[Senate Hearing 111-157]
[From the U.S. Government Publishing Office]
S. Hrg. 111-157
INVESTING IN HEALTH IT: A STIMULUS FOR A HEALTHIER AMERICA
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HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
ON
EXAMINING THE INVESTING IN HEALTH INFORMATION TECHNOLOGY (IT), FOCUSING
ON STIMULUS FOR A HEALTHIER AMERICA
__________
JANUARY 15, 2009
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
senate
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46-710 PDF WASHINGTON : 2009
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut MICHAEL B. ENZI, Wyoming
TOM HARKIN, Iowa JUDD GREGG, New Hampshire
BARBARA A. MIKULSKI, Maryland LAMAR ALEXANDER, Tennessee
JEFF BINGAMAN, New Mexico RICHARD BURR, North Carolina
PATTY MURRAY, Washington JOHNNY ISAKSON, Georgia
JACK REED, Rhode Island JOHN McCAIN, Arizona
BERNARD SANDERS (I), Vermont ORRIN G. HATCH, Utah
SHERROD BROWN, Ohio LISA MURKOWSKI, Alaska
ROBERT P. CASEY, JR., Pennsylvania TOM COBURN, M.D., Oklahoma
KAY R. HAGAN, North Carolina PAT ROBERTS, Kansas
JEFF MERKLEY, Oregon
J. Michael Myers, Staff Director and Chief Counsel
Frank Macchiarola, Republican Staff Director and Chief Counsel
(ii)
C O N T E N T S
__________
STATEMENTS
THURSDAY, JANUARY 15, 2009
Page
Mikulski, Hon. Barbara A., a U.S. Senator from the State of
Maryland, opening statement.................................... 1
Cochran, Jack, M.D., FACS, Executive Director, The Permanente
Federation, Oakland, CA........................................ 4
Prepared statement........................................... 6
Corrigan, Janet, Ph.D., President, The National Quality Forum,
Washington, DC................................................. 11
Prepared statement........................................... 13
Neupert, Peter, Vice President, Microsoft Health Solutions,
Redmond, WA.................................................... 17
Prepared statement........................................... 18
Grealy, Mary, President, Healthcare Leadership Council,
Washington, DC................................................. 24
Prepared statement........................................... 25
Melvin, Valerie, Director, Information Technology, The Government
Accountability Office (GAO), Washington, DC.................... 33
Prepared statement........................................... 34
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
Kennedy, Hon. Edward M., a U.S. Senator from the State of
Massachusetts.............................................. 54
Enzi, Hon. Michael B., a U.S. Senator from the State of
Wyoming.................................................... 55
Murray, Hon. Patty, a U.S. Senator from the State of
Washington................................................. 55
Article--Reinventing Healthcare Through Health Information
Technology................................................. 23
(iii)
INVESTING IN HEALTH IT: A STIMULUS FOR A HEALTHIER AMERICA
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THURSDAY, JANUARY 15, 2009
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The committee met, pursuant to notice, at 10:00 a.m. in
Room SD-430, Dirksen Senate Office Building, Hon. Barbara A.
Mikulski, presiding.
Present: Senators Mikulski and Merkley.
Opening Statement of Senator Mikulski
Senator Mikulski. Good morning, everybody. The Working
Group on Quality Healthcare will come to order. This is the
very first hearing that this working group is going to have. We
are going to begin quite promptly.
We want to acknowledge that Senator Enzi cannot be here
because of scheduling conflicts, and also Senator Alexander.
But today is a wonderful and exciting day in the Senate. We
will be welcoming a new Senator from Illinois, and we are going
to be saying good-bye to two very special Senators, Biden and
Clinton, and they will be getting their farewell speeches.
So we would like to move expeditiously, but robustly in
this hearing so that we can, more of us, be done by 11:00 a.m.
so that we could at least be there for part of the farewells.
So I am going to move this along, but I think we need to
move healthcare along. So this is the spirit of the committee.
First of all, this is a working group established by
Senator Kennedy on quality. The theme of this working group
will be called ``Quality Healthcare: The Means for Saving Lives
and Saving Money.''
Health reform is absolutely on the national agenda. The
content will be extremely difficult, but the process is
something that we can do.
In the spirit of both our President-elect, Mr. Obama, and
also the Democratic Party, we want to reach out to our
Republican colleagues to assure them that the working groups on
this committee will continue the spirit of bipartisanship that
has been established by both Senator Kennedy and Senator Enzi.
They have set the tone. They have set the process, and they
have actually set the methodology. And we intend to do that.
It is not the Democratic intent to have a healthcare reform
bill that will squeak by by a vote or two. We want it to pass,
if not unanimously, to pass in a robust way. And we think the
way you do good legislation is to have good manners, and good
manners starts with a good process.
We had an excellent model here in the way we worked on
higher education and some of the others in the last committee.
Senator Enzi said it well yesterday when he said because of the
way they worked together, the once most cantankerous committee
in the Senate is now one of the most productive. That is the
way we are going to be here.
Senator Kennedy has established three working groups--one
on coverage that Senator Bingaman chairs, one on prevention
that Senator Harkin chairs, and the one on quality that I
chair. So today is my kickoff in a series of hearings on
quality. And to use a well-known phrase, ``I am fired up and
ready to go.''
When it comes to healthcare, we want to also, in that
spirit of bipartisanship, let others know that we have reached
out by making sure we had bipartisan witnesses. We invited
really the experience and insights of former House Speaker Mr.
Gingrich and our very beloved colleague Dr. Bill Frist and also
Senator Snowe because of her quite broad experience in dealing
with particularly the health IT and the Finance Committee. They
couldn't come, but we welcome their ongoing advice and input on
this.
Our witnesses today, I think, represent a great deal of
experience and knowledge, and, wow, do we need you. And at the
same time, we think it represents broad views--Jack Cochran
from Permanente Federation; Peter Neupert from Microsoft; Janet
Corrigan from the National Quality Reform; Val Melvin, a sister
University of Maryland graduate, from GAO; and Mary Grealy of
the Healthcare Leadership Council.
The purpose today is to talk about health IT, and everybody
sees it as a silver bullet. Well, we believe it is one of the
major tools and that we cannot do healthcare reform without it.
It is also being discussed in the stimulus. So we want to get
the best views and the best thinking.
We know that under the Wired Act of the previous Congress,
a lot of thinking is already going on, and we are going to add
to that. What we want is, No. 1, health information technology
to be patient centered and patient secure. We want it to be
interoperable. Because if it is not interoperable, it is not
going to function.
We don't want another techno boondoggle. As someone who
appropriates for the Commerce, Justice, and Science Committee,
I am really familiar with a lot of things that we did on
interoperability. The CJS bill had the terrible problem with
the FBI when we wanted interoperable case files and field
offices, and we ended up spending over $1 billion, and it
wasn't worth a warm spit.
Well, you get where I am heading here. So we don't want
techno boondoggles. We want techno opportunity. And most of
all, it has got to be user-friendly so that it will be adopted
particularly in clinical practice, where there is wonderful
onesie, twosie doctors out there, particularly often in our
rural communities. So we have got a lot to listen to.
Over the years, every major group from IOM to others have
talked about why we need health IT. Every industrial Nation has
it. Germany, UK, Australia lead the way. Our survey showed that
only 4 percent of physicians have electronic health records.
Very few have access to it, and what we do have is certainly
not even beginning interoperable.
And it might very well be that even within an acute care
facility, surgery might have one, but maybe that is orthopedic
surgery. But they are not linked to cardiology or with the
diabetes. And for many of our patients, they come in with more
than one thing going on in their lives.
So we have got a lot to listen to. We think there is
tremendous potential in this--quality improvements,
efficiencies in medical utilization, economic savings. Just
think of the idea of preventing costly medical errors by 50 to
90 percent and also particularly avoidable medication errors.
Helping doctors with clinical decision support systems,
reminding them when they are going to schedule a test, and
hoping to see if there is patient compliance in following up.
To that diabetic, gosh, let us make sure and ask did they
really go to the ophthalmologist? Gee whiz, the record shows
you didn't, and we talked about it 3 months ago.
Efficiencies could mean cutting the cost of delivering
care, duplicated or inappropriate diagnostic tests, reducing
paperwork, promoting the appropriate use of prescription drugs,
actually even being able to read prescriptions. Wow.
However, the potential of health information technology is
easier predicted than achieved. Our challenge is to develop it,
fund it, and promote its use and always keep it fresh and
contemporary.
We have got a lot to talk about today. So instead of
listening to myself talk, I want to listen to you. So I am
going to just bring to the committee's attention this
outstanding panel, and I really want to welcome you with
enthusiasm for being here.
I am going to do all of the introductions now. And then we
are just going to start with Mr. Cochran and go all the way
down, and Ms. Grealy, you are going to be the wrap-up hitter,
OK?
We are going to welcome Dr. Jack Cochran, who is the
executive director of Permanente Federation. I have been
reading your ads, and I have been reading about you. We really
understand that you have extensive experience in health IT, and
your executive experience and actually this hands-on practical,
how does it go in clinical practices. All of the pluses, and we
want to hear the minuses.
Janet Corrigan, you are the CEO of the National Quality
Forum and a board member of IOM. We know that you have written
a number of IOM reports, and you have shaped the thinking of
Congress to improve healthcare quality. We want to know how we
can use this to improve the delivery of healthcare. And really,
you have seen a lot of it now.
Mr. Neupert, you bring the private sector experience from
Microsoft. We know that we can't develop this system in-house.
This is not a system that is going to be developed inside of
HHS. We know that inside HHS and working with other appropriate
Government agencies like NIST, we are going to establish the
national standards.
But we are going to count on the private sector to help us
achieve this. So we need to hear your ideas on not only the
technology, but how the technology can continue to be
modernized as we go along.
This isn't like building an airfield, where much is made
about the super information highway. You know, when you build
I-95, you don't have to build a new I-95 every 6 weeks or every
6 months or every 6 years. We have got to do potholes and speed
bumps. But one of our questions is after they build it and we
have got them to come, how do we keep them coming and make it
worthwhile? And who is going to pay for it?
Ms. Grealy, you come from the Health Leadership Council,
which represents a wide range of business healthcare interests.
We want you at the table. We know that you have tremendous
insight in what needs to be developed, but I think you bring
both the concept of operationality, functionality, but also
cost, cost, cost.
Not only who is going to pay for it, but who is going to
keep on paying for it? Because sustainability and continuing to
modernize is going to be one of the issues.
Then, of course, we are going to turn to Valerie Melvin,
the director of IT at GAO, a graduate, as I said, of the
University of Maryland. She has received many awards and has
looked extensively at the standard-setting process, and this
gives me heartburn.
You don't give me heartburn, but--
[Laughter.]
Senator Mikulski [continuing]. But really, we know the VA
development. I am really proud of the VA facility in Maryland
that pioneered this. But you have seen a lot, and we really
need to discuss the standards.
Having said that, we are just going to get right to the
testimony. Actually, you know, Ms. Melvin, I think I am going
to wind up with you because you are the standards lady, and I
think it will be very useful after we listen to this content-
rich discussion that we wrap up with you with really--well, you
know, a lot was said about Joe the plumber, but we are going to
talk about Ms. Melvin, the interoperable lady here.
You are going to help us with, really, setting the
standards and so on. So I will stop.
Mr. Cochran, let us start with really something working in
the real world and what we need to know about your extensive
experience at Kaiser, one of the true flagships in the
delivering of healthcare.
STATEMENT OF JACK COCHRAN, M.D., FACS, EXECUTIVE DIRECTOR, THE
PERMANENTE FEDERATION, OAKLAND, CA
Dr. Cochran. How am I doing?
Senator Mikulski. You are doing great.
Dr. Cochran. I get 6 seconds back. I am Dr. Jack Cochran,
the executive director of the Permanente Federation, which is
the national umbrella organization for the eight regional
Permanente medical groups, which employ more than 14,000
physicians who care for 8.7 million members of Kaiser
Permanente. I appear today on behalf of the National Kaiser
Permanente Medical Care Program, the Nation's largest
integrated delivery system.
As Congress considers ways to stimulate the economy, it
should explore investing in the Nation's healthcare delivery
system. I am delighted to be here to discuss how promoting the
effective use of information technologies can improve
healthcare quality and efficiency and literally save lives.
In 2003, Kaiser Permanente began the KP HealthConnect
Project. KP HealthConnect is a comprehensive health information
system that includes one of the most advanced electronic health
records available.
Today, KP HealthConnect securely connects 8.7 million
people to their physicians, their healthcare teams, their
personal health information, and the latest medical knowledge.
With the support of a shared clinical record, we have
experienced tremendous breakthroughs in coordination of care,
patient safety, and clinical quality.
Some key lessons we have learned about implementing and
gaining value from an HIT system are, No. 1, implementing
health information technology in a clinical setting is
disruptive. You should expect a reduction in productivity for
the first few months and should not expect immediate cost
savings.
You have to go slow to go fast in many ways because the
initial stages of implementation must be well thought out.
Patience and persistence is key, and physician leadership is
critical.
No. 2, implementing the technology is a first step. A much
more crucial evidence is figuring out how to translate the data
collected in the system into useful information and delivering
value. It is not just about digitizing the visit. It is about
using the data from that visit and other sources to inform and,
ultimately, transform care delivery. And once again, physician
leadership is essential.
Physician input can lead to the creation of tools that
organize the data into clinical decision support tools, disease
registries, and other applications that help caregivers more
effectively care for their patients. HIT can help facilitate
processes like medication reconciliation at critical
transitions of care, such as from the hospital to the home.
And one of the greatest lessons, No. 3, that we have
learned is how much patients value using online tools to
interact with us and manage their health. Our personal health
record, My Health Manager, has more than 2 million active users
who are taking advantage of such robust features as securely e-
mailing their doctors, accessing lab tests, scheduling
appointments, refilling prescriptions.
Having patients involved in their care in this way results
in more engaged patients, ultimately better care, especially
for those with chronic conditions.
So, as you consider the economic stimulus package, Congress
should be clear about what returns it wants on its investment.
Rather than rewarding providers for simply purchase or
implementation of IT, dollars should be tied to actual usage
and the value derived in terms of process improvements and
health outcomes.
Incentives must be focused not simply on ensuring that a
physician office has implemented an EHR, but incorporating a
requirement that these systems are interoperable using
federally sanctioned standards. And while not perfect, our
experience has been that these standards are available now.
Finally, done well, we believe an electronic care support
system can help to restore and enhance the physician's healing
mission. Maximizing access to information for the clinician
means optimizing care for the patient.
The right systems provide more time with patients, better
information about care, and less time with traditional
paperwork. The right system also needs to be focused on the
patient's needs for affordable, well-informed, customized, and
compassionate care, and we believe that health IT is needed to
support our Nation's healthcare reform agenda and help our
Nation fulfill its ethical responsibility to improve healthcare
access, reduce costs, and ensure quality of care for all.
Thank you.
[The prepared statement of Dr. Cochran follows:]
Prepared Statement of John H. Cochran, M.D., FACS
Senator Mikulski and Senator Enzi and other distinguished members
of the committee, thank you for the invitation to be here today. I am
Dr. Jack Cochran, the Executive Director of The Permanente Federation,
the national umbrella organization for the regional Permanente Medical
Groups. The Permanente Medical Groups employ more than 14,000
physicians, who care for approximately 8.7 million Kaiser Permanente
members. I appear today on behalf of the national Kaiser Permanente
Medical Care Program, the Nation's largest integrated health care
delivery system.
the promise of health information technology
As Congress considers ways to stimulate the economy, it should
explore investing in the Nation's health care delivery system. I am
delighted to be here to discuss how promoting the effective use of
health information technologies can improve health care quality,
efficiency, and literally save lives.
Medicine is far behind other industries in adopting and leveraging
information technologies. While other industries have been quick to
automate, the health care industry has often been slow to adopt.
Individual medical records, medication lists, along with the latest
medical research and up-to-date information on applicable clinical
trials must be available for clinicians and patients at the click of a
mouse. Under appropriate patient confidentiality safeguards, secure
electronic health records (EHRs) should allow various health care
providers across vast geographic spans to collaborate and coordinate
care for their patients based on current, comprehensive clinical
information. The economic stimulus package should promote the
development of effective, interoperable clinical information systems
and the skills to use them.
But it is important to link these improvements in processes with
systemic changes in financial incentives to continually advance the
effectiveness and reliability of health care delivery. As you know, our
Nation's health care delivery system is fragmented, disorganized, and
hampered by ineffective and perverse incentives for quality and
efficiency. Health information technology (HIT) is one critical tool
that can help move our system toward a highly functioning, organized,
patient-centered one. However, it is important that these investments
be strategic and worthwhile. As one wise policymaker quipped, ``making
the wrong investments in HIT could simply result in doing the wrong
things faster.''
kaiser permanente
When she invited me to speak today, Senator Mikulski asked me to
share some of the lessons we've learned in developing what we believe
is the world's largest civilian deployment of an EHR. As Senator
Mikulski knows, we are proud to serve members in the State of Maryland.
We also provide health care to nearly nine million individuals in eight
other States including California, Oregon, Colorado, Georgia, Hawaii,
Ohio, Virginia, Washington, and the District of Columbia.
At Kaiser Permanente, we have found strength and opportunity
through the fundamental and often unique partnerships within our
organization: the physician and patient relationship; the collaboration
between labor and management; the linkage of clinical research to
improved care delivery; our investments and involvement in the
communities we serve; and the shared coordination of care across
inpatient, outpatient, ancillary services, and all the settings of care
delivery.
In 2003, Kaiser Permanente began the KP HealthConnectTM project. KP
HealthConnect is a comprehensive health information system that
includes one of the most advanced electronic health records available.
Our success with this endeavor is the result of decades of work
developing health records and training physicians and staff to use
them. This experience spanned most of our operating regions. For
example, the Colorado region, where I practiced, had a complete
electronic health record beginning in 1997.
Today, KP HealthConnect securely connects 8.7 million people to
their physicians, their health care teams, their personal health
information, and the latest medical knowledge, leveraging the
integrated approaches to health care available at Kaiser Permanente.
Kaiser Permanente has made a huge investment in HIT, both
financially and philosophically. We believe it has the power to
transform the way we deliver health care and improve patient health.
physician adoption and acceptance of hit
In April 2008, we completed implementation of KP HealthConnect in
every one of our 421 medical office buildings, ensuring that our 14,000
physicians and all other ambulatory caregivers have appropriate
electronic access to their patient's clinical information. In addition,
we have completed the deployment of inpatient billing; admission,
discharge, and transfer; and scheduling and pharmacy applications in
each of our 32 hospitals. Now, we are in the midst of an aggressive
installation schedule for bedside documentation and computerized
physician order entry (CPOE). As of the end of 2008, we had 25 of our
32 hospitals fully deployed. (An interesting anecdote: the new
hospitals we are building in California as a response to the seismic
upgrade requirements are being built without medical record rooms.)
Now, you may ask, did this all happen easily? Did our physicians
and nursing staff immediately embrace our EHR? The simple answer is,
no. Any major transition like this requires fundamental change in
workflows. We had to build in time for testing, training, and some
belly aching too. But if we tried to take KP HealthConnect away from
any of our doctors and nurses now, a riot would ensue.
Implementing HIT in a clinical setting is tremendously disruptive.
You have to expect about a 20 percent reduction in productivity in the
first 3 to 6 months, and you should not expect immediate cost savings.
You have to go slow to go fast. Initial stages of implementation must
be well planned and tested. Patience is key, and physician leadership
is critical.
Change can cause apprehension and concern. If not handled properly,
it can also interfere with the quality of care that is delivered. In an
outpatient setting, you can build in time for training by scheduling
patients differently or making sure you do not implement a new IT
system during flu season, for example. In an inpatient setting, you
simply do not have the same flexibility, so the challenges are
different.
At first, Permanente physicians were reluctant to complete after-
visit summaries as a written acknowledgement of everything that was
discussed during the visit. These after-visit summaries are stored in
each patient's EHR. Because patients can access them later, the
summaries can help remind them about what they and their doctors
discussed regarding medications, follow-up treatment, etc. Primary care
providers who give their patients an after-visit summary typically
score an average of 14 points higher on satisfaction surveys.
Since the deployment of our integrated medical record, we have
begun to see major advances in using health information systems as a
diagnostic tool (for identifying and understanding patients with
certain risk factors) as well as for appropriate therapeutic
intervention (for encouraging adherence and for intensification or
moderation of therapy when needed).
The EHR has allowed our physicians to be more efficient by giving
them better practice management and communication tools that help them
reduce unnecessary visits and phone calls. Today, our doctors don't
ask, ``How many patients can I see? '' but rather, ``How many problems
can I solve? '' Data gathered in three of our regions (Colorado,
Hawaii, and the Northwest) demonstrate how implementing an EHR lowers
both primary and specialty care office visit rates by enabling the
clinician to resolve certain issues for patients with fewer face-to-
face contacts. For example, a simple response to an e-mail may be all
that a patient needs from his or her doctor. Because our system allows
our physicians to view appropriate medical information online, patients
and physicians can interact with each other when it's most convenient
for both of them.
patient acceptance and adoption of hit
One of our greatest lessons has been how much KP members value the
ability to use online tools to manage their health. Launched in 2005,
our personal health record, My Health Manager, now has more than 2
million active users. This represents the largest user base of online
personal health records (PHRs) in the United States. Using direct links
to actual clinical and operational systems, we are able to provide our
members with access to robust features, including access to lab test
results, appointment scheduling, prescription refills, and even the
ability to securely e-mail their doctors. To date, our members have
viewed over 56 million lab test results online, sent over 5 million
secure e-mail messages, made over 2 million online visits to book and
review future appointments, and logged over 1 million online visits to
view past office visit information.
