[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]
HEALTH CARE INFORMATION TECHNOLOGY:
WHAT ARE THE OPPORTUNITIES FOR AND
BARRIERS TO INTER-OPERABLE HEALTH
INFORMATION TECHNOLOGY SYSTEMS?
=======================================================================
FIELD HEARING
BEFORE THE
SUBCOMMITTEE ON ENVIRONMENT, TECHNOLOGY,
AND STANDARDS
COMMITTEE ON SCIENCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
__________
FEBRUARY 23, 2006
__________
Serial No. 109-37
__________
Printed for the use of the Committee on Science
Available via the World Wide Web: http://www.house.gov/science
U.S. GOVERNMENT PRINTING OFFICE
26-205 WASHINGTON : 2006
_____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512�091800
Fax: (202) 512�092250 Mail: Stop SSOP, Washington, DC 20402�090001
______
COMMITTEE ON SCIENCE
HON. SHERWOOD L. BOEHLERT, New York, Chairman
RALPH M. HALL, Texas BART GORDON, Tennessee
LAMAR S. SMITH, Texas JERRY F. COSTELLO, Illinois
CURT WELDON, Pennsylvania EDDIE BERNICE JOHNSON, Texas
DANA ROHRABACHER, California LYNN C. WOOLSEY, California
KEN CALVERT, California DARLENE HOOLEY, Oregon
ROSCOE G. BARTLETT, Maryland MARK UDALL, Colorado
VERNON J. EHLERS, Michigan DAVID WU, Oregon
GIL GUTKNECHT, Minnesota MICHAEL M. HONDA, California
FRANK D. LUCAS, Oklahoma BRAD MILLER, North Carolina
JUDY BIGGERT, Illinois LINCOLN DAVIS, Tennessee
WAYNE T. GILCHREST, Maryland DANIEL LIPINSKI, Illinois
W. TODD AKIN, Missouri SHEILA JACKSON LEE, Texas
TIMOTHY V. JOHNSON, Illinois BRAD SHERMAN, California
J. RANDY FORBES, Virginia BRIAN BAIRD, Washington
JO BONNER, Alabama JIM MATHESON, Utah
TOM FEENEY, Florida JIM COSTA, California
BOB INGLIS, South Carolina AL GREEN, Texas
DAVE G. REICHERT, Washington CHARLIE MELANCON, Louisiana
MICHAEL E. SODREL, Indiana DENNIS MOORE, Kansas
JOHN J.H. ``JOE'' SCHWARZ, Michigan VACANCY
MICHAEL T. MCCAUL, Texas
VACANCY
VACANCY
------
Subcommittee on Environment, Technology, and Standards
VERNON J. EHLERS, Michigan, Chairman
GIL GUTKNECHT, Minnesota DAVID WU, Oregon
JUDY BIGGERT, Illinois BRAD MILLER, North Carolina
WAYNE T. GILCHREST, Maryland MARK UDALL, Colorado
TIMOTHY V. JOHNSON, Illinois LINCOLN DAVIS, Tennessee
DAVE G. REICHERT, Washington BRIAN BAIRD, Washington
JOHN J.H. ``JOE'' SCHWARZ, Michigan JIM MATHESON, Utah
VACANCY
SHERWOOD L. BOEHLERT, New York BART GORDON, Tennessee
AMY CARROLL Subcommittee Staff Director
MIKE QUEAR Democratic Professional Staff Member
JEAN FRUCI Democratic Professional Staff Member
OLWEN HUXLEY Professional Staff Member
MARTY SPITZER Professional Staff Member
SUSANNAH FOSTER Professional Staff Member
CHAD ENGLISH Professional Staff Member
JAMIE BROWN Majority Staff Assistant
C O N T E N T S
February 23, 2006
Page
Witness List..................................................... 2
Hearing Charter.................................................. 3
Opening Statements
Statement by Representative David G. Reichert, Subcommittee on
Environment, Technology, and Standards, Committee on Science,
U.S. House of Representatives.................................. 11
Written Statement............................................ 12
Statement by Representative David Wu, Ranking Minority Member,
Subcommittee on Environment, Technology, and Standards,
Committee on Science, U.S. House of Representatives............ 12
Witnesses:
Mr. William Jeffrey, Director, National Institute of Standards
and Technology
Oral Statement............................................... 14
Written Statement............................................ 16
Biography.................................................... 22
Dr. Jody Pettit, M.D., Project Chair, Portland Health Care
Quality Corporation, Portland, Oregon
Oral Statement............................................... 23
Written Statement............................................ 25
Biography.................................................... 30
Ms. Diane E. Cecchettini, President and CEO, MultiCare Health
System, Tacoma, Washington
Oral Statement............................................... 30
Written Statement............................................ 32
Biography.................................................... 46
Mr. John Jay Kenagy, Chief Information Officer, Oregon Health and
Science University
Oral Statement............................................... 46
Written Statement............................................ 48
Biography.................................................... 54
Dr. Homer L. Chin, Medical Director, Clinical Information
Systems, Kaiser Permanente; Northwest Chief Information
Officer, Oregon Health and Science University
Oral Statement............................................... 54
Written Statement............................................ 56
Mr. Luis Machuca, President and CEO, Kryptiq Corporation,
Hillsboro, Oregon
Oral Statement............................................... 59
Written Statement............................................ 60
Biography.................................................... 65
Mr. Prem Urali, President and CEO, HealthUnity Corporation
Oral Statement............................................... 65
Written Statement............................................ 67
Biography.................................................... 69
Discussion....................................................... 70
Government Role in Health IT................................. 71
Training on IT Systems....................................... 74
Role of Patient in Health IT................................. 76
Privacy Issues............................................... 77
Unique Patient Identifier.................................... 78
Questions From the Audience.................................. 81
Top-down or Bottom-up Approach............................... 84
HIPAA........................................................ 87
Appendix: Additional Material for the Record
HEALTH INFORMATION TECHNOLOGY: HHS Is Taking Steps to Develop a
National Strategy, United States Government Accountability
Office, Report to the Chairman, Committee on the Budget, House
of Representatives............................................. 94
HEALTH CARE INFORMATION TECHNOLOGY: WHAT ARE THE OPPORTUNITIES FOR AND
BARRIERS TO INTER-OPERABLE HEALTH INFORMATION TECHNOLOGY SYSTEMS?
