national standards.
Mr. MCCRERY. I know, but you said in your testimony that
you thought the lack of adoption of national standards was an
impediment to hospitals and doctors and others implementing IT.
Ms. MARCHIBRODA. To correct----
Mr. MCCRERY. Dr. Wiesenthal seemed to say that is not a
problem.
Ms. MARCHIBRODA. To correct my statements, what I was
saying was in the past or even now, given the low level of
adoption of standards, the lack of standards and interoperable
systems creates a barrier to widespread adoption. Because of
the fragmented nature of our health care system where we need
to mobilize lab data, prescription data, data about the
patient, without standards we are not able to do that. So, we
need to adopt the codes and the HL7 messages, we need standards
to be adopted, and that will remove a barrier.
Mr. MCCRERY. That is what I thought you said. Do you agree
with that, Dr. Wiesenthal?
Dr. WIESENTHAL. I do. What I meant when I made my statement
earlier was that I think that the target standards are pretty
clear now. Ten years ago, when we started, it was more of a
risk to say SNOMED CT is going to be it, and we might have made
an investment that would have been very, very expensive and
very, very wrong. I don't think that that is a risk anymore.
The targets, people know what the big targets are, and that
isn't slowing them down now.
Mr. MCCRERY. Okay. I believe in both of your testimonies,
Ms. Marchibroda and Dr. Wiesenthal, you allude to the fact that
some physicians are reluctant to adopt IT, and they are a
barrier to doing this. Is that right?
Dr. WIESENTHAL. I don't believe that that is the case
anymore. I think there may be a few. The fact is, as
Congressman Gingrey said, I think most physicians feel as he
does, it is time to get on with it. They know that this is
going to be difficult and painful, they know that it is going
to be very disruptive in their practices. They know that at the
end of the day they can't be modern without doing it. Doctors
are not technophobes; they adopt new technology when it is
going to make their quality of care better or their practices
more efficient. What they are really afraid of--and the same
thing is true of nurses--is that we might introduce something
that will actually make them less efficient and less effective,
and that would be bad.
Ms. MARCHIBRODA. To clarify what I said in my testimony. I
think adopting IT by clinicians, it is really hard. It is like
playing tennis with the left hand when you are right-handed and
you have to change processes within your office. It is a
barrier, but I think it is one that can be overcome. I think a
comprehensive set of policy changes and practical strategies to
support clinicians as they make this migration is very
important, and it has to do with getting systems out there that
use standards, number one, having leadership at the highest
levels of each organization, providing some support and
incentives for those who need it, and aligning those incentives
between those who bear the cost of those tools and those who
reap the benefits. Then helping to support them along the way.
Dr. Brailer talked about a resource center that AHRQ is
funding, and there are a wide range of initiatives that are
sprouting up across the country to help clinicians with this
migration.
Mr. MCCRERY. Okay. Thank you.
Chairman JOHNSON. Thanks. I wanted to pursue this issue of
incentives. A number of you mentioned that the incentives are
misaligned. We are aware of that, but I would like to hear from
your point of view what is misaligned and what you think we can
do about it. The standards issues will move along, we will be
hearing back from Dr. Brailer, he has a report due in just a
couple of months, and at each step we will work together. We
certainly have to do something about money. Any comments you
want to make about what you think it costs, how we could help
incentivize people to make the investment would be welcome.
On the larger issue, there are laws and regulations and
structures and old ways of doing business that discourage the
integration of care, and we are going to this year and next
year have to find a way of reforming the way we pay physicians.
So, if we can think through this change in the way we manage
care and the way that the physician participates in care at the
same time we are thinking through how do we pay physicians,
since clearly the current system isn't working, that would be
very helpful. You are far more in a position to do that than I
am, and I invite you over the next months to take back to your
organizations that challenge to think, how does this change in
the system through which we deliver care? What are its
implications for the way we pay people for care? That is one
item. Then if you will just talk about misaligned incentives,
barriers a little bit more, I would appreciate that. Dr.
Safran.
Dr. SAFRAN. I think one of the ways that we have organized
care in this country is around the episode of care. Our
incentives for payment then are based on this episode of care.
For the patient, being well is really a health trajectory, it
is a journey, and there is no incentive for the clinician to
necessarily make the patient well. The health care expenditures
are obligated by a patient's decision whether or not to seek
care. So, we need to be interacting with patients before they
come to the physical encounter, the physician's office or the
hospital. We need a vision of a virtual encounter whereby we
are providing care and we are incenting clinicians to provide
care virtually.
Right now, 40 percent of your constituents would say that
they would like to e-mail their physicians. Probably no more
than 5 to 10 percent of American physicians right now want
another channel of communication with their patients. They are
not reimbursed for that. That is not considered part of the
care process. Yet that communication, before care worsens,
might prevent a hospitalization. It might prevent intravenous
therapy where a simple oral medication prescribed early via
telephone, Internet, telemedicine, whatever you want to call
care at a distance, we could enable that kind of care. We
prevent physicians inside of hospitals for reimbursing them for
care once their patients go home. This is particularly true of
care of infants where the hospital-based pediatricians,
neonatologists, can't bill for the continued care once a child
goes home.
So, we have created all these barriers. The technology,
while we talk about it as computers, it is really a
communication device that allows us to coordinate, communicate,
and collaborate with our patients in a way. We need to
recognize that and then reimburse around the entire process of
care rather than just the episode.
Chairman JOHNSON. Dr. Overhage.
Dr. OVERHAGE. Thank you. It is a very important and central
question that you ask, obviously. I think that there are two
components that we have to think about. One is the
inefficiencies, the excesses that are available to squeeze out
of the process, which can be captured more quickly and easily.
I have used the example in my testimony of sending a laboratory
result from a laboratory to a physician's office costs 80 cents
today. That type of cost can be addressed very directly and has
a rapid turnaround and a rapid payoff and may support the
infrastructure, at least partially support the infrastructure
that is needed.
The other is this larger issue that Dr. Safran was
referencing which is, as we can use tools to improve the
quality and safety of care, there are huge potential savings.
Capitalizing on those will require very dramatic changes in how
we reimburse our clinicians. That is going to be a longer road.
So, I think we have to take advantages of those shorter term
efficiency issues in order to get started and to demonstrate
the value early so that we don't have to wait.
Chairman JOHNSON. Dr. Wiesenthal.
Dr. WIESENTHAL. I agree with our colleagues. I would point
out that Kaiser Permanente is an example of what happens when
incentives are aligned, because we are an integrated system, so
it is our pharmacy, our laboratory, our hospitals. If I do
something as a clinician that turns out to create an efficiency
for the pharmacy, it acts powerfully in the right direction;
whereas, if Dr. Safran decides to transmit prescriptions
electronically, it doesn't save him any money. He isn't any
better off. The pharmacy down the road, or wherever that goes,
will be able to reduce their costs, but he doesn't see any of
the benefit of that. That is a fundamental issue in a
nonintegrated system that somehow has to be addressed. Somehow
the physicians in the fee-for-service community, which is two-
thirds of the doctors in the United States today, have to
somehow see the benefit of the up front expense that is
enormous they must make in order to put these systems in that
creates efficiencies for everybody else but not for them.
Chairman JOHNSON. I think it is very important that you try
to think about these things with your folks. How do we--do we
put it in with a no interest loan, and then through your
savings you can pay it back? How do we front the cost? We can
incentivize the costs. We have done that before: we won't pay
you unless you do it electronically. There are lots of things
that you can do, but you need to be able to say here is the
various choices of equipment, here is the training that comes
with it, and then here is how you can afford it. I am perturbed
about, why the medical community as a whole. I see individual
physicians very excited about this, and they will show you but
it doesn't spread. Sometimes they can't get their own
colleagues to--so it is a problem.
Dr. WIESENTHAL. This is the hardest thing I ever did. When
I changed 7 years ago from paper records, and I led the
development of the system, I understood exactly how it worked,
I knew all the functions. It literally changed every step I
took during the day. It was that that was hard. Not learning
how the software works or putting the computers in or making
the connections go okay. It is--I would ask you to try to
imagine how--if somebody came to your office tomorrow and
changed the way you did everything. That is what is difficult.
Actually, in terms of our cost of implementation, those costs,
the change of management costs and training costs related to
them, the change in the way work is done are more than 50
percent of the costs of implementing the system. Trying to
figure out a way to pay for that in a nonintegrated system,
unlike ours, I think is extremely difficult.
Chairman JOHNSON. It is interesting you say it is 50
percent of the cost. Okay. Thank you very much. I appreciate
it. Your testimony was excellent. I enjoyed reading it. We will
continue to learn a lot from it. If you have information you
think we should be aware of as we move through this process,
our goal is to increase the general level of knowledge of the
Congress in these areas, and then to work closely with the
Administration to push forward on this initiative, and
eventually to be positioned when we legislate next year, if
necessary, to change rules and regulations and payment
structures so that they are more appropriate to an electronic
era. Thank you very much for your help today and for your
participation.
[Whereupon, at 4:28 p.m., the hearing was adjourned.]
[Submissions for the record follow:]
Statement of American Academy of Family Physicians
Introduction
This statement is submitted to the Ways and Means Health
Subcommittee hearing entitled ``Health Care Information Technology,''
on behalf of the 93,700 members of the American Academy of Family
Physicians. Family physicians practice office-based primary care,
predominantly in medical practices consisting of one to five physicians
and often in underserved areas. In fact, slightly more than a quarter
of family physicians work in single or two-person practices that
provide health care to some 38 million patients every year. These small
practices survive on extremely tight operating margins and usually are
unable to capitalize new technology equipment, provide necessary
training and support serious disruption of their practice. The primary
care physicians who provide most of the health care in this nation do
not have access to the finances and capital available to hospitals,
academic health centers and other large institutions. Despite a strong
interest in electronic health record (EHR) technology, the large up-
front costs like the initial fees and licensing agreements are
prohibitively expensive for these physicians.
Nonetheless, Academy members are convinced that patient safety,
effective evidence-based care coordination and the reduction of
duplicative and unnecessary care require EHRs. Therefore, the AAFP's
goal is to have at least half of its members using EHRs by 2006. As a
result, the Academy has created a Center for Health Information
Technology to improve the availability of health information technology
products aimed at this segment of the physician market.
The Center's mission is to promote the adoption and optimal use of
health information technology by AAFP members, office-based physicians
and allied health professionals, for the purposes of improving the
quality and safety of medical care, as well as to increase the
efficiency of medical practice. The Center is using a multi-faceted
approach to realize this mission through advocacy, education,
cooperation, and standardization. At the heart of these efforts is the
EHR. The EHR enables family physicians to deliver the highest quality,
most efficient, and safest care for their patients.
The following programs, currently ongoing through the AAFP Center
for Health Information Technology, illustrate the facets of our
efforts.
Partners for Patients
In October 2003, the Academy's Center for Health Information
Technology announced that it had negotiated purchasing agreements with
a core group of software and hardware vendors around four principles.
These joint purchasing agreements between the Academy and twelve
information technology vendors is called, ``Partners for Patients.''
The Partners for Patients initiative demonstrates our collaboration
with the health information technology industry. It is also a forum to
work with vendors on standards development. In addition, we are
establishing best practices to address contracting, pricing, and
technical support. Partners for Patients vendors have agreed to the
following principles:
<bullet> Affordability: the costs for the acquisition and use of
health information technology should be within the budget of small--to
medium-sized medical practices.
<bullet> Compatibility: adoption of health information technology
should not require that clinicians and practices completely and
routinely replace current systems when new components are needed.
Information systems and their components should increasingly be based
on standards that result in ``plug and play'' compatibility, similar to
that found in the video and audio industries. There should be no
``vendor lock'' resulting from proprietary systems or interfaces.
<bullet> Interoperability: Data exchange schema and standards
should permit data to be shared between clinician, lab, hospital,
pharmacy, and patient regardless of application or application vendor.
<bullet> Data Stewardship: Clinicians who use health information
technology should retain control of the data that are the product of
their work, subject to the rights of patients to access their health
information and control its release. Physicians should be entitled to
choose an independent and unbiased third party to be a steward of the
data on their behalf.
These principles address significant technological and financial
barriers to the widespread adoption of health information technology in
the ambulatory physician office. With the commitment of our partners,
coupled with the support of 40 additional vendors, we believe that
progress toward achievement of the principles is accelerating.
Continuity of Care Record
Until there is adoption of widespread interoperable data standards
that are being used by every component of the health care system, the
Academy will work to produce and promote the use of a patient summary
content standard to allow patients access to an easily updated,
portable copy of their pertinent medical history. This new standard is
called the Continuity of Care Record (CCR).
Unlike other health information technology standards, the
Continuity of Care Record (CCR) is designed from the start to
facilitate communication from clinician to clinician and clinician to
patient. This commonly shared method of exchanging this critical
clinical information among clinicians is particularly important.
The CCR is a newly established patient summary content standard
that can be accessed as a PDF, HTML or Word document with basic health
information such as diagnoses, medication list, allergies, and recent
procedures. Physicians can forward this document to subspecialists when
a patient is referred and patients can carry it with them to promote
continuity, quality, and safety of care. Having this information
readily available at the time of care or in emergencies could
significantly reduce duplication of lab tests or diagnostic procedures,
as well as improve patient quality and reduce medical errors from
faulty or incomplete information.
The CCR is being sponsored and developed by the AAFP, the
Massachusetts Medical Society, and Healthcare Information and
Management Systems Society, with input from many other individuals and
organizations, under auspices of the standards development organization
American Society for Testing and Materials. Balloting was completed in
early 2004 and pilot projects are likely to start later this year.
The CCR is that digital file, produced by using readily available
software like Microsoft Word, or generated from hospital and practice
EHR systems when a patient leaves the ER, office, or is referred from a
primary care physician to a subspecialist. Because the CCR is being
designed to be a simple content standard, it will be possible for
different EHR systems to both import and export the information
contained in the CCR, and to update that information after each
encounter or visit. Data in similar documents can be displayed in a
variety of formats, such as HL7 messages, HTML (browser), PDF, and
Word, and thus printed versions of the CCR will be available for
patients who desire them. Adoption of the CCR by the medical community
and information technology vendors will be a first step in achieving
interoperability of medical records. To promote both the CCR and the
dissemination of EHR technology, several medical specialty societies
have formed a coalition of experts in health information technology.
Because the CCR is a critical step toward interoperability right now,
the federal government whole-hearted support of this standard is
critical.
Physicians' Electronic Health Record Coalition
The AAFP is one of the founding members of the Physicians'
Electronic Health Record Coalition (PEHRC), which recently formed to
collaborate on issues of health information technology. The medical
specialty societies that form the membership of the PEHRC agree that
promoting workable information technology solutions for the health care
system is too big for just one organization. PEHRC will be a strong
physician voice in the health information technology sphere. The
coalition will influence industry, government, and physicians to
provide better health information technology that will achieve better
efficiency, quality and safety.
Doctor's Office Quality--Information Technology (DOQ-IT) and EHR Pilot
Project
The following two projects in which the AAFP is involved, explore
how to best implement EHR technology in physician offices. Both
projects promise to reveal critical success factors for small--to
medium-sized practices in preparing, choosing and implementing an EHR
package.
The Doctor's Office Quality Information Technology (DOQ-IT)
project, funded by the Centers for Medicare & Medicaid Services, was
awarded to California's quality improvement organization (QIO) in
partnership with the AAFPCenter for Health Information Technology, in
October of 2003.
The DOQ-IT project endeavors to lead the way in assisting small--to
medium-sized physician offices in migrating from paper-based health
records to EHR systems, storing health information electronically and
utilizing computer-generated decision support tools, including
preventive service reminders and clinical guidelines. This project
offers an integrated approach to improving care for Medicare
beneficiaries in the areas of diabetes, heart failure, CAD,
hypertension, osteoarthritis, depression, and preventive care.
The DOQ-IT project will educate small--to medium-sized physician
offices on EHR system solutions and alternatives as well as provide
information on cost, risks, and benefits of IT adoption. Working
closely with participating physician offices, the project will conduct
a needs assessment, identifying an EHR system from multiple vendors
that meets specific office needs. Technical and quality improvement
assistance will be provided, including uploading data, acquiring
reports, and reorganizing physician office workflow to integrate and
optimize IT use, to ensure EHRs are used to their fullest capability to
improve quality of care. Through comparative clinical quality measure
reports, the project also will assist physician offices in identifying
potential areas for quality improvement.
In May of this year, the Academy was awarded $100,000 from the
Centers for Medicare and Medicaid Services to evaluate the
implementation of an EHR Pilot Project. This project implements EHR
technology in small--and medium-sized ambulatory care practices. This
project operationalizes our collaboration with the industry. The AAFP
and Partners for Patient vendors are moving from policy and agreement
to action. Education of the AAFP members on EHR implementation in
small--and medium-sized practices is an expected outcome of this
project.
AAFP is leading this small-scale collaborative pilot project with
Medplexus, Siemens Medical Solutions, and Hewlett-Packard to implement,
study and promote the transition to use of EHR in small--and medium-
sized family practices. Six practices have implemented EHR technology
and are currently utilizing it as part of their clinical workflow.
Participating practices consist of solo physician offices in California
and Pennsylvania; two physician practices in Utah and North Carolina; a
four physician practice in Ohio and a five physician practice in
Oregon.
In June 2004 each office a six-month demonstration using the
Medplexus XML--and Java-based EHR software application, at no cost to
the practices. Siemens Medical Solutions, Hewlett-Packard, and
Medplexus have generously committed to host the application, provide
hardware and provide the software, training, and application management
without charge to the participating practices. The Health Information
Management Systems Society (HIMSS), the nation's largest health IT
industry membership organization, is co-administering the pilot with
AAFP and has lent valuable assistance to the Center for Health
Information Technology staff.
The pilot project's main objectives are to intensively study the
barriers and keys to success during the implementation process, and to
combine this goal with a proof-of-concept for the applications service
provider model of delivery of scalable electronic health record
systems. An additional goal is to identify those special needs for
small and solo practices and help Medplexus, and subsequently other
vendors, address those needs in their EHR.
Summary
The Academy has made promoting the dissemination and utilization of
health information technology a strategic priority for the
organization. We are committed to helping physician offices begin the
process of transforming the ambulatory setting. This transformation
will require physician offices to rely upon health information
technology to achieve advances in chronic care management, quality
improvement and improved patient safety.
However, so many individual factors can affect the choice of
adopting technology in the small--to medium-sized practice that it
would be counter-productive to mandate the immediate implementation of
any EHR technology. The lessons learned through DOQ-IT and the AAFP's
EHR Pilot Project are expected to yield vital information for small--to
medium-sized ambulatory physician practices. For example, physicians
currently lack adequate information about how to ready their practice
for an EHR, how to choose an appropriate technology package and how to
quickly implement an efficient clinical workflow utilizing an EHR.
These barriers to technology adoption exist beside the significant
financial hurdles that currently prevent many practices from purchasing
EHRs.
The Center for Health Information Technology has been pleased to
work with Dr. David Brailer, National Health Information Technology
Coordinator within the Department of Health and Human Services. Dr.
Brailer is committed to the active promotion of the CCR and
dissemination of EHR. The clear intersection of priorities between Dr.
Brailer and the Center for Health Information Technology has lead to a
close working relationship. No one entity can solve the problems that
plague our health care system, yet collaboration to utilize health
information technology among physicians, patients, technology vendors,
insurers, and the federal government holds great promise. The AAFP has
been leading collaborative efforts around health information
technology, and we believe Dr. Bailer's work will break down barriers
to collaboration and promote action.
The Academy appreciates the opportunity to submit this statement
outlining the experience that the ambulatory physician's office has had
with EHR and looks forward to continue out work with the Ways and Means
Committee on issues related to health information technology.
<F-dash>
Statement of American Clinical Laboratory Association
The American Clinical Laboratory Association (ACLA) congratulates
Chairwoman Johnson 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 two private sector coalitions on health
care IT, the E-Health Initiative (E-Hi) and the National Alliance for
Health Information Technology (NAHIT).
ACLA is also currently working in collaboration with the Centers
for Medicare and Medicaid Services' (CMS) Office of Research,
Development, and Information on the development of IT in the health
care sector. 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 Chairwoman Johnson 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.
<F-dash>
Statement of American College of Physicians
The American College of Physicians (ACP), representing over 115,000
internal medicine physicians and medical students, is pleased to
provide written comments on the Federal role in providing incentives to
promote health information technology (IT). These comments are provided
for the June 17, 2004 hearing held by the United States (U.S.) House of
Representatives Subcommittee on Health of the House Ways and Means
Committee.