With secure e-mail messaging, patients can communicate with their
doctors at any time, from anywhere. Demonstrating the growing consumer
interest in e-visits, our patients send more than 300,000 secure e-mail
messages each month to their doctors and care teams. The average
doctor's visit takes 3 hours out of an individual's day, so members
value the ability to use My Health Manager on kp.org to handle routine
health care needs, including refilling their prescriptions, which can
be delivered directly to their home or a pharmacy. Results from a study
published in the American Journal of Managed Care showed an 8 percent
reduction in office visits and a 14 percent reduction in phone calls
among My Health Manager users.\1\ The study also confirmed that secure
messaging is used primarily for non-urgent issues; nearly two-thirds
were coded as ``brief '' or lower.
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\1\ Zhou YY, Garrido T, Chin H, Wiesenthal A, Liang L, ``Patient
Access to an Electronic Health Record with Secure Messaging: Impact on
Primary Care Utilization,'' American Journal of Managed Care. July
2007; 13: 418-424.
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transforming health care delivery
While we have documented some specific dollar savings, our greatest
benefits are improvements in clinical and service quality. With 24/7
access to comprehensive health information, our care teams are able to
coordinate care at every point of service--physician's office,
laboratory, pharmacy, hospital, on the phone, and even online. Unlike
the paper chart locked in a physician's office, an EHR can be shared
among all physicians caring for a patient. For example, when a patient
comes into the Emergency Department at 2 am: (1) there will be no
duplication of effort to collect data that already exists; (2) the
insights of one physician are more easily available to others; and (3)
care can be better coordinated. Our early results demonstrate what
Crossing the Quality Chasm predicted: HIT helps to make care safer,
more effective, patient-centered, timely, efficient, and equitable.
Through our experience with KP HealthConnect, we have found that
implementing the technology was just the first step. A far more crucial
endeavor is determining how to translate the data collected within the
system into useful information that will deliver value. It's not just
about digitizing the visit--it's about using the data from that visit
and other sources to inform and ultimately to transform care delivery.
For example, our use of HIT and our comprehensive approach
(partnership of primary care providers, cardiologists, nurses, and
pharmacists with accountability across the continuum of care--
preventive, chronic, and acute) have significantly reduced emergency
department visits and mortality. In Colorado, we have seen a 76 percent
reduction in cardiac mortality for those who participated in our
Collaborative Cardiac Care Service compared with those who received
regular treatment.\2\ Based on NCQA data, as compared to the national
HMO average, we prevent more than 280 cardiac events annually in
Colorado. This improvement saves $2 million in annual hospital costs.
In northern California, if you are a member of Kaiser Permanente, you
have a 30 percent less chance of dying of heart failure compared to a
member of the general population. In Oregon and Washington, by using KP
HealthConnect in a new Regional Telephonic Medicine Center staffed with
emergency room physicians and advice nurses, we have achieved an 11
percent reduction in the number of members who need to visit the
emergency room between the hours of 12 noon and 10 p.m. In southern
California, from 2004 to 2007, combining the power of our IT systems
and our integrated delivery model, we were able to increase mammography
screening rates for women aged 50-69 from 80 percent to nearly 90
percent.
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\2\ Sandhoff, B., Kuca, S., Rasmussen, J., Merenich, J.,
``Collaborative Cardiac Care Service: A Multidisciplinary Approach to
Caring for Patients with Coronary Artery Disease,'' The Permanente
Journal. Summer 2008, 12:3; 4-11.
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This last example was highlighted for me by a recent letter that
puts a human face on these statistics:
Early last year, I came to your facility to have a foreign
body removed from my eye. I visited your Ophthalmology
Department, and your competent staff dealt with this minor
emergency.
What made this visit so meaningful was my interaction with
your nurse after my visit with the doctor. In addition to
giving me some after-visit instructions, she noticed in the
computer that I needed a mammography exam. I had been reminded
before, but I tend to be too busy to take care of my own
health. This time the nurse was very insistent. She even made
me an appointment so I could walk in and get an exam within the
hour. Since I did not have to wait too long, I had an exam done
that day. Well, they found a mass in my right breast, and it
was cancer. I have gone through chemotherapy and radiotherapy,
and today I am cancer free.
I am convinced that I am alive today because of your
organization's focus on my total health. My interaction with
your entire health care system has been nothing but positive. I
am especially appreciative to the young nurse who took the time
to convince a stubborn old lady to take responsibility for my
health.
Thank you for giving me many more years to thrive.
This letter describes a simple act by one of our nurses that was
possible only because the nurse had access to that patient's
information, acted on it, and was part of an integrated health care
system that encourages this series of events.
KP HealthConnect also allows us to share content across all
regional facilities, providing the best technical platform to
disseminate drug formulary changes, best-practice alerts, and automated
clinical guidelines to the entire enterprise. Our members can move
through any facility within a given region, and their clinical and
administrative information will follow them.
As an example, during the 2007 wildfires in San Diego, when Kaiser
Permanente facilities within the fire lines closed, we contacted
members and directed them to open facilities. When our members arrived
at these new facilities, their new care teams had appropriate access to
their records via KP HealthConnect, ensuring continuity of care in a
time of crisis.
When we started down this path, Kaiser Permanente faced many of the
same barriers that other health care organizations and providers face
today when they start to utilize HIT to improve care delivery. These
barriers involve both process (e.g., complexity of health care is
increasing, workflows will be disrupted, end-to-end patient-centered
view is not well known) and technology (e.g., data is ``locked away''
in various paper files, applications, and databases; data standards,
interoperability standards, usability standards must be integrated). I
am here to tell you that these issues can be overcome.
Kaiser Permanente and other multi-specialty groups like Group
Health Cooperative, Intermountain Healthcare, and Geisinger can set the
gold standard with a sophisticated EHR and integrated care delivery
systems. Harder to overcome are the misaligned incentives in systems
that are not vertically integrated, because these do not encourage
providers to re-design care delivery to incorporate evidence-based care
processes for improving quality and effectiveness. As a nation, we can
decide to create payment incentives that reward health professionals
who share information, who learn from each other, and who hold
themselves and one another accountable in order to generate the best
health outcome at the most reasonable cost for each patient.
an interoperable hit system
Congress has the ability to create a system that is truly
interoperable. Today, far too often, our systems speak different
languages. Even when electronic information exists for patients,
critical clinical information can be lost during an emergency or when
patients transfer from one system to another because the different
systems simply cannot communicate with one another.
After discussing interoperability of medical records for years,
Kaiser Permanente recently demonstrated successful data exchange of
health records involving our shared patient population with the
Veterans' Administration. This demonstration project uses test data for
fictitious patients, but it also shows that privacy and security
requirements will work to protect real patient data. The demonstration
uses the national interoperability standards recognized by the
Department of Health and Human Services (HHS), proving they work in the
real world.
Sound HIT policy should stress the critical importance of
standards-based interoperability to achieve coordinated patient-
centered health care. The ability of separate HIT systems to
interconnect with each other depends on uniform adherence to strictly
defined standards. Most of these standards exist today. Kaiser
Permanente supports the HHS-adopted interoperability standards selected
by the Healthcare Information Technology Standards (HITSP) and used in
the National Health Information Network (NHIN).
Only when these existing technical standards are used consistently
across the delivery system will HIT be able to achieve its promise for
both direct care of individual patients and for population-based care.
Connected HIT will not be adopted by most clinicians and
institutional providers without mandates or a system of incentives and
penalties that are materially more advantageous or costly to providers
than those outlined in current and previous proposals. For instance,
one approach could use Medicare conditions of participation (COP) as a
means to promote adoption, with metrics for adoption of HIT, determined
by the Secretary and used by HHS as benchmarks. Achieving benchmark
measures for HIT could trigger loan forgiveness or incentive payments.
Above all, dollars should be attached to outcomes. For example,
organizations that receive HIT incentives could be required to adhere
to certain clinical care pathways or demonstrate that they have
``functional EHRs.'' This may mean that their EHR must show it is
capable of sending and receiving lab, pharmaceutical, and other
clinical information--not just payment claims information.
HIT system functions and interoperability are essential
cornerstones for policies such as primary care-centered medical homes,
coordination of care for chronic conditions, value-based care,
comparative effectiveness research, and pay-for-performance/pay-for-
quality initiatives. Some EHR-systems come as ``blank slates,'' with
functionality, but without built-in clinical content or knowledge;
these systems demand tremendous amounts of time, skill, and energy to
harness the tools to the purpose of actually improving quality. Linking
the implementation of HIT to health system reforms is essential. To
promote appropriate and clinically effective uses of HIT over the mere
acquisition of technology, the Secretary of HHS should develop and
implement measures for HIT connectivity and data exchange as well as
measures for EHR-based quality reporting.
privacy
All consumers should be able to rely on appropriate and consistent
minimum levels for privacy and security protections among all
entities--both public and private--that access or use individual health
information. A high level of trust in these protections is crucial for
HIT to succeed. It will be important for Congress to strike an
appropriate balance between the competing interests of protecting
privacy concerns versus advancing HIT, EHRs, and public health
initiatives. Both can be achieved. Today, many State laws risk slowing
down the rate of progress by allowing consumers to opt out of disease
registries and other community health initiatives due to privacy
concerns.
We believe that HIPAA should remain the basis of new privacy rules.
However, privacy policy also must cover personal health data
consistently, regardless of what entity holds the records. Privacy
requirements can achieve better protection for consumers without adding
to the cost of HIT, changing the practice of medicine, or creating
medical liability issues.
There are good models in State law for guarding against security
breaches in ways that do not impede access to health information by
clinicians; it is important to remember that the lack of appropriate
and complete health information for clinicians who are treating a
patient can also endanger that patient's life.
In our experience, California law provides a model for breach
notification that is clear and consistent across all types of entities,
events, and circumstances. We believe HIPAA disclosure accounting for
treatment, payment, or health care operations purposes would add a
significant amount to the total cost of HIT implementation and could
harm the practice of medicine by disrupting clinical workflows. HIT
innovators should not be penalized by regulations that force
unnecessary or disproportionate system overhauls to achieve compliance,
especially when such modifications will consume resources that could be
spent to deliver high quality care. Efficiency should be a goal of new
investments and rules.
improving safety, quality, and efficiency
The real objective of HIT in the economic stimulus package should
not be technology, but rather to improve safety, quality, and
efficiency.
At Kaiser Permanente, we believe the keys to the solution will be
health care led by clinicians, integrated with functional IT systems,
and staffed with innovative, enthusiastic, computer-enabled health care
professionals.
Having HIT and the means to exchange information will do us little
good if we do not foster and support better information about the
effectiveness of care, including the relative benefits, risks, and
costs of treatments and services. We need a robust Federal commitment
to comparative effectiveness research so that health professionals can
ensure that each individual patient gets the care that is right for him
or her. Reforms must also ensure that patient information can be used
not only to optimize care for one specific patient but also to improve
care for all patients through, for example, the development of clinical
care guidelines and disease management protocols. These goals require
the use of patient information and appropriate access to patient
records, with privacy safeguards as currently required under HIPAA
rules.
Ultimately, however, to effect real change, provider payment
systems should be based on value rather than the number of procedures,
drugs, tests one orders--regardless of whether the best evidence calls
for such action. To keep coverage affordable and to really fix our
broken health care system, we must change the way we deliver and pay
for health care. Financial incentives must be changed so that plans
compete on quality and efficiency, providers are rewarded for quality
and keeping their patients healthy rather than for the volume of
services delivered, and individuals are encouraged to seek high-quality
care and to be more actively involved in maintaining their own health.
We believe a computerized care support system that is well-designed
and implemented appropriately can help restore and enhance the
physician's healing mission. Maximizing information available to the
clinician means optimizing care for the patient. The right systems will
yield more time with patients, better information about care, and less
time with traditional paperwork. The right systems also must focus on
the patient's need for affordable, well-informed, customized, and
compassionate care. We believe a new HIT system will support our
Nation's health care reform agenda and can help our Nation fulfill its
ethical responsibility to improve health care access, reduce costs, and
ensure quality care for all.
We look forward to working with you to achieve these goals.
Senator Mikulski. Well, you have covered a lot of ground.
And just looking at your testimony; we could just spend all
morning in a dialogue with you, and we will be coming back.
Thank you. And thank you for being within the time limit.
Ms. Corrigan.
STATEMENT OF JANET CORRIGAN, PH.D., PRESIDENT, THE NATIONAL
QUALITY FORUM, WASHINGTON, DC
Ms. Corrigan. Chairwoman Mikulski and members of the
committee, thank you for inviting me here today to talk about
health information technology and quality.
My name is Janet Corrigan. I am the president and CEO of
the National Quality Forum. NQF is a private sector standard-
setting organization whose mission is to improve the quality of
American healthcare by setting national priorities and goals
for performance improvement and endorsing standardized
performance measures that can be used to assess, publicly
report, and, most important, improve performance on the front
line.
A standardized performance measurement and reporting system
is a core building block for creating a higher quality, more
affordable healthcare system, and it is necessary to
successfully implement virtually all reform strategies,
including changes in payment policies, public reporting, and
regulatory oversight. Investing in health information
technology is critical to that standardized measurement and
reporting system.
I commend the committee for focusing attention on how HIT
investments can achieve maximum benefit, both for our economy
and the quality of care our patients receive. You have probably
heard it said that a crisis is a terrible thing to waste. And
as unfortunate as they are, crises provide a prime opportunity
to force clear thinking and prioritization of our actions and
investments.
In my comments today, I am going to focus on the linkage
between HIT investments and improvements in patient care. More
specifically, I will cover three points. First, Federal funding
to promote adoption of HIT is an essential foundation for
improving safety, quality, and affordability, and we should
make substantial investment now.
Second, investments in HIT will result in far greater
improvement in patient care if steps are taken to ensure that
electronic health records and personal health records possess
the necessary capabilities to support performance measurement,
reporting, and improvement.
And third, HIT investments and incentives should be tied to
the effective use of HIT to improve safety, outcomes, and the
experience of care, not just having the technology in place.
We are making progress in improving healthcare performance,
but it is happening at a slower pace than it should. There are
many examples of efforts to improve quality in virtually all
types of settings that are substantial and lifesaving. But our
healthcare system lacks the ability to bring these innovations
to scale.
One of the reasons for this slow rate of improvement is
that our current healthcare delivery system is extraordinarily
fragmented. HIT can facilitate the exchange of patient
information and communication between providers and across
settings.
Much of the healthcare sector lacks critical organizational
supports that are needed to manage patients across their entire
episode of illness. I want to emphasize that HIT alone is not
enough to transform the delivery system. HIT is a tool. It must
be used effectively.
Investments in HIT will have the greatest impact if pursued
within a broader policy agenda that encourages the development
of higher levels of organizational capacity in all practice
settings.
The second point I want to make is that for investments in
HIT to have the greatest impact, EHRs and PHRs must be capable
of capturing the necessary data to calculate measures and to
provide clinical decision support to providers to enhance
performance. Efforts are now well underway to create a bridge
between the quality community and the HIT community.
In 2007, with initial support from AHRQ, NQF established
the Health Information Technology Expert Panel. The initial
work of HITEP has focused on identifying types of data that
must be captured in EHRs to calculate performance measures that
are currently used by Medicare for public reporting purposes.
HITEP works closely and collaboratively with the Health
Information Technology Standards Panel that translates the
quality dataset into HIT standards and with the Certification
Commission for Health Information Technology to promote the
development of EHRs capable of supporting performance
measurement and improvement. I encourage you to build on this
important collaborative work and not to reinvent the wheel.
My third and last point is that Federal funding to promote
the adoption of HIT will only result in improvements in care if
HIT systems are effectively used to perform key value-enhancing
functions, including the exchange of data on prescriptions,
laboratory tests, and imaging procedures, and developing
evidence on the safety and effectiveness of the treatments.
Interoperability and technical capabilities are important,
but not enough. Investments should be tied to changes in care
delivery that translate into real improvements in patient
safety and clinical outcomes.
To support that need, NQF has endorsed a set of performance
measures emphasizing HIT in five areas and its use--in
electronic prescribing, interoperability, care management,
quality registries, and the medical home.
In conclusion, NQF supports Federal funding to promote
adoption of HIT as an essential foundation for improving
safety, quality, and affordability. But it is important to
invest wisely. The investment will yield far greater returns in
terms of higher quality, more affordable care if EHRs and PHRs
are built with the necessary capabilities to support
performance measurement and improvement and if investments are
tied to the effective use of HIT to enhance patient care.
Thank you very much.
[The prepared statement of Ms. Corrigan follows:]
Prepared Statement of Janet Corrigan, Ph.D.
Chairman Kennedy, Chairwoman Mikulski, Ranking Member Enzi and
members of this committee, thank you for inviting me here today to talk
about Health Information Technology (HIT) in the stimulus package, and
its potential to help us move toward making higher-performing, lower-
cost healthcare available to every American.
My name is Janet Corrigan. I am the President and CEO of the
National Quality Forum. NQF is a private sector standard-setting
organization with more than 375 members representing virtually every
sector of the health care system. NQF operates under a three-part
mission to improve the quality of American health care by:
setting national priorities and goals for performance
improvement;
endorsing national consensus standards for measuring and
publicly reporting on performance; and
promoting the attainment of national goals through
education and outreach programs.
NQF endorsement, which involves rigorous, evidence-based review and
a formal Consensus Development Process, has become the ``gold
standard'' for health care performance measures. Major health care
purchasers, including the Centers for Medicare & Medicaid Services,
rely on NQF-endorsed measures to ensure that the measures are
scientifically sound, relevant and help standardize and raise the bar
for performance across the industry. To date, NQF has endorsed more
than 500 measures. A standardized performance measurement and reporting
system is a core building block for creating a higher quality, more
affordable health care system, and is necessary to successfully
implement virtually all reform strategies. Investing in health
information technology is critical to routinely assessing performance.
I commend the committee for focusing needed attention on how HIT
investments can achieve maximum benefit--both for our economy and the
quality of care our patients receive. You've probably heard it said
that a crisis is a terrible thing to waste. Crises provide a prime
opportunity to force clearer thinking and prioritization of our actions
and investments. I believe this to be true of the current economic
crisis and Congress and the Administration's efforts to address it,
particularly when it comes to healthcare.
Healthcare spending and our economy are inextricably linked. We can
no longer sustain healthcare spending at a rate that will reach more
than 20 percent of the GDP by 2020. After a stock market freefall in
2008, the Nation's financial condition dropped to what is considered
the worst economy in 70 years. Experts now agree that we have not yet
hit bottom and that 2009 may bring the worst conditions faced in
generations. We cannot continue to act as we always have. We can no
longer afford the health care system we have, particularly considering
that 30 percent of spending is wasteful--$600-$700 billion spent on
care that is often unnecessary and even harmful care. HIT is not just a
good idea, not just an innovation--HIT is essential if we hope to
achieve the goals we have set to achieve higher quality, affordable
care that fuels rather than drains our economy.
In my comments today, I am going to focus on the importance of
strengthening the linkage between HIT investments and improvements in
patient care. More specifically, I intend to cover three points. First,
Federal funding to promote adoption of HIT is an essential foundation
for improving health care safety, quality and affordability. Second,
investments in HIT will result in far greater improvement in patient
care if steps are taken to ensure that electronic health records (EHRs)
and personal health records (PHRs) possess the necessary capabilities
to support performance measurement, reporting, and improvement. Third,
HIT investments and incentives should be tied to the effective use of
HIT to improve patient safety, outcomes and experience of care, not
just having it.
hit's role in improving quality
We are making progress in improving healthcare performance, but it
is happening at a slower pace than it should. For example, the National
Health Care Quality Report shows an average annual improvement of only
1.9 percent on a selected set of performance measures between 2000 and
2004. By contrast, the rate of healthcare expenditures grew 7.6 percent
during the same time period. There is entrenched over-use, mis-use and
under-use of services. These gaps in quality, use and access affect
everyone, but place the greatest burden on minorities. Efforts to close
the disparities gap have to date had little impact.
There are many examples of efforts to improve quality in hospitals,
small and large ambulatory practices, and long-term care settings that
have been substantial and life-saving. But the health care sector lacks
the ability to bring these innovations to scale; best practices in care
delivery may take years if not decades to spread throughout a community
and the Nation.
One reason for this slow rate of improvement is that our current
health care delivery system is extraordinarily fragmented. The average
Medicare patient sees two primary care physicians and five specialists
annually, across a median of four different practices. The
fragmentation of care is even more pronounced for patients with chronic
conditions; for example, a Medicare patient with coronary artery
disease sees three primary care physicians and seven specialists in a
given year. This kind of fragmentation, particularly for the
chronically ill, makes it extremely challenging to coordinate care and
share information in a timely way that is responsive to patients'
needs. HIT can facilitate the exchange of patient information and
communication between providers and across care settings, which can
create safer, more effective and patient-centered care.