----------
THURSDAY, FEBRUARY 23, 2006
House of Representatives,
Subcommittee on Environment, Technology, and
Standards,
Committee on Science,
Washington, DC.
The Subcommittee met, pursuant to call, at 12:18 p.m., at
the Providence St. Vincent Medical Center, Souther Auditorium,
9205 S.W. Barnes Road, Portland, Oregon, the Honorable David
Reichert presiding.
hearing charter
SUBCOMMITTEE ON ENVIRONMENT, TECHNOLOGY, AND STANDARDS
COMMITTEE ON SCIENCE
U.S. HOUSE OF REPRESENTATIVES
Health Care Information Technology:
What Are the Opportunities For and
Barriers to Inter-operable Health
Information Technology Systems?
thursday, february 23, 2006
12:00 p.m.-2:00 p.m.
providence st. vincent medical center
souther auditorium, 9205 s.w. barnes road,
portland, oregon 97225
Purpose
On February 23, 2006 at 12:00 p.m. in Portland, Oregon, the
Subcommittee on Environment, Technology, and Standards of the House
Science Committee will hold a field hearing about the opportunities for
and barriers to inter-operable health information technology (IT)
systems.
The purpose of this hearing is to learn about the potential
benefits of IT to health care providers and consumers, the impact of IT
on health care costs and quality, and about the major challenges to
implementing a national health information technology system. The
hearing will review federal, State and private-sector efforts to
promote connectivity, which would enable health care providers to
access patient data from any location. The hearing will examine efforts
to develop standards for security, privacy and inter-operability, which
are crucial to the adoption of nationwide health IT systems.
The Committee plans to examine these overarching questions:
1. What are the potential benefits of information technology
to the health care industry and health care consumers?
2. What should Federal and State governments and the private
sector do to foster the development of better health IT
systems? What is preventing the widespread adoption of these
systems?
3. What is happening in the states of Oregon and Washington to
help insurers, hospitals, doctors, and other providers develop
more comprehensive health IT systems? What role has the Federal
Government played? What else needs to be done?
Witnesses:
Dr. William Jeffrey, Director of the National Institute of Standards
and Technology (NIST). NIST's mission is to promote U.S. innovation and
industrial competitiveness by advancing measurement science, standards,
and technology in ways that enhance economic security and improve our
quality of life. NIST has a memorandum of understanding with the
Department of Health and Human Services (HHS) to collaborate on the
development of health IT infrastructure and standards.
Dr. Jody Pettit, Project Chair, Oregon Health Care Quality Corp
(QCorp). The Oregon Health Care Quality Corp provides both a forum for
sharing information and best practices and a mechanism to identify
strategic projects for improving health care through community based
activities. Dr. Pettit chairs the Oregon Health Information
Infrastructure (OHII) Project for the QCorp. The OHII seeks to create
an Oregon multi-stakeholder collaboration to apply health care
information and communication technology so that care is timely,
effective, efficient, safe, equitable and patient-centered.
Mr. Luis Machuca, President and CEO of Kryptiq Corporation. Kryptiq
makes software products for health care providers for secure messaging,
electronic prescribing, disease management and contract management.
Dr. Homer Chin, Medical Director for Clinical Information Systems,
Kaiser Permanente Northwest. Kaiser Permanente is America's leading
integrated health care organization, with 8.2 million enrolled members.
Kaiser Permanente Northwest started a pilot health IT system in 1994
and rolled out a full system in 1998.
Mr. Prem Urali, President and CEO of HealthUnity Corporation.
HealthUnity makes software and hardware health IT products for health
care providers.
Ms. Diane Cecchettini, RN, President and CEO of MultiCare Health
System. MultiCare Health System is the largest provider of key medical
services in Pierce County, south King County and much of southwest
Washington State. MultiCare has adopted a comprehensive health IT
system throughout its network of providers.
Mr. John Jay Kenagy, Chief Information Officer, Oregon Health & Science
University (OHSU). OHSU offers instruction in health care, biomedical
science, environmental engineering and computer science for more than
3,900 students, interns, residents, fellows and clinical trainees each
year. Furthermore, the University provides education and training for
about 18,000 health professionals through its continuing education
programs. OHSU is currently implementing an electronic health record
system for its patients.
Background:
What Are Inter-operable Health IT Systems?
Inter-operability allows different information technology systems
and software applications to communicate, exchange data, and use that
information. Inter-operable health IT systems can involve the use of
and the ability to share: up-to-date patient electronic health records
(EHRs); electronic physician orders for drug prescriptions and lab
tests; electronic referrals to specialists and other health care
providers; and electronic access to current treatments and research
findings. For these systems to share information, especially if they
are different IT systems, they must use common standards for data
transmission, medical terminology, security, and other features.
Potential Benefits of Health IT Systems
Studies suggest that eliminating errors related to paperwork and
enabling better communication between health care providers could
improve treatment and lower costs in the health care industry. For the
purposes of this charter, health care providers include both
individuals (such as physicians, nurses and lab technicians) and
institutions (such as hospitals and medical practices). According to a
study in the Annals of Family Medicine, miscommunication is a major
cause of 80 percent of medical errors, including poor communication
between physicians, misinformation in medical records and misfiled
charts.\1\ Providing doctors with access to EHRs could reduce duplicate
medical tests and adverse drug interactions. A patient's EHR would
include all of his or her lab tests and/or drug allergies, thereby
reducing the chance for error. In addition, EHRs could provide health
care workers with the ability to access a patient's medical history at
short notice in emergency situations. Inter-operable health IT systems
could allow physicians to: share patient medical information and lab
results between hospitals, labs, and clinics; order drug prescriptions;
and alert patients of drug recalls much faster than by sharing paper
records. Several health associations estimate that the potential
savings of greater IT adoption by the health care industry run into the
tens of billions of dollars. A recent study in the journal Health
Affairs estimates that a fully inter-operable national health IT
network could yield $77.8 billion per year in savings, or five percent
of America's annual health care spending.\2\
---------------------------------------------------------------------------
\1\ Annals of Family Medicine. July/August 2004.