Introduction
The United States healthcare system is highly fragmented in terms
of the vast array of disparate, proprietary non-communicating
healthcare information systems in use. Perhaps the largest barrier to
adoption of health information technology besides cost is that the
current Medicare and private sector insurance plans actually
incentivize physicians and other healthcare providers not to use
medical information technology. This results from most health IT
systems not being designed to communicate with other health IT systems,
which has resulted in the creation of thousands of health information
silos all over the country. Another problem that has contributed to the
creation of the information silos is that for virtually every component
of care--drugs, lab results, digital imaging, disease classification,
procedures performed, and electronic health records--there are multiple
terminologies in use within each component. For drugs alone, there are
at least 12 separate systems for naming medications, their ingredients,
dosage, and route of administration.\1\ So, even if the U.S. developed
a system that allowed physicians and other health care providers to
easily transmit health care data and if these providers implemented the
systems into their medical practice, they'd still not be using a single
uniform language.
---------------------------------------------------------------------------
\1\ ``Establishing an Electronic Infrastructure,'' Draft Report of
the Electronic Medicine Committee of the Florida Medical Association,
Glen Davis, MD, January 10, 2004.
---------------------------------------------------------------------------
The Institute of Medicine's (IOM) 2001 report Crossing the Quality
Chasm--A New Health System for the 21st Century, highlights the U.S.
healthcare system's reticence in taking advantage of the information
technology revolution ``that has been transforming every other aspect
of society.'' The IOM report warns: ``In the absence of a national
commitment and financial support to build a national health information
infrastructure--the progress of quality improvement will be painfully
slow.'' \2\ President Bush, in his January 20, 2004 State of the Union
speech, agreed that the time to bring advanced information technology
to healthcare is now: ``By computerizing health records, we can avoid
dangerous medical mistakes, reduce costs, and improve care.'' \3\ The
President has backed his support for expanding IT use in the healthcare
sector by earmarking $152 million in his proposed Fiscal Year 2005
budget for health IT initiatives.\4\ To underscore the federal
commitment to these goals, in April 2004, the President announced
creation of a new position to lead the federal effort, the National
Health Information Technology Coordinator and tasked the coordinator
with developing a national plan within ninety days.
---------------------------------------------------------------------------
\2\ Crossing the Quality Chasm--A New Health System for the 21st
Century, Institute of Medicine, March 2001.
\3\ Bush, George W., State of the Union Speech, Washington, D.C.,
January 20, 2004.
\4\ ``White House Budget Includes Healthcare IT Funds,''
www.ihealthbeat.org, February 4, 2004.
---------------------------------------------------------------------------
The American College of Physicians (ACP) agrees with the IOM's and
President's call to bring the latest advances of information technology
to all sectors of the healthcare marketplace, underwritten with federal
support and leadership. Health information technology and creating an
interoperable healthcare data system, i.e., one that allows HIT systems
throughout the country to communicate with each other, will
revolutionize healthcare and will give individual patients greater
knowledge and ability to improve their health status. An interoperable
healthcare data system will facilitate the delivery of a higher
standard of quality to the U.S. healthcare system by increasing the
availability of healthcare data, making care safer and less costly. As
such, ACP believes creating incentives to improve health IT adoption
and creating interoperability are goals well worth the effort.
Achieving these goals will not be easy. It will require overcoming
steep barriers of resistance to system change, and a willingness to
endure what will surely be a long and taxing process of converting old
systems to new. Financial incentives for health IT adoption are needed
and health IT standards should be developed cooperatively and
voluntarily with active provider input, with the federal government
sharing in the cost of achieving the interoperability of health care
data that is sorely needed. In addition, new interoperable systems be
carefully tested before widespread implementation.
Even if the United States were able to overcome the enormous
challenges which must be surmounted to attain a truly interoperable
national healthcare information system, physicians likely would not
elect to use the system and continue to use a paper-based or an
unconnected legacy health IT system that is already in place in their
medical practice. This is because the current Medicare and private
sector insurance plans actually incentivize physicians not to invest in
or use medical information technology. The balance of this testimony
will focus on the benefits, barriers, and incentives for adopting
health information technology in the physician practice and ACP
recommendations for achieving this critical national goal.
Benefits of Health Information Technology Adoption in the Physician
Practice
Recent reports <SUP>5,}6,}7</SUP> show that while only 5% to 9% of
American physicians use electronic health records (EHRs) on a regular
basis, there is a great deal of variability within geographic regions.
For example, EHR adoption in Massachusetts is as high as 30.2%.\8\ A
much smaller number of physicians, about 0.1% nationally according to
one expert in the field,\9\ have taken the next big step to make their
practices virtually ``paperless.'' The core of a paperless office is a
system that integrates EHRs with physician practice management, patient
scheduling, and clinical decision support software. Such software has
the ability to facilitate many critical practice functions, including
patient record keeping, scheduling and communications, issuance of
bills and tracking of claims, ordering and receipt of diagnostic test
information, generation and tracking of physician referrals,
measurement of physician and staff productivity and performance,
internal administrative workload and budget control, and real-time
clinical decision support (CDS). CDS software, such as the Physicians'
Information and Education Resource (PIER), ACP's highly regarded real-
time point-of-care system, delivers current medical research
information and best clinical practice information to the physician at
the point of care when the physician needs it. PIER aids physicians in
the diagnosis and treatment of hundreds of conditions and also offers
educational support to patients, with physician-selected print-outs
available at the push of a button.
---------------------------------------------------------------------------
\5\ Computer-based patient records: searching for the right
solution. Healthcare Informatics. 2003.
\6\ Renner K. A cost-benefit analysis of electronic medical
records. Am J Med. 1 April 2003.
\7\ U.S. trails other English speaking countries in use of
electronic medical records. Harris Interactive News. 1 October 2001.
\8\ Berman J. Survey reveals growing number of tech-savvy doctors.
Health-IT World. 14 August 2003.
\9\ Squires S. Doctors go digital. Washington Post. 15 May
2001:HE10.
---------------------------------------------------------------------------
In its fully realized form, a paperless office can enhance the
quality of care that a physician practice delivers while also offering
an array of other benefits. These can include the following:
A.
Instant access to patient health data from any location with a computer and
Internet access;
B.
Real-time clinical decision support at the point of care;
C.
Updating of the EHR while the patient is being seen;
D.
Digital transmission and receipt of all patient lab requests and results,
physician consult requests and reports, and patient prescriptions;
E.
Medication and formulary information and advice, aimed at avoiding errors
and untoward drug interactions and keeping drug costs as low as possible;
F.
Coding advice to physicians to assure accurate documentation of a visit's
level of complexity;
G.
Generation of patient bill and patient take-home medical summaries,
condition-specific information, and treatment instructions for patients
before leaving the office;
H.
Scheduling patient appointments and sending reminders to patients about
important treatment items and upcoming tests and appointments;
I.
Digital transmission and tracking of claims sent to insurers; and
J.
Physician performance measurement and health care outcomes research.
Technology and software already exist that would allow physicians
to spend more time seeing patients and less time on paperwork; however,
physicians in the United States have been slow to embrace this new
technology. England has committed $17 billion to wire every hospital,
clinic, and doctor's office. All of England's 50 million citizens are
expected to get an electronic medical record by 2005, and, by the end
of 2008, the system will handle an estimated 5 billion transactions a
year, including electronic appointments, prescriptions, and access of
patient records.\10\
---------------------------------------------------------------------------
\10\ England's health system to get major technological upgrade.
Wall St J. 4 December 2003.
---------------------------------------------------------------------------
In paperless offices, all patient information is instantly
available to the physician; not only in the exam room but anywhere an
Internet-linked computer can be accessed. With the proper safeguards,
this connectivity can be achieved over the Internet, thus allowing
physicians to obtain the necessary patient information to render an
appropriate clinical decision. Quality of care should be improved by
eliminating the risk of having to rely only on the physician's and/or
patient's memory or the patient's description of symptoms left in a
telephone message.
The quality of patient care may also be enhanced by automated
system reminders, which alert both physicians and patients to the need
for necessary treatments and tests, such as periodic physicals, flu
shots, hemoglobin A1c tests for diabetics, colonoscopies, and
mammograms.
A study of small physician practices in California documented how
using EHRs had had a visible impact on quality: ``Quality benefits were
common . . . almost all users reported increased quality of patient
care due to better data legibility, accessibility, and organization, as
well as prescription ordering, and prevention and disease management
decision support''.\11\
---------------------------------------------------------------------------
\11\ Electronic Medical Records: Lesson from Small Physician
Practices. Ihealth Reports. California HealthCare Foundation; October
2003.
---------------------------------------------------------------------------
Most EHR software includes physician prompts for key clinical
questions that should be asked based on past history and diagnosis,
avoiding critical oversights. Prescription errors caused by illegible
handwriting are avoided when physicians can simply place a check mark
next to correct medication(s). Such software also provides medication
conflict warnings, thereby averting potentially dangerous drug--drug
interactions.
The benefits for patients and the health care system at large can
be enormous. According to the Leapfrog Group for Patient Safety,
computerized physician order entry for prescriptions alone can
substantially reduce serious medication errors. One major Boston,
Massachusetts, hospital had a 55% decrease in medication errors after
its computerized physician order entry was installed, while a hospital
in Salt Lake City, Utah, experienced a 70% decrease in antibiotic-
related adverse drug events.\12\
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\12\ Computerized Physician Order. Leapfrog Group for Patient
Safety Fact Sheet. 18 April 2003.
---------------------------------------------------------------------------
Barriers to Health IT Adoption in the Physician Practice
Three recent major studies that examined barriers to EHR adoption
found that the largest barrier to health IT adoption cited in the
studies is lack of adequate funding and resources. This finding held
true in the physician and hospital sector and across the spectrum of
physician practice size.<SUP>13,}14,}15</SUP>
---------------------------------------------------------------------------
\13\ Medical Group Management Association (MGMA), Medical Group
Management Association Survey, 2001.
\14\ Healthcare Information and Management Systems Society (HIMSS),
13th Annual HIMSS Leadership Survey, 2002.
\15\ Medical Record Institute (MRI), 4th Annual Survey of
Electronic Health Record Trends and Usage, 2002.
---------------------------------------------------------------------------
Adopting major health IT components and converting to a paperless
physician office has many costs and obstacles physicians must fully
weigh before making such a major change in how they do business. The
time, cost, and practice disruption involved in purchasing and learning
how to use a new system has to be balanced against its potential
benefits and ability to recover the initial investment. Important
start-up costs and obstacles that the physician must carefully consider
include the following:
A.
The cost of purchasing and/or upgrading hardware and new software.
B.
The time and cost of system testing and customization before implementing
new EHR, practice management, clinical decision support, and other
software.
C.
The cost of designing and building or redesigning and renovating the
office's physical layout to accommodate a paperless operation.
D.
The cost and time of training staff to use new health IT software and
related updated office protocols.
E.
The time and cost for existing practices to upload paper medical records
into an electronic health record format.
F.
Short-term loss of productivity and practice revenue while the new system
is being installed and debugged and staff is learning new software and
office protocols.
G.
Lack of interoperability of healthcare data among health IT systems.
H.
Ongoing costs of system maintenance, upgrading, technical support, and
staff training.
I.
Temporary loss of system access due to computer crashes or power failures.
J.
Use of digital data entry devices, such as an electronic stylus, electronic
dictation, or a keyboard.
K.
Patient resistance to the new system's outputs, such as computer-generated
bills, referrals, and prescriptions.
Software/hardware start-up costs for adopting health IT solutions
and creating a paperless office depend on a wide array of factors.
These factors include the number of physicians comprising the practice
and deciding whether to purchase EHR/practice management/clinical
decisions support software and install new servers and workstations, or
to lease software and/or servers from an application service provider.
Cost is also driven by the number of links to the servers, e.g., links
to reference labs and to area hospitals, which allow direct electronic
transmission of patient medical data. Besides initial hardware and
software costs, practices need to consider ongoing costs, such as
Internet access and ongoing system maintenance costs. An October 2003
report entitled ``Electronic Medical Records--Lessons from Small
Physician Practices,'' which studied 20 small practices in California,
showed that ``initial costs ranged from $15,000 to $50,000 per
physician, with a median cost of $30,000 per physician'' \11\; this
report focuses on EHRs, so creating a true paperless office would
require an even greater capital investment.
---------------------------------------------------------------------------
\11\ Electronic Medical Records: Lesson from Small Physician
Practices. Ihealth Reports. California HealthCare Foundation; October
2003.
Incentives to Health Information Technology Adoption in the Physician
---------------------------------------------------------------------------
Practice
The vast majority of small physician groups and hospitals, as well
as many large organizations, are not implementing EHRs and other health
IT solutions despite the potential gains to patient safety and improved
quality. The primary reason for not implementing these health IT
solutions is that EHRs have an adverse financial effect on most
physicians' practices and those of other healthcare providers, even if
they believe the technology to be useful and efficacious. This lack of
health IT adoption allows avoidable medical errors and deaths to occur
while these beneficial technologies remain underused.
Despite the long term benefits realized by patients, payers,
purchasers and society as a whole, physician groups and hospitals are
making rational economic decisions when they choose not to invest in
EHRs and other health IT solutions. Hospital and physician investments
in EHRs are costly, pose substantial economic risks and have few
economic benefits to the purchasers. Despite being on the market for
over a decade, demand for a robust EHR health IT solution is low
because total cost of ownership (purchase price, implementation,
maintenance, and impact on operations costs) is too high. EHRs are
costly because of the large upfront investment needed for technology
and infrastructure, but also because of the high costs of managing
concomitant clinical and administrative changes. They are risky because
the implementations may not succeed, and also because of the EHR-driven
changes in the workflow, communication and decisionmaking processes for
those who implement these systems.
The current federal approach to reimbursement of health care
services did not contemplate health IT. EHRs and health IT present a
new and unique category of clinical technology financing. The current
Medicare reimbursement system for physicians--the Medicare Resource-
Based Relative Value Scale (RBRVS)--does not recognize use of EHRs and
health IT. The reason is that the use of these health care solutions
are considered ``atypical'' and therefore not a reimbursable service
under Medicare. There are no allowable billing codes for critical new
health IT solutions such as e-visits/e-consults, which are structured
e-mail communication between the patient and physician which allow for
a cost-effective medical service to be delivered to patients beyond the
face-to-face clinical setting. Thus, the Medicare payment system is a
disincentive for physicians to invest in health IT solutions such as
EHRs.
At the same time that physicians are considering implementing
health IT solutions into their medical practices physician payment cuts
are expected in 2006 due to the fundamentally flawed Medicare
Sustainable Growth Rate (SGR) formula. The SGR is formula is simply
unworkable; it requires Medicare actuaries to predict the
unpredictable, leads to constantly-changing government cost estimates
and creates volatile payment swings that undermine medical practices'
ability to make rational business decisions such as health IT
investment and remain financially viable. The Congressionally-created
Medicare Payment Advisory Committee (MedPAC), recommends replacing the
SGR. Medicare reduces payments to physicians and other practitioners
whenever program expenditures for their services exceed a set target,
the SGR. At the same time, however, the government induces greater use
of physician services through new coverage decisions, quality
improvement initiatives and a host of other regulatory decisions that
are good for patients but are not recognized in the SGR. Of particular
note, the SGR does not properly account for investment in health IT. As
a result, from 1991-2004, payment rates for physicians and health
professionals fell 15% behind practice cost inflation as measured by
Medicare's own conservative estimates. As such, ACP supports MedPAC's
recommendation to replace the SGR with an annual update system which,
like those of other Medicare providers, reflects actual increases in
physicians' costs.
The solution to properly incentivize healthcare providers to invest
in health IT is multilayered. Physicians and other health care
providers need access to capital to make the investment in health IT.
One way to do this is to create a government-backed loan program. The
interest in EHRs among hospitals and physicians and the frequently
cited financial barriers suggest that strong latent demand for these
systems would be stimulated by capital availability. Cost offsets may
be particularly beneficial to physician practices, independent
hospitals, and other small organizations such as public sector clinics
and agencies, for which capital is particularly scarce and where cash
flow inhibits investment in health IT and specifically EHRs. Loan funds
should be made available for more than just the purchase of an EHR
system, it must cover the cost of EHR purchase, implementation,
training and concomitant workflow changes that are necessary to lower
implementation risk and deliver results from EHR implementation. The
program also should be structured so that health IT purchases support
systems that promote national goals such as interoperability of
healthcare data, not proprietary, unconnected health IT systems.
Once the investment capital is made available, the purchasers of
these health IT systems must have a means to pay these purchases off.
Therefore, Medicare and private sector payment policy must be changed
to encourage, rather than discourage the use of health IT. The Medicare
SGR formula must be replaced with a more coherent payment update
formula and the Medicare RBRVS must explicitly pay for the use of
health IT.
Legislative Recommendations
It's clear from the benefits discussed in this testimony that
investment in health IT solutions are a sound investment for the future
health and well-being of Americans. In order to stimulate investment in
health IT, ACP recommends that Congress consider enacting legislation
that will incentivize physicians to acquire HIT, including
consideration of the following options:
1. Create a revolving health IT loan program--modeled on the
current student loan program--for physicians and other health care
providers interested in investing in health IT with clinical decision
support tools designed to be interoperable and to enhance medical
practice to improve the quality of care delivered.
2. Create a grant program to provide direct dollar subsidies to
physicians who agree to acquire health information technology linked to
clinical decision support tools and who agree to voluntarily
participate in performance measurement/quality improvement programs
and/or in studies to assess the impact of such HIT systems on improving
health care quality while achieving system-wide savings.
3. Authorize the creation of tax credits, specifically targeted to
physicians in small and solo practices, for the purchase of HIT with
clinical decision support, conditioned on an agreement by the tax
credit recipients to participate in performance measurement/quality
improvement programs and/or in studies to assess the costs and benefits
of HIT linked to quality improvement.
4. Replace the flawed Medicare SGR formula for physician payment
with a new formula that provides for recognition of the acquisition and
ongoing costs associated with HIT systems.
5. Build into the Medicare RBRVS system an add-on code for
evaluation and management (E/M) services to identify that the E/M
service was assisted by an EHR with clinical decision support tools
designed to be interoperable. The add-on code would increase payment
for the identified service by an amount that not only recognizes the
investment of dollars and practice resources required to acquire and
maintain such technologies but also the ongoing system-wide value to
Medicare associated with use of such technologies.
6. Recognize and separately reimburse telephone and e-consults
(structured email communication between patient and physician or other
health care provider) that result in a distinctly identifiable medical
service.
7. Authorize Medicare payment of a ``case management fee'', which
would provide additional reimbursement per patient per month for
physicians who agree to acquire and utilize HIT with clinical decision
support to manage and improve care of patients with chronic illness.
8. Exempt such additional reimbursement incentives from Medicare
budget neutrality requirements. Because Medicare is likely to
experience system-wide savings associated with an investment in HIT,
creating on financial incentives to support the acquisition of such
cost-saving technologies should not be subject to budget neutrality
cuts.
Conclusion
Organizations that invest in health IT generate benefits for their
patients and for health care purchasers, but often realize lower
revenue (e.g., prevented hospitalizations and reduction of redundant
medical services) and increased costs from supporting the health IT.
Even if EHRs and other health IT products were free to purchase and
use, and could be implemented in a risk-free manner, the financial
consequences of the changes they induce in health care organizations
slows adoption substantially because the current payment system incents
providers not to adopt health IT solutions. The financial penalties of
health IT and EHR use are a direct consequence of the obsolete
reimbursement methods used by Medicare and private insurers. These
methods of reimbursement are misaligned with society's needs and health
care's mission, and require fundamental reform.
<F-dash>
Statement of David G. Schulke, American Health Quality Association
I am David Schulke, Executive Vice President of The American Health
Quality Association (AHQA) which represents the national infrastructure
of Quality Improvement Organizations (QIOs).
The QIOs are a national quality infrastructure whose primary
mission is to monitor and measurably improve the quality of health care
delivered to Medicare beneficiaries and the general public by taking
evidence-based health practices from the bookshelf to the bedside.
QIOs, under contract with the Centers for Medicare & Medicaid Services
(CMS), concentrate on systems of care, rather than the care delivered
to individual patients. This systems approach improves the quality of
care for all Americans receiving services from providers at health
facilities that work with QIOs.
The QIOs have become systems change experts focusing on effective
ways to bring about transformational change in our health care system.
We believe that, when implemented effectively, one of the areas that
holds great promise for truly transforming our health care system and
improving the quality of care is health information technology (IT).
We applaud the Subcommittee for your work over the past few years
that has recognized the inherent potential of IT, and we support your
efforts to promote its widespread adoption and use. As you know,
however, while the promise of IT is great, its proliferation to date is
not.
To this end, I am pleased to say that beginning next year, the QIOs
in all 50 states and the U.S. territories will begin to focus
intensively on promoting the adoption, implementation and effective use
of health information technology, starting with small to medium-sized
physician offices. Thanks in large part to the Chairman Johnson, a
promising effort led by the California QIO, Lumetra, is already
underway to develop and implement a successful model for achieving
these aims.