Much of the health care sector lacks critical organizational
supports necessary to consistently provide effective, safe and
efficient care across the entire patient-
focused episode. HIT is one of those critical organizational supports,
but I want to emphasize that HIT is not enough on its own to transform
the delivery system. HIT is a tool that must be used effectively. In
its landmark report, Crossing the Quality Chasm, the Institute of
Medicine emphasized the importance of using HIT to:
Design care processes based on best practices.
Translate new clinical knowledge and skills into practice.
Support the work of multi-disciplinary teams.
Enable the coordination of care across patient conditions,
services and settings.
Measure and improve performance.
Investments in HIT will have the greatest impact if pursued within
a broader policy agenda that encourages the development of higher
levels of organizational capacity in all practice settings.
Investment in HIT now will also enable more effective
implementation of other elements of a comprehensive reform agenda over
the coming years including: availability of information on the
effectiveness of alternative treatments; reform of payment programs to
promote value; and informed patient choice and shared decision-making.
Virtually all of these strategies will require more comprehensive
performance information than is currently available--performance
information on the entire patient-focused episode including measures of
patient outcomes, care processes, and resource use.
hit that supports performance measurement and improvement
Funds for HIT included in the stimulus provide an opportunity to
take important steps towards the establishment of a secure,
interoperable, nationwide health information network. With strong
leadership from the Office of the National Coordinator, working
collaboratively with a wide variety of stakeholders, a good deal of
progress has been made in recent years. The current state of the
technology and standards is adequate to support this investment now.
At the same time, we should continue our efforts to ensure that
EHRs and PHRs possess the necessary capabilities to support performance
measurement, reporting, and improvement. In short, EHRs and PHRs must
capture the necessary data to calculate measures; and provide clinical
decision support (CDS) to providers to enhance performance.
Establishing an HIT infrastructure to fully support performance
measurement and improvement requires close and ongoing collaboration
between the ``quality community'' and the ``HIT community.''
Efforts are now well underway to create such a ``bridge.'' In 2007,
with initial support from the Agency for Healthcare Research and
Quality and pursuant to recommendations of America's Health Information
Community (now a public-private partnership known as the National
eHealth Collaborative), NQF established the Health Information
Technology Expert Panel (HITEP), chaired by Paul Tang, M.D., Palo Alto
Medical Foundation. The initial work of HITEP has focused on
identifying the types of data that must be captured in EHRs to
calculate the performance measures that are currently used by Medicare
for public reporting purposes. HITEP is now working collaboratively
with the Health Information Technology Standards Panel (HITSP), to
translate the ``Quality Data Set'' into HIT standards, and the
Certification Commission for Health Information Technology, to promote
the development of EHRs capable of supporting performance measurement
and improvement.
I encourage you to build upon this important collaborative work and
not to reinvent the wheel. The ``Quality Data Set'' will support both
public reporting and enhanced patient care. It will enable both real-
time feedback to clinicians on their performance and clinical decision-
support (i.e. prompts and reminders to a clinician to ask a question or
supply a drug; alerts that inform a clinician that something is amiss,
such as a drug being prescribed that will react badly to another
prescribed drug).
incentives for using, not just having hit
Federal funding to promote the adoption of HIT will only result in
improvements in care if HIT systems are used to perform key value-
enhancing functions, including:
exchanging data on prescriptions, laboratory tests, and
imaging procedures;
developing evidence on the safety and effectiveness of
treatments; and
reporting on safety, quality and affordability.
Interoperability and technical capabilities are important, but
investments will prove most effective if tied to process changes that
improve patient safety and clinical outcomes, while making the health
care experience more meaningful.
HIT investments and incentives should be tied to the effective use
of HIT to improve patient safety, outcomes and experience of care, not
just having it. To support this need, NQF has endorsed a set of
performance measures emphasizing HIT use in five areas: electronic
prescribing, interoperability/information exchange, care management,
quality registries, and the medical home. For example, the two care
management measures endorsed by NQF assess the use of HIT to identify
specific patients in need of care, track their preferences and lab
results, and assist the clinician in providing evidence-based care
according to national guidelines using automated alerts and reminders.
To ensure information about patients doesn't fall through cracks in the
healthcare delivery system, the first of these NQF measures addresses
HIT used during a patient-clinician visit and the second addresses
capturing and sharing clinical results between visits.
In conclusion, the NQF supports Federal funding to promote the
adoption of HIT as an essential foundation for improving health care
safety, quality and affordability, but it is important to invest
wisely. This investment will yield far greater returns in terms of
higher quality, more affordable care, if steps are taken now to ensure
that EHRs and PHRs possess the necessary capabilities to support
performance measurement and improvement; and if investments are tied to
the effective use of HIT to enhance patient care.
Thank you again for your focus on how HIT can drive improvements in
healthcare quality and efficiency.
______
Summary
The NQF supports Federal funding to promote the adoption of health
information technology (HIT) as an essential foundation for improving
health care safety, quality and affordability, but it is important to
invest wisely. This investment will yield far greater returns in terms
of higher quality, more affordable care, if steps are taken now to
ensure that EHRs and PHRs possess the necessary capabilities to support
performance measurement and improvement; and if investments are tied to
the effective use of HIT to enhance patient care.
hit's role in improving quality
HIT is one critical organizational support; however HIT is not
enough on its own to transform the delivery system. HIT is a tool that
must be used effectively. Investments in HIT will have the greatest
impact if pursued within a broader policy agenda that encourages the
development of higher levels of organizational capacity in all practice
settings. Investment in HIT now will also enable more effective
implementation of other elements of a comprehensive reform agenda over
the coming years including: availability of information on the
effectiveness of alternative treatments; reform of payment programs to
promote value; and informed patient choice and shared decisionmaking.
Virtually all of these strategies will require more comprehensive
performance information than is currently available--performance
information on the entire patient-focused episode including measures of
patient outcomes, care processes, and resource use.
hit that supports performance measurement and improvement
Funds for HIT included in the stimulus provide an opportunity to
take important steps towards the establishment of a secure,
interoperable, nationwide health information network. The current state
of the technology and standards is adequate to support this investment
now. EHRs and PHRs must capture the necessary data to calculate
measures; and provide clinical decision support (CDS) to providers to
enhance performance. Establishing an HIT infrastructure to fully
support performance measurement and improvement requires close and
ongoing collaboration between the ``quality community'' and the ``HIT
community.''
Efforts are now well underway to create such a ``bridge.'' In 2007,
NQF established the Health Information Technology Expert Panel (HITEP),
chaired by Paul Tang, M.D., Palo Alto Medical Foundation. The initial
work of HITEP has focused on identifying the types of data that must be
captured in EHRs to calculate the performance measures that are
currently used by Medicare for public reporting purposes. HITEP is now
working collaboratively with the Health Information Technology
Standards Panel (HITSP), which is translating the ``Quality Data Set''
into HIT standards and the Certification Commission for Health
Information Technology (CCHIT), which promotes the development of EHRs
consistent with national standards.
The NQF recommends that future efforts build upon this important
collaborative work and not to reinvent the wheel. The ``Quality Data
Set'' will support both public reporting and enhanced patient care. It
will enable real-time feedback to clinicians on their performance and
clinical decision-support.
incentives for using, not just having hit
Federal funding to promote the adoption of HIT will only result in
improvements in care if HIT systems are used to perform key value-
enhancing functions, including: exchanging data on prescriptions,
laboratory tests, and imaging procedures; developing evidence on the
safety and effectiveness of treatments; and reporting on safety,
quality and affordability.
HIT investments and incentives should be tied to the effective use
of HIT to improve patient safety, outcomes and experience of care, not
just having it. To support this need, NQF has endorsed a set of
performance measures emphasizing HIT use in five areas: electronic
prescribing, interoperability/information exchange, care management,
quality registries, and the medical home. To ensure information about
patients doesn't fall through cracks in the healthcare delivery system,
the first of these NQF measures addresses HIT used during a patient-
clinician visit and the second addresses capturing and sharing clinical
results between visits.
Senator Mikulski. Thank you. That was excellent. It really
complements with what Mr. Cochran says and this whole issue of
not only having it, but using it. So it has got to be usable,
and then this buy-in from the physicians.
Well, I think that is a good time now to turn to our
private sector experience, and Mr. Neupert, let us hear from
the microchip crowd.
[Laughter.]
STATEMENT OF PETER NEUPERT, VICE PRESIDENT, MICROSOFT HEALTH
SOLUTIONS, REDMOND, WA
Mr. Neupert. Thank you, Senator Mikulski.
My name is Peter Neupert, and I am the corporate vice
president of Microsoft's Health Solutions Group.
For over a decade, Microsoft has increased its commitment
to health, developing software solutions supporting both
consumers and businesses. And I am glad you are fired up
because I am, too.
We have a powerful vision of the future. We see a dynamic
patient-centric health system that transforms how physicians
provide care and individuals manage their health, a totally
connected network enabling the seamless exchange and reuse of
health data.
Across the healthcare industry today, there are examples of
organizations starting to realize this vision. The Marshfield
Clinic, Kaiser Permanente, the Department of Veterans Health
Affairs, and many others whose leadership thought about clear
outcomes and embraced technology as a means to drive improved
outcomes, efficiency, quality, and a reduction of costs. They
built patient-centric, connected systems.
We believe that these kinds of successes need to be scaled
nationally. We can expand on these successes and embrace their
core ideals by doing the following three things.
First, we must drive the right health outcomes and payments
to incent innovation. We must build an industry focused on
lifelong wellness and reward caregivers when diseases and
conditions do not develop. We need to reward doctors who
provide preventive care and allow them to innovate in
delivering care in new connected electronic ways.
Second, we must connect and share data among and between
health organizations. Having access to a lifetime record of
treatments, prescriptions, and tests will allow individuals and
healthcare providers to make better medical decisions, reduce
wasteful spending, and increase the quality of care. Health
data is and should be treated as a valuable asset.
Third, we must empower consumers to be stewards of their
own health data. Just as credit scores represent a lifetime of
active and passive financial decisions and transactions, so
should health data. We must help consumers to start building
their health data into a lifelong asset, to manage it over
time, and to share with those who support them in making key
health decisions. We should begin today, with the health data
that already exists electronically.
To move forward, we recommend that the public and private
sectors take the following five steps. First, encourage
innovation in health IT by setting out objective goals and
criteria, not by mandating specific technologies or development
models.
Second, reward innovative doctors who make the Internet the
foundation for the patient-physician connection.
Third, provide incentives for sharing data today.
Fourth, focus on making data interoperable today, not
waiting for future standards and insist that vendors separate
data from their applications.
And fifth, and last, enable the private sector to develop
an information infrastructure that connects data, systems, and
people.
When we wanted to go to the Moon, we didn't focus on
building the rocket. We set the goal of landing on the Moon,
and we used money, technology, and innovation to make it
happen. Once health objectives are set, stakeholders in the
health ecosystem can figure out the right technology to reach
these goals.
Microsoft looks forward to collaborating with the public
sector and others in industry to drive real change in our
healthcare system.
Thank you for the opportunity to appear before you today.
[The prepared statement of Mr. Neupert follows:]
Prepared Statement of Peter Neupert
Chairman Kennedy, Ranking Member Enzi, and distinguished members of
the committee, my name is Peter Neupert, and I am Corporate Vice
President of Microsoft's Health Solutions Group. Thank you for the
opportunity to share Microsoft's perspective on investments in health
IT. We appreciate how much time and attention the committee has spent
on this critical issue, and we commend you for your work in advancing
the debate on information technology as part of healthcare reform.
My testimony begins by describing what we believe to be the future
of U.S. healthcare--a totally connected, patient-centric system. It
explains how technology can help make that future a reality by
encouraging better outcomes and innovation, connecting patient data,
and empowering consumers to be stewards of their own health. It then
outlines ways in which the public and private sectors can work together
to create an efficient, data-driven healthcare system, benefiting
patients, healthcare providers, and the overall U.S. economy. Finally,
it concludes by describing Microsoft's existing investments in health
IT and how they are being implemented today.
i. the future: the u.s. health system transformed by technology
At Microsoft, we envision a dynamic, patient-centric health system
that transforms the way physicians provide care and individuals manage
their own health--a totally connected network that delivers predictive,
preventive, and personalized medicine in an accessible, affordable, and
accountable way. Specifically, we see:
Patients as consumers.--Experiencing more control, more
convenience, better service, and ultimately better value for what they
spend on healthcare.
Physicians as knowledge workers.--Professionals getting
the right data in the right format at the right time to provide the
best treatment and preventive care.
New interactions among the key members of the healthcare
ecosystem.--Physicians, patients, pharmacies, researchers, and
insurance providers benefiting from a new flow of data to make better,
faster decisions.
The extension of modern healthcare to the virtual
space.--Patients getting care when they want it, wherever they need it,
thanks to virtual medical clinics, virtual doctor visits, virtual lab
results, medical homes, and personalized medicine based upon genomic
data.
A learning healthcare system.--One that measures
everything, identifies errors, and makes improvements in order to
deliver value.\1\
---------------------------------------------------------------------------
\1\ Institute of Medicine Roundtable on Evidence-Based Medicine,
Learning Healthcare System Concepts v. 2008 (2008).
In summary, it is a world where everyone in the health ecosystem
has the right information at the right time with computer-assisted
decision support, enabling the seamless exchange and re-use of data.
Health data is the asset that drives an efficient, high-quality, value-
based, evidence-focused future for medicine.
ii. the blueprint: building a scalable, patient-centric health it
system
We all know that information technology is a vital component in
improving our healthcare system. But simply spending more money on
information technology, without considering all the factors driving
behavior in our healthcare system, is unlikely to lead to better health
outcomes. There have been many investments in technology that did not
solve the problems of better quality outcomes, increased access, or
reduced costs.
However, across the healthcare industry today, there are many
examples of successful technology investments--the Marshfield Clinic,
Kaiser Permanente, the Department of Veterans Affairs, and others.
These are organizations whose leadership thought about clear outcomes
and embraced technology on many different levels to drive improved
efficiency, quality, and a reduction of costs across their systems. In
essence, they created patient-centric systems. We believe that these
are the kinds of successes that need to be scaled nationally.
A. Driving the Right Health Outcomes and Payments to Incent Innovation
An industry focused on lifelong wellness and outcomes would reward
caregivers when diseases and conditions do not develop.
The problem with our current healthcare system is that it is
designed to care for people who are ill, not to keep people healthy.
For example, we focus on providing episodic treatment and medication to
diabetics instead of asking how we can raise awareness of diabetes risk
factors and prevent people from developing diabetes in the first place.
The system is this way because we do not reward doctors who provide
preventive care or innovative services.
Doctors typically receive a flat fee for each treatment they
perform, regardless of the quality of the care, and the amount of the
fee is set by a bureaucracy of insurers, health plans, and regulators.
In this fixed-price system, there is no incentive for providers to
improve customer satisfaction. Most physicians are not reimbursed for
telephone or e-mail consultations, let alone more advanced uses of
technology. Doctors who attempt to innovate--for example, by investing
in systems to collect data from patients remotely--end up delivering
better care but making less money.
In health-related areas where prices are set by the market, such as
veterinary medicine, dentistry, and cosmetic surgery, providers do a
much better job of investing in services that attract customers. For
example, pet owners willingly pay for veterinarians who make house
calls, maintain electronic medical records, remind owners to bring
their pets in for scheduled vaccinations, call to make sure the pets
are taking their pills, and are available for e-mail or telephone
consultations. Veterinarians compete on price and quality, so they are
constantly looking for innovations that allow them to provide better
service and improve customer satisfaction. Because technology is often
a source of innovation, veterinarians are quick to embrace new
technologies that fuel better service and better patient care. We need
to learn from these examples.
B. Connecting and Sharing Data Among and Between Health Entities
We believe the first step is to connect the many medication lists,
laboratory test results, and diagnostic images that are already
maintained electronically. Eventually, we can build a lifetime record
of treatments, prescriptions, and tests that allows individuals and
healthcare providers to make better medical decisions, reduce wasteful
spending, and increase the quality of care.
Our current system is built around the idea of a specific provider
prescribing specific treatment for a specific condition. Patients'
health data is locked inside each provider's silo, without being
connected or shared. Physicians are forced to either make treatment and
prescription decisions without all available clinical data, or else
waste time and resources attempting to aggregate data. MedStar Health's
Washington Hospital Center estimates that 60 percent of a clinician's
time is spent searching or waiting for information, with only 16
percent spent on direct patient care.\2\
---------------------------------------------------------------------------
\2\ Microsoft Health Solutions: Helping People Live Longer,
Healthier Lives (June 26, 2007).
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The right investments in health IT can tear down these silos,
offering patients and doctors a holistic picture of a patient's health
history and thereby improving care. Consider chronic diseases, which
account for over 75 percent of healthcare spending.\3\ Even though most
care for chronic diseases occurs at home, data from at-home care is not
integrated with data available at the hospital or at the doctor's
office. Individuals and providers would all benefit if, for example,
patients with diabetes could upload their blood glucose readings to a
Web site that offered personalized advice and guidance; receive
information alerts regarding changes in recommended treatment or
behavior; share their results with a supportive community of fellow
patients; and securely transmit readings to their clinician. Patients
would have more information on managing their condition, would be in a
better position to prevent acute incidents, and would need to make
fewer trips to the doctor. Treating physicians would have a greater
ability to understand their patients' health over time, allowing them
to identify the best treatment for existing patients and to help people
who are at risk of developing the disease in the future.
---------------------------------------------------------------------------
\3\ Centers for Disease Control and Prevention, Chronic Disease
Overview (Nov. 20, 2008), http://www.cdc.gov/nccdphp/overview.htm.
---------------------------------------------------------------------------
c. empowering consumers to be stewards of their own health data
Finally, we need to empower consumers to manage their health data.
Just as credit scores represent a lifetime of active and passive
financial decisions and transactions, so should health data. We must
help consumers to start building their health data into a lifelong
asset, to manage it over time, and to share with those who support them
in making key decisions both within and outside of the health system.
Today, in order to manage their health, consumers must deal with
both paper documents and electronic files. They fill out form after
form, calling multiple doctors' offices for appointments. Few people
have the resources to keep track of medication lists, vaccination
histories, appointment calendars, lab results, diet plans, exercise
schedules, and all the other components of health data. Many have
little knowledge of how to prevent disease and little, if any, support
for managing their healthcare.
Now imagine if consumers could connect all their health and
wellness data electronically, share it securely from provider to
provider, and keep it in one place over time, no matter the doctor or
the insurance company. They would have all the relevant data at their
fingertips, accessible at any time and any place. They could sign up
for services that would provide personalized alerts and information.
They could track fitness goals across numerous devices, such as
exercise bikes that monitor vital signs, smart watches that record the
number of miles run, and scales that measure body fat as well as
weight. They could research relevant medical conditions online and
interact with support groups so that they would be better prepared and
informed for their next visit to the doctor. They could share data with
their support systems and make better health decisions for themselves
and their families.
We believe technology can make this vision a reality. The Internet
and online social networks have already become an everyday resource for
consumers seeking information in order to make health decisions, but
what is missing is a way to link this information back to the
individual's personal health history. And consumers are ready for it:
78 percent of Americans favor giving doctors the ability
to share access to their medical records if done with their
permission.\4\
---------------------------------------------------------------------------
\4\ Council for Excellence in Government et al., The American
Public on Healthcare: The Missing Perspective (2008), http://
www.excelgov.org/Programs/ProgramDetail.cfm?ItemNumber=
9404.
---------------------------------------------------------------------------
66 percent see value in including their own information
anonymously in a large database to help researchers.\5\
---------------------------------------------------------------------------
\5\ Id.
Pharmacy benefit managers maintain medication lists electronically,
and many hospitals digitally record laboratory test results and
diagnostic images. As a first step in empowering consumers, we could
require providers to give patients electronic copies of any data that
is already available in electronic format. Providing consumers with
access to their healthcare data in a secure and private way, and
allowing them to keep it in one place over time and share it from
provider to provider, will permit them to make the best daily decisions
about their health. It also will enable healthcare professionals to
deliver better care.
iii. the next steps: recommendations for moving forward
Microsoft has learned a great deal over the past several years as
we have worked to improve healthcare through information technology. We
know that just spending more money on health IT will not solve the
problems in today's healthcare system. We believe the right investments
are those that focus on the right outcomes. We believe that it is
essential that data be connected and shared so that consumers and
health enterprises can build their health data assets over time.
To achieve our vision will require that the public and private
sector take several steps, including:
Encourage innovation in health IT by setting out objective
goals and criteria, not by mandating specific technologies or
development models. Hundreds of innovative health IT products and
services are available on the market today, and many companies are
investing large sums to develop new technologies and solutions. Even as
they compete, however, companies are collaborating to enable their
products to work together and share information regardless of their
underlying development, licensing, or business models. To take one
example, Microsoft's HealthVault can interface with the open source
VistA EHR system and other open source healthcare applications.