\2\ Health Affairs. January 2005. ``The Value of Health Care
Information Exchange and Inter-operability,'' by Jan Walker et al.
---------------------------------------------------------------------------
Barriers to Adoption of Health IT Systems
The adoption of EHRs and other health-related IT has been slow.
According to a May 2005 Government Accountability Office report on the
subject, the Department of Health and Human Services (HHS) has
identified the health care industry as the largest part of the U.S.
economy that has not fully embraced IT.\3\ An expert at Brigham and
Women's Hospital in Boston, found that the health care industry invests
only about two percent of its revenues in IT.\4\ Other information-
intensive industries invest approximately 10 percent of revenues. There
are many reasons for this relative lack of adoption including: cost of
purchasing IT systems and institutional resistance to the adoption of
new technology; contradictory incentives for health care providers and
payers; concerns about security systems for patient records; and the
lack of standards necessary for uniform data entry and exchange,
software, and terminology.
---------------------------------------------------------------------------
\3\ ``Health Information Technology: HHS is Taking Steps to Develop
a National Strategy,'' GAO Report to the Chairman, Committee on the
Budget, House of Representatives. May 2005.
\4\ The Economist, April 28, 2005. ``The No-Computer Virus.''
---------------------------------------------------------------------------
Estimates of the number of providers who currently utilize EHRs
range from five percent to 20 percent nationwide, meaning that the
remainder rely on paper-based records that must be faxed or mailed if a
doctor outside of a medical office or provider network wants to see a
patient's history. According to a study in Health Affairs, only 12
percent of practices with five or fewer full-time-equivalent
physicians, where most physicians work and most patients receive care,
use EHRs.\5\ A major reason for low rate of utilization is the cost of
IT systems. Large health care providers and hospitals have a distinct
advantage over smaller and rural practices because they have greater
access to capital to purchase new technology, more integrated offices,
and larger physical concentrations of doctors and patients. In
addition, many physicians have used paper records and files for years,
and are uncomfortable abandoning this system to use IT.
---------------------------------------------------------------------------
\5\ Health Affairs. September 2005. ``Medical groups' adoption of
electronic health records and information systems,'' by D. Gans et al.
---------------------------------------------------------------------------
A typical medical practice in the U.S. has five doctors handling
approximately 4,000 patient visits in a year. The Markle Foundation in
New York finds that these practices would lose money if they had to
invest in, and learn how to use an inter-operable health IT system.
Furthermore, the current medical reimbursement system creates a
contradiction between insurers and patients on the one hand, who would
benefit from IT adoption, and health care providers on the other hand,
who would have to pay for IT adoption. Providers do not necessarily
have the economic incentive to adopt these systems, even if they are
more convenient to use. Currently, most health care providers operate
on a financial reimbursement system, which does not reward efficiency.
For instance, a physician may wish to order a duplicate test for a
patient rather than wait for the physical transfer of the patient's
test results from another practice. The patient's health plan or
insurance company will reimburse the provider for this additional test.
Use of an IT system could reduce this inefficiency by providing remote
access to the patient's original test results. HMOs, such as Kaiser
Permanente, are exceptions to this model and have incentives to adopt
IT because the payer and provider exist in a single financial entity.
In 2005, ChoicePoint informed approximately 163,000 people that
their personal information, including names, addresses, birth dates,
social security numbers and credit summary information were obtained by
suspected criminals posing as legitimate business people. This data
breach highlights security concerns for IT. Most patients want to
restrict access to their medical records, which contain sensitive
personal information, to their doctors and to other vital medical
personnel. Whereas paper files may not provide ideal security, breaches
require deliberate action, and even then the bulk of paper records
prevents or discourages large-scale mischief. With EHRs, it is easier
to access a lot of information quickly because data can be distributed
to hundreds or even thousands of people at the click of a button. Last
February, for example, the names and addresses of over 6,000 HIV
carriers were accidentally e-mailed to all 900 staff members of the
Palm Beach County Health Department. For these reasons, system
designers must ensure that passwords and encryption provide adequate
security to prevent hackers and other unauthorized users from gaining
access to sensitive personal information. The system design itself must
also include checks that protect this information from inadvertently
being transmitted to inappropriate recipients.
Some health care networks, organizations, municipalities and states
have been working to develop health IT systems. They recognize the need
for connectivity using agreed-upon inter-operability standards.
Comprehensive health care networks, such as Kaiser Permanente Northwest
and the Veterans Health Administration, have sophisticated IT systems,
which allow extensive connectivity within their networks. However,
these are closed systems which cannot share electronic patient
information with outside providers. Some cities have implemented pilot
programs which allow interconnectivity at various levels, but this
often involves the exchange of information in PDF form. PDF files are
not easily transferred into searchable databases. If agreed-upon
standards existed for EHR data exchange, these burgeoning systems could
adopt them, making seamless and efficient connectivity between them
much easier.
Federal Initiatives:
In April 2004, President Bush established a national goal that most
Americans have EHRs within 10 years. To carry out the President's goal,
HHS, in partnership with the National Institute of Standards and
Technology (NIST), has embarked on a number of initiatives, with both
public and private entities, to facilitate health IT adoption without
directly mandating standards.
Office of National Health Information Technology Coordinator
In April 2004, President Bush signed an executive order
establishing the position of the National Health Information Technology
Coordinator (National Coordinator) in HHS. The National Coordinator was
charged to develop a plan to ``guide the nationwide implementation of
inter-operable health IT in both the public and private health care
sectors that will reduce medical errors, improve quality, and produce
greater value for health care expenditures.''
On May 6, 2004, Dr. David Brailer was appointed as the National
Coordinator for Health IT. Dr. Brailer previously served as a Senior
Fellow at the Health Technology Center in San Francisco, CA, a non-
profit research and education organization that provides advice to
health care organizations about the future impact of technology in
health care delivery. Dr. Brailer announced a plan to achieve health
inter-operability nationwide, which includes having NIST work with the
National Coordinator's Office to oversee the development of standards
to facilitate this process. HHS and NIST signed a Memorandum of
Understanding, which transfers $6 million from HHS to NIST to pay for
its health IT work. The National Coordinator's Office and NIST are
collaborating with industry, standards organizations, consortia, and
government agencies to build tools and prototypes to advance the
adoption of IT within health care systems.