The Medicare Modernization Act promotes and supports IT adoption
and use in several ways. In particular, Section 649 advances a
previously unavailable avenue for promoting adoption and effective
use--payment incentives for providers and practitioners to adopt and
use IT to achieve better quality care.
Under the Doctor's Office Quality--Information Technology project,
or DOQ-IT, which was codified and improved by Section 649, the QIOs in
California, Utah, Massachusetts and Arkansas are working together to
develop a model for improving office efficiency and patient outcomes by
assisting small to medium-sized physician offices in their
implementation of Electronic Health Record (EHR) systems. These QIOs
are also working to ensure that practices use their EHR systems to the
fullest capacity so that ultimately, physicians can use clinical data
reports to monitor and improve their performance in several key areas
of health care. In keeping with the Institute of Medicine's Crossing
the Quality Chasm report, the primary aim of this model is to provide
no-cost support and assistance to providers such that their IT systems
help them improve patient safety and quality of care through the
practice of evidence-based medicine. Those that do improve can be
eligible for additional reimbursement from CMS.
QIOs have found overwhelming support for this endeavor from key
national organizations such as the American Medical Association, the
American Academy of Family Physicians, the American College of
Physicians, the eHealth Initiative and the National Council on Quality
Assurance. High level consensus to support the success of the QIOs'
work in this area is critical, and we have received not only support,
but a high degree of teamwork and consensus building from these
organizations.
However, given the promise of positive outcomes, one of the
questions we must consider today is why, when academic evidence exists
that points to the ability of information technology to improve patient
safety and health care quality, and to potentially hold down costs, is
adoption so low? And how do we accelerate it?
To be sure, several barriers play a key role in preventing health
care providers and practitioners from adopting and using IT. Lack of
standards, upfront capital investment, perceived high physician time
costs and difficulty integrating a new system into a physician's
workflow and care process are obvious sources of resistance.
The focus of my testimony today will be in the area of what the
QIOs can bring to bear in helping to overcome some of these key
barriers.
QIOs serve as a national infrastructure for quality improvement in
health care. These private sector organizations have strong local
relationships with the providers and practitioners in their states. It
is these relationships, coupled with the unique mix of skill sets,
expertise, adaptability and proven track record of success that will
enable the QIO infrastructure to help overcome some of the barriers
inherent to the widespread use of information technology in health
care--particularly in the area of implementation.
As Health Information Technology Coordinator Dr. David Brailer
wrote in a research paper published by the California HealthCare
Foundation last fall, ``Unless substantial support is given, physicians
will not be able to configure their systems, train for their use,
integrate them into their workflow, and support the transition of their
staff. In other words, if left alone, most physicians will fail at CPR
[computerized patient record] implementation.''
In looking at those health care organizations that have not failed,
but who have succeeded in implementing IT and in actually improving
patient safety, patient outcomes and health care quality, we find that
they share at least one thing in common--the resources and effort up
front to assess problems and inefficiencies in their practices and to
subsequently redesign the way they manage and deliver care in order to
address those issues. In other words, these successful organizations
have utilized IT as a catalyzing path to the solution, but not the
solution in and of itself.
Why is this process of systems redesign so important? Because
simply buying an expensive IT system to integrate with an existing
system that is inefficient and produces poor quality will only make for
an expensive, inefficient and poor quality system. We must remember
that the fundamental goal of IT is to achieve better quality outcomes
for patients; its promise lies not in simply automating current
practices, but in transforming them.
To achieve this goal, providers and practitioners need support--
support that goes far beyond what IT vendors can and typically do
provide. They need support from systems change experts who can help
ensure that core processes are redesigned with the aim of quality and
efficiency in mind. Providers also need support to ensure that they are
utilizing their IT system to its fullest capacity, helping them engage
in the type of care management that improves quality.
A 2003 research study by Drs. Miller and Sims of the University of
California, San Francisco regarding the implementation of Electronic
Medical Records (EMRs) indicates that the more time physicians invest
in learning the system, making practice changes to complement the EMR
and reorganizing their exam rooms and office workflows, the more
financial and quality benefits they receive from EMR implementation.
But perhaps the largest barrier in this area is a lack of resources to
invest such time and energy. In fact, studies indicate that one of the
largest barriers to IT adoption, after financial resources, is high
physician time costs and physician resistance (Brailer and Terasawa,
2003. Miller and Sims, 2003).
This is one of the primary areas in which QIOs can contribute. QIOs
serve as a no-cost resource of systems change experts who, thanks to
the DOQ-IT project, will have studied the most effective methods for IT
implementation and will apply those methods in their work with
providers. It is our hope that QIOs offering these supportive resources
will help make significant headway toward overcoming some of the key
barriers to adoption and implementation of IT--particularly by helping
to decrease demands on physician time, improve workflow and care
process redesign, and decrease productivity loss associated with such
redesign. In other words, we believe that this additional assistance
can ultimately result in more widespread adoption and effective use of
IT.
Finally, we must also be mindful of one potential adverse effect of
promoting IT adoption and use. If left alone, without significant
support or resources, it is likely that the locus of IT adoption will
be limited to large physician group practices and health systems,
creating a kind of digital divide where the promise of quality and
efficiency offered by IT is realized only by those with the resources
to support the level of effort required for effective implementation
and use.
Referring again to the research paper written by Dr. Brailer, the
rate of adoption in large urban areas appears to be one and a half
times greater than in smaller, non-urban areas. The size of the
physician practice also plays a key role. As Dr. Brailer notes, ``--
there are separate concerns about the growing CPR adoption gap between
large, urban organizations and their smaller, non-urban counterparts.''
Importantly, QIOs can also play a mitigating role in this area by
focusing initially on small to medium-sized physician offices. By
utilizing their existing local relationships with these providers and
practitioners, QIOs will work to encourage IT adoption and subsequently
provide the kind of additional support these offices need in the area
of planning, implementation and improvement. As QIOs achieve successes,
we also hope to offer assistance to larger practices in the ambulatory
setting and to providers of varying size and location in the inpatient
setting.
On behalf of the national network of QIOs, we fully support your
work to promote the widespread use of IT to improve health care quality
in America. We agree that health information technology holds great
promise for improving patient safety and outcomes when implemented in a
way that is integrated with care management and workflow changes. We
urge the Subcommittee to support innovative and effective models for
supplying the assistance that providers and practitioners need to
ensure that IT delivers on its promise of transforming quality in our
health care system.
<F-dash>
Statement of F. Lee Marston, Broadlane, Inc., San Francisco, California
I am pleased to be able to provide written testimony to this
Committee on the topic of technology advances in healthcare. While most
people think of clinical applications in this regard, Broadlane is
introducing sophisticated technologies to the back offices of
hospitals, physician offices and other clinical settings. These
technologies will help advance the quality of care, while also bringing
cost savings and efficiencies--already enjoyed in industries from
computing to automobile manufacturing--to healthcare providers.
My name is Lee Marston and, as chief information officer, I head
Broadlane's health information technology efforts. Prior to joining
Broadlane, I was chief information officer at Owens & Minor, the
nation's largest distributor for name-brand medical/surgical supplies.
I also held senior management consulting positions with Arthur Andersen
& Co. and CSC Consulting and have been a frequent guest lecturer at
Georgia Institute of Technology on the subject of information
technology's role in the supply chain.
Broadlane's Healthcare Business Solutions
Broadlane began in 1999 with the mission to provide group
purchasing and supply chain management services to hospitals in an
effort to increase efficiency and dramatically lower supply costs for
our provider customers. Over four years, Broadlane's value proposition
has evolved to pair innovative health information technology with best
practice business process expertise in strategic sourcing, contracting
and procurement that deliver powerful savings for our provider
customers. By taking accountability for these services, leveraging
economies of scale and working in close partnership with customer
physicians, nurses and other professionals, we are proud to have
delivered dramatic cost savings that lead the industry. Our services
have resulted in millions in audited savings in areas accounting for
over fifty percent of the operating costs faced by hospitals--supplies,
capitol equipment, purchased services and temporary labor.
Our business model and suite of services have been well received in
the market, with more than 800 acute care hospitals and 3,400 sub-acute
care facilities now counted among Broadlane's customers. Broadlane
customers range from some of the largest not-for-profit and for-profit
delivery systems in the country to stand-alone community hospitals,
along with thousands of individual physician practices. Broadlane is
headquartered in San Francisco with offices in Oakland, California;
Cincinnati, Ohio; Dallas, Texas; and New York City, New York and has
grown from 30 to more than 400 employees in about four years.
Broadlane's Unique Back Office Health Information Technology Solutions
The hospital supply chain presents enormous opportunities for the
application of modern technology to increase efficiencies and
effectiveness around daily business processes. Many hospitals struggle
with constantly changing medical product technology, non-standard
product pricing from suppliers, and disparate purchasing systems across
multiple facilities. Errors, waste and missed opportunities abound.
Broadlane addresses these back-office supply chain challenges
through innovative health information technology solutions that links
e-procurement and automated data analysis in a real-time environment,
allowing us to accurately capture hospital purchase history, ensure
correct prices are being paid, and help identify new products that are
candidates for group purchase contracts. Broadlane is one the first
companies providing this type of service to healthcare providers. To
enable this new service, Broadlane has integrated our highly successful
and intelligent e-commerce exchange called BroadLinka with our Web-
based contract management system.
Contract Management System
BroadLink is an e-commerce business to business exchange that
electronically links hospitals to their suppliers to manage all
transactions involved with supply procurement, including purchase
orders, purchase order acknowledgements, advance ship notifications,
invoices and product and price updates. Our automated solution
virtually eliminates the need for hospitals to manually place orders
via telephone or facsimile. In doing so, BroadLink speeds the
purchasing process, reduces manual errors and serves as a support
mechanism for the functionality resident in Broadlane's contract
management system.
Today more than 375 hospitals are connected to BroadLink, which
currently processes more than $8.3 million in customer purchase orders
daily and is projected to process approximately $2 billion in purchase
orders this year.
Contract Management System
Broadlane's contract management system is one of the most advanced
systems available today for contract management in healthcare. It
extends the capabilities of the BroadLink engine by taking the e-
commerce information and adding automatic data analysis and real-time,
actionable reporting capabilities.
The contract management system houses provider contract data in a
central repository while continuously connecting to the BroadLink
exchange to capture and store transaction data, ensuring that e-
commerce transactions are verified against the provider's contract data
in a real-time environment. Our contract management system helps ensure
purchase order pricing accuracy, which in turn helps hospitals
eliminate overpayment of invoices, take advantage of all available
discounts and rebates, ensure compliance with all contractual
agreements, reduce administrative time, shorten the purchasing
transaction cycle and access accurate historical purchasing
information.
Broadlane's contract management system does not require a hospital
to purchase software, as it is a web-based solution that hospitals can
access via an Internet browser. It is highly secure and customizable.
The contract management system's application service provider (ASP or
Web-based) approach accommodates a variety of different ERP and
material management systems used by many healthcare providers.
Broadlane guides hospitals through a comprehensive implementation and
training process, coupled with ongoing customer support. We are proud
of our unique, integrated approach.
Brief Description of Broadlane's Products and Services
In addition to our health information technology, Broadlane
provides additional complementary services to our customers in the
areas of:
Supply Chain Services: Broadlane uses a unique customer committee-
driven approach to product selection and contract management. We
combine this approach with our clinical and operational expertise to
help implement contract compliance and utilization strategies that
achieve both measurable savings and physician satisfaction. For
customers who want to take advantage of the greatest overall cost
savings opportunity, Broadlane will take responsibility for the entire
materials management function--our highest level of supply chain
service.
Purchased Services: Broadlane provides additional services to help
customers solve particularly vexing cost management challenges in the
purchase of non-medical services and supplies for areas such as energy,
telecommunications, transcription, information technology and
professional services.
Labor Services: Broadlane has become the leading provider of
temporary labor agency contracting and management services to the
healthcare industry. Our contracting expertise and advanced health
information technology can finally help attack the soaring fees
associated with the burgeoning use of temporary staffing agencies,
while ensuring the quality of contract labor staff. Broadlane's unique
sourcing technology, ProSource, helps rationalize customer's temporary
labor contracting process. This technology allows a nurse supervisor,
sitting at his or her desk, to use a web-based tool for finding,
ordering, tracking and paying for exactly the right highly trained and
experienced nurse for the specific department needed, at a
substantially lower hourly rate.
Conclusion
Broadlane remains committed to helping advance health information
technology, for our customers and all participants in the healthcare
system. These advances are already increasing efficiencies, lowering
costs and improving the quality of care. Our customers are seeing real
results and cost savings. As this technology is adopted throughout the
health care system, others can also enjoy these savings as well.
Thank you for considering my written statement.
<F-dash>
Statement of Guidant Corporation
Guidant Corporation advocates public policies that foster timely
patient access to care, promote the viability of healthcare systems
founded on principles of competition and choice, and encourage private
sector investment in innovation. It is our belief that healthcare
information technology (IT) can play a significant role in achieving
these goals.
Headquartered in Indianapolis, Indiana, with manufacturing and/or
research and development facilities in the states of Minnesota,
California and Washington, as well as in Puerto Rico and Ireland,
Guidant Corporation is a leading designer and manufacturer of medical
technologies used to treat primarily cardiovascular and vascular
illnesses. Guidant's products save and enhance lives around the world.
Today, Guidant Corporation employee-owners play leadership roles in
groups dedicated to increasing the role of IT in healthcare, including
the Healthcare Leadership Council, National Alliance for Health
Information Technology, eHealth Initiative and Healthcare Information
and Management Systems Society. We also support the establishment of
system interoperability for information management systems to allow for
enhanced integration, data exchange and reporting capabilities. As
such, we are committed to the development of standards and are an
active participant in Health Level 7.
Currently, companies including Guidant Corporation are working to
seamlessly integrate data from an implantable cardiovascular device
into a patient's electronic medical record so that clinicians can
quickly determine a patient's condition and make timely therapeutic
adjustments. Such technologies will enable patients to be monitored
regularly with less inconvenience, and also allow physicians to detect
problems at an earlier stage, thus reducing potentially expensive
hospitalizations. The Congress recognized the promise of such
innovations when it included chronic care improvement provisions in the
Medicare Prescription Drug, Improvement, and Modernization Act of 2003
(MMA) (P.L. 108-173). We look forward to working with the Congress and
the Centers for Medicare & Medicaid Services (CMS) to ensure the
successful implementation of these provisions.
As the Congress and the Administration work to advance health
information technology, Guidant Corporation urges that policies adhere
to the following tenets:
<bullet> Be founded on principles of, and promote, market
competition;
<bullet> Incorporate transparent processes and rules; Advance
information sharing;
<bullet> Encourage adequate provider reimbursement by recognizing
clinical and economic value along the continuum of care;
<bullet> Promote the adoption of industry standards and provide
funds to support interconnectivity; and
<bullet> Minimize liability concerns and eliminate barriers to the
exchange of data within the private sector.
A brief explanation of each of the tenets cited follows.
Promote Market Competition
Guidant Corporation believes that while health IT standards are
clearly needed, a one-size fits all model will not work given the range
of healthcare providers having vastly different needs and capabilities
with regard to health IT. Competitive markets are best suited to keep
up with rapid changes in health IT innovation. As consumers and private
purchasers become more aware of the quality- and cost-related benefits
of electronic medical records, they will migrate to those providers and
facilities that make the most effective use of these technologies.
Successful adoption of health IT that accounts for the particular needs
of individual providers and health plans can be a significant source of
market advantage and also spur competition.
Incorporate Transparent Processes and Rules
Guidant Corporation and the medical technology industry generally
have significant experience with both the FDA approval process and
Medicare coverage process. We know that providers, patients and medical
technology innovators are best able to contribute to the development of
sound regulations and policies, when the rules--and the standards upon
which they are based--are clear. In fact, transparent and predictable
policy processes allow businesses, including providers and innovators,
to consider government decisions in business planning, thereby
incenting private investment. Given its complexity, it is imperative
that transparency and predictability be the hallmarks of any federal
government involvement in health IT policy.
Public-private conferences such as the planned July 2004 National
Health Infrastructure Summit--which is well publicized and invites the
participation of a wide range of stakeholders--are a good start. HHS
should publicize the findings of this conference and inform the public
how they will be used.
Advance Information Sharing
Guidant Corporation recognizes, as experts have testified before
this subcommittee, that there exists in the U.S. healthcare system
quality issues with could be ameliorated, at least in part, by better
information at the point of care. Access to such information is often
best achieved by the use of health IT including electronic medical
records accessible to all care providers who need them. For example:
<bullet> The potential savings from reducing excessive spending on
services of little or no value is estimated to be as much as 30% of
current Medicare spending levels. [Source: E.S. Fisher et al ``The
Implications of Regional Variations in Medicare Spending,'' Parts 1 and
2, Annals of Internal Medicine, 138, no. 4 (2003)]. For instance,
recent news reports indicate that a significant percentage of women who
have had hysterectomies continue to get pap smears. A robust system of
electronic medical records could flag such cases and reduce the use of
such unnecessary treatment.
<bullet> The healthcare system is also hurt by underuse of known
effective treatments, e.g. beta blockers for myocardial infarction,
etc. A recent study found that adults receive only about half of
recommended care leading to increased complications, morbidity,
mortality and costs to the healthcare system. Electronic medical
records could also serve to prompt the provision of medically necessary
care, including preventive services. [Source: E. A. McGlynn, ``The
Quality of Health Care Delivered to Adults in the United States,'' New
England Journal of Medicine, Vol. 348, No. 26 (2635-2645), June 26,
2003.]
<bullet> It takes approximately 17 years for new knowledge in
clinical trials to be incorporated into every day medical practice
because no information infrastructure now exists to help clinicians
easily apply that research at the point of care. Electronic medical
records could highlight the relevant findings of clinical trials in a
given patient's record. [Source: Markle Foundation, Connecting for
Health, The Steering Group, Key Themes and Guiding Principles, June 5,
2003.]
<bullet> Physicians spend an estimated 20-30% of their time
searching for and organizing information; robust electronic medical
records could ensure that providers have the information they need at
hand. [Source: eHealth Initiative]
Encourage Adequate Provider Reimbursement
Guidant Corporation believes that physicians and other providers
need to be incented to incorporate health IT into the practice of
medicine. Currently, Medicare does not generally reimburse for services
provided electronically. For example, while several new advanced
patient cardiac remote monitoring technologies have been introduced in
the last year, there is not yet standardized payment for the
physician's time, effort, and investment in IT, and in many states the
service is not covered at all. This provides a disincentive to adopt
and integrate the technology for many practitioners. We support the
creation of new CPT codes to facilitate appropriate payment for remote
IT-based services.
Promote Industry Standards and Provide Funds
Guidant Corporation applauds the Administration's efforts to
promote the development of private-sector health IT standards. Given
the federal government's existing purchasing power, Secretary
Thompson's March 2003 announcement that all federal health programs
will begin to use such standards is a significant development, as is
the May appointment of the nation's first healthcare IT coordinator.
We urge the Congress to fund the President's budget request for
health IT. This will make available seed money to providers to promote
the adoption of private sector standards.
Minimize Liability Concerns
Guidant Corporation understands that liability concerns may curtail
the adoption of health IT. Specifically, some physicians are believed
to be concerned that the greater information exchange allowed by health
IT could increase their liability exposure. Such concerns may disincent
the adoption of remote monitoring and other systems that allow the more
frequent monitoring and management of patient's care. We urge further
study of this issue and suggest that provisions addressing health IT be
specifically included as necessary in future medical malpractice reform
proposals.
We ask that this statement be included in the hearing record and
would be pleased to address any questions.
<F-dash>
Statement of Mary Griskewicz, Healthcare Information and Management
Systems Society Advocacy and Public Policy Steering Committee, Chicago,
Illinois
BACKGROUND:
Madame Chair, Congressman Stark, and distinguished members of the
Subcommittee, I am honored to submit this statement for the record. My
name is Mary Griskewicz and I have the pleasure of serving as the 2004-
2005 Chair of the Healthcare Information and Management Systems Society
(HIMSS) Advocacy & Public Policy Steering Committee. I live in
Connecticut and work professionally for IDX Systems Corporation as a
Regulatory & Compliance Program Manager.
HIMSS vision is to advance the best use of information and
management systems for the betterment of healthcare.
On behalf of the HIMSS and the thousands of professionals in the
healthcare information technology community, we want to commend you and
your Subcommittee for your leadership role in promoting initiatives
that increase the use of information technology throughout the
healthcare sector. In particular, Madame Chair, we know personally of
your commitment to this cause as was reflected during your remarks at
our congressional reception where you were presented with the 2003
HIMSS Advocacy Award.
HIMSS and our Healthcare IT community colleagues are thankful for
your efforts to highlight our shared goal of utilizing a National
Health Information Infrastructure (NHII) to seamlessly transmit
electronic healthcare records (EHRs) to improve patient safety and
healthcare quality.