As Congress considers how best to spur the broad adoption of health
IT systems, it should take care not to mandate or prescribe any
particular technology or development model. Doing so could deprive
healthcare providers of the best available solutions, exclude scores of
American companies and workers from competing to supply these
solutions, and weaken incentives for further private-sector investment
and R&D--just when we as a Nation should be trying to strengthen these
incentives. To the extent Congress seeks to influence the development
or adoption of health IT systems, it should set forth objective,
technology-neutral goals and criteria that these systems should meet,
such as those relating to security, privacy, interoperability, and
total cost of ownership. It should then open the door to all companies
to compete for the opportunity to supply health IT solutions that
satisfy these criteria.
Reward innovative doctors who make the Internet the
foundation of the patient-physician connection. The Internet has
created a society that has access to, and demands access to, up-to-date
information around the clock. Patients need information about their
medical conditions, appropriate drugs or treatments, pre-procedure
instructions, and post-visit follow-ups. The Internet is the most
efficient way for doctors to provide the ``trusted information'' that
consumers want. But the fixed-price nature of physician reimbursement
means that innovative doctors have no incentive to deliver this kind of
additional service. Physicians should be encouraged to embrace basic
Internet technologies that allow them to communicate more effectively
and consistently with their patients.
Provide incentives for sharing data. We believe that it is
critical to seamlessly connect data and empower individuals to take
control of their health and wellness. We hope that those in the public
sector will facilitate the transformation of health data into a vital
asset by removing barriers to data sharing and providing incentives for
data exchanges that reduce costs, increase value, and improve the
quality of care.
Focus on making data interoperable today, not waiting for
standards tomorrow, and insist that vendors separate data from
applications. Microsoft is committed to the development of
interoperability standards and works diligently with the rest of the
industry to reach consensus on those standards, but exchanging
healthcare data cannot wait--we need a migration path now. Today, data
is too often used for a single application or a single purpose, then
thrown away once that purpose is complete. We can use metadata--the
details that describe the data and how it has been captured--to ensure
that data is kept alive and made available for reuse, no matter what
its original application or purpose. By insisting that vendors supply
IT that allows data transfers to and from other non-vendor
applications, we can get data moving better and faster between
different systems today, without waiting for standards that may take
years to complete. Better use of metadata will pave the way for
integrating legacy data with standards-based data once these standards
are more widely adopted.
Enable the private sector to develop an information
infrastructure that connects data, systems, and people. To move from
today's fragmented delivery system to tomorrow's connected network, we
need technology infrastructure--``plumbing''--that allows data to flow
freely throughout the system and be reused. Without it, we will
recreate our disconnected paper system in the virtual space. This
infrastructure must be (1) flexible, to enable many different players
across the ecosystem to do what they need to do; (2) interoperable, to
leverage existing standards and infrastructure investments that work
toward more unified ways of organizing and sharing data; (3) scalable,
to adapt to the rate of medical and technology advances; and (4) secure
and private, to foster consumer trust.
iv. how microsoft can help: our investments in health it
More than 12 years ago, Microsoft started making investments in the
health industry. We saw software and the Internet as essential tools to
transform healthcare, as they have so many other industries--opening
new ways of working, new ways of communicating, and new economics. We
have steadily increased our investments and commitment to health
globally. Our vision was simple--to improve health around the world
through software innovation. From the beginning, we have thought about
improving health in the developed world as well as developing
economies. We have focused globally on openness and interoperability to
drive truly scalable solutions that can benefit all.
We are concerned with the current focus on electronic medical
records (EMRs) as a panacea. While some forms of EMRs are necessary,
they represent only a part of the solution. The future vision we
describe is far broader than simply making records electronic.
We have a set of solutions in the market facilitating the
connection and sharing of data for consumers and large health systems
to help them build their health data assets.
A. Empowering Consumers to Access, Consolidate, and Share Their Health
Data
For consumers, we launched HealthVault, a privacy and security-
enhanced data storage and sharing Internet-based platform. People can
use HealthVault to store copies of their health records from providers,
plans, pharmacies, schools, government, or employers; upload data from
home health devices like blood glucose monitors and digital scales;
provide data to health care providers, coaches, and trainers; and
access products and services to help improve their health. We worked
with leaders across the industry to ensure that the right privacy and
security standards would be in place, and we are seeing momentum
starting to happen. Since launching, we have enabled 50 devices, have
40 live applications--services on top of HealthVault such as PHRs,
alert services, etc.--and signed 91 partners across the country,
including leading organizations like Aetna, Kaiser Permanente,
Cleveland Clinic, and the Military Health System.
Of particular note is a pilot project with Cleveland Clinic that
could have a wide-ranging impact on care--extending care to the home
from traditional hospitals and doctors' offices. It is the first pilot
in the country to follow multiple diseases (it addresses chronic
disease management in the areas of diabetes, hypertension, and heart
failure) in the clinical delivery setting using multiple at-home
devices including glucometers, heart rate monitors, weight scales, and
blood pressure monitors. Patients enrolled in the pilot upload device
data to HealthVault using a home computer, and Cleveland Clinic
downloads the data into the patients' Cleveland Clinic MyChart
accounts, creating an online log of the readings available for
physicians. We are particularly excited about the results of the pilot.
Monitoring constant data, and having it shared in an efficient way with
physicians, can result in better quality of life and increased
efficiency. Even possible is the avoidance of acute care incidents,
impacting expense.
B. Empowering Health Systems to Provide Patient-Centric Care
For hospitals and health systems, just under a year ago, we
launched Amalga, our family of data sharing and intelligence solutions,
which connect a hospital's or health system's existing legacy systems
and any new systems. This allows patient data to be viewed and queried
holistically, enabling a shift from departmentally focused systems to
more patient-centric systems. Amalga has been adopted by many leading
health organizations--Johns Hopkins, New York Presbyterian, Mayo
Clinic, MedStar Health, St. Joseph Health System, Moffitt Cancer Center
and Research Institute, District of Columbia Primary Care Association,
Wisconsin Health Information Exchange, Novant Health, Children's
Healthcare of Atlanta, and the University of Washington.
Of particular note is the Wisconsin Health Information Exchange
(WHIE), the first health information exchange to use Amalga. Eight
months ago, the WHIE set specific goals to improve physician
decisionmaking and quality care in their emergency rooms. The project
aggregates patient data from State Medicaid claims, 13 area hospitals,
and more than 110 hospital-associated clinics in southeast Wisconsin.
Amalga presents a single view of aggregated patient data, in real-time,
to emergency department doctors at five area hospitals. Gaining a
comprehensive view of a patient--including pharmacy prescription data,
imaging and lab procedures, current and previous diagnoses as well as
hospital admission, discharge, and transfer records--enables emergency
room doctors to make fully informed decisions about the patient's care
in time-critical situations. The benefits include reduced errors, more
efficient care (physicians can see if tests have already been done so
that tests are not repeated), and more effective ways to treat patients
(physicians can see if patients have been to the ER multiple times,
enabling them to follow up more aggressively or put patients on a
different care routine to avoid further ER visits).
The early success of the WHIE Project has prompted Humana, one of
the Nation's largest health benefits companies, to provide an incentive
to providers for utilization of the WHIE. As part of its emergency care
initiatives, Humana has entered into a pilot program with the WHIE. In
this program, Humana recognizes the value of applying health
information exchange technology, and its impact on avoiding duplication
of services, and has agreed to provide a WHIE-administered incentive to
ER physicians for utilization of the tool.
As we move into 2009 and beyond, we will expand our products and
develop a new generation of software and services to help support and
speed the move towards efficient, data-driven medicine.
When we wanted to go to the moon, we did not focus on spending
exorbitant amounts of money to build a rocket. We set the goal of
landing on the moon, and we used money, technology, and innovation to
make it happen. Once health objectives are set, stakeholders in the
health ecosystem can figure out the right technology to reach the goals
as efficiently and effectively as possible.
Microsoft looks forward to collaborating with the public sector and
others in industry to drive real change in our healthcare system. Thank
you for the opportunity to appear before you today.
______
Reinventing Healthcare Through Health Information Technology
the future
Dynamic, Personalized, Consumer-Driven Healthcare. At Microsoft, we
have a powerful vision for how technology can improve healthcare, much
broader than simply the use of electronic medical records. We envision
a connected health ecosystem that delivers predictive, preventive, and
personalized care. We see:
Patients as consumers.--Experiencing more control, more
convenience, better service, and ultimately better value for what they
spend on healthcare.
Physicians as knowledge workers.--Professionals getting
the right data in the right format at the right time to provide the
best treatment and preventive care.
A learning healthcare system.--One that measures
everything, identifies errors, and makes improvements in order to
deliver value.
This new system will enable a data-centered approach to healthcare
that shifts the priorities from treatment and cure to prevention and
lifelong wellness.
the blueprint
A Scalable, Patient-Centric Health IT System. Instead of allowing
healthcare professionals to control the patient experience and
healthcare facilities to control patient records, individuals are now
poised to take greater responsibility for their overall health and
wellness. Technology can drive this transformation by:
Encouraging better outcomes and more innovation. Under
today's flat-fee system, most physicians are not reimbursed for
telephone or e-mail consultations, let alone more advanced uses of
technology. In contrast, providers who compete on price and quality are
constantly looking for ways to improve service.
Connecting patient data. Because patients' health data is
locked in silos, physicians are forced to either make treatment
decisions based on incomplete data, or else waste time and resources
aggregating information. A complete health history would enable
providers to make better medical decisions, decrease wasteful spending,
and increase the quality of care.
Empowering consumers. If consumers could connect all their
health and wellness data electronically, share their data securely with
different providers, and keep it in one place over time, they would
have information at their fingertips to make better choices about
physicians, care options, and ways to improve their overall well-being.
the next steps
Recommendations for Moving Forward. To facilitate the use of health
IT, we need to:
Encourage innovation in health IT by setting out objective
goals and criteria, not by mandating specific technologies or
development models. The proposed ``open source'' preference would
disadvantage a broad range of innovative, cost-effective health IT
offerings already available in the market and undermine incentives for
further industry investment in health IT. Rather than require the
Administration to adopt a particular technology or development model,
Congress should establish a framework based on objective, neutral
criteria and then encourage all companies to compete on the merits.
Reward innovative doctors who make the Internet the
foundation of the patient-physician connection. Physicians should be
encouraged to embrace basic Internet technologies that allow them to
communicate more effectively and consistently with their patients.
Provide incentives for sharing data. Removing barriers on
data sharing and providing incentives for data exchanges would help
shift healthcare economics, from expensive acute care setting to smart
services in the home.
Focus on making data interoperable today, not waiting for
standards tomorrow, and insist that vendors separate data from
applications. Vendors need to supply IT that allows data to be
separated from applications and made available for reuse. Metadata-
driven interoperability can get data moving better and faster between
different systems today.
Enable the private sector to develop an information
infrastructure that connects data, systems, and people. A system that
is flexible, interoperable, scalable, private, and secure will ensure
that data flows freely and is reused.
Microsoft is developing health IT solutions that facilitate the
connection and sharing of data. We look forward to collaborating with
the public sector and others in industry to drive real change in our
healthcare system.
Senator Mikulski. That was excellent and meaty. I hope you
are not recommending that we develop a health score because for
each and every one of us, there would be a lot of pass and
fails going along with it. But I think this is exactly what we
were looking for.
Before we go to you, Ms. Grealy, I want to acknowledge and
welcome a new member to the HELP Committee, Senator Merkley
from the State of Oregon.
Senator, we welcome you and look forward to your active
participation. We are taking our testimony, and I will be
asking some questions, and we will be sure to turn to you.
Senator Merkley. Thank you very much.
Senator Mikulski. Ms. Grealy.
STATEMENT OF MARY GREALY, PRESIDENT, HEALTHCARE LEADERSHIP
COUNCIL, WASHINGTON, DC
Ms. Grealy. Chairman Mikulski and members of the committee,
I want to thank you on behalf of the members of the Healthcare
Leadership Council for this opportunity to testify on health
information technology as a vital component of both economic
recovery and healthcare reform.
Last Sunday on ABC News, President-elect Obama expressed
again his determination to invest in health information
technology to make our healthcare system better, to reduce
medical errors, and to save Americans money. We could not be
more supportive of the President-elect's priorities.
There is considerable evidence of the impact, both on our
finances as well as our well-being, of HIT. Let me cite just
one example.
One of our members, NorthShore University HealthSystem of
Evanston, IL, has an electronic health record system that was
implemented in 2003. Today, over 50,000 NorthShore patients can
schedule appointments, refill prescriptions, or communicate
with their doctors via the Internet.
Thanks to the ability to immediately check whether patients
are receiving conflicting medicines, they have reduced
medication error rates by 80 percent.
Senator Mikulski. Whoa.
Ms. Grealy. Thanks to the ability also to quickly identify
infections in patients upon admission and their ability to
manage those infected patients, they have reduced their MRSA
infections by 70 percent.
Well, it is no wonder that HHS estimates savings as high as
$400 billion over a 5-year period if we implement a national
health information network. But how do we get to this bright
future?
There are three critical steps. The first is to create
funding mechanisms to assist healthcare providers with the
large infrastructure investments necessary for them to take
part in the HIT revolution.
As you noted, only a small percentage of physician offices
and 20 to 25 percent of hospitals have adopted an electronic
record system, and the predominant obstacle cited is cost.
Investing in HIT through economic recovery or stimulus
legislation would be a tremendous catalyst.
Second, we need to encourage innovation in the field of
standards development and foster innovation, which is
absolutely essential to achieving nationwide interoperability.
We firmly believe that the private sector should work
collectively to develop a road map for an effective, efficient
health information exchange.
The newly announced National eHealth Collaborative is
poised to do effective work in this regard, and it is an
important responsibility for the Federal Government to ensure
that all involved stakeholders are at that collaborative table.
And finally, the Healthcare Leadership Council believes
that engendering patient and consumer trust in the electronic
exchange of information will be paramount to successful
implementation of HIT. Progress hinges on striking a critical
balance, protecting privacy while ensuring that medical
professionals have ready access to the information that they
need to save lives and provide quality care.
As I noted earlier, Senator Mikulski, the evidence is
clear. HIT development will pay substantial dividends in the
form of healthier Americans, improved care, and lower cost. Our
members have absolutely seen the return on the investment that
they have made.
Including HIT funding in the economic recovery stimulus
measure will be a down payment on a brighter future that
deserves our enthusiastic support. We look forward to working
with you not only on HIT, but also on that larger issue of
healthcare reform.
Thank you.
[The prepared statement of Ms. Grealy follows:]
Prepared Statement of Mary R. Grealy
Senator Mikulski and other members of the committee, I want to
thank you on behalf of the members of the Healthcare Leadership Council
(HLC) for the opportunity to testify on health information technology
(HIT) funding as an important component of economic stimulus and its
role in health care reform.
My name is Mary Grealy and I am president of the Healthcare
Leadership Council (HLC), a not-for-profit membership organization
comprised of executives of the Nation's leading health care companies
and organizations. Fostering innovation and constantly improving the
affordability and quality of American health care are the goals uniting
HLC members.
Last May, HLC released Closing the Gap: A Proposal to Deliver
Affordable, Quality Health Care to All Americans. This proposal
represented months of work and collaboration among HLC members and an
acknowledgment that health care must be delivered more efficiently,
safely, and effectively in this country. Widespread adoption of HIT
affords us the opportunity to accomplish all of those things and more.
Members of HLC--hospitals, academic medical centers, health plans,
pharmaceutical companies, medical device manufacturers, biotech firms,
health product distributors, and pharmacies--have seen firsthand what
widespread adoption of HIT can mean to patients.
Several HLC member organizations are among the pioneers of health
information technology. The collective experiences and achievements of
these early adopters leads us to believe that HIT has the capability to
transform our health care system by providing increased efficiencies in
delivering health care; contributing to greater patient safety and
better patient care; and achieving clinical and business process
improvements. In combination with improvements to health care payment
and delivery systems, HIT could have an even greater impact on
improving health outcomes and lowering costs.
While many HLC members have embraced the promise of HIT, as many
have testified before this and other committees of Congress in the past
few years, physician and hospital uptake of this technology has been
slow to date. Health care lags behind other industries in embracing
information technology. When surveyed as to the reasons why they are
hesitant to ``go electronic,'' non-adopters often cite many reasons--
ranging from confusion or lack of understanding of new systems to
liability concerns. But time and again, cost is identified as the most
substantial barrier to widespread adoption and use of HIT.
In my testimony I will discuss the ways in which HIT brings greater
quality and value to our health care system. I've included as part of
my written statement an attachment (see Attachment 1) that describes
how various HLC member companies and organizations have already
achieved significant success utilizing information technology.
I also will outline the need for congressional action to remove
barriers to nationwide adoption of HIT by creating funding mechanisms
to assist health care providers with the sizable IT infrastructure
investments that are necessary if they--and their patients--are to be
part of this technological revolution. Lastly, I will address the need
for Congress to oversee the development of national, uniform standards
and address privacy concerns as part of an interoperable health
information network.
the benefits of hit
HIT holds the potential to move our country toward truly patient-
centered health care. The value proposition of HIT is putting tools in
place to empower patients and physicians to make better decisions with
more information at their fingertips. At the consumer level, HIT will
help patients navigate their health care journey and arm them with
decisionmaking abilities that have been elusive due to the lack of
meaningful and actionable information at their disposal. This would
lead to improvements in care management by empowering patients, their
care givers and providers with critical information to improve care
continuity and health outcomes.
Many HLC members are using electronic health records and other
forms of HIT and documenting their successes. For instance, one of our
members, NorthShore University HealthSystem of Evanston, IL, has
operated a patient-centric electronic health record (EHR) system since
2003. Over 50,000 of NorthShore's patients enjoy a direct link to the
system on their home computers and PDAs, which enables them to schedule
appointments online, refill prescription drug orders, and communicate
with their primary care providers.
Since that time, NorthShore has garnered concrete evidence that
EHRs are a critical tool that can improve care quality and patient
satisfaction, as well as create efficiencies that lead to a positive
return on investment. For example, they have cut in half the amount of
time it takes to deliver the first dose of medication to an inpatient
because of the speed with which they can check the possibility of
conflicting medications or allergic reactions. This has resulted in a
medication error reduction rate of close to 80 percent.
Furthermore, a March 2008 study in The Annals of Internal Medicine
that was also reported in The Wall Street Journal, demonstrated a 70
percent reduction in MRSA infections at the three hospitals in
NorthShore's system. The use of HIT to identify infections and manage
affected patients across the health care system was crucial to this
undertaking.
HLC believes that the establishment of similar nationwide health
information connectivity among physicians, and health care
professionals such as home health aides, care managers, health plans,
and others across the continuum of care, will dramatically improve both
the quality and effectiveness of care. That is not to say that we
believe HIT is the ``silver bullet'' that will address all of the
health care challenges we face. We believe, though, that combined with
comprehensive health system reform, HIT is a critical component in
lowering health care costs over the long-term and providing safe,
effective, efficient and equitable patient care.
Another way in which HIT would improve quality is by reducing or
eliminating duplicative medical care and over-utilization, which the
National Priorities Partnership has identified as one of the six areas
on which quality improvement efforts should focus. William Yasnoff,
former Senior Advisor on the National Health Information Infrastructure
for the U.S. Department of Health and Human Services (HHS), posits that
20 percent of all laboratory tests and radiology studies are redundant,
performed because the results of previous tests are not available at
the point of care. HHS estimates that nationally, savings could reach
more than $400 billion through the implementation of a national health
information network.
Perhaps the greatest benefit of HIT is its potential to reduce
medical errors. As is the case in other industries, technology in
medicine will help to prevent the incidence of human error. A February
2008 USA Today article and an Auburn University study show that as
Americans age, the projected odds of getting a prescription that
results in a serious, health-threatening error is about 1 in 1,000.
That could amount to 3.7 million such errors a year, based on 2006
national prescription volume. (USA Today. ``Five-year-old Took Wrong
Medication for Two Months.'' Brady, E. and McCoy, K., 2/12/08)
The HHS projects that medication errors alone cost the health care
system $76 billion per year (Yasnoff). For example, one of the most
common errors in medication use history occurs when a patient or other
caregiver forgets to tell a physician or nurse about a medication that
is taken at home; a computerized physician order entry system cannot
detect this omission without linkage to a community pharmacy database,
which could integrate the patient's medication history with the
physician's electronic record for that patient. This all points to the
need for a unified EHR to serve as a single source of comprehensive
clinical information across settings.
By having patient data, including laboratory and radiographic
results, instantly available to the patient and any provider of the
patient's choice via an interconnected network, HIT improves the
ability of health care professionals and patients to make more informed
decisions and avoid providing duplicative and redundant services.
Furthermore, reconciliation of medications will decrease the likelihood
of omission errors when medications are included in a unified EHR.
Thus, errors of omission and commission can be prevented; both
resulting in savings and, even more importantly, enhanced patient
safety.
HLC member companies have already demonstrated that medical errors
can be reduced by deploying proven technologies, including bedside bar-
coded medication administration systems, widespread e-prescribing, and
secure online, ``anytime, anywhere'' access for physicians to critical
patient medication information.
Widely-implemented, interoperable and effectively utilized HIT also
maintains the capability to improve population health by enabling
advances in critical, oftentimes lifesaving, efforts. For example, data
which could assist in early detection of a bioterrorism event include
many categories of information, much of which would be derived from
hospital computer systems, clinical laboratories, electronic health
record systems, medical examiner recordkeeping systems, and 911 call
center computers. Other efforts, such as monitoring the safety of drugs
and devices through post-market safety surveillance, as well as linking
interoperable standards to health care quality reporting efforts, are
an important means to improving quality and value in our health care
system.