In his 2006 State of the Union address, President Bush called for
the ``wider use of electronic records and other health information
technology, to help control costs and reduce dangerous medical
errors.'' The President's 2007 budget requests $116 million for the
Office of the National Coordinator for Health Information Technology,
an increase of $55 million or 90 percent over the FY 2006 enacted
level. Funding will support strategic planning, coordination, and
analysis of technical, economic, and other issues related to public and
private adoption of health IT. The total FY 2007 budget request for
health IT initiatives in HHS is $169 million, an increase of $58
million or 52 percent over the FY 2006 enacted level.
NIST
NIST is the Nation's oldest federal laboratory and conducts
research in a wide range of physical and engineering sciences. NIST
researchers collaborate with colleagues in industry, academic
institutions, and other government agencies to support the development
of standards for a broad array of technical fields including software,
hardware, communications, and computer security. NIST activities to
support the President's health IT goals include participation in key
standards-related efforts, developing performance and conformance
metrics for health IT, developing procedures for certifying conformance
to consensus-based standards, and helping to secure sensitive
information and information systems. NIST has extensive experience
working with industry on standards development, conformance testing,
and other aspects of standards. In particular NIST has worked with the
IT industry on standards for inter-operability and computer security,
which would be a significant component of health IT. NIST helped HHS
develop Requests for Proposals for contracts on heath IT, and it
continues to work on these projects, providing technical advice and
other support to the participants.
HHS Contracts for Health IT Development
On October 6, 2005, Secretary Michael Leavitt announced that HHS
has let three contracts to develop a Standards Harmonization Process, a
Compliance Certification Process, and Privacy and Security Solutions.
On November 10, HHS awarded contracts to four groups of health care and
health IT organizations to develop a Nationwide Health Information
Network.
Standards Harmonization Process: $3,300,000 annually for
three years
HHS awarded a contract to the American National Standards
Institute, a non-profit organization that administers and coordinates
the U.S. voluntary standardization activities, to convene the Health
Information Technology Standards Panel (HITSP). The HITSP will bring
together U.S. standards development organizations and other
stakeholders to develop, prototype, and evaluate a harmonization
process for achieving a widely accepted and useful set of health IT
inter-operability standards. NIST staff will work with the HITSP during
the standards harmonization process.
Compliance Certification Process: $2,700,000 total over
three years
HHS awarded a contract to a non-profit organization, the
Certification Commission for Health Information Technology (CCHIT) to
develop criteria and evaluation processes for certifying EHRs and the
infrastructure or network components through which they inter-operate.
More than 200 EHR products are on the market, but there are no criteria
for prospective buyers to objectively evaluate them. This hinders
informed purchasing decisions and further discourages the widespread
adoption of health IT systems. CCHIT submitted recommendations to HHS
for ambulatory EHR certification criteria in December 2005, and
developed an evaluation process for ambulatory health records in
January 2006. The CCHIT is currently developing pilots for these
projects. A cross disciplinary team of NIST researchers serves as a
technical advisory committee to support the CCHIT. An optional
extension to continue refinement and assessment of the processes during
a fourth year will be up for consideration as the base period is
completed.
Privacy and Security Solutions: $11,500,000 total for 18
months
Regulations promulgated pursuant to the Health Insurance
Portability and Accountability Act (HIPAA) established baseline health
care privacy requirements for protected health information and
established security requirements for electronic protected health
information. Many states have adopted policies that go beyond HIPAA. In
addition, the manner in which hospitals, physicians and other health
care organizations implement required security and privacy policies
varies and is tailored to meet their individual organizations' needs.
These variations in policies present challenges for widespread
electronic health information exchange, due to the lack of common
standards.
HHS awarded a contract to the Research Triangle Institute
International (RTI), a private, nonprofit corporation to oversee the
Health Information Security and Privacy Collaboration (HISPC). HISPC is
a new partnership consisting of a multi-disciplinary team of experts
and the National Governors Association. The HISPC will develop plans to
harmonize the variations in business policies and state laws that
affect privacy and security practices. NIST will provide expertise to
help ensure that the systems being developed are secure and address
privacy.
Nationwide Health Information Network: $18,600,000 total
for one year
HHS awarded contracts to four groups of health care and health IT
organizations to develop pilot projects for secure information sharing
in a nationwide health IT system. The four consortia are led by
Accenture, Computer Science Corporation, IBM, and Northrop Grumman.
NIST will create an architecture management system to serve as a
repository for the content of the four prototypes being proposed.
Health IT Adoption Initiative
The National Coordinator's Office is partnering with the George
Washington University and Massachusetts General Hospital/Harvard
Institute for Health Policy through a contract on the Health IT (HIT)
Adoption Initiative. The new initiative is aimed at better
characterizing and measuring the state of EHR adoption and determining
the effectiveness of policies aimed at accelerating adoption of EHRs
and inter-operability. These institutions will examine the current
state of metrics for assessing EHR adoption measurement and make
publicly available the gaps in adoption measurement data and the
currently known gaps in actual adoption. The HIT Adoption Initiative
will provide not only a baseline measurement on EHR adoption rates but
also a quantifiable method for measuring the anticipated increased
uptake of health IT. Beginning in the fall of 2006, an annual report
will synthesize multiple surveys using the methodologies developed
under the HIT Adoption Initiative, and ultimately provide metrics with
which to assess the progress of the entire program.
American Health Information Community
The April 2004 Executive Order called on the National Coordinator
to coordinate outreach and consultation by the relevant branch agencies
(including federal commissions) with public and private parties of
interest, including consumers, providers, payers, and administrators.
As part of this collaboration, Secretary Leavitt created the American
Health Information Community (AHIC) on September 13, 2005. The AHIC
provides input and recommendations to HHS on how to make health records
digital and inter-operable, and assure that the privacy and security of
those records are protected, in a smooth, market-led way. Membership
includes officials from HHS and its component agencies, and other
federal agencies, including the Department of Veterans Affairs, Office
of Personnel Management, Department of Commerce, Department of
Treasury, and the Department of Defense. Other members include
physicians, health care providers, a patient advocate, payers,
purchasers, public health experts and business officials. The AHIC was
chartered for two years with the option to renew, and will have a
duration of no more than five years. A list of Community members can be
found at: www.hhs.gov/healthit/ahic.html
State of Washington Initiatives:
The State of Washington has recently implemented a Health
Information Technology and Electronic Medical Records Initiative. The
initiative will develop a strategy for the adoption and use of
electronic medical records and health information technologies.