As you are well aware, in the past year alone, healthcare IT has
taken a major leap forward. The federal government's support of the
Institute of Medicine (IOM)/ Health Level Seven (HL-7) efforts on EHR
functional model and standards, sponsorship of the November 2003, IOM
report, Patient Safety, Achieving A New Standard of Care, establishment
of the National Health Information Infrastructure (NHII) Office and the
Council on the Application of Healthcare Information Technology
(CAHIT), release of the AHRQ $41M Transforming Healthcare Quality
Through Information Technology grants, and most recently the
appointment of a National HIT Coordinator have underscored the
importance of healthcare IT and the impact healthcare IT can have on
both lives saved and costs avoided.
Today's hearing is focused on what further initiatives are needed
to increase the use of information technology and management systems
throughout the healthcare sector. We have highlighted seven next steps
that we believe could help us reach our ultimate goal.
NEXT STEPS:
1. President Bush has requested doubling to $100 million the money
spent on projects that use promising health information technology in
the FY 2005 President's Budget Request. This funding would encourage
the replacement of handwritten charts and scattered medical files with
a unified system of computerized records. To quote the President from
his 1/24/04 radio address: ``And fifth, we can control healthcare costs
and improve care by moving American medicine into the information
age.'' We encourage the Congress to support this budget request for
utilizing technology to improve healthcare.
2. Ensure that all funding appropriated for demonstrations is
consistent with the overall vision for the NHII, as articulated by the
National Committee for Vital & Health Statistics.
3. Last year, Madame Chair, you submitted HR 2915 to provide for a
National Health Information Infrastructure (NHII) and data and
communication standards for health Information system interoperability.
This legislation has been co-sponsored by Reps. Burgess, Cooper,
Greenwood, Kennedy, Nussle, Shaw, Weldon, Shays, Castle, English,
Harris, Norwood, Ramstad, Nussle, Ryan and Walsh. We encourage the
Congress to pass this legislation to permanently create an office
reporting directly to the Secretary of Health and Human Services to
coordinate national health information technologyto allow electronic
health records to be seamlessly transmitted.
4. We must learn how to blend the health information technology
(HIT) solutions already realized by the Departments of Defense and
Veterans Affairs with those being developed under the umbrella of the
Department of Health & Human Services. These solutions can serve as the
tipping point for private sector initiatives.
5. We recommend that the federal government focus attention on
funding the rapid completion of critical healthcare standards by key
standards development organizations. Standards are a critical step
towards the realization of portable and interoperable electronic health
records in the United States. Without standards, we will not achieve
our mutual goal of improving the quality, safety, and cost-
effectiveness of patient care.
6. We recommend that the federal government focus attention on the
consistent implementation of standards. Such attention would take the
form of endorsing and partially funding the development of
implementation guides for the portability and interoperability of
health information. While the acceleration of standards development is
critical, standards alone are not sufficient. To ensure the consistent,
industry-wide implementation of such standards, we ask you to endorse
and support the industry-backed ``Integrating the Healthcare
Enterprise'' (IHE) process for enabling the accessibility,
interoperability and portability of secure patient information. IHE is
a proven, standards-based, vendor-neutral process that publishes its
solutions in the public domain.
7. Finally, we appreciate the federal government's dedication of
proposing expanded resources to deploying healthcare information
technology. We hope the Congress will encourage the Administration to
use the current funds (in addition to the $50M proposed for healthcare
IT demonstration projects being funded by AHRQ) for widely
disseminating the lessons learned and encouraging care providers to
implement EHR solutions. We believe the demonstration projects
currently underway or in development will yield significant knowledge
for implementing EHRs and know that the time is ripe to take action on
the outcomes. The Office of the NHII can provide leadership in helping
care providers across the health spectrum best understand how to: (1)
evaluate their setting's need for healthcare ITsolutions; (2) select
the best solution; (3) implement that solution and change the human
processes to best utilize it; and, (4) evaluate the return on
investment.
CONCLUSION:
We believe that these seven steps will greatly help us reach our
goal. We have noted that over the past 24 months, the interest and
attention on health information has exploded. Those of us who have been
in this industry for any period of time are both gratified by, and wary
of, this attention. Health information--primarily in the form of both
portable and interoperable health records--offers a key to improving
the quality, safety, and cost-effectiveness of patient care. That being
said, HIMSS also recognizes that technology is only as good as the
human processes and systems adopted to utilize the technologies.
As you proceed forward in the months and years ahead, the 14,000+
individual HIMSS members and over 240 corporate HIMSS members
representing over 1,000,000 employees are committed to working with you
and others to make our shared vision of the widespread adoption of
information technology and management systems in the healthcare sector
a reality. Please don't hesitate to contact us at anytime at
advocacy@himss.org.
<F-dash>
The Kryptiq Corporation
Beaverton, Oregon 97006
June 30, 2004
The Honorable Nancy L. Johnson
United States House of Representatives
Washington, DC 20515
Dear Chairwoman Johnson:
Thank you for the opportunity to provide written comments regarding
the Hearing on Health Care Information Technology held June 17, 2004.
At Kryptiq, we believe the adoption of technology is central to
addressing the current healthcare cost crisis in our country. We have
been developing technology for the private sector and recognize the
difficulty of achieving industry-wide benefits without significant
efforts on the part of the federal government. Your plan accurately
recognizes the adoption of information technology in healthcare as
critical to increasing both quality and efficiency in healthcare. Your
committee has also heard testimony which identifies one of the greatest
barriers to IT adoption, namely the lack of interoperability among
existing systems already in use today. Driving use of standards is the
best way to ensure data is made available where and when it is needed.
Federal initiatives have the potential to produce dramatic and positive
changes in the U.S. healthcare industry.
Kryptiq provides solutions that enable standards-based information
sharing across healthcare. Our solutions improve quality by enabling
online patient care and increase efficiency by integrating solutions
with existing clinical information systems (e.g. electronic medical
record systems) to accommodate existing physician workflow.
In order to deliver on the stated objectives of improved quality
and efficiency, we encourage you to consider the following two
suggestions:
1. The definition of Local Health Information Infrastructure
(LHII) should focus on a community's ability to share information
electronically among health care entities, irrespective of any formal
independent organization. While LHIIs may be managed by independent
organizations responsible for maintaining the communications
infrastructure, this is not necessary and should not be legislated.
2. Payment systems need to be considered for emerging care
practices that are enabled by adoption of IT with a particular emphasis
on ambulatory care.
Explanations of these suggestions are attached.
We admire your efforts to advance the adoption of information
technology in healthcare and look forward to the opportunity to
participate in this process.
Sincerely,
Luis Machuca
Chief Executive Officer
__________
Submission to Congressional Record regarding the Hearing on Health
Care Information Technology held June 17, 2004.
The definition of Local Health Information Infrastructure (LHII)
should focus on a community's ability to share information
electronically among health care entities, irrespective of any formal
independent organization. While LHIIs may be managed by independent
organizations responsible for maintaining the communications
infrastructure, this is not necessary and should not be legislated.
Currently, the definition of LHII is restricted to an
``independent organization of health care entities established
for the purpose of linking health information systems to
electronically share information.'' Technologies exist today
that enable healthcare organizations to establish information
sharing networks without first establishing a central governing
or maintenance body. These technologies allow organizations to
become part of the network simply by adopting the technology.
For example, deploying integrated clinical messaging for EMRs
based on the emerging Continuity of Care Record (CCR) standard
enables direct electronic communication of patient information
among providers. Such technologies show great promise to
affordably connect healthcare patients, providers, and payers
in a manner that can be easily adopted by any size
organization.
Payment systems need to be considered for emerging care practices
that are enabled by adoption of IT with a particular emphasis on
ambulatory care.
To ensure quality and efficiency in healthcare, it is
important that payment systems reflect current best practices
within the industry. Payment systems should be considered for
emerging care practices that are enabled by adoption of IT,
such as virtual encounters that have the capability to displace
office visits and enable remote clinical monitoring. Ambulatory
care reaches the greatest number of people and has the largest
impact on rural and underserved markets. Ambulatory care is the
most underinvested segment of healthcare in the area of IT.
Meanwhile, it has the greatest potential for reducing costs and
improving care on a broad basis. By encouraging emerging care
practices in the ambulatory setting, these structures will have
a significant impact on adoption of IT and will reduce
healthcare costs for all involved parties.
Significant attention in the industry has been paid to the
idea of ``pay for performance''. Until now, this notion has
gained little momentum due in large part to a lack of
supporting payment structures. It is important to consider
payment structures that would provide incentives to providers
for demonstrating quality performance based on electronic
tracking and reporting of standardized quality measures.
Analyzing and implementing these structures will provide a
foundation for ``pay for performance'' and will greatly
motivate providers to adopt technologies that will improve
quality and efficiency of care.
<F-dash>
Statement of Luis G. Kun, Washington, DC
My name is Luis Kun, Ph.D. and am a Professor of Systems Management
at the IRM College of the National Defense University. Last year I was
asked by Susan Christensen (the Senior Health Policy Counsel for
Representative Johnson) to send any comments I had with respect to HR
2915 / the NHII.
On February 24 I sent the attached letter, which reflected my
views. When I noticed this hearing taking place, I decided to forward
you this letter since I believe that my comments may be useful to you.
__________
Representative Nancy L. Johnson
2113 RHOB
Dear Representative (Nancy) Johnson
I would like first of all to congratulate you and your staff on
putting forward in the 108th Congress the Bill HR2915, to provide for a
National Health Information Infrastructure (NHII) and data and
communication standards for health information system interoperability.
Your efforts should be applauded for addressing a need that will
enhance the lives of all Americans now and in the future.
This Bill addresses first leadership, i.e., National Health
Information Officer. I concur that this is a crucial issue for success
and needs to be high on the priorities list for a successful
implementation of a NHII.
I will describe three major issues, starting with a recommendation
then providing a current and/or future environment, and finally posing
some questions. The information that follows is my own opinion. It does
not represent the Committees/Working Groups that I chair nor my
employer (i.e., IRMC / NDU, DOD or the US Government).
SUGGESTIONS for Issue #1 Goals and Objectives: HR-2915 addresses
particularly the ``institutional'' environment and somewhat the
provider environment, but not the patient/consumer one. The NHII should
incorporate in its goals issues regarding the patient/consumer, the
health care provider and the institutions involved in the process. The
NHII should provide guidance in getting to a patient centered system.
Issue 1: Goals and Objectives
<bullet> The goals of this NHII vision seem to apply only a subset
of health related applications where the focus is oriented towards the
clinical environment (i.e., maximize outcomes, minimize medical errors
especially in hospitals and in the administration of contraindicated
drugs, reduce redundant paperwork such as the repeated taking of
patient histories, decrease costs from repetitive testing, establish a
compatible information technology architecture that increases health
care quality and cost-savings, enhances security of information, and
avoids the financing and development of health information technology
systems that are not readily compatible.) Although these goals address
some current needs, they seem to be more reflective of an environment
we had in the eighties and early nineties where the focus was the
hospital-centered environment and not the current one, i.e., patient/
consumer centered.
<bullet> Current environment-background:
<bullet> Consumers that not only are more educated and have
more information available to make (better) decisions, but an
environment that permits them do consultations before, during
and after a health related situation arises. This allows them
for example to be better prepared for an appointment which
possibly translates into better outcomes.
<bullet> Many other consumers (and their relatives) that lack
the access, or the understanding of content (i.e., their main
language of communication may not be English, their reading
ability/education level and/or understanding may be much lesser
than others) will be at a disadvantage (Digital Divide).
<bullet> Many consumers for example are managing their health
via the Internet. They may use the system [i.e., computer and/
or TV] to/for:
<bullet> Consult with their physician and/or nurse
regarding their health.
<bullet> Plan their diets.
<bullet> Have customized exercise routines planned and
managed via the network (through their TVs).
<bullet> Purchase their drugs via the Internet (and
sometimes self administer them).
<bullet> Health care providers that:
<bullet> Do consultations through mobile devices with
colleagues and/or libraries located anywhere in the
world.
<bullet> Educate themselves through distance learning
curricula, and/or access important and most current
needed information (i.e., clinical guidelines,
prevention guidelines, etc.) from the US and/or abroad.
<bullet> Perform Telehealth visits anywhere in the US
and/or abroad.
<bullet> May do homecare visits (real and/or virtual) for the
elderly with chronic diseases.
<bullet> Institutions that need an Information Technology
Infrastructure to support (technologically) their staffers in
all the related activities mentioned above. This requires
resources, training, education and competency.
Some questions:
1. How will the NHII deal with consumers?
2. What are the consequences for consumers from using the NHII?
3. How many ``health/medical'' related errors are consumers
committing with the self prescribing and self administration of drugs?
i.e., If the issue is ``medical errors'' what about all the
consequences from self-diagnosing/self-administering drugs/prescription
coming from questionable sources.
4. Since the price of drugs is constantly escalating, many,
particularly the elderly can not afford buying drugs the
``conventional'' way. Many pursue cheaper alternatives via the
Internet/World Wide Web (WWW). What is the number of people that are
self prescribing, purchasing and administering drugs and what are the
consequences?
5. How can we assure the quality of the information read on the
Internet/WWW? i.e., How reliable is the information consumers get on
the Internet and how can the NHII make it better?
6. How can we assure the quality of the drugs [bought outside]
they may purchase for example through e-Commerce?
7. How reliable are the products (``quality assurance'') purchased
through the Internet? i.e., where are these drugs manufactured?
8. How can reliability of (Internet/WWW) purchased drugs be
assured?
9. How will the NHII address the population that is either
undereducated (can not read), unemployed (can not access) or can not
understand what they read (content-intellectually handicapped)?
SUGGESTIONS for Issue #2 Stakeholders / Partnerships:
1. Both DOD and the VA should be part of a team that builds the
NHII.
2. The USDA, EPA, DOE, and DHS and perhaps other stakeholders need
to be at the table to help define their requirements for the NHII.
3. The FDA, CMS, the CDC, HRSA, Indian Health Services, etc. need
to be part of the team building the NHII.
Issue 2: Stakeholders / Partnerships: Under Section c) Collaboration
with Stakeholders; item (3) Parties Represented.
The Bill names: (A) The National Committee on Vital and Health
Statistics, the National Institutes of Standards and Technology, the
National Library of Medicine, and the Agency for Healthcare Research
and Quality. (B) Individual and institutional health care clinical
providers, including a teaching hospital and physicians. (C) Clinical
and health services researchers. (D) Health care purchasers. (E)
Private organizations with expertise in medical informatics. (F)
Patient groups. (G) A State or local public health department. (H) The
health care information technology industry and national alliances
formed to achieve standards-based health care information systems.]
Current environment:
<bullet> The VA has a network of 165 + hospitals interconnected
using electronic records (VISTA) of their patients (about 5.000.000)
throughout the nation.
<bullet> The armed forces not only are in a similar predicament as
the VA but they actually use throughout the world their resources, i.e.
electronic health records, clinical decision support, telemedicine /
Teleconsultation, etc.
<bullet> DOD has developed the Government computer-based patient
record (GCPR).
<bullet> If a terrorist event (i.e. a biological, chemical,
nuclear/radiological, cyber) or a natural disaster occurs then
Department of Homeland Security needs to be involved (i.e. Emergency
Management /FEMA).
<bullet> If the terrorist event involves the air/water, chemicals,
food, nuclear radiological threats then the EPA, USDA, DOE would need
to get involved.
<bullet> Users go to the FDA and CMS (HCFA) to get answers
regarding regulatory matters, i.e. drugs, procedures, payments, etc.
<bullet> Users go currently the Centers for Disease Control and
Prevention since it is the agency that addresses Public Health and
disease prevention issues.
<bullet> Users go to HRSA and Indian Services for specific type of
information.
Some questions:
1. Will this NHII be used only on ``peace'' times? Or also during
times of crisis?
2. How can the NHII be used during major natural catastrophes /
events, i.e., earthquakes, floods, tornados?
3. How can the NHII be used during times of war and/or major man
made crisis, i.e., wars, terrorism threats, etc?
4. Shouldn't the VA be a partner in the NHII / ``national''
solution?
5. Shouldn't the DOD be a partner in the NHII / ``national''
solution?
6. Shouldn't the DHS be a stakeholder on the NHII?
7. What if the health issue is regarding the food, chemicals,
nuclear/radiological, water/air?
8. Should the USDA, EPA, DOE also be involved in the development
and maintenance of the NHII?
9. Should the owners of the government computer-based patient
record (GCPR) be able to use the NHII?
10. Shouldn't the FDA, CMS, CDC, HRSA, Indian Health Services,
etc. be partners in the NHII?
SUGGESTIONS for Issue #3 Globalization, Standards and National Security
1. International standards organizations need to be part of the
NHII definition team.
2. The World Health Organization (WHO), the Pan American Health
Organization (PAHO), the European Commission (and the likes for Asia,
Africa and Oceania) need to be part of the proposed solution.
3. Following steps 1 and 2 will allow the US to do effective
epidemiology and surveillance of all infectious diseases which can
appear anywhere in the world and affect our own population.
Issue #3 Globalization, Standards and National Security:
Current and future environment: The Bill ignores that we live in a
global economy and many of the consequences of globalization. In
particular it ignores the fact that both consumers, and health care
practitioners in this Information Age, have a very different behavior
than in prior times.
<bullet> The globalization effects of Internet and the WWW pose
many unanswered question beyond ``quality of the information read''.
Treatments and/or other alternatives can be sought outside the US
borders.
<bullet> US citizens can do consultations with foreign
practitioners from the comfort of their homes and/or offices.
<bullet> The US healthcare providers can consult, diagnose, treat,
(i.e. generate business) ``electronically'' anywhere in the world from
anywhere in the US.
<bullet> US citizens becoming sick while traveling abroad could
benefit from using their personal health information in local (foreign)
institutions. For these institutions to be able to read their records,
will require for us (the US) to use identical standards (not just
nationally but internationally).
<bullet> According to the census, the US population growth occurs
from immigration. In many cases these individuals bring along medical
histories and paper records. In some cases they bring them in
electronic form. It would greatly enhance the lives of this very large
population if their prior records could seamlessly be incorporated into
new electronic records generated in this country.
<bullet> Infectious diseases are by far one of the worst threats
to the world population. [For example every 30 seconds a child dies
from malaria]. It is a matter not only of Public Health but one of
National Security. Healthcare is part of the National Critical
Infrastructure and therefore the NHII will become part of it.
<bullet> Surveillance and epidemiology of Public health threats
can be better achieved when information can be shared at the global
level. Examples: In 2003 alone SARS, West Nile Virus, Monkey Pox, Mad
Cow Disease, etc. This requires for us and the rest of the world to use
a common infrastructure and standards for the exchange of critical
information. The NHII should be a subset of the Global Health
Information Infrastructure.
I appreciate the opportunity to offer you my opinion. If I can be
of further help do not hesitate in contacting me.
Sincerely yours,
Luis G. Kun, Ph.D.
<F-dash>
Medistore
Houston, Texas 77042
June 28, 2004
Committee on Ways and Means
1102 Longworth House Office Building
Washington, DC 20515
Dear ladies and gentlemen:
Our Nation's goal of every man, woman and child in the US having a
life long electronic health record (EHR) by 2014 is achievable if the
right approach is taken. The pages that follow address the issues and
possible solutions associated with the take up and use of information
technology in healthcare. Before I discuss the issues and possible
solutions I would like to tell you of some of my experiences with
information technology in another industry, which I think will help
clarify some of the issues that our Nation's healthcare system faces
today and in the future.
My background includes working in the petroleum industry for 29
years during which time I was involved in applying information
technology to improve the profitability of the company's for which I
worked. I worked in British Petroleum management for twelve years in
operations, research, information technology and strategy and planning.
After leaving BP I co-founded a software solutions company in the
petroleum industry.
For the past two years I have been involved in healthcare
information technology. I am currently a member of the Great Houston
Partnership Public Health Task Force, which is charged with working
with the private and public sector to create public clinics and a Local
Health Information Infrastructure in Houston.
For a reference frame I would estimate the petroleum industry is at
least 5 to 10 years ahead of the healthcare industry in the use
information technology to run their business. Nearly every petroleum
company large and small uses information technology to make decisions
on a daily basis. There are many lessons we can take from the petroleum
industry in healthcare.
You may ask, what can the petroleum industry possibly have in
common with healthcare. Here are just some of the similarities that I
have found during the past two years of studying healthcare.
1. Both industries have a large number of highly specialized
experts who need to access and share information to make timely and
accurate decisions about a specific individual entity (patient, oil
well).
2. Both are information businesses that have traditionally been
paper based.
3. Both are very conservative and resist change.
4. Patients and oil wells have long lives and large amounts of
diverse information is collected and used over many years to make
decisions about them.
5. Patients and oil wells are dynamic and may change
unexpectedly.
6. Preventive maintenance is necessary to increase longevity,
lower cost and improve quality.