Pressure is mounting for reform of current payment policy to
encourage quality improvement, transparency and efficiency.
Consequently, there is a growing need to measure the efficacy and
efficiency of health care delivery. HLC believes the health care
delivery system needs rapid adoption of HIT interoperability standards
that not only facilitate the clinical management of an individual
patient but that also support the ready aggregation of data for quality
and safety measurement and reporting.
Currently, most EHRs cannot transmit quality data for reporting. As
a result, hospitals must use a manual and resource intensive process to
report mandatory quality data. It is not uncommon to see a nurse
reviewing a patient record in an EHR, writing down the information
needed and then entering that information into a quality reporting tool
because there is no way to automatically extract the required data from
the EHR to feed the quality reporting tool. To alleviate this problem,
the Federal Government should require the adoption of transaction and
semantic interoperability standards for the storage and transmission of
data captured within EHRs. Further, the standard-format data captured
in EHRs should be readily accessible to be transmitted to quality
reporting systems.
Lastly, there is growing interest in comparative effectiveness
research and evidence-based medicine to assist providers in evaluating
the best care for patients. A well-functioning HIT system would be a
crucial component of disseminating comparative effectiveness
information to providers at the point of care. HIT tools such as
Clinical Decision Support help providers gain easier access to the most
current practice guidelines and evidence-based medicine information
during patient encounters. Furthermore, initiatives aimed at chronic
disease management are much more easily facilitated by an automated
health care system.
federal funding to spur adoption of hit
Given the benefits of HIT to the Nation's health care system, HLC
believes that it is critical that the Federal Government invest funds
to promote the widespread implementation of HIT.
Though some providers have begun the transition to electronic
medical records (EMR), most medical records are still stored on paper.
The United States lags behind many other countries in its use of EMRs.
Only 15 to 20 percent of U.S. physician offices and 20 to 25 percent of
hospitals have adopted some version of an EMR system, and the majority
of these systems can't effectively interconnect through networks to
coordinate care with other health care providers. (RAND)
In 2003, HLC established a Technical Advisory Board, comprised of
clinicians and others with information technology expertise within HLC
and other organizations, to provide insights regarding their HIT
implementation experiences. In this and other more recent surveys, the
high cost of HIT systems is repeatedly cited as a barrier to effective
implementation. In addition to the front-end cost of investment, there
are significant initial and ongoing maintenance and operational costs
for HIT, including software, hardware, training, upgrades, and
maintenance. Systems are virtually unaffordable for those providers who
do not have ready access to the operating capital needed for such an
investment. This reality is especially prevalent among rural providers,
who are most likely to need help overcoming the financial and
workforce-based barriers to connecting their practices to a nationwide
system.
To date, while there has been considerable discussion and desire to
enact legislation that would provide this much-needed capital, Congress
has yet to complete action. Investing in HIT through an economic
recovery package will help lead the way toward a ``recovery'' of our
Nation's health care system. HLC believes that the Federal Government
should provide a robust impetus to the Nation's implementation of HIT
through financial incentives and funding mechanisms to help providers
defray the huge costs of acquiring and operating HIT. Congress has
significant interest in doing so both as a major payer of health care,
through the Medicare, Federal Employee Health Benefits Program, and
other Federal programs, and to further the quality of the Nation's
health at-large. For example, as evidenced during natural disasters
such as Hurricane Katrina, interoperable HIT is a critical component to
successful public health responses during emergency situations.
While grants and contracts from the Agency for Healthcare Research
and Quality (AHRQ) and the Office of the National Coordinator for
Health Information Technology (ONCHIT) help to support the development
of a national information network, we need to do more to get every
provider using electronic health records now.
HLC advocates the implementation of multiple HIT funding
mechanisms. These could include:
payment rewards or ``add-ons'' for health care services
administered in conjunction with the use of HIT;
a revolving low-interest loan fund with debt forgiveness
in accordance with specified criteria, such as long-term savings to the
Medicare trust fund
tax incentives for physicians, hospitals, and other health
care entities;
reimbursement incentives based on improved patient
outcomes;
matching private funds with public funds through grants
from the HHS; and
revising the exceptions to the physician self-referral
(Stark) and anti-kickback rules that allow hospitals to share their HIT
investment with physicians.
We look forward to working with the committee to determine how
Congress might best be able to assist in this regard.
It is important to note that funding initiatives need not be
limited solely to promoting physician uptake of EHRs. HIT systems such
as safe medication technologies, e-prescribing, telemedine, and
educational and training initiatives will all need to be part of a
successful strategy to digitize our health system. Expanded funding
directed not only to physicians and hospitals, but also to other health
care professionals who touch all aspects of the delivery of care
supports a tangible move from reactive, episodic care to a fully-
integrated continuum of care.
national standards to insure interoperability
In the area of standards, several public and private sector
initiatives are making great strides in identifying and developing HIT
interoperability standards that will enable disparate systems to
``speak the same language.'' The Health Information Technology
Standards Panel (HITSP) has made considerable progress testing these
standards, and the work of the Certification Commission for Health
Information Technology (CCHIT) complements these efforts by certifying
that products are compliant with criteria for functionality,
interoperability and security. This will help reduce provider
investment risks and improve user satisfaction.
Aside from cost, providers also routinely express concerns that
systems they choose to purchase now could become second-rate or
obsolete. Continuing the standards development and certification work
that is already in progress can help assure them that systems they
adopt now can be easily upgraded to facilitate ongoing
interoperability.
HLC believes, first and foremost, that in setting national
standards to ensure interoperability, we must also continue to
encourage innovation in the field of standards development. We firmly
believe that the private sector should work collectively to develop a
roadmap for effective health information exchange that specifies the
priorities and the standards necessary to make such an exchange
possible. The newly announced National eHealth Collaborative, formerly
the AHIC Successor, is poised to continue the important work that the
American Health Information Community started. Such standards will
foster smooth and efficient communications and cooperation, regardless
of individual system structure or architecture. Among other things,
this work should address the increasing need for data, connectivity,
interface, and communications standards. The health care industry also
needs standards for commonly accepted clinical definitions, vocabulary,
and terminology. Currently, a great deal of data goes into systems, but
little automatically comes out in a way that readily supports health
care providers and researchers.
While it may seem appropriate to write standards-setting into
statute, care should be taken to assure that existing activities are
not duplicated or hampered by new efforts. The Federal Government can
assist these activities by ensuring that all interested stakeholders
are seated at these collaboratives (including those representing public
entities) and that standards being developed align with the policy
goals for national HIT. Harmonized technical standards to facilitate
reporting quality measures, for example, would be one such requirement.
privacy
With the development of electronic data exchange comes renewed
concern over the privacy and security of health information. HLC has a
longstanding involvement in the debate over health privacy and, through
its chairing of the Confidentiality Coalition, played an integral role
in the promulgation of the Health Insurance Portability and
Accountability Act (HIPAA) Privacy and Security rules.
HLC strongly believes that engendering patient and consumer trust
in EHR and other applications will be paramount to successful
implementation of HIT. Thus, we continue to advocate for a balanced,
consensus-driven approach to setting privacy policy as it relates to
HIT. We recognize that, as we move towards widespread use of HIT, some
aspects of the HIPAA Privacy Rule will need to be updated to meet these
emerging privacy and security concerns. For example, meaningful
notification of privacy or security breaches is an important
improvement necessary to protect individuals whose identifiable health
information has been compromised. We also have proposed that holders of
personal health information not covered under HIPAA be held accountable
to equitable and enforceable privacy standards.
Developing a multi-state, interoperable system depends not only on
national technical standards but also on national uniform standards for
confidentiality and security. Because the HIPAA Privacy Rule's
preemption standard permits significant State variation, providers,
clearinghouses and health plans are required to comply with the Federal
law as well as many State privacy restrictions that differ to some
degree from the Federal HIPAA Privacy Rule.
We believe congressional action to establish a uniform Federal
privacy standard is vital in order to ensure the viability of a
national health information network. State health privacy protections
vary widely and are found in thousands of statutes, regulations, common
law principles and advisories. Health information privacy protections
can be found in a State's health code as well as its laws and
regulations governing criminal procedure, social welfare, domestic
relations, evidence, public health, revenue and taxation, human
resources, consumer affairs, probate and many others. Virtually no
State requirement is identical to the Federal rule.
Addressing this issue appropriately will be essential to achieving
the interoperability necessary to improve the quality and cost
effectiveness of the health care system--while still assuring patients'
confidence that their information will be kept private.
conclusion
In looking at the original HIT recommendations that HLC developed
and issued in 2004, it is clear that there has been progress since that
time.
Legislation to facilitate greater adoption of HIT enjoys bipartisan
support and continues to gain momentum. Senate action in the past 2
years suggests that we are close to reaching consensus on the details
surrounding HIT policy, such as standard setting and privacy and
security policy. We believe that legislation that would begin to build
an HIT infrastructure offers Congress a clear and important opportunity
to improve our health care system. By creating a dedicated funding
source and facilitating the development, adoption, and use of
interoperable standards, legislation can focus on areas in which
Congress must act to remove barriers to widespread adoption.
HIT expansion alone will not enable us to close the gap between the
health care system we have today and the one we are capable of
achieving. We all agree that we need reforms to achieve greater quality
for patients and value for our dollar. The electronic exchange of
health information will be crucial to long-term goals to overhaul our
health care system. Working to build a virtual HIT infrastructure today
will pay dividends over the long-term in the form of healthier
Americans, safer care, and lower costs. For that reason, including
significant funding in the economic recovery package to assist
providers and others to adopt HIT would serve as an important down
payment on the future of our Nation's health and long-term economic
sustainability.
The Healthcare Leadership Council appreciates this opportunity to
testify on HIT. Any questions about my testimony or these issues can be
addressed to me or to Ms. Tina Grande, Senior Vice President for
Policy, Healthcare Leadership Council (telephone 202-452-8700, e-mail
[email protected]).
______
Attachment 1.--Examples of HLC Member Organizations' Successes with
Health Information Technology
Aetna's ActiveHealth CareEngine(r)-powered personal health
record (PHR) helps over 8 million members manage and organize their
health data so that they can work with their physicians to make
informed decisions. Aetna will make this tool available to more members
by the end of 2009. Aetna has also partnered with RxHub and the
National e-Prescribing Patient Safety Initiative (NEPSI) to improve
physician access to decision-support information and e-prescribing
technology.
Aetna was the first health insurer and one of the first employers
to sign the statement of support for the Department of Health and Human
Services' ``Four Cornerstones of Value-Driven Health Care,'' which
calls for the development and use of HIT, as well as tools that provide
quality and pricing information to consumers. To that end, Aetna has
developed an innovative price and clinical quality transparency program
to provide members with doctor and facility specific information.
Aetna is one of the Nation's leaders in health care, dental,
pharmacy, group life, and disability insurance, and employee benefits.
They are one of the Nation's leading diversified health care benefits
companies, serving approximately 37.2 million people with information
and resources to help them make better informed decisions about their
health care.
Amerinet is a group purchasing organization that promotes
quality health care delivery and helps all types of providers more
effectively manage expenses. They specialize in solutions related to
technology, clinical operations, data management, executive-level
decisions, and supply chain management.
An Amerinet member, the Virginia Mason (VM) Medical Center, is a
private, non-profit organization that offers a system of integrated
health services made possible through its large, multispecialty group
practice of more than 480 physicians. Virginia Mason has been testing
telemedicine services in rural areas throughout Washington State and
Alaska for over 10 years, including a live, interactive video feed
between VM and other remote clinics in the Pacific Northwest. This
capability allows them to provide real-time information and store-and-
forward communications related to a variety of medical fields,
including radiology, dermatology, cardiology, and others, to a region
that has been identified as lacking a sufficient health professional
workforce. VM is able to use this service to transmit radiological
studies, consult on diagnosis and referral, and conduct pre- and post-
surgical examinations.
Ascension Health is the Nation's largest Catholic and
largest nonprofit health system, serving patients through a network of
hospitals and related health facilities providing acute care services,
long-term care, community health services, psychiatric, rehabilitation
and residential care.
Spearheaded by Ascension Health, the Austin, Texas-based, Indigent
Care Collaboration (ICC) has demonstrated the effectiveness of HIT in
improving health care for the uninsured and underinsured. Drawing from
funding through Federal and foundation grants, this community
collaborative built I-Care, an integrating information structure
providing for a shared patient record. This HIT system enables the area
safety net providers, including hospitals and outpatient clinics and
health centers, to obtain on a real-time basis a record for each
patient's previous health care encounter. It also permits the ICC to
map patients and diagnoses for health care planning and research;
document, monitor, and manage diseases in the population, and measures
the effects of policy changes on populations in the local region. In
addition to improving the health and lives of vulnerable patients, ICC
has become a self-sustaining business model upon which other
communities can draw for expertise and inspiration.
BlueCross BlueShield of Tennessee is an independent, not-
for-profit, locally governed health plan company that provides health
insurance benefits to Tennessee business customers and plan members.
SharedHealth, an independent subsidiary of BlueCross BlueShield of
Tennessee, is the largest public-private electronic health information
exchange in the United States and has made TennCare the only Medicaid
program in the country to convert all its beneficiaries to an
electronic health record application at the point of care.
By replacing paper-based systems with advanced technologies,
TennCare effectively links authorized clinicians and patients with
secure, up-to-date information at the point of care via an encrypted
web-based system, including previous medical visits, service
utilization, lab results, medications, allergies, and immunizations.
The system also allows physicians to e-prescribe and will soon have
additional function-
ality related to chronic care management.
Recent third-party studies have indicated that consistent
utilization of SharedHealth increases clinician efficiency by 17%,
resulting in savings of approximately $59 per episode of care and $9
per medication prescribed electronically.
Hospira is a global specialty pharmaceutical and
medication delivery company dedicated to Advancing WellnessTM by
developing, manufacturing and marketing products that help improve the
productivity, safety and efficacy of patient care. To meet the needs of
hospitals working to minimize errors, adhere to the best clinical
practices, maintain continuity of care standards and fully utilize
infusion devices, Hospira developed Hospira MedNet Software. Hospira
MedNet Software is a server-based suite of applications designed to
connect data from a hospital's drug information library to infusion
devices throughout the hospital to monitor, control and provide reports
at the device, group or systemwide levels.
The adoption by hospitals of ``smart pumps,'' infusion pumps with
safety software, helps to prevent medication errors at the patient's
bedside. The system helps hospitals define medication dose limits and
track intravenous drug delivery to help prevent errors. It involves
hospital pharmacists with the rest of the hospital team to develop and
program best-practice dose recommendations for the infusion of drugs
into a database that can then be transferred to the pump. HLC members,
Cardinal Health and Baxter International, also manufacture similar
devices.
The Marshfield Clinic is one of the largest private,
multispecialty group practices in the United States today and includes
over 750 physicians in 84 medical specialties and subspecialties
located in over 40 centers throughout northern, central and western
Wisconsin. Although Marshfield Clinic has become synonymous with the
city of Marshfield, Wisconsin, the Clinic's ``community'' goes well
beyond the immediate area, embracing nearly all of Wisconsin and much
of Michigan's Upper Peninsula. Patients from every State in the Nation
and 25 foreign countries were seen in the Clinic system during fiscal
year 2006.
As part of its participation in the 3-year CMS Physician Group
Practice (PGP) Demonstration, Marshfield Clinic has relied on
substantial investments made in tools such as their long-established
telemedicine initiative and an EHR. Using the data in the EHR at the
point of care ultimately allowed clinicians to deliver higher quality
care at a more efficient rate. CMS recently announced that Marshfield
was successful over the first-year of the project in improving quality
of care while controlling costs to Medicare.
Marshfield Clinic has been pioneering integrated computer
technology for patient care for nearly 20 years. The Clinic is
chartless as of 2007. Wireless tablet computers allow access to EMRs
and prescription writing through an advanced electronic prescribing
program called Medications Manager. Marshfield also employs an
application called iList that allows providers to quickly identify and
reach out to patients that have one of three chronic illnesses--
diabetes, heart failure, or hypertension--yet do not meet all of their
recommended health goals.
Mayo Clinic is a non-profit medical practice dedicated to
the diagnosis and treatment of virtually every type of complex illness.
Mayo provides clinic and hospital services at its locations in
Rochester, MN; Jacksonville, FL; and Phoenix and Scottsdale, AZ.
The Automation of the Clinical Practice (ACP) at Mayo Clinic in
Jacksonville, FL is a project undertaken in 1993 to encompass the
computer-based patient record with the addition of the mechanisms for
automated charging and order creation by physicians. This vision was
crystallized and communicated as the ``paperless'' practice of medicine
that would increase patient safety and improve physician effectiveness
while at the same time driving down expenses. The last paper-based
record was circulated in January 1996 and the integrated outpatient
practice continues to the present day.
The Automated Clinical Practice program involves all clinical
users. The areas that are automated now include most aspects of the
practice and examples include:
An electronic medical record (EMR) including all clinical
documents, orders, scheduling, and laboratory.
A fully electronic filmless radiology department with
speech recognition for radiologist documentation.
An automated Intensive Care Unit with EMR integration and
bedside medical device interfaces directly to the EMR.
Inpatient and outpatient surgery areas consisting of
surgical scheduling, material management, and nursing documentation.
From this level of automation patient safety initiatives have been
possible. For example:
Orders automatically generate task lists for nursing,
respiratory, etc., in the hospital.
Automated fall risk assessment and Braden skin scale
assessment are generated in the hospital.
A medical data warehouse allows free text searching
against the entire repository of millions of documents in the EMR for
patient care and research.
An infectious disease application allows bioterrorism
surveillance and automated infection control monitoring.
Dictating notes shifted work from the physician and improved both
legibility and medical record turnaround time. The system allowed for
real time availability of clinical information (notes, Lab, X-ray, and
other results), automatic checking for duplicate redundant orders,
simultaneous access to the same patient chart, improved ability to
answer ad hoc questions for patient calls, more timely response from
physicians when patients have questions, and improved flow of
information to the physician enabling him or her to have a more
``complete'' picture of what is known about the patient's condition at
the time of the appointment. Savings to the organization have been
significant.
McKesson and their subsidiary, McKesson Provider
Technologies, deliver vital pharmaceuticals, medical supplies, and HIT
solutions that touch the lives of more than 100 million patients each
day. McKesson is the world's largest health care services company and a
leader in wholesale delivery of medicines and health care products.
Customers of McKesson Provider Technologies, a leader in the
distribution and deployment of HIT solutions, have demonstrated the
benefits of implementing HIT firsthand. One hospital that introduced
bedside bar-code scanning of medications reduced its already-low
medication error rate by 80 percent and sustained that rate for over 10
years. Additionally, a clinic in the process of deploying an ambulatory
EHR and e-prescribing system reduced nurse time spent on charts by 24
percent and increased time spent with patients by 16 percent.
Similarly, transitioning to electronic charts at a rural medical center
cut the average nurse daily paperwork by 1.5 hours. Examples like these
and many more demonstrate the potential for HIT to improve the quality
and efficiency of care, allowing clinicians to spend more time and
resources on providing better care to patients and less time on
burdensome paperwork.
Pfizer is the world's largest research-based biomedical
and pharmaceutical company, with corporate headquarters located in New
York and major research and development locations in the United States
and England.
Since March 2006, Pfizer has been working with a small group of
other pharmaceutical companies, including other HLC member
organizations, to evaluate and explore how clinical research could be
improved by leveraging the National Health Information Network (NHIN)
and other Health Information Exchanges through an effort called the
NHIN Slipstream Project. This group explored many important ways that
the exchange of health information could improve patient health through
the research, development, and commercialization of new therapies, and
determined that the three most important areas of initial focus in the
ONC NHIN process are: post-marketing drug safety surveillance,
connecting patients to clinical trials, and establishing appropriate
care standards through outcomes, pharmacoeconomic, and personalized
medicine research.
Pfizer has also participated in the Cancer Biomedical Informatics
Grid (caBIG), a voluntary network individuals and institutions to
enable the sharing of data and tools related to cancer research. caBIG
is a partnership between the National Cancer Institute (NCI) and the
private sector to facilitate integration of clinical information and
the growing volume of genomic and proteomic data for the purpose of
advancing development of new therapies. In conjunction with 80
companies as well as NCI, NIH, and FDA, Pfizer is working on the CRIX
(Clinical Research Information eXchange) initiative to expand the caBIG
vision from cancer to other therapeutic areas. caBIG is being built on
open source, open access, open development, and federation principles.
Senator Mikulski. Thank you. And just the data that you
gave on saving--I remember earlier in my own remarks, I said
quality is about saving lives or improving the delivery of
service and then saving money. And what you are saying, we
already have demonstrable evidence that in very specific areas,
even in so-called e-prescribing, it has had a tremendous
impact.
Really, you know, my background is that of a social worker.
And I love case examples because I think that is when you can
get the picture of really what is the impact. But in listening
to Mr. Cochran, what are some of the speed bumps and potholes
not only in the technology, because we will focus on developing
the technology. But it is really people--providers, including
nurses, physician's assistants, diabetic educators who know
what the doctors told the patient--I think this is what you are
talking about.