The Washington State Health Care Authority (HCA), together with the
Health Information Infrastructure Advisory Board (HIIAB), will develop
the health information and technology strategy. In addition to the
HIIAB, the HCA is also creating a Health Information Infrastructure
Stakeholder Advisory Committee (HIISAC) that will provide feedback and
input to the HIIAB. Unlike the HIIAB, the HIISAC will represent a broad
variety of stakeholder groups such as consumers, clinicians, business,
payers of health care, employers, and health care organizations
(hospitals, carriers, long-term care facilities).
State of Oregon Initiatives:
The Oregon Health Policy Research (OHPR) office has been working
closely with key health care experts and stakeholders around the state
on electronic health records and data connectivity issues through its
staffing of the Oregon's Health Policy Commission (OHPC). The OHPC is
directed by statute to develop and oversee health policy and planning
for the state and includes key health leaders from both the private
sector and the State legislature. The Commission's recent Subcommittee
on Electronic Health Records and Data Connectivity, developed key
recommendations to move the state's health information technology
agenda forward. The Oregon Healthcare Quality Corporation (QCorp) acts
as a non-profit private sector partner with the OHPR.
QCorp has worked in partnership on a number of state initiatives
for health IT including the Oregon Chronic Disease Data Clearinghouse.
The Clearinghouse merged data from 11 health plans on 150,000 patients
with asthma and diabetes for use in developing reports for physician
practices. On a 10-point rating scale, clinicians and practice managers
rated the value of the merged, single source and format reports from
the Clearinghouse as 8.4 (highly favorable) compared to 1.4 (highly
unfavorable) for the traditional approach with multiple report sources
and formats. QCorp also works on the Electronic Health Record
Inventory. An important part of this work is assessing the current
state of EHR adoption. In addition, QCorp is currently working with the
Oregon Business Council EHR Leadership Team to develop next steps for
health data exchange.
Witness Questions:
The witnesses were asked to answer the following questions in their
testimony.
Dr. William Jeffrey, Director of NIST
1. What are the most significant standards-related barriers to
the widespread adoption of information technology within the
health care industry?
2. What is NIST's role in removing these barriers and what is
the expected time line for the completion of these activities?
3. How is NIST working with the health-care industry,
information technology companies, federal agencies, states and
other stakeholders to facilitate this process?
4. What role will NIST play in the HHS National Health
Information Infrastructure? What responsibilities has HHS
assigned NIST?
Dr. Jody Pettit, Project Chair, Oregon Health Care Quality Corp.
1. What role or potential role does health information
technology play in improving the delivery of health care in
Oregon?
2. What role does the Oregon Health Care Quality Corporation
play in this process?
3. What incentives and barriers exist to the adoption of
information technology in the health care industry, and are
these financial, technical, or of some other nature? What has
been the experience of the State of Oregon in this regard?
4. What specific measures can the Federal or State governments
take to encourage broader adoption of health information
technology?
Mr. Luis Machuca, President and CEO of Kryptiq Corp.
1. What role or potential role does health information
technology play in improving the delivery of health care in
Oregon?
2. What benefits have been realized or are expected from the
widespread adoption of information technology in the health
care industry?
3. What incentives and barriers exist to the adoption of
information technology in the health care industry, and are
these financial, technical, or of some other nature? What has
been Kryptiq's experience with these incentives and barriers?
4. To what extent have the Department of Health and Human
Services and NIST reached out to businesses like yours in its
effort to develop a national strategy on Health IT?
5. What specific measures can the Federal or State governments
take to encourage broader adoption of health information
technology?
Dr. Homer Chin, Medical Director for Clinical Information Systems,
Kaiser Permanente Northwest
1. How does Kaiser Permanente use health care-specific
information technology? What benefits has Kaiser Permanente
realized so far? What future benefits are expected from the
further adoption of this kind of technology?
2. What incentives and barriers exist to the broader adoption
of information technology in the health care industry, and are
these financial, technical, or of some other nature? What was
Kaiser Permanente's experience with these incentives and
barriers?
3. How does Kaiser Permanente differ from other non-HMO
providers? Do these differences affect the incentives for
adoption of health care IT?
4. To what extent have the Department of Health and Human
Services and NIST reached out to businesses like yours in its
effort to develop a national strategy on Health IT?
5. What specific measures can the Federal or State governments
take to encourage broader adoption of health information
technology?
Mr. Prem Urali, President and CEO of HealthUnity Corp.
1. What role or potential role does health information
technology play in improving the delivery of health care in
Washington?
2. What benefits have been realized or are expected from the
widespread adoption of information technology in the health
care industry?
3. What incentives and barriers exist to the adoption of
information technology in the health care industry, and are
these financial, technical, or of some other nature? What has
been HealthUnity's experience with these incentives and
barriers?
4. To what extent have the Department of Health and Human
Services and NIST reached out to businesses like yours in its
effort to develop a national strategy on Health IT?
5. What specific measures could the Federal or State
governments take to encourage broader adoption of health
information technology?
Ms. Diane Cecchettini, RN, President and CEO of MultiCare Health System
1. How does MultiCare use health care-specific information
technology? What benefits has MultiCare realized from adoption
of health IT? What future benefits are expected from the
further adoption of this kind of technology?
2. What incentives and barriers exist to the broader adoption
of information technology in the health care industry, and are
these financial, technical, or of some other nature? What has
been MultiCare's experience with these incentives and barriers?
3. To what extent have the Department of Health and Human
Services and NIST reached out to businesses like yours in its
effort to develop a national strategy on Health IT?
4. What specific measures can the Federal or State governments
take to encourage broader adoption of health information
technology?
Mr. John Jay Kenagy, Chief Information Officer, Oregon Health & Science
University (OHSU)
1. How does Oregon Health and Science University (OHSU) use
health care-specific information technology? What benefits has
OHSU realized so far? What future benefits are expected from
this kind of technology?