7. Patients and oil wells undergo diagnostics and treatment.
8. Interventions are required at various times.
9. Much of the information is collected in a digital form and
then output to paper to be analyzed and shared. For example real time
monitoring, laboratory measurements and imaging are three prime
examples of similar types of information.
10. Studying an individual or groups of individuals can assist in
developing new diagnostics and treatments.
The one paramount difference between the two is that in the
petroleum industry when a mistake is made due to lack of information in
the decision process it can have a negative economic impact, whereas in
healthcare, lack of information in the decision process can be the
difference between life and death.
Petroleum Industry Lesson Learned.
While at BP, I was instrumental in co-founding the Petrotechnical
Open Software Corporation (POSC) in 1990. This company was founded to
solve the problem of accessing and sharing information intra and inter-
organization on a global basis. Within two years this company had 134
members from around the world from the private and public sector,
including the US Department of Energy, US Department of Interior and US
Department of Defense. The company and its members took a standards
approach to solving the problem of accessing and sharing information.
Within 3 years the company had defined and agreed a set of free
published standards for hardware, operating systems,
telecommunications, a common dictionary of terms, a set of grammatical
rules to share information and a common way to share information
between applications. The project was an information technology
success, but has had limited economic success and use.
The four primary reasons for limited success were:
1. There was an existing large investment in vendor and
proprietary information technology in the petroleum companies,
government agencies and vendors. It was basically cost prohibitive to
move to the POSC standards.
2. The majority of the petroleum companies, government agencies
and vendors did not have the resources to migrate their data or rewrite
their applications.
3. The software vendors did not have any financial incentive to
rewrite their applications, to access the petroleum companies or
government agencies data in a POSC format or to have common standards
with their competitors.
4. The highly specialized experts had to change the way they were
doing their jobs and did not want to go through the change process.
The majority of the member organizations did not take up the POSC
specified standards. The organizations that did move to the POSC
standards were some of the nationally owned petroleum companies and
government agencies. Those that did take up the standard was because
they had the resources and could mandate the cultural change. Since
healthcare involves both the private and public sectors and they work
together I would suggest that STANDARDS are not a viable commercial
solution to the problem of accessing and sharing information in a
competitive industry like healthcare.
During my tenure as Chairman of POSC I realized that the commercial
solution to the problem of sharing information was to create technology
that accessed information where it resides. In 1994 I co-founded The
Information Store, which delivers secure information in context intra
and inter-organization via intranet, extranet or Internet from a
multitude of information sources anytime and anywhere to those so
authorized.
Solution and Benefits for Healthcare
From the lessons learned in the petroleum industry, the solution is
accessing healthcare information where it resides and delivering it in
the context of the caregiver.
Solution:
1. Access information where it resides.
2. Use Internet technology to make the information connections to
existing information sources.
3. Deliver information in the context of the caregiver--familiar
and useful form.
4. Since most patients interact with multiple providers in
multiple locations during their life, it is necessary to have
transparent access to those multiple providers and locations by the
caregivers and patients (intranet, extranet, and Internet technology
provides this flexibility).
Benefits:
1. Leverages the prior investment in information technology by the
hospitals, clinics, pharmacies, laboratories, government agencies and
vendors i.e. it is cost effective and does not disenfranchise previous
investments in information technology and people (the approach is low
cost and fast).
2. Requires very limited additional human or capital resources.
3. There is very limited change in the way physicians, nurses,
pharmacists, researchers, laboratory technicians, and others do their
jobs because the information is being delivered in a familiar and
useful form where and when they need it. (minimum disruption, cultural
change and training).
4. Limits changes on the part of the Information Technology
organization i.e. they are still maintaining and supporting their
current systems.
5. Easy to introduce new information systems (just connect the new
information source).
6. Easy to access and share information intra and inter-
organization (hospitals, clinics, pharmacies, laboratories, government
agencies, etc.)
7. The technology to solve the problem of information access is
readily available and cost effective.
The good news in healthcare is that only 25% of hospitals and 5% of
clinics in the US have an investment in clinical information systems
(CSI). This means that there are many green fields where standard based
systems could be employed if one existed. I would submit there is not a
CIS vendor in the market today that has industry standards based
technology. They each have their own standards. Their technology
implementation is their competitive advantage. Rather than interface
with other vendors or a hospital's own products the vendor prefers the
healthcare provider replace their own systems or another vendor's
system with their product. This is good for the vendor but not very
good for the healthcare provider or the escalating cost of healthcare.
In addition, no single vendor today has an integrated CIS that meets
all the needs of the customer.
I would suggest that the approach that is being taken by the Health
and Human Services in creating the National Health Information
Infrastructure and Local Health Information Infrastructure is correct.
That is using technology to connect various EHR systems and using
standards where appropriate. Keeping in mind that the cost and change
management barriers are very large and difficult to overcome when
implementing standards.
Near Term Suggestions:
1. Focus on the most wired hospitals, clinics, pharmacies,
laboratories, and government agencies and create a shared information
environment between a limited numbers of these organizations within a
community and demonstrate the viability of the Local Health Information
Infrastructure. This approach limits the risk and increases the chances
of success.
2. Do not mandate STANDARDS. Use STANDARDS only where they are
cost effective and where people will buy in to them.
3. Do not try and force CIS vendors to adopt standards. They have
no financial incentive to change their product. In addition, if there
is one common standard they lose their competitive position in the
market.
4. Do not try and force healthcare providers that develop their
own CIS to adopt standards. Just like the vendors they have no
financial incentive to change.
5. Use an Internet GLUEWARE approach, to facilitate the
connectivity between various organizations in the Local Health
Information Infrastructure (LHII) and the National Health Information
Infrastructure (NHII). If the LHII works the NHII will work by
definition.
6. For the 75% of hospitals and 95% of clinics that do not have
EHR today, HHS can provide financial incentives for them to implement
CIS through Medicare and Medicaid.
7. Make sure the caregivers are on board before starting any CIS
initiative. Many CIS installations still fail because the caregivers
were not intimately involved in the decision process of which CIS
vendor should be used. Physicians have a great deal of influence in the
hospitals concerning the technology used or in many cases not used.
Highly educated experts do not take kindly to mandates.
8. Do not repeat the mistakes of the petroleum industry. One size
may fit all, but it is difficult at best to get a person to wear the
garment if they don't pick it out themselves.
9. Most physicians have told me they spend limited time with their
patients in the hospital, therefore it is imperative that the patient's
EHR is accessible from the clinician's office, home and on the road.
10. Since many of us spend a large amount of time away from home and
move frequently it is critical that our EHR is available to our
caregivers and ourselves throughout the US. Internet technology
provides this capability.
The real challenge in meeting the goal of an EHR for all of us is
not so much a technology challenge but a culture change in the way
highly trained people work. If the correct information is available in
context for the caregivers when and where they need it to make
decisions the EHR will be a success. I went through information
cultural revolution in the petroleum industry.
I sincerely appreciate the opportunity to provide any insight, I
can, in to the challenge of providing an accessible life long
electronic health record for the citizens of our great nation. I am
very encouraged to see that our leaders and congress are taking action
to improve our Nation's healthcare system in a substantive way. If I
can be of any further assistance, please do not hesitate to contact me.
Thank you for your time and consideration.
Sincerely,
Glenn R. Breed
Chief Executive Officer and President
<F-dash>
Statement of MedMined, Birmingham, Alabama
SUCCESSFUL USE OF INFORMATION TECHNOLOGY TO IMPROVE HEALTHCARE OUTCOMES
``Bloodstream infections were reduced 31%, for a measured P/L
impact of 1.8M.'' Bill Wing, CFO, Florida Hospital
``In only six months, non-reimbursed costs from hospital infection
were down $618,000.'' Lance Peterson, MD, Evanston Northwestern
``After only one year, infections were down 19% hospital-wide,
saving $1.05M.'' Gerry Fornoff, CEO, Lakeland Medical Center
Hospital-acquired infections affect about 6% of all patients
admitted to U.S. Hospitals. In addition to morbidity and mortality,
these infections are a major financial burden. When they occur among
the fixed fee patient population (approximately 55% in the average U.S.
hospital), most of the average $13,973 in direct treatment costs are
not reimbursed. These non-reimbursed costs total millions of dollars
each year and are a drag on operating margins. Thus, reducing the
incidence of hospital-acquired infections both improves the quality of
care and operating margins.
The key to reducing the number of infections is the proactive
correction of process breakdowns that cause them. However, finding
specific opportunities to improve care is a daunting challenge. Using
current methods, Infection Control must wade through oceans of data to
identify a few pieces of critical information. This data comes to
Infection Control mostly in the form of printed reports regarding
individual patients and results. The vast majority of time is currently
spent digesting, organizing and analyzing this data (and not on the
teaching and interventions that actually prevent infections). Many
warning signs that reveal important issues remain concealed by the
volume and complexity of data that must be monitored. And, tracking
outcomes and measuring financial impact hospital-wide is nearly
impossible.
MedMined combines patented technology, clinical support, evidence-
based action plans, outcomes measurement, and cost/benefit analysis
into a comprehensive, hospital-wide initiative to reduce hospital-
acquired infections. This model has proven effective in measurably
reducing the incidence of hospital-acquired infections and their
associated costs in many types and sizes of hospitals. This success has
been highlighted in publications as diverse as Fortune, MIT Technology
Review, and the New England Journal of Medicine and in over twenty
efficacy studies.
Human and Financial Impact of Hospital-Acquired Infections
Each year in the United States hospital-acquired infections affect
2 million patients and account for 50% of all major hospital
complications.\1\ Behind heart disease, cancer, and strokes, hospital-
acquired infections are responsible for approximately 88,000 deaths
annually, making them the fourth leading cause of death in the United
States.\2\
---------------------------------------------------------------------------
\1\ Centers for Disease Control and Prevention. Public health focus
surveillance: prevention and control of nosocomial infections.
Morbidity and Mortality Weekly Report 1992; 41:783-7.
\2\ Hacek DM, Suriano TS, Noskin GA, et al. Medical and economic
benefit of a comprehensive infection control program that includes
routine determination of microbial clonality. Am J Clin Path 1999;
111:647-654. Jarvis WR. Selected aspects of the socioeconomic impact of
nosocomial infections: morbidity, mortality, cost and prevention.
Infect Control and Hosp Epidemiol 1996;17:552-557.
---------------------------------------------------------------------------
In addition to morbidity, mortality, legal risk, impact on
malpractice rates, etc., hospital-acquired infections take a
substantial, direct economic toll on hospitals. A May 2002 audit of
over 50 studies about the cost of hospital-acquired infections computed
the average, direct cost per infection to be $13,973.\3\
---------------------------------------------------------------------------
\3\ Stone PW, Larson E, Kawar LN. A systematic audit of economic
evidence linking nosocomial infections and infection control
interventions 1990-2000. Am J Infect Control 2002; 145-52.
---------------------------------------------------------------------------
When these infections occur among the fixed fee patient population,
very little of these costs are reimbursed. A study published in the
Journal of the American Medical Association directly addressed this
issue.\4\ Under a DRG-based payment system, reimbursement for the cost
of treating a hospital-acquired infection must overcome several major
obstacles. The study found that among this patient population, 95% of
the treatment costs were not reimbursed (avoidance of which would be a
direct financial gain to the hospital).
---------------------------------------------------------------------------
\4\ Haley RW, et al. The financial incentive for hospitals to
prevent nosocomial infections under the prospective pay system. An
empirical determination from a nationally representative sample. JAMA.
1987; 257(12):1611-4.
---------------------------------------------------------------------------
The effect of these non-reimbursed costs is quite substantial. In a
study of 151,459 admissions among a seven hospital system in the
Southeast, we found that the 95% of admissions that had not acquired an
infection provided a $59M inpatient operating profit. However, the 5%
of admissions that had acquired a hospital infection accounted for $33M
in net operating loss (risk adjusted). Thus, 5% of admissions eroded
55% of operating profits. (See the Figure at right).
[GRAPHIC] [TIFF OMITTED] 99674A.001
In one Midwest hospital, a 2001 financial analysis revealed the
following differences between patients with and without a hospital-
acquired infection (HAI):
------------------------------------------------------------------------
Without HAI With HAI
------------------------------------------------------------------------
Ave. Length of Stay 5 days 24 days
------------------------------------------------------------------------
Ave. Total Cost Per Patient $5,026 $28,864
------------------------------------------------------------------------
Ave. Direct Cost Per Patient $3,119 $21,006
------------------------------------------------------------------------
An examination of net operating margin (Net Revenue-Variable Cost)
by payor, comparing patients with a hospital infection with patients
without a hospital infection in the same DRG, revealed that every one
of the 519 patients with a hospital infection was unprofitable for the
hospital.
----------------------------------------------------------------------------------------------------------------
Blue Cross
Medicare Medicaid Commercial ManagedCare HMO/PPO Self-Pay
----------------------------------------------------------------------------------------------------------------
Total Loss ($3,766,757) ($914,166) ($435,978) ($342,978) ($102,255) ($42,960)
----------------------------------------------------------------------------------------------------------------
# Patients with HAI 379 81 27 12 12 9
----------------------------------------------------------------------------------------------------------------
Ave. Loss per Patient ($10,793) ($11,286) ($16,148) ($28,582) ($8,521) ($4,773)
----------------------------------------------------------------------------------------------------------------
Infection Control Surveillance
Many hospital-acquired infections are preventable, because they
stem from correctable process breakdowns (staff using poor sterile
technique, improperly cleaned equipment, etc.) that recur. Although the
solutions are straightforward and inexpensive (one study found the
average cost of correcting such breakdowns was less than
$1,200<SUP>3</SUP>) the real challenge has always been identifying
where and when these systematic patient care breakdowns are occurring
early enough to avoid unnecessary morbidity, mortality, length of stay
and cost.
Better surveillance is the key to reducing hospital-acquired
infections, antimicrobial resistance, and their associated costs. This
has been proven in many studies, including the landmark SENIC Project
of the 1970's.\5\ At Northwestern Memorial Hospital in Chicago (683
beds), investigators showed that modest improvements in Infection
Control surveillance with increased pattern detection led to a 23%
reduction in the number of patients with a hospital-acquired infection
and an estimated cost savings of $4.3 million over two years.\6\
---------------------------------------------------------------------------
\5\ Haley RW, Culver DH, White J, et al. The efficacy of infection
surveillance and control programs in preventing nosocomial infection in
U.S. hospitals. Am J Epidemiol 1985; 121:182-205.
\6\ Hacek DM, et al. Medical and economic benefits of a
comprehensive infection control program that includes routine
determination microbial clonality. Amer J Clin Path. 111:647-54, 1999.
---------------------------------------------------------------------------
Traditionally, surveillance for outbreaks of hospital-acquired
infections includes a manual review of microbiology data and suspected
cases of hospital-acquired infection followed by the tabulation of
basic summary statistics. Such summaries are arduous, time consuming,
lack timeliness, and often mask emerging, complex patterns.
Consequently, it has been widely recognized that sophisticated, active,
and timely intra-hospital surveillance is needed.
Integrated Solution
MedMined's unique and patented technologies target quality
improvement resources in ways not currently possible. But, technology
alone does not improve process. MedMined has created a comprehensive
model to elevate infection prevention to an effective, hospital-wide
initiative. These components work together to produce measurable cost
savings. The model includes: 1) capture, cleaning and mapping of
existing data sources, so that they are amenable to electronic
epidemiological analysis, 2) patented technologies, such as data
warehousing and data mining/artificial intelligence, that automatically
detect warning signs of patient care breakdowns and direct staff to
problem areas, 3) clinical support by MedMined's expert clinical staff
to help address known issues, 4) evidenced-based action plans and
educational materials that generate real process improvement, 4)
outcomes measurement to track progress at all levels, and 5) financial
reporting to allow management at the executive level and support
investments in infection prevention.
[GRAPHIC] [TIFF OMITTED] 99674A.002
``Where Can We Improve?''--Data Mining Surveillance <SUP>'</SUP>
Specific and correctable quality breakdowns that cause hospital
complications are evidenced by subtle patterns of related infections,
colonization, contamination, and antibiotic resistance. However,
because there are billions of potential patterns within electronic
patient and laboratory data, these patterns often remain hidden.
MedMined's Data Mining Surveillance Service (DMSS) rapidly
identifies patterns that indicate a specific and correctable quality
breakdown. Because DMSS is able to ``learn'' from the millions of
records within your hospital's varied databases, it can identify these
breakdowns without search criteria, data entry, or lengthy paper chart
review. The Data Mining Surveillance Service empowers your hospital to
proactively address quality breakdowns that cause hospital-acquired
infections.
Fusion of Technology and Clinical Expertise
DMSS is not software. It is a service whereby clinical staff get
the important actionable information they need to improve process
without having to learn and maintain very complex technology.
Data mining is a form of artificial intelligence which allows
scientists to discover important, useful patterns within large amounts
of data without predefined search criteria. Using specially-designed,
patented data mining techniques, MedMined monitors billions of
potential patterns across inpatient and outpatient communities, and
identifies relevant, actionable information. Results from the
technology are reviewed by MedMined clinical staff and reduced to a
concise report (including expert interpretation and suggested course of
action) of important and clinically actionable items.
Each report from MedMined's Data Mining Surveillance Analysis
represents a concise overview of important patterns indicating issues
which should be investigated and addressed by hospital Infection
Control and Quality staff. The reports delivered by MedMined typically
contain 3-5 ``alerts'' each month. Each pattern describes a cluster of
patients or isolates which represent a statistically significant
departure from the baseline at your facility, and indicate a
potentially important Infection Control issue.
Sample Alert:
Hospital Staphylococcus aureus Isolates from 5West Resistant to
Clindamycin, Oxacillin
[GRAPHIC] [TIFF OMITTED] 99674A.003
Issue: There is a 520% increase in the incidence of Hospital
Staphylococcus aureus Isolates from 5West resistant to Clindamycin and
Oxacillin. Given the baseline history and the unusual resistance to
Clindamycin, we suspect this represents a breakdown in barrier
precautions on 5West. This organism has a very long survival time--
weeks to months in the environment--environmental survival is believed
to play a part in transmission.
Recommended Actions:
<bullet> Person to person spread via direct contact, especially
between a patient and the transiently colonized hands of a health care
worker, is thought to be the principal mode of transmission. Assure
that the staff has a waterless hand cleanser close at the bedside for
use between patient contacts.
<bullet> The staff in the 5West area should be directly involved
in the plans for control of this organism in their patients. Include
all services who provide care or consultation, such as PT/OT,
nutrition, respiratory therapy, physicians, nursing, environmental
services, radiology and all others.
<bullet> Recent findings also suggest that virtually all patients
colonized or infected with MRSA have acquired their strain from an
external source, thus control must focus on prevention of transmission
as well as antimicrobial use. This finding has applied to patients with
both community and ``Hospital'' isolates.
<bullet> Current recommendations for control include surveillance
cultures for patients, stringent barrier precautions and cohort
nursing.
<bullet> Environmental contamination occurs rapidly for both
continent and incontinent patients, therefore gowns plus gloves are
recommended for contact with the patient or the patient's environment.
<bullet> All equipment that comes into direct contact with the
patient becomes capable of transmitting this organism; therefore each
patient must have their own stethoscope at the bedside, their own
blood-pressure cuff, and all other equipment. Any equipment that cannot
be individualized must be thoroughly wiped down with a hospital-grade
disinfectant before removing it from the patient room or area.
``We Need More Time to Act''--Virtual Surveillance Interface
Forty percent (40%) or more of Infection Control Professionals'
time is spent reviewing laboratory and patient data. Time spent
reviewing data is time taken away from infection prevention activities.
That is why MedMined streamlines this process with the Virtual
Surveillance Interface (VSI), which allows customizable event
monitoring and reporting of patients across the entire health system.
As a secure online service, the VSI is accessible from any
Internet-enabled PC, and can travel with the busy ICP as rounds are
made throughout a healthcare facility or across multiple sites. Event
monitoring can be customized to the specific goals of each surveillance
program, and can include reportable diseases, sentinel results, and
bioterrorism agents.
[GRAPHIC] [TIFF OMITTED] 99674A.004
Reporting capabilities of the VSI allow rapid, targeted review of
important information, with the option of exporting results to
Microsoft Excel for further analysis or formatting. Drill-down
capabilities allow patient movement data to be rapidly correlated with
laboratory results.
Studies have demonstrated that this service alone can save
Infection Control Professionals 8-14 hours of manual data review each
week.\7\ This effort saved, allows Infection Control to focus more
attention on educational initiatives and effective interventions.
---------------------------------------------------------------------------
\7\ MA Gould, PA Hymel, SE Brossette. Paperless Infection Control:
Time Savings and Process Improvements. Presented at SHEA 2002.
