JUNE 17, 2004

SERIAL 108-55

Printed for the use of the Committee on Ways and Means






BILL THOMAS, California, Chairman

E. CLAY SHAW, JR., Florida
NANCY L. JOHNSON, Connecticut
WALLY HERGER, California
JIM MCCRERY, Louisiana
DAVE CAMP, Michigan
JIM RAMSTAD, Minnesota
PHIL ENGLISH, Pennsylvania
J.D. HAYWORTH, Arizona
RON LEWIS, Kentucky
PAUL RYAN, Wisconsin
ROBERT T. MATSUI, California
RICHARD E. NEAL, Massachusetts
JOHN S. TANNER, Tennessee
EARL POMEROY, North Dakota

Allison H. Giles, Chief of Staff
Janice Mays, Minority Chief Counsel

NANCY L. JOHNSON, Connecticut, Chairman

JIM MCCRERY, Louisiana
DAVE CAMP, Michigan
JIM RAMSTAD, Minnesota
PHIL ENGLISH, Pennsylvania

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.



Advisory of June 10, 2004, announcing the hearing


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

U.S. Department of Veterans Affairs, Veterans Health Administration, Dr. Robert M. Kolodner, M.D., Acting Chief Information Officer

American Medical Informatics Association, Charles Safran

eHealth Initiative, Janet Marchibroda

Indiana University School of Medicine, Regenstreif Institute, J. Marc Overhage

Permanente Federation, Andrew M. Wiesenthal


American Academy of Family Physicians, statement

American Clinical Laboratory Association, statement

American College of Physicians, statement

American Health Quality Association, David G. Schulke, statement

Broadlane, Inc., San Francisco, CA, F. Lee Marston, statement

Guidant Corporation, statement

Healthcare Information and Management Systems Society Advocacy and Public Policy Steering Committee, Chicago, IL, Mary Griskewicz, statement

Kryptiq Corporation, Beaverton, OR, Luis Machuca, letter and attachment

Kun, Luis G., Washington, DC, statement and attachment

MediStore, Houston, TX, Glenn R. Breed, letter

MedMined, Burlington, AL, statement

National Association of Chain Drug Stores, Alexandria, VA, statement

National Electronic Attachment, Inc., Atlanta, GA, Thomas W. Hughes, statement

National Initiative for Children's Healthcare Quality, Boston, MA, Charles Homer, statement

National Quality Forum, Kenneth W. Kizer, statement

Patient's Healthcare Card, statement

Weed, Lawrence L., Burlington, VT, statement

Wu, Hon. David, a Representative in Congress from the State of Oregon, statement


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:]

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.


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:]

Chairman JOHNSON.  Thank you very much, Dr. Brailer.  Dr. Kolodner.


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-1990s. 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:]

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. 


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, start-up 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 time frame 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.


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. 

Lastly, we should turn our focus from the hospital and the physicians office towards 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 towards 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:]

Chairman JOHNSON.  Thank you very much.  Ms. Marchibroda. 


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 decision making 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 build upon 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. 

Secondly, 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 towards 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:]

Chairman JOHNSON.  Thank you very much. Dr. Overhage.


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 of 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:]

Chairman JOHNSON.  Thank you very much, Dr. Overhage.  Dr. Wiesenthal.


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 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 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, et cetera, 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 caregiver.  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:]

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:]

American Academy of Family Physicians, statement

American Clinical Laboratory Association, statement

American College of Physicians, statement

American Health Quality Association, David G. Schulke, statement

Broadlane, Inc., San Francisco, CA, F. Lee Marston, statement

Guidant Corporation, statement

Healthcare Information and Management Systems Society Advocacy and Public Policy Steering Committee, Chicago, IL, Mary Griskewicz, statement

Kryptiq Corporation, Beaverton, OR, Luis Machuca, letter and attachment

Kun, Luis G., Washington, DC, statement

MediStore, Houston, TX, Glenn R. Breed, letter

MedMined, Burlington, AL, statement

National Association of Chain Drug Stores, Alexandria, VA, statement

National Electronic Attachment, Inc., Atlanta, GA, Thomas W. Hughes, statement

National Initiative for Children's Healthcare Quality, Boston, MA, Charles Homer, statement

National Quality Forum, Kenneth W. Kizer, statement

Patient's Healthcare Card, statement

Weed, Lawrence L., Burlington, VT, statement

Wu, Hon. David, a Representative in Congress from the State of Oregon, statement