2. What incentives and barriers exist to the broader adoption
of information technology in the health care industry, and are
these financial, technical, or of some other nature? What has
been OHSU's experience with these incentives and barriers?
3. To what extent have the Department of Health and Human
Services and NIST reached out to institutions like yours in its
effort to develop a national strategy on Health IT?
4. What specific measures can the Federal or State governments
take to help the broader adoption of health information
technology?
Mr. Reichert. Well, good afternoon. It's a pleasure to be
here. Someone asked me, earlier if I had--if this is my first
time to Portland, and it's not. I went to college here in
Portland, at Concordia University, so I've been here a little
while. It's nice to be back again.
This hearing will now come to order. Good afternoon and
welcome to today's hearing entitled ``Health Care Information
Technology: What Are the Opportunities For and Barriers to
Inter-operable Health Information Technology Systems?''
Today we are here to discuss the potential benefits of IT
to health care providers and consumers, the impact of IT on
health care costs and quality, and the major challenges to the
widespread use of IT in the health care industry. We will learn
about federal, State, and private sector efforts to promote
electronic systems that enable health care providers to access
patient data from any location.
Information technology has profoundly changed the way we
live and work. Computers are everywhere, and we increasingly
expect their convenience to touch on every aspect of our daily
lives. However, go into a doctor's office and in most cases,
the records of that visit, the prescriptions that are written,
and referrals to specialists will all be made on paper. Many
health experts tout the benefits of converting to electronic
records for billing, referrals, and prescriptions. Experts
claim that not only would it be cheaper in the long run and
more convenient, but the conversion to electronic records will
also enable doctors to share patient data more easily, which
would make for better diagnosis and treatment, prevent deaths
from drug interactions and allergic reactions, and help public
health agencies track diseases in populations.
In addition to serving on the Science Committee, I also
chair the Subcommittee of Emergency Preparedness Science and
Technology. And this is under the Homeland Security Committee.
During one of our recent hearings we held on pandemic flu, we
heard testimony on the real-world benefits of IT in the health
sector. One of the best ways to slow the spread of pandemic is
to quickly identify health trends in an area. Health IT enables
us to do that. We must recognize that we are incapable of
storing, moving, and accessing information in times of crisis.
Health IT would have been beneficial in the aftermath of
Hurricane Katrina as well, while a lack of electronic patients'
medical records contributed to the difficulties and delays in
the medical treatment of evacuees.
There are many challenges to the widespread adoption of
electronic health records and linking health care providers to
computers to exchange information. These systems are often very
expensive and complicated to implement. Standards are needed to
allow different systems to talk to each other. There are
serious security and privacy concerns associated with putting
sensitive patient data on computers. Experts must consider
these and other factors when thinking about the use of IT in
health care.
I want to thank Congressman David Wu, the Ranking Member of
the Subcommittee on Environment, Technology, and Standards, for
suggesting this topic for discussion this afternoon, which is a
matter of great interest to myself and my constituents, and I'm
sure it is to Mr. Wu's as well. I also want to thank our
witnesses today who have taken time out of their busy schedule.
I look forward to learning more from our witnesses from the
region and what they are doing to help with health care in the
Pacific Northwest to become more IT enabled and how the lessons
learned can be applied nationwide. The Chair now recognizes Mr.
Wu.
[The prepared statement of Mr. Reichert follows:]
Prepared Statement of Representative David G. Reichert
Good afternoon. Welcome to today's hearing entitled ``Health Care
Information Technology: What Are the Opportunities For and Barriers to
Inter-operable Health Information Technology Systems?''
Today we are here to discuss:
the potential benefits of IT to health care providers
and consumers,
the impact of IT on health care costs and quality,
and
the major challenges to the widespread use of IT in
the health care industry.
We will learn about federal, State and private-sector efforts to
promote electronic systems that enable health care providers to access
patient data from any location.
Information technology has profoundly changed the way we live and
work. Computers are everywhere, and we increasingly expect their
conveniences to touch on every aspect of our daily lives. However, go
into a doctor's office and in most cases, the records of that visit,
the prescriptions that are written and referrals to specialists will
all be made on paper. Many health experts tout the benefits of
converting to electronic records for billing, referrals and
prescriptions. Experts claim that not only would it be cheaper in the
long run and more convenient, but the conversion to electronic records
would also enable doctors to share patient data more easily, which
would make for better diagnosis and treatment, prevent deaths from drug
interactions and allergic reactions, and help public health agencies
track diseases in populations.
In addition to serving on the Science Committee, I also Chair the
Subcommittee on Emergency Preparedness under Homeland Security. During
one of our recent hearings we held on the Pandemic Flu, we heard
testimony on the real world benefits of IT in the health sector. One of
the best ways to slow the spread of a pandemic is to quickly identify
health trends in an area. Health IT enables us to do that. We must
recognize that we are incapable of storing, moving and accessing
information in times of crisis. Health IT would have been beneficial in
the aftermath of Hurricane Katrina as well, when a lack of electronic
patient medical records contributed to difficulties and delays in the
medical treatment of evacuees.
There are many challenges to the widespread adoption of electronic
health records and linking health care providers' computers to exchange
information. These systems are often very expensive and complicated to
implement. Standards are needed to allow different systems to ``talk''
to each other. There are serious security and privacy concerns
associated with putting sensitive patient data on computers. Experts
must consider these and other factors when thinking about the use of IT
in health care.
I want to thank Congressman David Wu, the Ranking Member on the
Subcommittee on Environment, Technology, and Standards, for suggesting
the topic for this hearing, which is a matter of great interest to
myself and my constituents, as I am sure it is to Mr. Wu's. I also want
to thank our witnesses, who have taken time out of their busy schedules
to testify before us today. I look forward to learning more about what
our witnesses from the region are doing to help health care in the
Pacific Northwest become more IT-enabled, and how the lessons learned
here can be applied nationwide.
Mr. Wu. Thank you very much, Mr. Chairman.
I want to welcome everyone to this afternoon's hearing, and
I would like to begin by thanking Representative Reichert for
traveling from the Puget Sound area to take part in this
hearing. I also want to thank Dr. Bill Jeffrey, the Director of
the National Institute of Standards and Technology, for
traveling from Washington, D.C., out of a snowstorm, to take
part in this hearing as well.