---------------------------------------------------------------------------
Financial Outcomes Measurement
The bedrock of current Infection Control practice is the National
Nosocomial Infection Surveillance (NNIS) program, orchestrated by the
Centers for Disease Control and Prevention (CDC). NNIS is a
benchmarking program, allowing hospitals to measure their infection
rates among certain types of infection in certain hospital locations
against their peers.\8\
---------------------------------------------------------------------------
\8\ National Nosocomial Infections Surveillance (NNIS) System
Report, data summary from January 1992 through June 2003, issued August
2003. Am J Infect Control 2003;31:481-98.
---------------------------------------------------------------------------
Because it was designed in 1970 to account for the difficulty of
manual surveillance, the NNIS system has limitations. For example, the
focus on only certain infections in certain locations may leave many
opportunities to reduce nosocomial infections undiscovered. Julie
Gerberding, Director of the CDC, wrote, ``Data from the NNIS System
have generally been used to motivate institutions with higher-then-
expected infection rates to strive for the relevant national benchmark
rate. The result may be both an underestimation of the preventable
infections and missed opportunities to discover new prevention
strategies.'' \9\ Moreover, data on the inaccuracy and subjectivity of
NNIS reporting has been published.\10\
---------------------------------------------------------------------------
\9\ Gerberding JL. Hospital-Onset Infections: A Patient Safety
Issue. Ann Intern Med 15 October 2002/Volume 137 Issue 8/Pages 665-670.
\10\ Emori, TG, Edwards JR, Culver DH, et al. Accuracy of reporting
nosocomial infections in intensive-care-unit patients to the National
Nosocomial Infections Surveillance System: A pilot study. Infect
Control and Hosp Epidemiol 1998;19:308-16.
---------------------------------------------------------------------------
Perhaps the biggest limitation on Infection Control departments
caused by NNIS' epidemiological focus is the lack of translation to
financial outcomes. As in most businesses, the allocation of scarce
resources among departments requires that each department demonstrate
its financial impact on the business. Those departments which cannot
measure their impact to the bottom line are at a significant
disadvantage in each budget cycle. Many Infection Control departments
suffer this fate, because the statement that ``ABCHospital has 2.6
central-line associated bloodstream infections per 1,000 central line
days in the SICU, which is 25% percentile'' does not say anything about
how much nosocomial infections are impacting the bottom line of
ABCHospital.
MedMined tracks the incidence of nosocomial infections (hospital-
wide) and their financial implications through the use of the patent-
pending Nosocomial Infection Marker<SUP>TM</SUP> (NIM). The NIM is a
method for identifying distinct nosocomial infections through the
analysis of existing electronic patient movement and microbiology data.
Because it is automated, it is objective, efficient and comprehensive.
The MedMined Marker has been validated by several studies. In the
first, clinical chart review of consecutive admissions revealed that
the NIM had a sensitivity of >80% and a specificity of 99% (compared to
traditional manual/NNIS surveillance sensitivity of 0.4% and
specificity of 95%) in the identification of nosocomial infections.
[GRAPHIC] [TIFF OMITTED] 99674A.005
In a second study of 308,000 admissions across 18 hospitals, each
NIM (patients may have more than one, just as they may have several
separate nosocomial infections) correlated to 6.35 extra days LOS and
$11,967 in extra variable cost (risk-adjusted).
This study found that the 5% of patients that had at least one NIM
eroded 56% of the total inpatient operating profits. The 95% of
patients that did not acquire a hospital infection accounted for $59M
in profit, whereas the 5% of patients that did acquire a hospital
infection accounted for $33M in operating losses.
A third study of 66,780 admissions across 14 hospitals concluded
that each MedMined Marker added 7.2 days to LOS and $15,300 in variable
cost (risk-adjusted).
Thus, the Marker is a not only a clinically valid measurement tool,
but also useful for measuring the financial implication of these
infections.
Published Case Studies
At a 600-bed university-affiliated, tertiary-care hospital,
MedMined's Data Mining Surveillance increased pattern/cluster detection
of related infections 10-fold, when compared to traditional NNIS
surveillance, while maintaining 90+% specificity. Among patterns
discovered by both traditional methods and the data mining analysis, a
bloodstream outbreak of VRE was identified 4 weeks earlier by the data
mining analysis.\11\
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\11\ Hymel PA, Brossette SE, Moser SA. Data Mining-Enhanced
Infection Control Surveillance: Sensitivity and Specificity. Presented
at SHEA 2001.
---------------------------------------------------------------------------
Seven months of DMSS at LakelandHospital (156 beds) led to
significant changes in policies and procedures, as well as direct
intervention by Infection Control staff. Previously unidentified
patterns detected include: (1) A pattern of multidrug-resistant
Klebsiella among ventilated patients in the ICU (2) An increase in
blood culture contaminants from the ED (3) An unusual cluster of
resistant E.coli on a specific ward (4) A cluster of VRE from urinary
isolates (5) A cluster of Alcaligenes on a specific ward.\12\ After 12
months of prospective DMSS reporting, LakelandHospital documented a 22%
overall reduction in hospital-wide infection rates.
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\12\ Vance, P, Meyers, D, Hymel, PA. Prospective Identification of
Quality Issues Related to Nosocomial Infections through Data Mining
Surveillance in a Community Hospital. Presented at SHEA 2002.
---------------------------------------------------------------------------
MedMined's Virtual Surveillance Interface reduced time spent by
Infection Control reviewing paper charts by 8-14 hours per week at
Children's Hospital of Alabama (250 beds), while also rapidly
identifying unsuspected outbreaks of nosocomial Acinetobacter and
community-acquired Yersinia.\13\
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\13\ MA Gould, RN, CIC and SE Brossette, MD, PhD. An outbreak of
Acinetobacter baumannii in ventilated patients of a pediatric hospital
identified by data mining surveillance. Presented at SHEA 2002. MA
Gould, PA Hymel, SE Brossette. Paperless Infection Control: Time
Savings and Process Improvements. Presented at SHEA 2002.
---------------------------------------------------------------------------
Retrospective DMSS analysis at a 100-bed VA facility revealed the
source of a multi-drug resistant Pseudomonas outbreak 6 weeks before it
was detected by traditional surveillance methods. Prospective analysis
revealed several patterns of multi-drug resistant Acinetobacter and
Klebsiella which were proactively managed.\14\
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\14\ SE Brossette, BD Taylor, B Warren, KC Avent, SA Moser.
Improving Infection Control Surveillance Using Data Mining Technology.
Presented at ICAAC 2001. September 22-25, 2001. Chicago.
---------------------------------------------------------------------------
DMSS detected a previously unknown outbreak of central line-
associated bloodstream infections at a 250-bed pediatric hospital. This
discovery led to focused investigation and interventions. In the months
following implementation of these targeted interventions, patient-day
adjusted analysis revealed that the incidence of hospital-acquired CVL-
associated bloodstream infections decreased by 43% (p=0.03).\15\
---------------------------------------------------------------------------
\15\ DC Branca, MA Gould. A reduction of bloodstream infections in
an oncology unit following data mining surveillance and targeted
interventions. Submitted for poster presentation, SHEA 2003.
---------------------------------------------------------------------------
At Hilo Medical Center (278 beds) Data Mining Surveillance alerted
Infection Control to a previously unrecognized, dramatic (410%)
increase of hospital Pseudomonas aeruginosa isolates. Chart reviews
revealed that 15 of the 18 isolates were hospital-acquired infections,
resulting in a yield of 83% predictive value. Focused investigation led
to intervention efforts on the unit with the majority of cases. In the
third quarter, only 1 subsequent respiratory isolate of hospital P.
aeruginosa occurred. From Oct 1 through Nov 30, 2002, only 2
respiratory isolates of hospital P. aeruginosa were noted. Had the
cases continued unchecked for the following three months,
HiloMedicalCenter would have spent approximately $628,785 in treatment
costs for infected patients.\16\
---------------------------------------------------------------------------
\16\ JH Halloran. Rapid Mitigation of Pseudomonas aeruginosa
outbreakidentified by novel surveillance technology at Hilo Medical
Center, Hilo, Hawaii in June 2002. Submitted for poster presentation,
SHEA 2003.
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At FloridaHospital (1,752 beds), Data Mining Surveillance revealed
a 190% (p value 0.004) increase from baseline of A. fumigatus
respiratory isolates. Since HVAC systems are often suspect in cases of
hospital-acquired aspergillus the air handlers were examined. Fungal
cultures were obtained from the final filters of the suspect HVAC.
Cultures grew out A. fumigatus. Physical inspection of the filters
revealed that they had not been seated properly, allowing some passage
of unfiltered air. The filters were replaced and seated properly. The
incidence of hospital-acquired aspergillus decreased 80% (p
value=0.034).\17\
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\17\ Kaptur KC. Identification of Nosocomial Aspergillis Fumigatus
Using Virtual Surveillance. APIC 2004.
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At Providence St. Vincent Hospital (450 beds) in Portland, Oregon,
Data Mining Surveillance detected an unsuspected, significant increase
in hospital-associated Serratia marsescens isolates from respiratory
sources. Upon IC investigation, it was discovered that respiratory care
staff on the units involved were utilizing tap water in the humidifiers
on the ventilators. A pre-packaged humidifier with sterile water system
was implemented (that was cheaper than the old system). Compared with
the three month period in which the alert was generated, the process
change generated a 58% reduction.\18\
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\18\ Church NK. Cluster of Serratia marsescens associated with tap
water utilization on ventilated patients: Identification, investigation
and correction. APIC 2004.
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Data Mining Surveillance identified a previously unknown pattern of
community-acquired urinary isolates from patients collected while in
outpatient radiology. This cluster represented a 4-fold increase from
the previous 9 month baseline (p= 0.026). All patients had a
urethrogram procedure. Infection Control discussed pattern with unit
director, staff educator and charge nurse. Supervisors reviewed
policies and performed competency checks on staff. ICP visited staff at
random to establish if technique was consistent with policy. In the 20
weeks following full implementation there was a 33% reduction in
positive urine cultures from this unit versus the 20 weeks prior to
improvement efforts. (p = 0.039).\19\
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\19\ Vasson BA. Identification, investigation and correction of
urethrogram-associated urinary tract infections in a pediatric
facility. SHEA 2004.
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The combination of Data Mining Surveillance, the ability to provide
regular feedback on progress, and a team-based approach to infection
prevention led to an 87% reduction in the incidence of nosocomial MRSA
in an ICU and a concurrent decrease in VRE hospital-wide. The cost
avoidance was estimated to be $3,183,030. A decrease in average length
of stay of 2 days was also noted on this ICU unit over the post-
intervention period.\20\
---------------------------------------------------------------------------
\20\ Breaux DB, Baker JD, et al. A Unit Based Council Develops a
Team Approach to Reduce Methicillin-resistant Staphylococcus aureus
Infections in the Intensive Care Unit. APIC 2004.
---------------------------------------------------------------------------
MedMined alerted Children's Hospital of Alabama to four patients in
June 2003 with initial blood isolates obtained late in the hospital
stay among patients on the Oncology Unit, representing a 16-fold
increase from the previous 4 month baseline (p=.009). Culturing
practices were unchanged, during, and after pattern identification.
Interventions directed at bloodstream infection prevention were
implemented. In the 12 weeks following full implementation only one
hospital-associated isolate was obtained, a reduction of 90% (p =
0.014).\21\
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\21\ Vasson BA, et al. A reduction of bloodstream infections in a
pediatric oncology unit following electronic surveillance and targeted
interventions. APIC 2004.
---------------------------------------------------------------------------
At St.FrancisHospital in Memphis, MedMined's service enabled an
aggressive team approach to reducing the incidence of bloodstream
infections and contaminated specimens. Weekly average of non-duplicate
bloodstream isolates fell from.85 (17 pts / 20 weeks) to.30 (6 pts / 20
weeks), a 64% reduction. Focused surveillance for clinical infection
yielded 14 weeks without a single hospital-acquired bloodstream
infection in the post intervention period.\22\
---------------------------------------------------------------------------
\22\ Breaux DB, Baker JD, et al.Focused Bloodstream Infection
Prevention Success Using a Team-based Unit Level Approach. APIC 2004.
---------------------------------------------------------------------------
MedMined's objective measurement of hospital-acquired infection
rates received clinical validation at EvanstonNorthwesternHospital.
Using its Nosocomial Infection Marker<SUP>TM</SUP>, MedMined calculated
the hospital-acquired infection rates across the hospital to be 4.56%
of admissions. An independent chart review of consecutive admissions
calculated the infection rate to be 4.67%. Over the same period,
traditional targeted surveillance methods indicated the rate was 0.3%
and required significantly more time and resources to compute. Thus,
MedMined's method was more accurate and efficient method of computing
infection rates.\23\
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\23\ Gavin PJ, et al. Comparison of `Whole House' Versus Routine
Targeted Surveillance for Detection of Nosocomial Infection. SHEA 2004.
<F-dash>
Statement of National Association of Chain Drug Stores, Alexandria,
Virginia
Madame Chairwoman and Members of the Health Subcommittee. The
National Association of Chain Drug Stores (NACDS) is pleased to submit
this statement for the record regarding health care information
technology. NACDS represents more than 200 chain pharmacy companies
that operate nearly 32,000 community-based retail pharmacies. We are
the primary provider of outpatient prescription drugs in the United
States, dispensing about 70 percent of the 3.1 billion prescriptions
that are provided each year. We believe that our industry has been in
the forefront of using technology to increase efficiencies and improve
patient care in the delivery of pharmacy services. Almost all pharmacy
claims are adjudicated and paid through an online real time standards-
based communications system.
We recognize and appreciate the leading role that you and this
Subcommittee have played in moving forward the health care information
technology agenda. In particular, we want to thank you for your efforts
in including specific language in the Medicare Modernization Act (MMA)
of 2003 that requires the development of standards for an E-Rx (E-Rx)
program for Medicare prescriptions. We also know of your interest in
exploring the issues and benefits that can be derived from the use of
electronic health records. We believe that both initiatives will
enhance quality of health care for patients, as well as create
unparalleled efficiencies in the health care delivery system.
``E-Rx'' Principles
NACDS is working with the HHS National Committee on Vital and
Health Statistics (NCVHS) as its members prepare to recommend standards
to the Secretary for the E-Rx program mandated by MMA. Many of our
pharmacies are already electronically connected to physicians, and are
able to receive approvals from physicians for prescription refills. We
look forward to the additional efficiencies that will result as the
more expanded E-Rx program is implemented over the next several years.
To improve the overall prescribing process, and create momentum for
the adoption of E-Rx, the National Community Pharmacists Association
(NCPA) and NACDS created SureScripts in 2001. SureScripts is a neutral,
secure E-Rx network that is compatible with all major physician and
pharmacy software systems.
More than 60 percent of the nation's retail pharmacies have now
tested and certified their pharmacy application on the SureScripts
network. That number is expected to grow to more than 75 percent of the
pharmacies in the U.S. by end of summer 2004. SureScripts uses the
National Council for Prescription Drug Programs (NCPDP) SCRIPT Standard
to serve as the foundation for the software used to transmit
prescriptions. SCRIPT was developed through a consensus process among
community pharmacy organizations, pharmacy software vendors, database
providers, and other stakeholders. Currently, the standard addresses
the electronic transmission of new prescriptions, prescription refill
requests, prescription fill status notifications, and cancellation
notifications.
The strength of NCPDP SCRIPT standard is that it is a national
standard that addresses the vast majority of the core functionality
required by the MMA. It currently facilitates the bidirectional
transmission of prescription information between prescribers and
dispensing pharmacies and pharmacists, and holds the potential to allow
for the transmittal of information on eligibility and benefits and
medication history. SCRIPT will likely be among the standards that are
suggested by NCVHS to the Secretary to serve as basis for the broader
E-Rx system.
As we move forward with building on these existing standards for an
E-Rx system, and prepare for more widespread use of this technology,
NACDS believes the following principles should be incorporated into any
pilot or program for the electronic transmission of prescriptions:
Physician-pharmacist-patient choice and relationship should be
protected: Prescriptions are communications between health care
professionals--primarily physicians and pharmacists--regarding a
specific course of pharmaceutical treatment. Most of these
communications are currently paper based, but the goals of E-Rx are to
replace this paper system with a secure, efficient, quality-enhancing,
high-tech system.
E-Rx should be used as a tool to enhance the pharmacist-physician-
patient relationship, not displace or change it. For example, patients
must still be able to obtain needed prescriptions from the pharmacy of
their choice. That is, this technology should not be used for the
purposes of steering patients to ``preferred'' drugs that are not in
the best interest of the patient, or steering patients to pharmacies
that may not be the patient's choice.
Physicians must be assured of their ability to prescribe both ``on
formulary'' and ``off formulary'' and consumers must be assured of
their choice of pharmacy, and not be coerced into using mail order
prescription drug sources.
Prescriptions should be not be altered once sent by to the
pharmacy: Electronic prescriptions should be transmitted directly from
physicians to pharmacies without interference from third party payers
or PBMs who may manipulate or change the prescription for various self-
interested economic reasons. Once a physician has transmitted an
electronic prescription, no intervening entity should alter the
prescription information or content, or change the pharmacy site that
the patient has chosen. Physicians and pharmacists must be able to rely
on the security of the transmitted prescription information. Any
altering by an intermediary of prescribed drug, strength, quantity,
allowed refills, or directions would certainly adversely affect patient
safety, and would constitute the unauthorized practice of medicine and
pharmacy in most instances. Changes to the prescription should only be
made after a dialogue between the prescribing physician and the
dispensing pharmacist.
Patient medication and medical history should be routed through the
pharmacy: The goal of the E-Rx system should be to help the physician
make the best choice of medication possible at the point of
prescribing. The most complete information about the patient's medical
and medication history will be provided to the physician if all
information is routed through the pharmacy to the physician. That is
because payers have only a subset of the full medical and medication
history, and can only provide information on prescription that they
have paid for.
This excludes anything that the patient paid for out-of-pocket,
such as prescriptions not covered by the payer, and a vast array of
nonprescription items including herbal and nutritional supplements.
Payers also do not have information that patients provide specifically
to the pharmacy during patient counseling, such as potential allergies,
sensitivities, and other adverse reactions. Therefore, the most
complete medication history would be provided to the physician if it
was routed through the pharmacy.
Value of the pharmacist must be preserved: Pharmacists are
medication experts that collaborate with physicians to enhance overall
prescription drug use, and reduce the likelihood of medical errors and
adverse drug reactions.
We believe it is only logical that E-Rx programs encourage such
collaboration, and should not create standards or procedures that would
disrupt such collaboration. Moreover, the E-Rx system should not push
some of pharmacists' traditional duties upon already overworked
physicians, such as drug utilization review (DUR) and checking for
other medication-related concerns. Such proposals would act as a
barrier to physician adoption of E-Rx.
E-Rx standards and tools must be free of non-clinical influence:
MMA requires E-Rx standards to ``allow for the messaging of information
only if it relates to the appropriate prescribing of drugs, including
quality assurance measures and systems.'' An efficient E-Rx process
would not burden physicians with extraneous electronic promotional
messages. To protect the prescriber-patient relationship, a physician
should not be influenced by advertising, such as ``pop-up messages'' at
the point of E-Rx. MMA standards should enhance the physician's
clinical decision-making process.
The program should also allow physicians to ``have ready access to
neutral and unbiased information on the full range of covered
outpatient drugs.'' Physicians should be able to view with equal ease
all necessary information, including information about drugs that are
preferred on-formulary, non-preferred on-formulary, and off-formulary,
without having to click through multiple screens or other burdensome
steps. All information provided to physicians should be fact-based and
transparent, and should identify the source of the information. Any
incentive payments given to technology vendors to display information
in a particular way should be fully disclosed to the physician and
pharmacist and any advertisements, such as banner ads, should be
clearly labeled as a paid advertisement.
In addition, the system should show the physician and the patient
all the choices of pharmacy providers that they have--both in network
and out of network. There should be no steering of beneficiaries to
mail order pharmacies. While the selection of a particular pharmacy
would not change the cost sharing required, it would allow the patient
the full range of options when selecting their pharmacy provider.
EHR should be compatible with E-Prescribing: The primary goal of an
electronic health information system is to allow the sharing of
information between E-Rx and Electronic Health Records (EHRs). However,
the MMA requires more information to be shared than the e--prescribing
SCRIPT messaging format standard can share today. Therefore decisions
must be made to determine the most appropriate standards to carry the
additional MMA required information. A number of possibilities exist.
Some of the MMA required information could be added to the SCRIPT
standard. However, only that information that is to be shared between
prescribers and pharmacists should be added to the SCRIPT standard,
which has historically been limited to that use.
In addition, some of the additional MMA required information could
be included in the new EHR standards, which are currently being created
by the standards development organization known as Health Level 7
(HL7). The good news is that work is already underway to make sure that
information included in the EHR standards can be transmitted to those
using the e-prescribing SCRIPT standard and vise versa. NACDS is
involved in this effort.