Because it is a network even among a variety of providers,
not only M.D. to M.D. Am I correct in that?
Ms. Grealy. Right.
Senator Mikulski. Yes, OK.
Well, now, Ms. Melvin, let us hear from GAO.
STATEMENT OF VALERIE MELVIN, DIRECTOR, INFORMATION TECHNOLOGY,
THE GOVERNMENT ACCOUNTABILITY OFFICE (GAO), WASHINGTON, DC
Ms. Melvin. Thank you, Madam Chairwoman, Senator Merkley.
I am pleased to be here today to comment on Federal efforts
to advance the use of health information technology. Properly
implemented, technology can, as you have noted, help make
patients' information more readily available to healthcare
providers, help reduce medical errors, and contribute to
streamlined administrative functions, all of which could help
improve the efficiency and the quality of healthcare.
Yet achieving the transition to a nationwide capability is
a complex endeavor involving many stakeholders, technologies,
and activities, and the best way to accomplish this has been
subject to much debate.
Over the years, our various reviews of Federal health IT
initiatives have determined that a successful transition will
require addressing a range of important issues, as have been
noted here today, three of which I am highlighting.
First, clearly defined health IT standards are needed to
allow different systems to work together and to provide the
right people access to the information they need. For example,
technology standards must be agreed on, and a host of content
issues must be addressed, such as the need for consistent
medical terminology.
We previously recommended that HHS build the mechanisms and
structures for defining such standards, and the National
Coordinator for Health IT responded by tasking key
organizations to address this issue. However, while progress
has been made, continued work on standards initiatives remains
essential to extend the use of health IT and fully achieve its
potential benefits.
Second, because achieving interoperable health IT involves
many stakeholders, technologies, and activities over an expanse
of time, it is important that they be guided by comprehensive
plans that include milestones and performance measures to allow
the results of activities to be monitored and assessed and
corrective actions to be taken as needed.
Yet across our work at HHS and elsewhere, we have seen
repeated instances in which planning activities have not been
sufficiently comprehensive. A framework for strategic action
that the national coordinator released in July 2004 lacked
these components, and we have noted similar management
weaknesses in DOD's and VA's health IT efforts.
Last July, HHS released a new strategic plan. And if the
milestones and measures contained therein are appropriate and
properly implemented, this could help to further overall
progress toward an interoperable health IT infrastructure.
Finally, a consistent approach to privacy protection is
needed to help encourage public acceptance and adoption of
electronic health records. We have identified key privacy
principles and challenges that this approach would need to
address, such as obtaining individuals' consent to use and
disclose their personal health information.
Although HHS has begun to establish such an approach, more
is needed, including a process to ensure that key privacy
principles and challenges we identified are fully and
adequately addressed.
Madam Chairwoman, this concludes my prepared statement, and
I would be happy to respond to your questions.
[The prepared statement of Ms. Melvin follows:]
Prepared Statement of Valerie C. Melvin
Highlights
why gao did this study
As GAO and others have reported, the use of information technology
(IT) has enormous potential to help improve the quality of health care
and is important for improving the performance of the U.S. health care
system. Given its role in providing health care, the Federal Government
has been urged to take a leadership role to improve the quality and
effectiveness of health care, and it has been working to promote the
nationwide use of health IT for a number of years. However, achieving
widespread adoption and implementation of health IT has proven
challenging, and the best way to accomplish this transition remains
subject to much debate.
At the committee's request, this testimony discusses important
issues identified by GAO's work that have broad relevance to the
successful implementation of health IT to improve the quality of health
care.
To develop this testimony, GAO relied largely on its previous work
on Federal health IT activities.
Health Information Technology--Federal Agencies' Experiences
Demonstrate Challenges to Successful Implementation
what gao found
Health IT has the potential to help improve the efficiency and
quality of health care, but achieving the transition to a nationwide
health IT capability is an inherently complex endeavor. A successful
transition will require, among other things, addressing the following
issues:
Establishing a foundation of clearly defined health IT
standards that are agreed upon by all important stakeholders.
Developing, coordinating, and agreeing on standards are crucial for
allowing health IT systems to work together and to provide the right
people access to the information they need: for example, technology
standards must be agreed on (such as file types and interchange
systems), and a host of content issues must also be addressed (one
example is the need for consistent medical terminology). Although
important steps have been taken, additional effort is needed to define,
adopt, and implement such standards to promote data quality and
consistency, system interoperability (that is, the ability of automated
systems to share and use information), and information protection.
Defining comprehensive plans that are grounded in results-
oriented milestones and measures. Using interoperable health IT to
improve the quality and efficiency of health care is a complex goal
that involves a range of stakeholders, various technologies, and
numerous activities taking place over an expanse of time, and it is
important that these activities be guided by comprehensive plans that
include milestones and performance measures. Without such plans, it
will be difficult to ensure that the many activities are coordinated,
their results monitored, and their outcomes most effectively
integrated.
Implementing an approach to protection of personal privacy
that encourages public acceptance of health IT. A robust approach to
privacy protection is essential to establish the high degree of public
confidence and trust needed to encourage widespread adoption of health
IT and particularly electronic medical records. Health IT programs and
applications need to address key privacy principles (for example, the
access principle, which establishes the right of individuals to review
certain personal health information). At the same time, they need to
overcome key challenges (for example, those related to variations in
States' privacy laws). Unless these principles and challenges are fully
and adequately addressed, there is reduced assurance that privacy
protection measures will be consistently built into health IT programs
and applications, and public acceptance of health IT may be put at
risk.
______
Mr. Chairman and members of the committee: I am pleased to be here
today to comment on Federal efforts to advance the use of health
information technology (IT). Studies published by the Institute of
Medicine and others have long indicated that fragmented, disorganized,
and inaccessible clinical information adversely affects the quality of
health care and compromises patient safety. Further, long-standing
problems with medical errors and inefficiencies have contributed to
increased costs of health care. With health care spending in 2007
reaching approximately $2.2 trillion, or 16 percent of the U.S. gross
domestic product, concerns about the costs of health care have
continued to grow, and have prompted calls from policymakers, industry
experts, and medical practitioners to improve the U.S. health care
system.
As has been recognized by you and other members of Congress, as
well as President Bush and President-elect Obama, the use of
information technology to electronically collect, store, retrieve, and
transfer clinical, administrative, and financial health information has
great potential to help improve the quality and efficiency of health
care. The successful implementation of health IT offers promise for
improving patient safety and reducing inefficiencies and has been shown
to support cost savings and other benefits. At the same time,
successfully achieving widespread adoption and implementation of health
IT has proven challenging, and the best way to accomplish this goal
remains subject to much debate. According to the Department of Health
and Human Services (HHS), only a small number of U.S. health care
providers have fully adopted health IT due to significant financial,
technical, cultural, and legal barriers, such as a lack of access to
capital, a lack of data standards, and resistance from health care
providers.
Given its role in providing health care, the Federal Government has
been urged to take a leadership role to improve the quality and
effectiveness of health care and has been working to promote the
nationwide use of health IT for a number of years. In April 2004,
President Bush issued an executive order that called for widespread
adoption of interoperable electronic health records by 2014,\1\ and
HHS, in turn, initiated activities to advance the nationwide
implementation of interoperable health IT. In addition, for the past
decade, the Departments of Defense (DOD) and Veterans Affairs (VA) have
been pursuing initiatives to share data between their health
information systems. In an effort to expedite the exchange of
electronic health information between the two departments, the National
Defense Authorization Act for Fiscal Year 2008 \2\ included provisions
directing the two departments to jointly develop and implement, by
September 30, 2009, fully interoperable \3\ electronic health record
systems or capabilities.
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\1\ Executive Order 13335, Incentives for the Use of Health
Information Technology and Establishing the Position of the National
Health Information Technology Coordinator (Washington, DC: Apr. 27,
2004).
\2\ Pub. L. No. 110-181, Sec. 1635 (2008).
\3\ Interoperability is the ability of two or more systems or
components to exchange information and to use the information that has
been exchanged.
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Since 2001, we have been reviewing aspects of the various Federal
efforts undertaken to implement information technology for health care
and public health solutions. We have reported both on HHS's national
health IT initiatives as well as on DOD's and VA's electronic health
information sharing initiatives.\4\ Overall, our studies have
recognized progress made by these departments, but we have also pointed
out areas of concern that could jeopardize their success in advancing
the use of interoperable health IT. At your request, my testimony today
discusses important issues identified by our work that have broad
relevance to the successful implementation of health IT to further
improve the quality of health care.
---------------------------------------------------------------------------
\4\ GAO, Computer-Based Patient Records: Better Planning and
Oversight by VA, DOD, and IHS Would Enhance Health Data Sharing, GAO-
01-459 (Washington, DC: Apr. 30, 2001); Computer-Based Patient Records:
VA and DOD Efforts to Exchange Health Data Could Benefit from Improved
Planning and Project Management, GAO-04-687 (Washington, DC: June 7,
2004); Health Information Technology: HHS Is Taking Steps to Develop a
National Strategy, GAO-05-628 (Washington, DC: May 27, 2005); Health
Information Technology: HHS is Continuing Efforts to Define its
National Strategy, GAO-06-1071T (Washington, DC: Sept. 1, 2006);
Information Technology: DOD and VA Have Increased Their Sharing of
Health Information, but More Work Remains, GAO-08-954 (Washington, DC:
July 28, 2008); Health Information Technology: HHS Has Taken Important
Steps to Address Privacy Principles and Challenges, Although More Work
Remains, GAO-08-1138 (Washington, DC: Sept. 17, 2008); and Electronic
Health Records: DOD and VA Have Increased Their Sharing of Health
Information, but Further Actions Are Needed, GAO-08-1158T (Washington,
DC: Sept. 24, 2008).
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In developing this testimony, we relied largely on our previous
work. We conducted our work in support of this testimony between
December 2008 and January 2009 in Washington, DC. All work on which
this testimony is based was performed in accordance with generally
accepted government auditing standards. Those standards require that we
plan and perform audits to obtain sufficient, appropriate evidence to
provide a reasonable basis for our findings and conclusions based on
our audit objectives. We believe that the evidence obtained provides a
reasonable basis for our findings and conclusions based on our audit
objectives.
In summary, transitioning to a nationwide health IT capability is
an inherently complex endeavor. Achieving this transition and the
potential efficiencies and quality improvements promised by widespread
adoption of health IT will require consideration of many serious
issues, including the need for a foundation of clearly defined health
IT standards that are agreed upon by all important stakeholders,
comprehensive planning grounded in results-oriented milestones and
measures, and an approach to privacy protection that encourages
acceptance and adoption of electronic health records.
Developing, coordinating, and agreeing on standards are
crucial for allowing health IT systems to work together and to provide
the right people access to the information they need. Any level of
interoperability depends on the use of agreed-upon standards to ensure
that information can be shared and used. Developing and implementing
health IT standards requires structures and ongoing mechanisms that
include the participation of the relevant stakeholders, in both the
public and private health care sectors who will be sharing information.
Although important steps have been taken, additional effort is needed
to define, adopt, and implement such standards to promote data quality
and consistency, system interoperability, and information protection.
Using interoperable health IT to improve the quality and
efficiency of health care is a complex goal that involves a range of
stakeholders, various technologies, and numerous activities taking
place over an expanse of time; in view of this complexity, it is
important that these activities be guided by comprehensive plans that
include milestones and performance measures. Milestones and performance
measures allow the results of the activities to be monitored and
assessed, so that corrective action can be taken if needed. Without
comprehensive plans, it will be difficult to ensure that the many
activities are coordinated, their results monitored, and their outcomes
integrated.
An important consideration in health IT is an overall
approach for protecting the privacy of personal electronic health
information. The capacity of health information exchange organizations
to store and manage a large amount of electronic health information
increases the risk that a breach in security could expose the personal
health information of numerous individuals. Addressing and mitigating
this risk is essential to encourage public acceptance of the increased
use of health IT and electronic medical records. We have identified \5\
key privacy principles that health IT programs and applications need to
address \6\ and key challenges that they need to overcome.\7\ Unless
these principles and challenges are fully and adequately addressed,
there is reduced assurance that privacy protection measures will be
consistently built into health IT programs and applications, and public
acceptance of health IT may be put at risk.
---------------------------------------------------------------------------
\5\ GAO, Health Information Technology: Early Efforts Initiated but
Comprehensive Privacy Approach Needed for National Strategy, GAO-07-238
(Washington, DC: Jan. 10, 2007).
\6\ We based these privacy principles on our evaluation of the HHS
Privacy Rule promulgated under the Administrative Simplification
provisions of the Health Insurance Portability and Accountability Act
of 1996 (HIPAA), which define the circumstances under which an
individual's health information may be used or disclosed. For example,
the uses and disclosures principle provides, among other things, limits
to the circumstances in which an individual's protected health
information may be used or disclosed by covered entities, and the
access principle establishes individuals' rights to review and obtain a
copy of their protected health information held in a designated record
set. For more details, see GAO-07-238.
\7\ We identified key challenges associated with protecting
personal health information based on input from selected stakeholders
in health information exchange organizations. These challenges are
understanding and resolving legal and policy issues (for example, those
related to variations in States' privacy laws); ensuring that only the
minimum amount of information necessary is disclosed to only those
entities authorized to receive the information; ensuring individuals'
rights to request access and amendments to their own health
information; and implementing adequate security measures for protecting
health information. See GAO-07-238.
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background
Health care in the United States is a highly decentralized system,
with stakeholders that include not only the entire population as
consumers of health care, but also all levels of government, health
care providers such as medical centers and community hospitals, patient
advocates, health professionals, major employers, nonprofit health
organizations, insurance companies, commercial technology providers,
and others. In this environment, clinical and other health-related
information is stored in a complex collection of paper files,
information systems, and organizations, but much of it continues to be
stored and shared on paper.
Successfully implementing health IT to replace paper and manual
processes has been shown to support benefits in both cost savings and
improved quality of care. For example, we reported to this committee in
2003 \8\ that a 1,951-bed teaching hospital stated that it had realized
about $8.6 million in annual savings by replacing outpatient paper
medical charts with electronic medical records. This hospital also
reported saving more than $2.8 million annually by replacing its manual
process for managing medical records with an electronic process to
provide access to laboratory results and reports. Other technologies,
such as bar coding of certain human drug and biological product labels,
have also been shown to save money and reduce medical errors. Health
care organizations reported that IT contributed other benefits, such as
shorter hospital stays, faster communication of test results, improved
management of chronic diseases, and improved accuracy in capturing
charges associated with diagnostic and procedure codes.
---------------------------------------------------------------------------
\8\ GAO, Information Technology: Benefits Realized for Selected
Health Care Functions, GAO-04-224 (Washington, DC: Oct. 31, 2003).
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There is also potential benefit from improving and expanding
existing health IT systems. We have reported that some hospitals are
expanding their IT systems to support improvements in quality of care.
In April 2007, \9\ we released a study on the processes used by eight
hospitals to collect and submit data on their quality of care to HHS's
Centers for Medicare & Medicaid Services (CMS). Among the hospitals we
visited, officials noted that having electronic records was an
advantage for collecting the quality data because electronic records
were more accessible and legible than paper records, and the electronic
quality data could also be used for other purposes (such as reminders
to physicians). Officials at each of the hospitals reported using the
quality data to make specific changes in their internal procedures
designed to improve care. However, hospital officials also reported
several limitations in their existing IT systems that constrained the
ability to support the collection of their quality data. For example,
hospitals reported having a mix of paper and electronic systems, having
data recorded only as unstructured narrative or other text, and having
multiple systems within a single hospital that could not access each
other's data. Although it was expected to take several years, all the
hospitals in our study were working to expand the scope and
functionality of their IT systems.
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\9\ GAO, Hospital Quality Data: HHS Should Specify Steps and Time
Frame for Using Information Technology to Collect and Submit Data, GAO-
07-320 (Washington, DC: Apr. 25, 2007).
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This example illustrates, among other things, that making health
care information electronically available depends on interoperability--
that is, the ability of two or more systems or components to exchange
information and to use the information that has been exchanged. This
capability is important because it allows patients' electronic health
information to move with them from provider to provider, regardless of
where the information originated. If electronic health records conform
to interoperability standards, they can be created, managed, and
consulted by authorized clinicians and staff across more than one
health care organization, thus providing patients and their caregivers
the necessary information required for optimal care. (Paper-based
health records--if available--also provide necessary information, but
unlike electronic health records, do not provide automated decision
support capabilities, such as alerts about a particular patient's
health, or other advantages of automation.)
Interoperability may be achieved at different levels (see fig. 1).
For example, at the highest level, electronic data are computable (that
is, in a format that a computer can understand and act on to, for
example, provide alerts to clinicians on drug allergies). At a lower
level, electronic data are structured and viewable, but not computable.
The value of data at this level is that they are structured so that
data of interest to users are easier to find. At still a lower level,
electronic data are unstructured and viewable, but not computable. With
unstructured electronic data, a user would have to find needed or
relevant information by searching uncategorized data.
It is important to note that not all data require the same level of
interoperability. For example, computable pharmacy and drug allergy
data would allow automated alerts to help medical personnel avoid
administering inappropriate drugs. On the other hand, for such
narrative data as clinical notes, unstructured, viewable data may be
sufficient. Achieving even a minimal level of electronic
interoperability would potentially make relevant information available
to clinicians.
Any level of interoperability depends on the use of agreed-upon
standards to ensure that information can be shared and used. In the
health IT field, standards may govern areas ranging from technical
issues, such as file types and interchange systems, to content issues,
such as medical terminology.
For example, vocabulary standards provide common
definitions and codes for medical terms and determine how information
will be documented for diagnoses and procedures. These standards are
intended to lead to consistent descriptions of a patient's medical
condition by all practitioners. The use of common terminology helps in
the clinical care delivery process, enables consistent data analysis
from organization to organization, and facilitates transmission of
information. Without such standards, the terms used to describe the
same diagnoses and procedures may vary (the condition known as
hepatitis, for example, may be described as a liver inflammation). The
use of different terms to indicate the same condition or treatment
complicates retrieval and reduces the reliability and consistency of
data.
Another example is messaging standards, which establish
the order and sequence of data during transmission and provide for the
uniform and predictable electronic exchange of data. These standards
dictate the segments in a specific medical transmission. For example,
they might require the first segment to include the patient's name,
hospital number, and birth date. A series of subsequent segments might
transmit the results of a complete blood count, dictating one result
(e.g., iron content) per segment. Messaging standards can be adopted to
enable intelligible communication between organizations via the
Internet or some other communications pathway. Without them, the
interoperability of health IT systems may be limited, reducing the data
that can be shared.
Developing interoperability standards requires the participation of
the relevant stakeholders who will be sharing information. In the case
of health IT, stakeholders include both the public and private sectors.
The public health system is made up of the Federal, State, tribal, and
local agencies that may deliver health care services to the population
and monitor its health. Private health system participants include
hospitals, physicians, pharmacies, nursing homes, and other
organizations that deliver health care services to individual patients,
as well as multiple vendors that provide health IT solutions.
Federal Health IT Efforts Highlight Importance of Establishing
Standards, Developing Comprehensive Plans, and Ensuring Privacy
Widespread adoption of health IT has the potential to improve the
efficiency and quality of health care. However, transitioning to this
capability is a challenging endeavor that requires attention to many
important considerations. Among these are mechanisms to establish
clearly defined health IT standards that are agreed upon by all
important stakeholders, comprehensive planning grounded in results-
oriented milestones and measures, and an approach to privacy protection
that encourages acceptance and adoption of electronic health records.
Attempting to expand the use of health IT without fully addressing
these issues would put at risk the ultimate goal of achieving more
effective health care.
mechanisms and structures for harmonizing and implementing health it
standards are essential to enable interoperability
The need for health care standards has been broadly recognized for
a number of years. In previous work, we identified lessons learned by
U.S. agencies and by other countries from their experiences. Among
other lessons, they reported the need to define and adopt common
standards and terminology to achieve data quality and consistency,
system interoperability, and information protection.\10\ In May 2003,
we reported that Federal agencies recognized the need for health care
standards and were making efforts to strengthen and increase their
use.\11\ However, while they had made progress in defining standards,
they had not met challenges in identifying and implementing standards
necessary to support interoperability across the health care sector. We
stated that until these challenges were addressed, agencies risked
promulgating piecemeal and disparate systems unable to exchange data
with each other when needed. We recommended that the Secretary of HHS
define activities for ensuring that the various standards-setting
organizations coordinate their efforts and reach further consensus on
the definition and use of standards; establish milestones for defining
and implementing standards; and create a mechanism to monitor the
implementation of standards through the health care industry.
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\10\ GAO, Health Information Technology: HHS Is Taking Steps to
Develop a National Strategy, GAO-05-628 (Washington, DC: May 27, 2005).
\11\ GAO, Bioterrofism: Information Technology Strategy Could
Strengthen Federal Agencies' Abilities to Respond to Public Health
Emergencies, GAO-03-139 (Washington, DC: May 30, 2003).