Health care costs and efficiency have become the issue of
the moment and will be the issue of tomorrow. The most recent
report by the Centers for Medicare and Medicaid Services
predicts that health care costs could consume close to 20
percent of our GDP within ten years. There's general agreement
that increased utilization of information technology in the
health care industry may save billions of dollars in costs and
save thousands of lives each year. It will certainly improve
the patient experience and provide a better work environment
for health care providers.
This hearing is a follow-up to a round table discussion
that I held in August of 2005. Before that round table, the
solution seemed obvious: To get all patient information out of
paper files and onto electronic databases that can be connected
with each other; in this way, our health care providers can
access all the information that they need to help any given
patient, at any time, in any place. In other words, we would
create an inter-operable system of doctors, hospitals,
laboratories, pharmacies, and insurers.
If I can use any ATM in almost any place in the world, and
international financial markets operate seamlessly and
transparently--well, much of the time--why must I fill out a
patient information form every time I am referred to a medical
specialist?
The initial round table we held last August made me aware
of not only the technical barriers but also the system and
financial barriers to the widespread adoption of IT in the
health care industry. Today's field hearing will focus on the
technical barriers to developing a comprehensive health care IT
system. Technical standards are critical not only to issues of
inter-operability of systems, but also to the privacy and
security of electronic health records.
I hope our witnesses will identify some of the stumbling
blocks to the development of the required standards and make
recommendations on how we can best move forward together. We
need technical standards to create a functional IT network;
however, in order to reap the benefits of a comprehensive
health care IT network, it must fully--it must be fully
utilized in all health care settings.
There is agreement that IT use lags in the health care
industry, with only 10 percent of hospitals and five percent of
doctors using IT effectively. Anecdotally, the health care
industry apparently has the same percentage of gross revenues
devoted to IT as the mining industry, and these two industries
are at the lowest level of investment in IT.
We need to understand these nontechnical barriers to the
adoption of IT by our health care industry. And I hope that our
witnesses will address factors such as capital costs, training
and education of medical personnel, reimbursement structure,
patient confidence and confidentiality, in their testimony. If
we want to be successful in our efforts, we need to address
these issues early on in the process.
Many of you will be wondering about the Science Committee's
involvement in health care IT issues. The Science Committee in
the mid-1990s held hearings on the technical aspects
surrounding the security and privacy issues of the Health Care
Insurance Portability and Accountability Act, which you all--
which everyone knows as HIPAA. As a result of those hearings,
the National Institute of Standards and Technology, NIST,
assisted HHS in the development of some of those regulations,
which many of you came to discuss with me in my offices prior
to their implementation.
I was pleased that HHS turned to the NIST early on in the
development of the President's health information technology
plan. NIST has a long history of working with the private
sector in the development of standards for the IT industry as
well as many other industries.
In the Pacific Northwest, we have a group of experts who
have been working on these health care IT issues, and just a
few of them are represented by the panelists here today. I
intend to profit from their experience and knowledge as federal
efforts move forward. I want to thank all of the witnesses for
taking time from their busy schedules to appear before us. We
value your expertise and we are looking forward to your
guidance.
Mr. Chairman.
Mr. Reichert. Thank you, Mr. Wu.
At this time, I'd like to introduce our witnesses. The
first is Dr. William Jeffrey; he's the Director of the National
Institute of Standards and Technology, also known as NIST.
Second, Ms. Diane Cecchettini is the President and CEO of
MultiCare Health System, headquartered in Tacoma, Washington.
And third, Mr. Prem Urali is the President and CEO of
HealthUnity Corporation, headquartered in Bellevue, Washington.
And for the purpose of introductions, the Chair yields to
the Ranking Member, Mr. Wu.
Mr. Wu. Thank you.
Dr. Jody Pettit is Project Chair at the Portland Health
Care Quality Corporation, based in Portland, Oregon.
Luis Machuca is the President and CEO of Kryptiq
Corporation, based in Hillsboro, Oregon.
Dr. Homer Chin is the Medical Director for Clinical
Information Systems at Kaiser Permanente Northwest. And I have
to say that, as a Kaiser patient, I appreciate your hard work
and the availability of that data.
Mr. John Kenagy is the Chief Information Officer at Oregon
Health and Science University, in Portland, Oregon.
Mr. Chairman.
Mr. Reichert. Thank you, Mr. Wu.
As our witnesses should know, spoken testimony is limited
to five minutes each; after which, the members of the science
committee will have five minutes each, to ask questions.
And we will start by hearing the testimony of Dr. Jeffrey.
STATEMENT OF MR. WILLIAM JEFFREY, DIRECTOR, NATIONAL INSTITUTE
OF STANDARDS AND TECHNOLOGY
Dr. Jeffrey. Thank you very much, Representative Reichert
and Representative Wu. I'm very pleased to be here today to
take part in this important hearing. And I'm also very pleased
to be in Portland, which is the first time I've been here, and
I'm very impressed with what I've seen.
With your permission, I ask that my full statement be put
in the record so that I can summarize it in the short time
frame.
Mr. Reichert. Without objection.
Dr. Jeffrey. Americans expect the world's best health care,
and whereas our current health care system is second to none,
we can make it even better. Today Americans spend an increasing
share of their income on health care. In fact, when I was born,
in 1960, the U.S. spent five percent of its GDP on health care;
and as Representative Wu said, that is supposed to go up to--
it's estimated to go up to 20 percent by the year 2015.
In addition to increase in costs, there are indications
that lack of information or confusing information reduces the
quality of care. The Institute of Medicine estimated about five
years ago that between 44,000 and 98,000 Americans die each
year from inpatient medical errors. The Agency for Health Care
Quality and Research estimates more than 770,000 people are
injured or die each year in hospitals from adverse drug
effects; and a significant cost is borne for treatments and
tests that may not improve health, may be redundant, or may be
inappropriate.
Health care is a critical issue facing the Nation,
impacting our economic security and quality of life. In the
most recent State of the Union Address, President Bush proposed
a comprehensive agenda to make health care in America more
affordable, portable, transparent, and efficient. The portion
of the President's plan that I'll touch upon today is the
incorporation of IT into routine health care, with the goal of
lower costs, fewer medical errors, and improved quality.