Financial incentives for E-Rx should be provided to pharmacies: MMA
provides for grants to physicians to encourage physician adoption of E-
Rx. The grant money is intended to assist physicians in computer system
upgrades and staff training that will enable them to engage in E-Rx.
There are significant costs associated with the successful
implementation of E-Rx for both physicians and pharmacists; incentives
should be made available to pharmacists as well.
Conclusion
NACDS believes that enactment of the E-Rx provisions of MMA will
encourage the further development and enhancement of E-Rx. We look
forward to active engagement in the development of policies, standards
and infrastructure to make widespread E-Rx a reality, along with
electronic interactivity among physicians and other health care
practitioners for the sharing of patient medical and medication
histories.
<F-dash>
Statement of Thomas W. Hughes, National Electronic Attachment, Inc.,
Atlanta, Georgia
My name is Thomas W. Hughes and I am the President and CEO of
National Electronic Attachment, Inc. Our company is in the electronic
attachment business (attachments being defined as anything sent to an
insurance payor in support of an electronic claim. In dental, this
could be an x-ray, perio-chart, and/or narrative or in medical this
could be a certificate of medical necessity, doctor's notes, ambulance
notes, lab reports, etc.)
Today attachments in the non-MEDICARE world, transmitted between a
provider and a clearinghouse can move over a secure internet. In fact,
attachments for Medicare patients transmitted from a general provider
to a specialist also can move over a secure internet. However, an
attachment or claim may not be transmitted over a secure internet
between the clearinghouse and the medical payor.
In many cases, the Medicare payor receives non-medical claims and
attachments over the secure internet. However, the moment the patient
becomes Medicare eligible, the claim MUST be sent electronically
(previously it MIGHT be sent electronically) and the attachment must be
sent via mail (previously it MIGHT have been sent electronically even
to the same payor).
We as a company as well as well as the Association for Electronic
Health Care Transactions (AFEHCT), are working through this
organization toward standardizing both transactions and attachments. My
best guess is that a mandated electronic attachment rule will be ready
by 2008, even if the NPRM comes out in the Fall of 2004. At this time
next year, our own company should have about 600 hospitals and 30,000
providers processing electronic attachments, all over the internet.
The latest research for attachments on the institutional side shows
a cost of processing each attachment as $20-$24 per attachment to the
institution. Cost on the payor side is $6-$10 per attachment. On the
physician/professional side cost is approximately $4-$8 each to the
physician, and in dental $1-$2 each to prepare.
The cost of administrative work in this area is alarming,
especially when the cost would fall to less than 25% of the current
rate if the internet could be used to transmit Medicare attachments
from provider to payor. As we move to the electronic health records, it
is imperative that we as a country open up the secure internet to all
possibilities of getting these records into the hands of healthcare
professionals as well as to the patients themselves.
Since covered entities fall under the HIPAA umbrella, we have
proper safeguards built in our system for both privacy and security. I
am concerned that we have tools today available to cut healthcare
costs, and are not using them. The marketplace is waiting for this to
open up and I predict if the government does open up the secure
internet, the electronic health record will be a lot closer than ten
years out. In my conversations with various vendors, I find that the
lack of being able to use the internet in MEDICARE is a major stumbling
block to progress in healthcare. Since the federal government pays out
more than half the healthcare dollars, they have been the only ones to
deny free use of the secure internet.
<F-dash>
Statement of Charles Homer, National Initiative for Children's
Healthcare Quality, Boston, Massachusetts
Introduction
The National Initiative for Children's Health Care Quality (NICHQ)
is pleased to submit this statement for the record as part of the
Subcommittee's Hearing on Health Care Information Technology (IT).
NICHQ, a premier independent national organization committed to leading
the way to high quality care for all children, enthusiastically
supports the President's goal of assuring that most Americans have
electronic health records within the next ten years. We represent
talented health professionals working every day to improve care for
children and adolescents, experts in pediatrics and quality, and
parents who share their stories and experiences to make sure that we
achieve our goals. With healthcare IT now a central focus of public and
private efforts to improve health care, Congress has a tremendous
opportunity to assure that this attention also contributes to better
quality and efficiency of care provided to children, particularly
thosewhose care is either financed or provided by public programs.
Nearly 25 million children have their care overseen or provided by
programs within various Federal Agencies, including the Department of
Health and Human Services, the Department of Defense, and the Federal
Employee Health Benefits Program.\1\ Realizing this benefit for
children will require understanding and attention to the specific
issues unique to IT applications in children's health care.
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\1\ Dougherty D, Simpson L. Measuring the Quality of Children's
Healthcare: A Prerequisite to Action. Pediatrics Supplement ( Editor
and paper Author), January 2004, Vol. 113, No. 1: pp 185-196
---------------------------------------------------------------------------
Background
A common saying among child health professionals is that ``children
are not little adults.'' These differences have been well described and
are often referred to as the four D's. Children are dependent on
parents and their families for access to the health care they need.
Thus, strategies must take into account how to collect and provide
information to more than one patient. Childhood is characterized by a
developmental trajectory that entails rapid change and emerging
abilities to use health information. Children's health is characterized
by a differential epidemiology of fewer major chronic illnesses, many
acute illnesses, and a high need for preventive services. Finally,
children have different demographic patterns, being the poorest and
most diverse segment of our population. Current census projections
estimate that by the year 2050, the majority of the U.S. population
will be represented by racial and ethnic minority groups.\2\
Projections for this transition in the pediatric population are even
more rapid, and some regions in the US already have experienced a shift
in pediatric demographics to ``majority minority.'' \3\ The poverty
rate among children and their families also means that they rely
disproportionately on public health insurance (through Medicaid and
SCHIP) and public health systems for health care, making the
coordination of services and information even more
critical.<SUP>4,}5</SUP>
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\2\ U.S. Bureau of the Census, decennial census and population
projections. Available at: www.census.govprod/3/98pubs/p23-194.pdf.
Last accessed July 1, 2004.
\3\ State of California, Department of Finance. CountyPopulation
Projections with Age, Sex, and Race/Ethnic Detail, July 1, 1990-2040.
Available at: http://www.dof.ca.gov/html/Demograp/projca.pdf. Last
accessed July 1, 2004.
\4\ Forrest C, Simpson L, Clancy C. Child Health Services Research:
Challenges and Opportunities. Journal of the American Medical
Association June, 1997, 277(22):1787-1793
\5\ Simpson L, Zodet MW, Chevarley FM, Owens P, Dougherty D,
McCormick M. Health care for children and youth in the United States:
2002 report on trends in access, utilization, quality, and
expenditures. Ambulatory Pediatrics. 2004; 4:131-153.
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At the same time, children experience the same chasm in the quality
and safety of care that the Institute of Medicine (IOM) documented for
populations overall.<SUP>6,}7,}8</SUP> Children present unique
challenges when studying quality and safety which often leads to their
exclusion from research. Indeed, the landmark IOM report on patient
safety noted above contained fewer than a half dozen citations that
were specific to children. Examples of poor quality of care for
children exist for all types of care (e.g. preventive, acute, chronic
and end of life care), in all settings (e.g. ambulatory care, hospital
care), and all types of systems (public, private, managed care, fee for
service). Millions of children fail to receive the care they need (e.g.
immunizations), receive care that has the potential to harm them (e.g.
medication errors), or care that they do not need and which provides no
benefit (e.g. antibiotics for the common cold. And racial/ethnic
minority children often suffer disproportionately from poor quality
care.<SUP>9</SUP> When errors do occur their impact may be greater due
to the different physiologic capability of children, particular
infants, to buffer the incorrect dosage or other error.<SUP>10</SUP> We
have the scientific knowledge, dedicated health professionals, and
tools available to do much better today!
---------------------------------------------------------------------------
\6\ Institute of Medicine, (1999). To err is human: building a
safer health system. Edited by L.T. Kohn, J.M. Corrigan, and M.S.
Donaldson. Washington, DC: NationalAcademy Press.
\7\ Institute of Medicine. (2001). Crossing the Quality Chasm: A
New Health System for the 21st Century. Washington, DC: NationalAcademy
Press.
\8\ Leatherman, S & McCarthy, D. (2004) Quality of Healthcare For
Children and Adolescents: A Chartbook. Commonwealth Fund, New York, NY.
Available at http://www.cmwf.org/programs/leatherman--pedchtbk--700.asp
\9\ Horn IB, Beal AC. Child Health Disparities: Framing a Research
Agenda. Ambulatory Pediatrics, forthcoming Summer 2004.
\10\ Kaushal, R., Bates, D.W., Landrigan, C., et al. (2001)
Medication errors and adverse drug events in pediatric inpatients. JAMA
Vol. 285:2114-2120.
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The Role of Healthcare Information Technology
Accelerating the use of information technology is an essential step
toward improving the quality and safety of children's health care.
Fortunately, momentum is building thanks to the efforts of the
Department of Health and Human Services with Secretary Tommy Thompson's
leadership and commitment. For example, the Agency for Healthcare
Research and Quality is supporting numerous research and other projects
to develop the information needed to understand the most effective ways
of integrating IT into healthcare as well as assisting hospitals to
plan and implement major IT deployments. Recently, a comprehensive
agenda was laid out at an important national meeting which was held in
Atlanta, Georgia last December and hosted by the Public Health
Informatics Institute.\11\ A follow-up meeting sponsored by the
American Academy of Pediatrics and the Maternal and Child Health Bureau
is planned for September. Also, thanks to the leadership of key
pediatric organizations,\12\ a pediatric Special Interest Group has
been formed within HL7 to address clinical standards. And pediatricians
will participate in the second meeting of the National Health
Information Infrastructure in July.
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\11\ Public Health Informatics Institute. Developing Child Health
Information Systems to Meet Medical Care and Public Health Needs.
Available at http://www.allkidscount.org/pdfs/12-03MeetingSummary.pdf
\12\ American Academy of Pediatrics, American Board of Pediatrics,
Child Health Corporation of America, National Association of Children's
Hospitals and Related Institutions, National Initiative for Children's
Healthcare Quality, Nemours Foundation.
---------------------------------------------------------------------------
However, because of numerous differences between adult and
pediatric services themselves as well as specific issues with pediatric
IT applications, one cannot assume that a high degree of IT investments
will naturally translate into similar levels of benefit for adult and
pediatric patients. The AmericanAcademy of Pediatrics has identified
special requirements to be included in electronic medical record
systems for use in pediatrics.\13\ For example, many of the medications
errors we see today that harm children are due to dosing errors because
most medications are prescribed based on a child's weight and require
calculation. Incorporating weight-based dosing features to electronic
health records will save children's lives. Children and families rely
on our health care system for health promotion and disease prevention
and monitoring growth is a key part of this important service.
Electronic health records need to facilitate the charting of a child's
height, weight, head circumference and body mass index using
standardized growth charts to identify problems early. This has never
been more important than now as we face an epidemic of childhood
overweight and obesity. Many children rely on multiple systems for
their health care needs, including schools and the foster care system,
and electronic health records should facilitate the coordination of
care across these settings. Finally, many of the strategies being used
today to foster more rapid adoption of evidence-based health care may
be particularly difficult for child health providers to implement.\14\
Because pediatricians and family practitioners have the lowest incomes
and may practice more often in undercapitalized settings,\15\ resources
for improvement, including information technology and participation in
improvement collaboratives, are less available. For all of these
reasons, we must make sure that children's unique needs are addressed
as we move forward. The following steps would assist in that goal.
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\13\ AmericanAcademy of Pediatrics, ``Special Requirements for
Electronic Medical Record Systems in Pediatrics'', Pediatrics 108 (2):
513-515.
\14\ Simpson L. Lost in Translation? Reflection on the Role of
Research in Children's Health Care Improvement. Health Affairs,
Forthcoming April, 2004
\15\ C.K. Kane and H. Loeblich, ``Physician Income: The Decade In
Review'', in American Medical Association, Physician Socioeconomic
Statistics, (American Medical Association, Chicago, Illinois, 2003)
---------------------------------------------------------------------------
Recommendations
1. Support specific attention to child health care's unique
characteristics as healthcare IT standardization moves forward.
2. Include a requirement that all government contracts for health
care IT which will be used in settings where children are cared for
specify how they will address the special information technology
requirements for optimal care of children.
3. Ensure that federal healthcare IT initiatives, such as those
detailed by Dr. David Brailer in his testimony, specifically include
the many settings where children receive care, including children's
hospitals, local health departments, and schools.
4. Facilitate monitoring of progress towards the reduction of
health care disparities for children by supporting efforts to include
race, ethnicity and primary language among standard demographic
measures.
5. Make investments in quality improvement and clinical
information systems (including registries) eligible for enhanced match
under Medicaid.
6. Establish access to low cost loans and other capital strategies
to support child health providers in the purchase of healthcare IT
systems.
7. Increase the budget of the Agency for Healthcare Research and
Quality to at least $443 million including adequate funding to support
additional research and demonstrations of the impact of healthcare IT
in child and adolescent health care with a particular emphasis on the
interoperability of systems across public and private sectors and
settings.
Madam Chairman and Members of the Subcommittee, the child health
professionals of this country stand ready to assist Congress and the
Administration in advancing the use of health information technology to
improve the quality and safety of health care for all Americans,
including our children.
<F-dash>
Statement of Kenneth W. Kizer, National Quality Forum
On behalf of our more than 200 member organizations, the National
Quality Forum (NQF) commends Chairwoman Johnson's leadership in calling
for greater use of information technology to make healthcare better and
safer.
Information Technology and Healthcare Quality
Few technological advances have held so much potential to improve
healthcare, yet has so far realized so little actual impact on everyday
patient care, as has electronic information management. This is
especially ironic when one considers that healthcare is the most
information-intense enterprise that human beings have ever engaged in
and that many diagnostic and treatment technologies are models of
electronic sophistication. Unfortunately, patient medical records and
methods of moving patient-related information along the continuum of
care have remained much the same as they were a hundred years ago.
The absence of a national electronic information management system
to support coordinated, comprehensive, patient-centered healthcare
contributes to the occurrence of medical errors; hinders efforts to
measure and improve health system performance; and makes improvements
in efficiency extremely difficult.
NQF's Role in Information Technology and Quality
The National Quality Forum (NQF) is a voluntary consensus standards
setting body (similar to the American National Standards Institute or
ANSI) that operates in accordance with the National Technology and
Transfer Advancement Act of 1995, OMB Circular A-119 and other relevant
federal guidance. The NQF is dedicated solely to healthcare, and
healthcare quality improvement in particular. The NQF was established
in 1999 subsequent to the recommendation of a Presidential Commission.
The NQF has a keen interest in healthcare IT because information
technology is a critical enabler of improved quality and because the
national performance measures, quality indicators and other standards
endorsed by the NQF will be core data elements used in healthcare IT
systems in the future for reporting of performance, pay-for-performance
programs and other similar purposes.
In so far as improved medical informatics is a critical enabler of
healthcare quality improvement, the NQF has promoted the development
and widespread deployment of improved healthcare information technology
since its creation. In this vein, in partnership with the Institute of
Medicine of the National Academy of Sciences and with support from the
Markle Foundation, the NQF held a National Summit on Information
Technology and Healthcare Quality in March 2002. Building on the work
of the National Committee on Health and Vital Statistics and others,
this Summit appears to have accelerated the momentum for more
collaborative efforts in this area and highlighted the need for a
shared vision of a national health information infrastructure (NHII).
Implementation of a national health information infrastructure is
one of the nation's most urgent needs. Participants in the National
Summit on Information Technology and Healthcare Quality agreed that
implementing a NHII is fundamental to achieving major improvements in
the efficiency and quality of healthcare, and they generally agreed on
the basic design principles for such a system.\1\
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\1\ Power EJ, Kizer KW, Nishimi RY, Gorban LD (eds). Information
Technology and Healthcare Quality: Proceedings of a National Summit.
Washington, D.C. National Quality Forum. 2003.
---------------------------------------------------------------------------
While the workgroups convened at this Summit occasionally differed
regarding specific potential strategies recommended for achieving
universal implementation of clinical information strategies, there was
remarkable consensus about several fundamental issues; namely:
1. The federal government has a crucial leadership role in
promoting a national health information infrastructure. However, to
achieve rapid adoption, compatible incentives, and consistent public
messages, it is essential that private organizations and government
entities collaborate and take reinforcing actions.
2. The highest priority should be given to adopting uniform
standards for message formats, nomenclature, data exchange, and other
aspects necessary for interoperability among systems. Without
underlying standards, healthcare IT investments will continue to be
risky, limited in function, unnecessarily costly, and potentially
rapidly obsolete. While the federal government can lead this effort
through its many regulatory and purchasing activities, private
healthcare entities must ``buy into'' the effort if they are to
purchase products using these standards.
3. Opportunities to provide financial support and incentives for
adopting and using healthcare IT abound. Although grants to support
connectivity and IT purchases are important, other incentives could
productively target health professional education, accreditation,
reimbursement, safety, and other objectives. Incentives also could be
targeted to particular clinical IT components, such as emergency public
health surveillance and computerized medication order entry systems.
The costs of investment can be shared by the various healthcare
stakeholders and across the public and private sectors.
The conclusions remain as relevant today as they were when the
Summit was held in March 2002.
Conclusion
The National Summit on Information Technology and Health Quality
reaffirmed the urgency of implementing a national health information
infrastructure. Although the participants realized the challenges in
reaching this objective, they all agreed on the importance of
standardizing the underlying components of healthcare information
technology and the necessity of both the public and private sectors
working together in this endeavor. There is a recognized need for
leadership--in all sectors of healthcare--to champion the
implementation of a NHII. Although there was some concern about the
Federal government imposing mandates, there was agreement that the
Federal government should exercise leadership and use the tools it has
available to move implementation forward. The existence of generally
agreed upon standards (e.g., HL7, ANSI-X12N and SNOMED), previous
recommendations (e.g., from the National Committee on Vital and Health
Statistics), and organizations such as the National Quality Forum,
which can be the vehicle for gaining broad national endorsement of IT-
related standards, provide the means to make immediate progress.
The National Quality Forum remains committed to making the goals
and action plans of the Summit a reality. We look forward to working
with the Committee and other healthcare, IT and community leaders to
achieve the vision of a ``connected'' healthcare system.
Thank you for holding this hearing to highlight this issue. The NQF
would be pleased to be of assistance to you in your efforts.
<F-dash>
Statement of Patient's Healthcare Card
The Patient's Healthcare Card recognized the need more than a
decade ago for implementation of information technology in health care
to control costs and improve quality of care. Patient's Healthcare Card
program is a patent-pending intellectual property with application to
the health care industry and is based on technology currently employed
by the financial services industry. Patient's Healthcare Card's initial
value proposition offers objective, equitable, and efficient management
of patient out-of-pocket--co-payments, deductibles, uninsured and
underinsured.
Current Medicaid regulations permit provider reimbursement even
though the patient may have the ability to pay some or all of his/her
obligation for health care products and services. Patient's Healthcare
Card program, as an independent third-party, eliminates conflicts of
interest to provide objective, accurate and timely information
concerning patients' eligibility for and the amount of public sector
benefits.
``For years, doctors and hospitals have lagged behind other
industries in joining the information-technology club-and it didn't
look like they'd ever sign up,'' according to Laura Landro in
``Healthcare Goes Digital,'' The Wall Street Journal, September 10,
2002. ``Because of the unusual payment structure of the health-care
industry, providers have never had many incentives to actually improve
the quality of their product or install clinical-information systems
that would let them manage patient care better.'' The primary reason is
when technology reduces operating costs, duplications, errors and
unnecessary care, the financial benefits don't go to the providers but
to insurers, third party payers, government, and patients.
Patient out-of-pocket is at the core of escalating costs in health
care and offers the greatest opportunity for technology to affect the
healthcare delivery system. Out-of-pocket represents 22%, projected to
increase to 25% by 2007, of provider revenue; however, providers
currently collect less than 20% of the potential revenue.
Implementation of existing, reliable, proven systems and methods from
the financial services industry adapted to the specific needs of health
care's patient out-of-pocket (consumer credit), offers a significant
opportunity for patients, government, providers and third-party payers.
The Patient's Healthcare Card program can be of service today, not in
ten years, with objective and equitable management, in real time, of a
patient's ability to pay health care obligations.
Credit experts (Experian, Equifax and TransUnion), based on income
of the unprotected, believe collection of patient out-of-pocket can be
increased to 50% or greater from the current 20%. Using today's
consumer credit technology and systems, an independent third party
administrator can objectively evaluate a patient's ``ability to pay''
(means testing), based on benchmarks established by public policy, and
manage that amount equitably at less operating expense. (Appendix 8,9)
U.S. Census Bureau, 2002, data demonstrates the financial capacity
of the unprotected to pay some or all of their out-of-pocket
responsibilities.