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HHS implemented this recommendation through the activities of the
Office of the National Coordinator for Health Information Technology
(established within HHS in April 2004). Through the Office of the
National Coordinator, HHS designated three primary organizations, made
up of stakeholders from both the public and private health care
sectors, to play major roles in identifying and implementing standards
and expanding the implementation of health IT:
The American Health Information Community (now known as
the National eHealth Collaborative) was created by the Secretary of HHS
to make recommendations on how to accelerate the development and
adoption of health IT, including advancing interoperability,
identifying health IT standards, advancing nationwide health
information exchange, and protecting personal health information.
Created in September 2005 as a Federal advisory commission, the
organization recently became a nonprofit membership organization. It
includes representatives from both the public and private sectors,
including high-level officials of VA and other Federal and State
agencies, as well as health systems, payers, health professionals,
medical centers, community hospitals, patient advocates, major
employers, nonprofit health organizations, commercial technology
providers, and others. Among other things, the organization has
identified health care areas of high priority and developed ``use
cases'' for these areas (use cases are descriptions of events or
scenarios, such as Public Health Case Reporting, that provide the
context in which standards would be applicable, detailing what needs to
be done to achieve a specific mission or goal).
The Healthcare Information Technology Standards Panel
(HITSP), sponsored by the American National Standards Institute \12\
and funded by the Office of the National Coordinator, was established
in October 2005 as a public-private partnership to identify competing
standards for the use cases developed by the American Health
Information Community and to ``harmonize'' the standards.\13\ As of
March 2008, nearly 400 organizations \14\ representing consumers,
healthcare providers, public health agencies, government agencies,
standards developing organizations, and other stakeholders were
participating in the panel and its committees. The panel also develops
the interoperability specifications that are needed for implementing
the standards. In collaboration with the National Institute for
Standards and Technology, HITSP selected initial standards to address,
among other things, requirements for message and document formats and
for technical networking. Federal agencies that administer or sponsor
Federal health programs are now required to implement these standards,
in accordance with an August 2006 Executive Order.\15\
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\12\ The American National Standards Institute is a private,
nonprofit organization whose mission is to promote and facilitate
voluntary consensus standards and ensure their integrity.
\13\ Harmonization is the process of identifying overlaps and gaps
in relevant standards and developing recommendations to address these
overlaps and gaps.
\14\ Members include representatives from the following sectors:
clinicians; providers; safety net providers and their representative
organizations; vendors that develop, market, install, and support
health IT products; healthcare purchasers or employers; healthcare
payers or health insurance companies; public health professionals;
national organizations with a broad representation of stakeholders with
an interest in healthcare IT standards; clinical and health-services
researchers' representative organizations; Federal, State, and local
agencies; coordinating bodies with responsibilities for and/or a
relationship to healthcare IT used in the public sector; and consumer
organizations with an interest in health IT standards.
\15\ Executive Order 13410, Promoting Quality and Efficient Health
Care in Federal Government Administered or Sponsored Health Care
Programs (Washington, DC: Aug. 22, 2006).
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The Certification Commission for Healthcare Information
Technology is an independent, nonprofit organization that certifies
health IT products, such as electronic health records systems. HHS
entered into a contract with the commission in October 2005 to develop
and evaluate the certification criteria and inspection process for
electronic health records. HHS describes certification as the process
by which vendors' health IT systems are established to meet
interoperability standards. The certification criteria defined by the
commission incorporate the interoperability standards and
specifications defined by HITSP. The results of this effort are
intended to help encourage health care providers throughout the nation
to implement electronic health records by giving them assurance that
the systems will provide needed capabilities (including ensuring
security and confidentiality) and that the electronic records will work
with other systems without reprogramming.\16\
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\16\ In May 2006, HHS finalized a process and criteria for
certifying the interoperability of outpatient electronic health records
and described criteria for future certification requirements.
Certification criteria for inpatient electronic health records were
finalized in June 2007. To date, the Certification Commission reports
that it has certified about 140 products offering electronic health
records.
The interconnected work of these organizations to identify and
promote the implementation of standards is important to the overall
effort to advance the use of interoperable health IT. For example,
according to HHS, the HITSP standards are incorporated into the
National Coordinator's ongoing initiative to enable health care
entities--such as providers, hospitals, and clinical labs--to exchange
electronic health information on a nationwide basis. Under this
initiative, HHS awarded contracts to nine regional and State health
information exchanges as part of its efforts to provide prototypes of
nationwide networks of health information exchanges.\17\ Such exchanges
are intended to eventually form a ``network of networks'' that is to
produce the envisioned Nationwide Health Information Network (NHIN).
According to HHS, the department planned to demonstrate the experiences
and lessons learned from this work in December 2008, including defining
specifications based upon the work of HITSP and standards development
organizations to facilitate interoperable data exchange among the
participants, testing interoperability against these specifications,
and developing trust agreements among participants to protect the
information exchanged. HHS plans to place the nationwide health
information exchange specifications defined by the participating
organizations, as well as related testing materials, in the public
domain, so that they can be used by other health information exchange
organizations to guide their efforts to adopt interoperable health IT.
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\17\ These exchanges are intended to connect providers and patients
from different regions of the country and enable the sharing of
electronic health information, such as health records and laboratory
results. DOD, VA, and the Indian Health Service are participating in a
Federal component of this initiative.
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The products of the Federal standards initiatives are also being
used by DOD and VA in their ongoing efforts to achieve the seamless
exchange of health information on military personnel and veterans. The
two departments have committed to the goal of adopting applicable
current and emerging HITSP standards. According to department
officials, DOD is also taking steps to ensure compliance with standards
through certification. To ensure that the electronic health records
produced by the department's modernized health information system,
AHLTA,\18\ are compliant with standards, it is arranging for
certification through the Certification Commission for Healthcare
Information Technology. Both departments are also participating in the
National Coordinator's standards initiatives. The involvement of the
departments in these activities is an important mechanism for aligning
their electronic health records with emerging Federal standards.
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\18\ AHLTA originally was an acronym for Armed Forces Health
Longitudinal Technology Application. The department no longer considers
AHLTA an acronym but the official name of the system.
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Federal efforts to implement health IT standards are ongoing and
some progress has been made. However, until agencies are able to
demonstrate interoperable health information exchange between
stakeholders on a broader level, the overall effectiveness of their
efforts will remain unclear. In this regard, continued work on
standards initiatives will remain essential for extending the use of
health IT and fully achieving its potential benefits, particularly as
both information technology and medicine advance.
comprehensive planning with milestones and performance measures
is essential to achieving health it goals
Using interoperable health IT to help improve the efficiency and
quality of health care is a complex goal that involves a range of
stakeholders and numerous activities taking place over an expanse of
time; in view of this complexity, it is important to develop
comprehensive plans that are grounded in results-oriented milestones
and performance measures. Without comprehensive plans, it is difficult
to coordinate the many activities under way and integrate their
outcomes. Milestones and performance measures allow the results of the
activities to be monitored and assessed, so that corrective action can
be taken if needed.
Since it was established in 2004, the Office of the National
Coordinator has pursued a number of health IT initiatives (some of
which we described above), aimed at the expansion of electronic health
records, identification of interoperability standards, advancement of
nationwide health information exchange, and protection of personal
health information.\19\ It also developed a framework for strategic
action for achieving an interoperable national infrastructure for
health IT, which was released in 2004. We have noted accomplishments
resulting from these various initiatives, but we also observed that the
strategic framework did not include the detailed plans, milestones, and
performance measures needed to ensure that the department integrated
the outcomes of its various health IT initiatives and met its overall
goals.\20\ Given the many activities to be coordinated and the many
stakeholders involved, we recommended in May 2005 that HHS define a
national strategy for health IT that would include the necessary
detailed plans, milestones, and performance measures, which are
essential to help ensure progress toward the President's goal for most
Americans to have access to interoperable electronic health records by
2014. The department agreed with our recommendation, and in June 2008
it released a 4-year strategic plan. If the plan's milestones and
measures for achieving an interoperable nationwide infrastructure for
health IT are appropriate and properly implemented, the plan could help
ensure that HHS's various health IT initiatives are integrated and
provide a useful roadmap to support the goal of widespread adoption of
interoperable electronic health records.\21\
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\19\ In prior work, we described programs that other divisions
within HHS, such as the Agency for Healthcare Research and Quality and
the Health Resources and Services Administration, administer to provide
funding to organizations engaged in building and testing health IT
systems, standards, and projects. See GAO-05-628 for a description of
these activities.
\20\ GAO, Health Information Technology: HHS is Taking Steps to
Develop a National Strategy, GAO-05-628 (Washington, DC: May 27, 2005).
\21\ In another example, as a result of the 2007 study of hospital
quality data collection mentioned earlier, we recommended that the
Secretary of HHS identify the specific steps that the department
planned to take to promote the use of health IT for the collection and
submission of these data, and that it inform interested parties of
those steps and the expected timeframe, including milestones for
completing them.
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Across our health IT work at HHS and elsewhere, we have seen other
instances in which planning activities have not been sufficiently
comprehensive. An example is the experience of DOD and VA, which have
faced considerable challenges in project planning and management in the
course of their work on the seamless exchange of electronic health
information. As far back as 2001 and 2002, we noted management
weaknesses, such as inadequate accountability and poor planning and
oversight, and recommended that the departments apply principles of
sound project management.\22\ The departments' efforts to meet the
recent requirements of the National Defense Authorization Act for
Fiscal Year 2008 provide additional examples of such challenges,
raising concerns regarding their ability to meet the September 2009
deadline for developing and implementing interoperable electronic
health record systems or capabilities. In July 2008, we identified
steps that the departments had taken to establish an interagency
program office and implementation plan, as required. According to the
departments, they intended the program office to play a crucial role in
accelerating efforts to achieve electronic health records and
capabilities that allow for full interoperability, and they had
appointed an Acting Director from DOD and an Acting Deputy Director
from VA. According to the Acting Director, the departments also have
detailed staff and provided temporary space and equipment to a
transition team. However, the newly established program office was not
expected to be fully operational until the end of 2008--allowing the
departments at most 9 months to meet the deadline for full
interoperability.
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\22\ GAO, Computer-Based Patient Records: Better Planning and
Oversight by VA, DOD, and IHS Would Enhance Health Data Sharing, GAO-
01-459 (Washington, DC: Apr. 30, 2001) and Veterans Affairs: Sustained
Management Attention is Key to Achieving Information Technology
Results, GAO-02-703 (Washington, DC: June 12, 2002).
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Further, we reported other planning and management weaknesses. For
example, the departments developed a DOD/VA Information
Interoperability Plan in September 2008, which is intended to address
interoperability issues and define tasks required to guide the
development and implementation of an interoperable electronic health
record capability. Although the plan included milestones and schedules,
it was lacking many milestones for completing the activities defined in
the plan. Accordingly, we recommended that the departments give
priority to fully establishing the interagency program office and
finalizing the implementation plan. Without an effective plan and a
program office to ensure its implementation, the risk is increased that
the two departments will not be able to meet the September 2009
deadline.
establishing a consistent approach to privacy protection is essential
for encouraging acceptance and adoption of health it
As the use of electronic health information exchange increases, so
does the need to protect personal health information from inappropriate
disclosure. The capacity of health information exchange organizations
to store and manage a large amount of electronic health information
increases the risk that a breach in security could expose the personal
health information of numerous individuals. Addressing and mitigating
this risk is essential to encourage public acceptance of the increased
use of health IT and electronic medical records.
Recognizing the importance of privacy protection, HHS included
security and privacy measures in its 2004 framework for strategic
action, and in September 2005, it awarded a contract to the Health
Information Security and Privacy Collaboration as part of its efforts
to provide a nationwide synthesis of information to inform privacy and
security policymaking at Federal, State, and local levels. The
collaboration selected 33 States and Puerto Rico as locations in which
to perform assessments of organization-level privacy- and security-
related policies and practices that affect interoperable electronic
health information exchange and their bases, including laws and
regulations. As a result of this work, HHS developed and made available
to the public a toolkit to guide health information exchange
organizations in conducting assessments of business practices,
policies, and State laws that govern the privacy and security of health
information exchange.\23\
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\23\ In June 2007, HHS reported the outcomes of its privacy and
security solutions contract based on the work of 34 States and
territories that participated in the contract. A final summary report
described variations among organization-level business practices,
policies, and laws for protecting health information that could affect
organizations' abilities to exchange data.
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However, we reported in January 2007 that HHS initiated these and
other important privacy-related efforts \24\ without first defining an
overall approach for protecting privacy. In our report, we identified
key privacy principles and challenges to protecting electronic personal
health information.
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\24\ Our January 2007 report (GAO-07-238) describes various
privacy-related efforts incorporated into HHS's overall health IT
initiative, including the activities of the American Health Information
Community, the Healthcare Information Technical Standards Panel, the
Certification Commission for Healthcare IT, and the Nationwide Health
Information.
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Examples of principles that health IT programs and
applications need to address include the uses and disclosures
principle, which provides limits to the circumstances in which an
individual's protected heath information may be used or disclosed, and
the access principle, which establishes individuals' rights to review
and obtain a copy of their protected health information in certain
circumstances.\25\
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\25\ We based these privacy principles on our evaluation of the HHS
Privacy Rule promulgated under the Administrative Simplification
provisions of the Health Insurance Portability and Accountability Act
of 1996 (HIPAA), which define the circumstances under which an
individual's health information may be used or disclosed.
---------------------------------------------------------------------------
Key challenges include understanding and resolving legal
and policy issues (for example, those related to variations in States'
privacy laws), ensuring that only the minimum amount of information
necessary is disclosed to only those entities authorized to receive the
information, ensuring individuals' rights to request access and
amendments to their own health information, and implementing adequate
security measures for protecting health information.\26\
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\26\ We identified key challenges associated with protecting
personal health information based on input from selected stakeholders
in health information exchange organizations.
---------------------------------------------------------------------------
We recommended that HHS define and implement an overall privacy
approach that identifies milestones for integrating the outcomes of its
privacy-related initiatives, ensures that key privacy principles are
fully addressed, and addresses challenges associated with the
nationwide exchange of health information.
In September 2008, we reported that HHS had begun to establish an
overall approach for protecting the privacy of personal electronic
health information--for example, it had identified milestones and an
entity responsible for integrating the outcomes of its many privacy-
related initiatives.\27\ Further, the Federal health IT strategic plan
released in June 2008 includes privacy and security objectives along
with strategies and target dates for achieving them.
---------------------------------------------------------------------------
\27\ GAO, Health Information Technology: HHS Has Taken Important
Steps to Address Privacy Principles and Challenges, Although More Work
Remains, GAO-08-1138 (Washington, DC: Sept. 17, 2008).
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However, in our view, more actions are needed. Specifically, within
its approach, the department had not defined a process to ensure that
the key privacy principles and challenges we had identified were fully
and adequately addressed. This process should include, for example,
steps for ensuring that all stakeholders' contributions to defining
privacy-related activities are appropriately considered and that
individual inputs to the privacy framework are effectively assessed and
prioritized to achieve comprehensive coverage of all key privacy
principles and challenges. Without such a process, stakeholders may
lack the overall policies and guidance needed to assist them in their
efforts to ensure that privacy protection measures are consistently
built into health IT programs and applications. Moreover, the
department may miss an opportunity to establish the high degree of
public confidence and trust needed to help ensure the success of a
nationwide health information network. To address these concerns, we
recommended in our September report that HHS include in its overall
privacy approach a process for ensuring that key privacy principles and
challenges are completely and adequately addressed.
Lacking an overall approach for protecting the privacy of personal
electronic health information, there is reduced assurance that privacy
protection measures will be consistently built into health IT programs
and applications. Without such assurance, public acceptance of health
IT may be at risk.
In closing, Mr. Chairman, many important steps have been taken, but
more is needed before we can make a successful transition to a
nationwide health IT capability and take full advantage of potential
improvements in care and efficiency that this could enable. It is
important to have structures and mechanisms to build, maintain, and
expand a robust foundation of health IT standards that are agreed upon
by all important stakeholders. Further, given the complexity of the
activities required to implement health IT and the large number of
stakeholders, completing and implementing comprehensive planning
activities are also key to ensuring program success. Finally, an
overall privacy approach that ensures public confidence and trust is
essential to successfully promoting the use and acceptance of health
IT. Without further action taken to address these areas of concern,
opportunities to achieve greater efficiencies and improvements in the
quality of the Nation's health care may not be realized.
This concludes my statement. I would be pleased to answer any
questions that you or other members of the committee may have.
contacts and acknowledgments
If you should have any questions about this statement, please
contact me at (202) 512-6304 or by e-mail at [email protected]. Other
individuals who made key contributions to this statement are Barbara
Collier, Heather Collins, Amanda C. Gill, Rebecca LaPaze, and Teresa F.
Tucker.
Senator Mikulski. Thank you very much, Ms. Melvin. It is
exactly what we had hoped to hear.
I am going to move right into my questions, and I am going
to take about 7 minutes and then turn to Senator Merkley. And
then, if we have time, we will come back for a second round.
But first, I want to say to the panel and to the many
people in this room, this isn't the only conversation we are
going to have. It might be the only formal hearing, but this
isn't the only conversation.
I am asking my staff as well as our Republican colleagues,
particularly Senator Enzi's staff and whoever else he will
designate, that we can have this to get it right.
I didn't want this to become an appropriations hearing on
the stimulus package, but I have to ask a question about what
will be before us in the stimulus package. Let me give
background quickly to my own thinking, and then I am going to
turn to your thoughts and recommendations.
There is great desire in our country for change, and one of
the areas is in healthcare. Our President has got it, and he
wants to do it. The appointment of Senator Daschle, soon to be
our Secretary of Health and Human Resources as well as the
health czar. They want to move on health IT. You heard it on
TV. We hear it everywhere.
I was a little skeptical of this. So let me tell you my
skepticism, and it goes back because in my other committees I
have watched where we dashed ahead with unbelievably good
intentions, the will of the American people behind us, and we
threw a lot of money at stuff. And we ended up with boondoggle.
I can't go there again, and we can't afford to go there
again. We can't afford to waste time on a fool's journey or
waste money. We just don't have either one.
I want to work with our President and really then move
health IT in the stimulus. So here is my question. We know
about the interoperable challenges. We know about privacy. And
for all in this room, from our ACLU friends and others who
really raise the voice of privacy, we want to consider that.
I want to focus, as you do in healthcare, we need to be
measured for performance and outcome. Having said that,
conceptual language in the healthcare stimulus, could we be
sure that when we spent it, we are achieving the goals?
Because there is fair unanimity here in what needs to be
achieved. There is no difference of opinion. And so, my
question is, No. 1, do you think we ought to put it in the
stimulus? And No. 2, what, in addition to adequate funding,
should we do? And should we be very prescriptive?
Could you share your thoughts because we are going to be
marking up next week or the week thereafter, and I want to get
it right. I am going to work with Tom Harkin and Senator Inouye
and Senator Thad Cochran because it will move to
appropriations. But we would like, really, your thinking.
Or do you think we should wait on it? Do you think we
should wait? And if we don't wait, how can we get it right so
that we make a down payment on what we need to do?
I am just going to go down the room in the way we testified
on that.
Dr. Cochran. Well, I appreciate, No. 1, your recognition to
be skeptical of how things have seemed simple in the past and
didn't turn out to be as simple. I think the desire for the
change in healthcare, we ought to all understand it is about
time that this country of such great wealth needs to take a
better view of the holistic healthcare system.
I think that we can debate, and I think what I heard this
morning was a lot of agreement around the issues of
interoperability and privacy and that sort of thing. What I
would say when you look at the funding and the totality of the
planning of health reform, to me, would be to really understand
holistically the complexity of the issues and not try to find
quick fixes.
Health IT is a perfect example that could be an investment
that really costs a lot of money and not get any returns
because it wasn't tied to significant improvements in
workflows, delivery system, and the way healthcare is paid for.
I came originally from a private surgical practice, became
a Permanente physician, went from fee for service to a
different model. And the way we pay for healthcare can be very
perverse in terms of does it really enable us to provide great
quality?
We have in our coding for fee-for-service medicine 10,000
codes for treatments and interventions, and we have very few
codes or none for outcomes and cure and treatment. So when you
plan this process, health IT is not a silver bullet. Financing
is not the only answer.
Resourcing healthcare personnel and some of those things to
build up the capabilities of more social workers and more
nurses and more primary care physicians, I think it has to be
looked at holistically.
The Clinton plan was very holistic but lost a lot of
political steam and lost a lot of acceptability. I think the
way that the President-elect is approaching it is very
formidable because he is really looking for input and being
very interactive.
So I would say that the silver bullet is not IT. It is not
in any necessarily financing mechanism. But if you are going to
really make a difference, you have got to look at all of those
factors. And I think what I have heard this morning is an awful
lot of congruence around some of the issues that you are
facing.
Senator Mikulski. Thank you.
Ms. Corrigan.
Ms. Corrigan.Yes, it is a wonderful question, Senator. I
think that some investment in health information technology in
the stimulus bill is very appropriate at this time. However, it
needs to be viewed in a broader context and a broader policy
agenda.
I would encourage a multi-pronged approach, that there be
initial support to encourage investments in health information
technology in the stimulus bill, but that that be health
information technology that has been demonstrated to possess
the necessary capabilities to actually perform some of those
important functions that will result in better care.
For example, it is certainly appropriate to invest in HIT
that is capable of exchanging data on prescriptions, laboratory
tests, and other critical information. But we need to know that
that functionality is there. That is what we should be paying
for.
I think a second part, though, of a broader strategy is to
begin to align our payment systems much better with paying for
actual outcomes and improvements in patient care. That, in
turn, will reward those who not only invested in good HIT with
the necessary functionality, but put it to effective use.
Senator Mikulski. Mr. Neupert.
Mr. Neupert. I need to support the views of the prior
speakers. I think payment reform is an important first step so
that the right actions are motivated. But I would say that one
additional comment is the data exist today. We don't need to
just invest in creation of new electronic data.
I really would focus the near-term stimulus to leverage the
existing data assets that are out there--prescriptions held by
the pharmacy benefit managers or the pharmacies, labs that are
held by the national labs--Quest, LabCorp--large health
systems, and images.
If we can just get those data starting to move today in
health information exchanges, we can go a long ways toward
enabling and empowering both consumers and their physicians to
deliver better outcomes right away. Then we can do the hard
work of thinking about, holistically, how do we reform the
system?
Senator Mikulski. I am going to turn to you, Ms. Grealy.
But just a quick follow-up to you, Mr. Neupert, because I think
many of my colleagues--because we are not geeks and techno
wizzes here, though we ought to be more with it. But I think
some envision like a national healthcare record that exists
like your Social Security record.
I think what you are saying and what others have also
indicated is that this is going to be a network of networks. So
that, for example, I have a primary care doc who is a physician
who has privileges at Mercy Hospital. Any acute care I have
needed has been--mine would either be Mercy, Hopkins, or
University of Maryland. But my point is, they will each have
their own, and my blood work is being done by Quest.
So what you are saying is meet the networks that are
already networking and then the stimulus, in other words, don't
think of it like a Social Security record, think of it as a
network of networks. Am I correct? And then, as we do the
stimulus, get started with the networks that exist and could
already begin to network?
Mr. Neupert. Yes. In many regards, the data is there today.
We have to think of there is not going to be one record. There
are going to be multiple records.
Hopkins needs to have its copy of your stuff. University of
Maryland, if they treated you, needs to have your copy. But
you, as a consumer, could have the longitudinal copy and share
it appropriately.
That is the important thing, that the data is embedded in
many of these systems already. It is not that hard to extract
it. We have the knowledge, the technical capabilities today to
make that available in an effective way, and then you start to
see the network of networks start to happen.
Right now, they are all closed systems, and it is getting
those open and sharing which is the most important first step,
in our opinion.
Senator Mikulski. OK. Ms. Grealy.
Ms. Grealy. Well, I think Mr. Neupert made a very critical
point, and that is critical data, rather than the whole
enchilada, as it were. That with imaging data, lab test data,
those really are the critical components that you want to share
among these various providers.
I often use a very personal example of trying to help my,
at the time, 89-year-old father, who was on dialysis, also
being treated for cancer, doing radiation treatment five times
a day. And the various providers--I spent 1 day--this is in
Fort Lauderdale, FL--going to six different appointments.
And for each time to have to hand over a paper copy or have
the dialysis center fax the latest blood test work, I mean it
was ridiculous and harmful for the patient. So I think that is
what it is all about. We do have the technology. We do have the
data. We can start doing this now.
As Janet Corrigan said, let us think on parallel tracks. We
would like to see in the stimulus package loans and grants to
really facilitate those that have taken this on, that have
taken the leadership and help others come onboard with e-
prescribing and a whole host of other things.
We need to do more work on establishing the standards. A
lot of good work has happened already, and I think all of us
want to make sure that we don't duplicate what has already been
done. Let us go ahead and build on it.
Then most importantly, I think, is not to be overly
prescriptive. There is a lot of innovation out there. We want
to foster that innovation. We can share the critical data, but
I think each system will want to tailor their system to their
particular needs. But we want to make sure that the critical
data components are interoperable and can be shared for
patients.
And as I noted in my testimony, we can see some very short-
term, very dramatic results, and we also can see a financial
return on the investment that has been made.
We have had members--I will use Baylor as an example. They
knew this was the right thing to do. They did not expect to
save money on it, and they have been very pleasantly surprised
to see that return on the investment that they have made.
Senator Mikulski. Ms. Melvin.
Ms. Melvin. Yes, speaking from an accountability
perspective, obviously, the most important aspect that we see
is a comprehensive approach to doing this.
And within that approach, where you are looking for the
ultimate outcomes in terms of what you are trying to achieve,
we think that it is important--and recognizing, again, what has
been said about the number of initiatives that are already
being undertaken--to take from those lessons learned, to see
how successes can be applied, to see what has worked already,
what hasn't worked, and to incorporate that into an overall
strategy or a framework, if you will, or a plan for how and
what is necessary to move forward.
Also trying to work at this in an incremental approach. I
think I have heard today some emphasis on the fact that this is
not something that you want to do very quickly. It is not
something that has proven itself to be able to be done very
quickly, as VA and DOD's experiences have already shown.
However, having an incremental approach would have the
benefit of allowing opportunities to step back momentarily,
assess what has worked, and to perhaps readjust and make
changes along the way. But at the same time to carefully
consider all of the experiences that have already been
undertaken and what opportunities there are for greater
enhancement in terms of quality of care and the successes
associated with that.
The demonstrated uses relative to the assistance that can
be provided. Oversight is another area that I would advocate
for early efforts toward. From the standpoint that, as I have
said in my statement, it is important to know what it is you
are trying to achieve, and it is important to have measures for
being able to assess your progress once you have gotten there.
So, from that standpoint, having some interim measures to
work toward a final outcome would be, in our view, an important
factor to have reflected early on in the process.
Senator Mikulski. Well, I appreciate this comment because
there is a consensus. Go ahead with it. Be skeptical because
that is a good thing. But don't use your skepticism to stop
you, but to look at this in a well-paced, prudent way, looking
at the endgame, which is that, ultimately, we will be doing
health insurance or health reform.
We want to keep the word ``health'' and not just be looking
at this as a new insurance scheme. But look at where we are
going to be heading. And I think there is agreement on what
needs to be accomplished.
When you look at your testimony, what Dr. Bill Frist has
said, what Newt has said, we all know the ultimate endgame that
we want to achieve with health IT and even with health reform,
which is improving patient care, management of chronic illness.
When you have an acute incident, everyone has access to
what they need to know about you, and also you have to take
responsibility for your own healthcare by keeping those
appointments and asking those right questions.
I think these are excellent recommendations. I am going to
ask when this is over, though, for my staff to have a little
bit not from podium-dais to you, but to really talk about what
you think would be essential so that Senator Harkin and those
of us who are the appropriators working with Kennedy and Enzi
can get into it.
I have some other questions, but now I am going to turn to
Senator Merkley now for questions that he might have.
Senator Merkley. Thank you very much, Madam Chair.
And thank you for your testimony this morning.
I want to clarify what this looks like from the point of
view of your average American. For example, consider the fact
that I have had many different health records that have been
built up and held in these different networks, and I am now
back here in Washington, DC. Perhaps I have a health incident,
and so the physician of the Capitol is going to access my
records.
Is he going to do that by name, by Social Security number?
Is he going to need a password? Is he going to see a list of
networks that have information, or is he going to be able to
use a simple identifier in order to gain access to the entire
set of records?
If one of you could just take that on and help clarify the
vision as you see it from the consumer's point of view?
Mr. Neupert. At Microsoft, we have developed a service
called HealthVault, which allows you to keep your own copy of
the records.
Senator Mikulski. Excuse me, Mr. Neupert. What is it
called? Health what?
Mr. Neupert. HealthVault.
Senator Mikulski. Vault.
Mr. Neupert. Vault, as in safe, secure, private, yours,
with a key.
Our vision doesn't imagine connecting all of those
electronic systems to each other. That would be very
complicated and might be kind of slow. But it is very easy to
connect each of those electronic systems to this one hub, or
Google has a competitive one, and there could be more than one
of these.
But just like you choose what bank or financial institution
you want to keep your assets in, you ought to be able to choose
where you want to store your critical health data assets. All
you need to do is be able to make sure that it is connected to
each of those providers and to the pharmacy.
Because lots of health happens not just in the doctor's
office. Some of it happens at home. You might want to keep your
weight. You might want to keep your exercise workout stuff
because those are important attributes. What you eat are
important attributes to your total health.
And then, when that acute incident happens, what you want
is an easy mechanism for the provider of service for you to
share, and this solves many of the privacy issues because you
can choose with whom you want to share your critical
information at every point in time and what part of that record
you want to share out.
So we took a different approach to trying to solve that
problem, and it exists today, and it is free for consumers.
Senator Merkley. If I am critically injured, how does the
emergency room access that information?
Mr. Neupert. There are lots of solutions to that problem.
The simplest solution is for you to carry something that gives
a particular code for them to get access to it.
Senator Merkley. Did you want to add something?
Dr. Cochran. Yes. First of all, the tension at the level of
the consumer is if you are injured or you are sick, you want
people to have access to that data. You want to make sure they
got it through a system that was very secure and very private,
which goes back to basically the Hippocratic Oath anyway, that
that is what physicians want.
So in a great world, an ideal world progressively. For
example, we are an organization that if we were a State, we
would be the 12th biggest State. So we have millions of
members, many locations. When we talked earlier about how
physicians were a little reluctant at first, it was hard
because it disrupted their day. They weren't used to having a
computer between them and the patient.
You could not get the computer out of their office. They
absolutely love it, and it is because of that, it is because
the information is available. It is secure.
If you are seeing a primary care physician with chest pain,
and you have an old cardiology appointment, they can both be
looking at your record at the same time and conferring with
each other, in State, out of State. So in a perfect world, if
we are large and leverageable, it could be done on a more
national level for members and patients who have got to get to
that security and privacy belief system before they are ever
going to want to have that happen.
It creates a very safe system for people because if they
have idiosyncratic diseases or complexity, they carry it around
on a piece of paper in their wallet or they carry it in an EHR,
which is very progressive, or PHR. But right now, you are
really kind of on your own. And so, it is not a very safe way
to have intercurrent disease.
Senator Merkley. Thank you for helping clarify that.
My wife works as a nurse for Providence, which has received
many awards for being one of the most wired hospitals, very
high technology use. However, it is much harder to get rural or
smaller institutions involved, and what kinds of efforts do we
need to really make the IT solutions reach out and connect to
the rural parts of our country?
Ms. Grealy. I think this is probably where we have the
greatest potential for seeing that return on the investment,
whether we are talking about telemedicine or being able to
share this information about patients over a broad geographic
area.
I would say the key component for those facilities is going
to be the financial support in order to implement and adopt
these systems, and I think it can make a tremendous difference
in helping patients in those rural areas have access to high-
quality health-
care.
Ms. Corrigan. Yes, and Senator, part of this has to do with
encouraging the development of more organized systems of care.
We have a two-class system right now in the country for those
who have access to HIT-enabled care and those who don't.
If you look at the organized systems, whether it is Kaiser
Permanente, it is the Veterans Health Affairs, it is Mayo, or
Geisinger system--it doesn't have to all be multispecialty
groups, but an organized system--they have upwards of 95
percent that have fully functional, sophisticated health
information technology systems in place. And those who receive
their services within a system like that are getting higher
quality, more affordable care.
It is when you move out into communities that are highly
fragmented where those relationships do not yet exist. So part
of the solution here is to encourage the development of those
relationships.
Mary Grealy mentioned Baylor earlier, and they have gone
down the road in the last 5 years or so to really begin to
reach out to the physicians that are the heavy admitters to the
Baylor health system and to begin to work with them
collaboratively on installing electronic health records that
have connectivity with the rest of the system.
So I think one of the keys here is to break down barriers,
and there are some important policy barriers to those
relationships developing. The Stark anti-kickback legislation,
I think, has unfortunately become a barrier to hospitals
working with the physicians in the community to help them get
the technological support and capital they need to be able to
be a part of an EHR system and exchange information together.
Senator Merkley. Thank you very much, and my time has
expired.
Senator Mikulski. Senator, first of all, those were
excellent questions that I think all of us would share. It
shows you are going to be a really active and great member of
our committee, and again, we welcome you.
I just want to, first, ask unanimous consent that all full
statements of our panelists be included in the record. Second,
I want to be sure that we have unanimous consent that any
Senator who wishes to place a statement in the record on this
topic can. All Senators who might have additional questions
will submit them.
I know that Senator Enzi in particular has a list of
questions. I believe Senator Alexander and some others do. So
anybody that has questions, they will be submitting those in
writing.
I am going to ask one final question, and then this
committee will adjourn. This goes to interoperability, and
really, I am going to go right to you, Ms. Melvin.
Because we have many good ideas--we could be talking about
the health manager that Kaiser has, the HealthVault that Micro
has, the need to know as part of privacy, etc., but if this
isn't interoperable, nothing is going to achieve our goals.
I looked at the chart of approval that is set over at HHS,
and also our outgoing Secretary even wrote an op-ed in the Post
about this. Ms. Melvin, what do you think we can do now?
Particularly, do you think we need to streamline the
interoperable process? How can we work on that now?
Then I invite our panel to submit to us even additional
thoughts about how we can get this interoperability thing going
now and have a streamlined, but ongoing process.
Ms. Melvin. What I would emphasize is prioritization. I
think that is probably the key. Whether that ultimately results
in a streamlined process or perhaps a process that over time
results in the ultimate outcome, the key, I think, will be to
look at what are the significant clinical needs? What are the
significant outcomes and results that are desired early on
based on experiences that have already been proven through the
initiatives that have been undertaken?
And use that information to drive what priority needs might
be the ones that you focus on initially. We have seen VA do
that in its work relative to specific types of information that
needed to be in its medical record. I would say VA and DOD, as
they have attempted to incorporate interoperability into their
sharing efforts. And as a result of that, they have identified
some key data that can be shared.
But one thing that is important to remember is that in
terms of interoperability, and I have noted this in my
statement, is that there are different levels. And not all
levels are necessary for all aspects of healthcare.
It is important to figure out what needs to be done and to
establish priorities for when they need to be done, and to let
that drive what the ultimate outcomes will be relative to how
standards are implemented and what particular data exchanges
are taking place, when, and for what purposes.
Senator Mikulski. So, as we develop interoperability, we go
for the goals that have been set here, that, ultimately,
whatever we are developing should be improving healthcare
outcomes and enabling all who are involved in patient care to
be able to do this.
But to go to what Mr. Neupert said, we can begin now with
what is already being developed in some ways by national
systems like the bloodwork people.
Ms. Melvin. There are important examples, very good
examples out there relative to what has been done and what is
capable of being done that do serve as great input to making
decisions on what are key and primary efforts to focus on.
Senator Mikulski. Well, I looked at the chart. You have
HHS, the Secretary. He has a policy recommendation for review
and approval group. Then he has the Office of National
Coordination. He has three things under him. You have the
American Health Information Community, which has nine
Government agencies. I mean, you have--we could be Rube
Goldberg here.
But we are going to leave that to our Secretary of Health
to streamline. I think what we need to do is take your input. I
think you have given us excellent guiding principles over what
we need to do and also what we need to be considering in the
health stimulus.
We really look forward to ongoing conversations with you,
with that which is represented in this room, with our privacy
people, lead groups like the ACLU, and so that we are mindful
of that because they have very good insights, and they often
raise questions we don't always think about.
But at the end of the day, we want to improve patient
healthcare and have providers be able to have the tools they
need or what they need to know and what they need to know from
each other.
This has been excellent. We would like to pursue this in
more detail, and we are going to continue to do that. I view
this hearing as a down payment on ongoing discussions on health
IT.
Thank you very much for participating, and any additional
information to be submitted is most welcome.
This committee will stand adjourned, subject to the call of
the Chair. Thank you.
[Additional material follows.]
ADDITIONAL MATERIAL
Prepared Statement of Senator Kennedy
In this new century of the life sciences, almost every day
brings new medical breakthroughs and extraordinary scientific
discoveries. Biotechnology has created undreamed-of solutions
to longstanding medical challenges. Conditions which once
required invasive surgery can now be treated through
increasingly less costly procedures. The human genome project
has begun to solve some of the most profound medical mysteries,
inspiring scientists to find better ways to treat cancer,
diabetes, Alzheimer's Disease, and other major illnesses.
Our health care system itself, however, is still plagued by
staggering inefficiencies. With the cost of health care
approaching 20 percent of our gross domestic product, serious
action is required to turn back this tide of rising costs. We
need to recognize that the technology revolutionizing the
development of new treatments can also increase patients'
access to good care at a much lower cost.
In recent years, information technology has transformed
many industries ranging from telecommunications to financial
services. Yet, the health care industry continues to lag behind
in implementing information technology, even though the
potential for major improvement has been known for years.
Today, one in every seven primary care visits is undercut
by missing medical information. More than 40 percent of
Americans have been victims of preventable medical errors, and
as many as 100,000 Americans die each year because of such
errors. In a nation that spends more on health care than any
other country, and that has the best doctors, nurses,
hospitals, and scientists in the world, such errors are
intolerable.
Information technology can reduce these errors
significantly. Yet the gap is widening each year in
implementing it. It now costs a physician's office about
$40,000 to install a new IT system. Increasingly, our public
hospitals and community health centers remain in the dark ages
of health technology, while health institutions with financial
means are implementing life-saving, cost-effective systems.
Estimates by the RAND Corporation indicate that the widespread
adoption of electronic health records could save up to $160
billion a year.
So far, the vast majority of investment in IT has come from
the private sector. But Federal grants such as those proposed
in the last Congress would enable the health care industry to
convert individual examples of health IT success into a
national trend.
The advantages of health IT must obviously be accompanied
by careful protection of patient privacy. Many of us have been
working with the provider and patient communities to develop
strong privacy protections, including notice to patients when
their medical information is wrongly disclosed. We also commend
Secretary-Designate Tom Daschle's commitment to work on patient
privacy, information security, and appropriate uses of health
IT in health reform.
I look forward to working closely with my colleagues on the
HELP and Finance committees and with the incoming Obama
administration to ensure that our promise of a coordinated
health care system is delivered to the American people. Thank
you, Senator Mikulski, for bringing this important issue to
light.
Prepared Statement of Senator Enzi
I would like to begin by thanking Senator Mikulski for
holding this hearing today and thanking the witnesses who are
before us.
I have been working on increasing the adoption of health
information technology for the past 4 years and I am hopeful
that this is the year when we can finally get something done. I
believe that promoting widespread use of health information
technology (health IT) will help to reduce health care costs
and improve health care quality. Investing in health IT will
pay enormous dividends not just in dollars saved, but more
importantly, in lives saved.
In order for health IT to achieve this potential, however,
it must be interoperable. Simply throwing around taxpayer
dollars as an investment in health IT is not a solution. We
need to establish consensus standards so that doctors will not
have to worry that the IT investment they make today will be
obsolete tomorrow. Purchasing health IT software should not be
like investing in compact discs the day before iTunes
launched.&
Any investments made in health IT need to be coupled with a
requirement that purchases comply with technology standards
harmonized by the Healthcare Information Technology Standards
Panel and certified by the Certification Commission for Health
IT. Additionally, I urge the President-elect to ensure all
Federal investments in health IT are fiscally sustainable and
financially sound.
I look forward to working with President-elect Obama and
Senator Daschle to build upon the progress of the Bush
administration. Greater adoption of health IT also presents an
opportunity to increase the privacy and security of patient
records. Health IT systems can build in protections and
tracking mechanisms that are impossible to achieve with a
paper-based system. In some of these instances it may be
necessary to take a fresh look at the current privacy and
security rules, but I urge my colleagues to proceed with
caution.
It is critical to strike the right balance between patient
privacy and proper access to health information. If information
is wrapped up in so much red tape that doctors and their staff
are not able to access it when they need it, patients will
suffer the consequences. It will take time and hard work, but
we must find the right balance so patient care does not suffer.
In closing, I would like to reiterate that my primary
reason for pursuing health IT legislation is to increase the
quality of health care. I hope that any legislation that moves
forward achieves that goal. I look forward to working with all
of you during this Congress to increase the adoption of health
information technology and improve the quality of health care
in this country.
Prepared Statement of Senator Murray
I am pleased that this hearing is being held so we can
discuss how to expand the use of information technology in the
health care system.
I've been a longtime advocate for increasing the use of IT
to improve health care, especially to create electronic health-
record systems.
And in my home State of Washington, I've been proud to
support efforts to use IT to expand access to health care in
remote communities--as well as to improve care for everyone.
On the national level, I think IT has the potential to
revolutionize our health care system.
And it's critical that we make these investments now--
especially in light of the economic crisis. Layoffs are on the
rise, families are losing their health insurance, and that
means more and more people are going without health care to
save money.
We need to talk seriously about ways to reduce health care
costs and improve care.
And I want to extend a special thanks to Peter Neupert from
Microsoft Health Solutions for being a panelist.
Microsoft has been a leader in the effort to create
electronic medical records and make them available to doctors
and administrators in real time. They're developing ways to
help doctors make better decisions about how to treat
patients--and they're helping administrators plan how to use
hospital resources.
Microsoft is already working with health care providers
around the country, including Seattle Children's Hospital and
the University of Washington. I'm sure that their valuable
experiences will be useful as we move to expand health IT.
[Whereupon, at 11:06 a.m., the hearing was adjourned.]