[GRAPHIC] [TIFF OMITTED] 99674A.006
Patient's Healthcare Card
<bullet> Providers have the same relationship with Patient's
Healthcare Card as participating banks have with the VISA program
<bullet> Patent-pending (intellectual property) system and methods
<bullet> Provider Account--Healthcare Card program creates a
discrete account for each provider
<bullet> Patient Account--providers create a singular discrete
account for each patient--universally accepted within healthcare
<bullet> Healthcare Card program maintains a registry (repository)
of each Patient Account for providers
<bullet> Secure infrastructure--accurate, complete, current
information
<bullet> Shared service model--providers share costs ratably
(proportionally)
<bullet> Patients benefit from single statement billing from all
providers--single payment
Federal and State FY 2007: Relief in Medicaid Payments:
(Assuming the same distribution of costs between the federal government
[CMS] and states)
In 2002, the Medicaid program cost $245 billion to provide medical
assistance (MAP) and $14 billion for administrative costs (ADM). MAP
average payments are currently divided with 57% CMS and 43% states. ADM
average payments are divided 55% CMS and 45% states.\1\ By 2007, MAP
and ADM costs are expected to increase by 5% or more annually, based on
prior experience.
---------------------------------------------------------------------------
\1\ ``The average enrollment for Medicaid was 39 million in FY
2002, about 13 percent of the U.S. population. Nearly 7 million people
are dually eligible, that is, covered by both Medicare and Medicaid.''
CMS Management's Discussion and Analysis FY 2002.
---------------------------------------------------------------------------
Substantial Reduction in Medicaid Payments with Implementation of
Patient's Healthcare Card
Federal (CMS) State Total
ADM $5.8 billion (55%) $4.7 billion (45%) $10.5 billion (reduction)
MAP The precise financial impact cannot be determined at this time due to the variables associated with
public policy, data, projections, assumptions, and the amount of long-term care expenses as a percentage of
total expense; however, the impact will be significant.
Reduced Administration Costs
Substantial Reduction in Administration Costs
Patient's Healthcare Card (PHC) offers a substantial reduction in
administrative costs; the amount can only be estimated. (Appendix 10,
11, 12, 13, 14) Based on private sector programs in operation for
years, the program, using a shared service model and secure internet
infrastructure, offers a projected 75% or greater reduction in
administrative costs as compared to current systems and methods.
Medicaid's current administrative expense is greater than $300.00
per beneficiary annually.
A typical ``quality service provider,'' such as American Express,
operates within parameters:
1. Cost to evaluate financial capacity and establish a new account
less than $3.00
2. Cost to maintain account annually $18.00
3. Cost per transaction in the account $.015
American Express' annual cost to establish and maintain an account
is less than $25 annually.
Increased Collection--Out-of-Pocket Charges
In a survey conducted of the nation's hospital CFOs, the
respondents indicated their own business office was performing below
their expectations. Healthcare providers lack the expertise and scale
necessary to effectively and efficiently manage patient out-of-pocket
(consumer credit). By utilizing proper management and structure,
experts (Experian, Equifax and TransUnion) believe out-of-pocket
collections can be improved from less than 20% currently to 50% or
greater.
Darren Lehrich, an analyst at SunTrust Robinson Humphrey, said in
2003: ``Of self-pay business, only 14 percent ends up being collectable
and last year it was in the 18 percent range'' for HCA Inc. (Appendix
5)
HCA Inc. reported ``in their first quarter (2004), the company's
provision for doubtful accounts--an indicator of unpaid bills--
increased to $694 million, or 11.7 percent of revenue, from $428
million, or 8.1 percent of revenue, a year ago.'' \2\
---------------------------------------------------------------------------
\2\ ``HCA Blames Uninsured for Income Drop,'' Reuters, New York:
April 22, 2004, Yahoo! News: May 11, 2004.
---------------------------------------------------------------------------
Increased Collection--Ability to pay
Illustration of potential financial impact:
Using ``ability to pay''--a patient is determined eligible for
public sector benefits.
Positive eligibility establishes MAP amount payment to provider--
$10,000.
Amount of patient's ``ability to pay''--$3,000.
Currently, the provider would receive the MAP amount funded
entirely by the public sector (taxpayers)--$10,000--with the patient
paying little or nothing.
Implementation of ``ability to pay'' in compliance with Medicaid
policy, permits a patient to have the same eligibility determination,
with the public sector (taxpayers) paying $7,000 and the patient paying
$3,000.
In the example, the provider will receive the $3,000 owed by the
patient at time of service in the form of a working capital loan, with
a cost of capital generally at commercial paper rates, from Alliance
National Healthcare Receivables Funding Corporation (ANHRFC). Servicing
of the provider's working capital loan is accomplished through the
patient's monthly payments; monthly payments are intuitive for patients
(car payments, house payments, etc.) Additionally, the provider
receives (earns) the interest income on outstanding patient balances.
In the example, the patient's positive eligibility determination
forces the provider to accept the associated payment code established
by Medicaid. The provider receives $10,000 under either payment scheme,
from government or government and patient. There is no financial
incentive for providers to increase patient out-of-pocket collection.
The public sector (taxpayers), as payer of the cost of Medicaid, would
be the beneficiary of any opportunity to redirect resources.
Patient's Healthcare Card was positively received in discussions
with the American Hospital Association, American Medical Association,
and many others. However, providers are concerned that government
(taxpayers), federal and state, would be the beneficiary of increased
collections. Providers feel they are entitled to some, if not all, of
the potential opportunity to redirect resources created from
implementation of the Patient's Healthcare Card.
The issue of provider participation in any opportunity to redirect
resources must be resolved. The incentive must be sufficient as to
promote provider participation and move the healthcare community beyond
its institutional ambivalence concerning information technology. An
objective of the initial demonstration project(s) will be to determine
the amount of incentive providers require to assure full participation
of the health care community.
Patient's Healthcare Card Creates An Objective, Equitable, Efficient
System
The U.S. Census Bureau, Statistical Analysis of the United States,
2002, Chart No. 112 projects a substantial increase in health care
spending to $2.174 trillion. (Appendix 6)
Based on benchmarks established by public policy, Patient's
Healthcare Card, as an independent third-party administrator, can
objectively evaluate a patient's ``ability to pay'' (means testing),
and service that amount equitably.
Patient's Healthcare Card program, using a shared service model,
internet-based application and infrastructure, will provide more
accurate and timely information concerning a patient's eligibility for
Medicaid benefits. Patients, providers and government benefit when
those using the health care system pay their share based on their
``ability to pay.'' Patient's Healthcare Card establishes an auditable
national standard for determining eligibility for benefits, eliminates
conflicts of interest and brings equity and integrity to the out-of-
pocket portion of health care.
With national implementation of Patient's Healthcare Card, CMS and
states will have the opportunity to redirect significant resources from
MAP and ADM by 2007. (Appendix 1)
Implementation of Patient's Healthcare Card program into the health
care delivery system is justified on its initial value proposition as
an opportunity for fiscal relief for patients, providers, government,
and other third party payers and as a network for claims processing and
payments.
Elimination and Streamlining of Operations
Patient's Healthcare Card's use of secure internet infrastructure
or approved gateway or EDI service that complies with Alliance National
Healthcare Network's (ANHN) reduced fee model moves the administration
of the Medicaid program from paper to the digital age at little or no
cost to government. The program's systems and methods eliminate or
streamline administrative activities within the program at both federal
and state levels. The following are some, but certainly not all,
activities that change.
Eligibility Validation
Patients will be issued a Healthcare Card with a discrete singular
account number. Providers, using a card swipe machine at the point of
sale, access the appropriate database via secure internet method or
ANHN approved, compliant gateway service to validate eligibility of the
patient (Blue Cross & Blue Shield, Charter, Medicare and Medicaid,
etc.) Once the card is swiped and the provider validates that the
patient who is covered is the individual presenting the Card,
eligibility is confirmed, electronically and in real time, to all
appropriate parties. Claims rejected due to eligibility can be
significantly reduced with real time validation of provider, payer and
patient. Additionally, the card swipe system and method are well
adapted to the dynamic nature of Medicaid beneficiaries.
Claims Process Flow
Using systems and methods refined in the financial services
industry (credit cards), providers file claims via secure internet
infrastructure. At time of eligibility validation, a discrete reference
number is created, which is applied to a web page to be used for filing
the claim. The discrete web page contains transaction data for
providers and payers, who can review and edit for any deficiencies,
make corrections or any other action required on their part to move any
pending claims onward through the adjudication process, without
requiring additional action by Medicaid servicing agents or incurring
further needless delays.
Claims Status Inquiry (CSI)
Just as a credit card holder is able to track and maintain his/her
credit card transactions via secure internet methods, providers can
access the discrete web page (reference number) in the same manner and
view the status of each discrete transaction (claim).
Claims Status Remittance Advice (ERA)
Pending ERAs for a patient/provider can be delivered to providers
as a component of a status inquiry. The notice will avoid/eliminate
providers needing to make additional ERA inquiries with the Medicaid
service center.
<F-dash>
Statement of Lawrence L. Weed, Burlington, Vermont
A deep, fundamental flaw in the infrastructure of the whole medical
enterprise is not only not being discussed and corrected; its existence
is not even being recognized.
The flaw: The diplomas from medical schools and the licenses to
practice from the states could not possibly mean what the public thinks
they mean.
The medical establishment and the public still believe that
graduate medical education and credentialing as now practiced are
adequate for controlling cognitive inputs. On this view, the minds of
licensed professionals are central to bringing knowledge from its
source in laboratories and libraries to the people who need the
application of that knowledge. We have lived with the belief that the
unaided minds of those professionals can solve two problems: first,
recall and process general knowledge relevant to unique individual
patients under time constraints no respectable scientist would ever
accept, and second, maintain awareness and control of all the patient-
specific data points that good problem solving requires.
The unaided minds of professionals cannot do these things. These
difficulties can only be overcome with external tools designed to
extend man's cognitive abilities. The tools are as necessary as
microscopes and X-rays are necessary to extend the unaided eye. As
Francis Bacon saw 400 years ago: ``The unassisted hand and the
understanding left to itself possess little power. Effects are produced
by means of instruments and helps, which the understanding requires no
less than the hand''.
The field of medicine is where astronomy was centuries ago when it
did not have the telescope. And the medical establishment and the
government are where the church was when it either refused to look
through the telescope or refused to accept what others saw when they
did look. New tools for controlling cognitive inputs in medicine have
been in existence for over 20 years but that existence has been either
ignored or denied.
A 9/11 commission is spending millions of dollars to investigate
3,000 deaths and the failed intelligence system that had not developed
the proper tools and infrastructure to ``connect the dots'' and prevent
what may happen again. And yet in medicine we have 90,000 deaths that
occur every year and no leaders of the medical establishment are being
publicly interrogated on why they persist in the use of such archaic
tools for moving knowledge from its source to those who need the proper
application of that knowledge. The transmission lines for knowledge are
so flawed and the voltage drops across them so great that it boggles
the mind that the government and the universities are not only blind to
the chaos but are actually providing the licensing laws and educational
systems that enable it.
This problem goes far beyond ``medical error'' as usually
conceived. The prevailing medical culture remains in denial about the
scope of the problem and the wrenching changes needed to solve it. The
consequence is that reliance on the physician's mind stifles use of a
superior alternative. For the want of that alternative, cognitive
inputs to medical decision making are uncontrolled. For want of
controlled inputs to medical decision making, the quality of care, the
cost of care, the education and credentialing of caregivers, and the
development of medical knowledge itself, are unmanageable.
The superior alternative is Knowledge Coupling tools. Knowledge
Coupling tools make possible a fundamental change in the way we move
knowledge from its source in laboratories and libraries to the people
who need the rigorous application of that knowledge. The physician's
mind is no longer required to be the vehicle for bringing medical
knowledge to the point of need in patient care. In turn, medical
education and credentialing of providers will have to change from a
knowledge-based to a skills-based approach. We must shed the illusions
instilled by graduate medical education. Physicians are ``educated'' to
believe that, in Herman Blumgart's words, ``The application of
knowledge at the bedside is largely the function of the sagacity
inherent in or personally developed by the individual physician.''
The way physicians are taught to function flies in the face of
decades of research in cognitive psychology, decades of research in
health care quality, decades of experience in other industries, and
common sense. Common sense tells us to rely on maps and a compass or
GPS device, not on our sense of direction, when navigating in
unfamiliar territory. An airline pilot uses radar; he does not claim to
be able to see through clouds. In other areas we have extended our
muscles with machines and our eyes with microscopes and telescopes.
Similarly, we should extend our cognitive capacities to recall and
process the many variables in solving clinical problems. Relying on
recall is unsafe, unreliable and unnecessary. We must use technology
and system organization to create a rational division of labor, where
people and machines are assigned functions to which they are suited.
The present infrastructure of the medical system with its flawed
beliefs, inadequate information tools, and poorly defined linkages
among its parts does not support such a rational division of labor.
Until a new infrastructure is put into place, acceptable quality and
productivity will remain out of reach.
How much longer can we get away with ignoring not only Francis
Bacon, but our own leading cognitive research scientists such has Robyn
Dawes who wrote:
States license psychologists, physicians, and psychiatrists to
make lucrative global judgments in the form of `It is my
opinion that . . .' People have a misplaced confidence in their
global judgments, a confidence that is strong enough to dismiss
an impressive body of research findings and to find its way
into the legal system. The greatest obstacles to using external
aids may be the difficulty of convincing ourselves that we
should take precautions against ourselves. The idea that self--
imposed, external constraints on action can actually enhance
our freedom by releasing us from predictable and undesirable
internal constraints is not a popular one
New premises and new tools have implications for cost and quality
of medical care, and in particular for coordination among patients and
providers. A few of the many implications are:
1. The gap between the fixed cognitive capacities of physicians
and the ever-increasing volume of medical knowledge and technique leads
physicians to specialize by body system (musculoskeletal,
cardiovascular etc) and by procedure (cardiac catheterization, hip
replacement etc). That specialization, however, can at times be a major
cause of failures of quality and economy, because the patient's
problems and total situation cross specialty boundaries. The cardiac
catheterization was done perfectly but the original patient problem of
chest pain had its origin in the thoracic spine or the esophagus. The
hip replacement may have been done perfectly but the patient died in
heart failure. Tolstoi understood this problem when he wrote about
Natasha's illness in ``War and Peace'', ``The simple fact never
occurred to any of them (the doctors) that they could not know the
disease that Natasha was suffering from, as no disease suffered by a
live man can be known, for every living person has his own peculiar,
personal, novel, complicated disease unknown to medicine--not a disease
of the lungs, liver, skin, heart, nerves and so on, mentioned in
medical books, but a disease consisting of one of the innumerable
combinations of the maladies of those organs''. (12) And Francis Bacon
understood this when he wrote 400 years ago ``And generally let this be
a rule, that all partitions of knowledge be accepted for lines and
veins rather than for sections and separations; and that continuance
and entireness of knowledge be preserved. For the contrary hereof hath
made particular sciences to become barren, shallow and erroneous, while
they have not been nourished and maintained from the common fountain.''
(13) In the field of medicine a patient needs a system that defines the
role of each provider and the connections among them, using tools to
access the current necessary, up-to-date knowledge. Many a patient has
suffered because no one ever ``connected all the dots''--a process that
only a system, not the unaided mind of the licensed physician, can ever
achieve. And that system must be based on: (1) a coherent philosophy of
total care over time, (2) powerful tools to extend the hand, the
senses, and the mind, (3) disciplined users of the tools, and (4)
strong leadership.
2. Rather than helping users cope with information overload in
medicine, some electronic information tools exacerbate the problem.
Tools that accelerate retrieval of general knowledge without
determining its relevance to the unique problem situation at hand
overwhelm the mind. The result is to worsen the disorder that results
from the failed functioning of the unaided mind when faced with large
volumes of information.
3. The only escape from disorder in medicine is the simultaneous
routine use by patients and providers of two types of information tool:
(1) a front-end tool for applying general knowledge to patient
problems, so that the right data can be selected and comprehended
efficiently, and (2) problem-oriented medical records, so that all
caregivers and the patient are constantly confronted with a complete,
organized picture of the whole patient's known medical needs.
4. With the right information tools, it becomes possible for
medical education and credentialing to become skills-based rather than
knowledge-based. Skills-based credentialing can foster a free market in
health professional services in three ways: (1) reducing educational
and financial barriers to entry in the health professions, (2)
equipping less expensive, non-physician skilled caregivers with
knowledge tools that will define when, and only when, it is appropriate
for them to exercise their particular skill on a given unique patient,
and (3) assuring skillful performance, so that patients and other
purchasers can safely choose among competing providers based on non-
medical factors (price, location, interpersonal skills) for which no
expert advice is necessary.
5. When patients and purchasers access the same information tools
on which their caregivers rely, they create an informational
environment of transparency and accountability. In that environment,
patients become autonomous decision makers and are aware of the degree
to which their individual constellation of findings fits the diagnostic
and management options that are in the textbooks and journals. At times
the match to a classical picture will be very good, whereas at other
times it will be poor and there will be much ambiguity. They will learn
to tolerate that ambiguity and not be victims of diagnostic notions and
unfounded therapeutic schemes. Credentialed caregivers will have little
opportunity to generate artificial demand for their own skills. And
third party purchasers will have little opportunity to disguise
economic decisions as medical ones.
6. The right information tools expose large gaps between the
generalizations of ``evidence-based'' medicine and the realities of
unique individual patients. Routine patient care thus becomes a vehicle
for refining medical knowledge in ways that expensive, limited
population studies and some clinical trials cannot achieve. Patients
should no longer hear or read statistical results of the mortality of a
given procedure or the effectiveness of a given therapy on large number
of patients. They should hear about how closely they match in great
detail those patients in whom a given drug or procedure succeeded and
how well they match those in whom the drug or procedure failed.
Tailoring medical action of this sort to individual patients cannot be
achieved without the routine use of new tools. Or put another way, an
astronomer without a telescope is a very limited astronomer indeed.
7. The common element of knowledge coupling software, the Problem-
Oriented Medical Record (POMR), and skills-based credentialing, is that
they permit tight control over provider inputs. Control over inputs is
a fundamentally different approach to quality improvement than the
prevailing approach of outcome-based comparisons. Outcomes cannot be
evaluated meaningfully without controlled inputs, and without reliable
outcome studies the development of the science of medicine as well as
the science of medical practice are compromised.
8. The POMR and the combinatorial standards of care, and skills-
based credentialing, are intended to satisfy the medical needs of
patients, not the expectations of physicians. Analogizing these
concepts to financial accounting standards in business, medicine lags
far behind the business world in developing standards for transparency,
accountability and control.
9. The POMR standard was once taught in most medical schools, but
is applied now only in fragmentary and diluted form, if at all. PKC's
knowledge coupling software is resisted because the combinatorial
standard it imposes is alien to the way physicians are trained to
function. Skills-based credentialing combined with a system that
clearly defines when these skills should be applied, is another
alternative to the current training. This, too, may be resisted because
it would subject physicians to competition by less expensive
caregivers.
10. Giving patients access to the necessary information tools, and
demonstrating to them the higher standards of care made possible by
those tools, is essential to overcoming the status quo. The difficulty,
however, is that the prevailing medical culture blocks awareness and
resists disruptive innovations. The outcome is that marketplace demands
are diverted to marginal improvements.
11. Change of the necessary magnitude requires four elements coming
together: philosophy, tools, committed users, and leadership. The next
step is for a few institutions and communities to become models of what
patients and skilled caregivers can achieve when equipped with the
necessary tools and informed with a clear vision.
<F-dash>
Statement of the Honorable David Wu, a Representative in Congress from
the State of Oregon
Chairwoman Johnson, thank you for giving me the opportunity to
testify this afternoon about an important topic for Oregonians and all
Americans--health care information technology.
We live in a time of vast technological advancements--today, our
cars have more computing power than the Apollo spacecraft. Yet our
doctors have not been able to take advantage of these advancements.
It is not for a complete lack of technology. Clinical decision
tools exist today that would allow doctors to pull up the latest
research information immediately. But currently, we do not have the
systems in place to ensure this technology gets used by our health care
professionals.
I am proud that one of the innovative companies in health care
information technology is located in the heart of my congressional
district. Formed in 2001, Kryptiq aids communication within the medical
industry through a Windows-based software system that utilizes secure
e-mail. Kryptiq's system adds a layer onto standard email that gives
medical professionals the ability to connect workflow, such as
patients' medical records, while maintaining privacy.
This is technology that we need to better serve patients and extend
health care information to rural areas. But we must ensure that we
restructure our health care system to ensure that that this type of
technology is not only expanded but that it is accessible to all
physicians and health care professionals.
That is why this hearing is so important, and I thank you for
holding it. I believe that information is the answer to improving
health care. If we use the technology that we have today, we can
drastically improve the quality of care we all receive in this country.
I look forward to working with Chairwoman Johnson and the Committee
to increase the amount of information generated in and about our health
care system, to improve the dissemination of that information to
everyone who needs it, and help to build the IT infrastructure that
will make that possible.
<all>