In 2004, the President launched an initiative to make
electronic health records available to most Americans within
the next ten years, and for the development of a nationwide
health information network to connect patients, practitioners,
and caregivers.
So how might this work? Let's say, hypothetically, that a
visitor from Washington, D.C., ends up getting sick and going
to the emergency room in Portland. Well, the patient's
electronic health record can be accessed by the ER physician,
removing the burden from the patient of having to accurately
remember his or her entire medical history. Vital signs are
monitored, tests run, and the results added to the electronic
record. The data is transferred to a consulting physician, who
orders a battery of tests. Several of these tests may have
already been conducted, and so the data is called up rather
than repeating the tests, which could be costly or
uncomfortable for the patient. Medication may be suggested; but
before ordered, the medication is checked against the patient's
known allergies and other known medications, to avoid the
adverse reactions. The prescription is then electronically sent
to a nursing station, avoiding the risk--if there's any nurses
here--of deciphering the doctor's handwriting. And all of this
information is securely sent to the hometown physician for
follow-up care.
So in this kind of vision, IT can clearly add to the
quality of the patient's life, can save money and potentially
save time in the diagnosis. So the administration is taking
steps toward making this vision, including establishing the
position of the National Coordinator for Health Information
Technology and providing funds for projects harmonizing
standards for electronic information exchange, developing
certification criteria to ensure health IT investments meet
proper standards, addressing privacy and security issues, and
developing models for a nationwide Internet-based health
information system. And through the American Health Information
Community, the administration and the private sector are
working together to provide input and make recommendations to
HHS, Health and Human Services, on how to make health records
digital and inter-operable and to ensure that the privacy and
security of the records are protected.
While the Department of Health and Human Services naturally
takes the lead in this initiative, it's clear that in this
area, as the President put it, step 1 is to set the standards.
NIST has a long and effective history of working with health
related standards organizations to improve our nation's health
care system. Because of these collaborations, NIST and HHS
signed an interagency agreement in September of 2005 for us to
support the office of the National Coordinator for Health IT
office, known as ONC.
Since signing of that agreement, NIST has been
collaborating with the ONC in standards harmonization,
conformity assessment, developing the architectural management
system for the health information network, and privacy and
security.
As you know, the efforts to develop a nationwide health IT
infrastructure is highly complex, with dozens of players. We
are therefore actively involved with the key health IT
standards, including ANSI, ASTM, IEEE, the American Telemedics
Association, Health Level 7, and scores of others. Because
there are so many different relevant standards in existence and
under development, we're collaborating with the community to
develop and demonstrate a prototype health care standards
landscape.
The landscape, as we call it, is a Web based repository of
information on health care standards and resources that can
assist in the development, implementation, and hopefully the
adoption of standards by the stakeholders. In addition to the
standards, we're helping to address conformity assessment.
Conformity assessment activities form a vital link between
standards and the performance of the products themselves. NIST
is collaborating with the ONC to enable performance testing, to
provide assurances that health care information technology
products deliver the functionality necessary for inter-
operability. This activity is important, because there are more
than 200 electronic health record products on the market, that
criteria exists for objectively evaluating product
capabilities.
The challenges are great but they're not insurmountable.
Working closely with the Office of the National Coordinator of
Health IT, NIST is happy to play our part in realizing the
President's vision. As he said two years ago, at the outset, by
introducing information technology, health care will be better,
the cost will go down, and the quality will go up.
Thank you, and I'd be happy to answer any questions.
Mr. Reichert. Thank you, Dr. Jeffrey.
[The prepared statement of Dr. Jeffrey follows:]
Prepared Statement of William Jeffrey
Introduction
Representative Wu and Representative Reichert, I am William
Jeffrey, Director of the National Institute of Standards and Technology
(NIST), part of the Technology Administration of the Department of
Commerce. I am pleased to be offered the opportunity to add to this
discussion regarding health information technology.
I will focus my testimony on NIST's role in meeting the challenges
we are facing as we incorporate advances in information technology to
the health care enterprise, critical to improving values in the
Nation's health care spending, now over 16 percent of the GDP.\1\
---------------------------------------------------------------------------
\1\ Smith, Cynthia, Cathy Cowan, Stephen Heffler, Aaron Caitlin and
the National Health Accounts Team, National Health Spending in 2004:
Recent Slowdown Led By Prescription Drug Spending. 25 HEALTH AFFAIRS
186 January/February 2006.
---------------------------------------------------------------------------
Our nation enjoys the best medical care and the brightest medical
personnel in the world. Nonetheless, the enterprise is fraught with
poor coordination, inefficiencies in administration, and avoidable
medical errors. Studies suggest that between 44,000 and 98,000
Americans die each year from inpatient medical errors;\2\ more than
770,000 people are injured or die each year in hospitals from adverse
drug events, which may cost up to $5.6 million each year per hospital
depending on hospital size;\3\ and a significant annual expenditure on
treatments that may not improve health, may be redundant, or may be
inappropriate.
---------------------------------------------------------------------------
\2\ Kohn, L.T., J. Corrigan, and M.S. Donaldson. To Err Is Human:
Building a Safer Health System. National Academy Press: Washington,
D.C., 2000.
\3\ Agency for Healthcare Quality and Research, http://
www.ahrq.gov/qual/aderia/aderia.htm.
---------------------------------------------------------------------------
Today, we have new technological opportunities to address these
problems. The President's Health Information Technology Plan, with the
ultimate mandate of making our country's premier health care system
safer, more affordable, and more accessible through the utilization of
information technology (IT), is designed to overcome all of these
trends, which are closely related to failure to adequately develop and
adopt information technology for the health care system. In particular,
the President has called for ensuring that most Americans have
electronic health records within the next ten years and for the
development of an Internet-based Nationwide Health Information Network
to connect patients, practitioners, and payers. These initiatives will
reduce redundancies and save administrative time, and could greatly
improve patient safety and quality of care.
When the President's vision is realized:
consumers will have their choice of providers and
will be able to move seamlessly between practitioners without
loss of information;
clinicians will have information needed when and
where it is needed, that is, at the point of care;
payers will benefit through the economic efficiencies
of fewer errors and less redundant testing; and
public health officials will benefit from more
efficient and effective reporting, surveillance, and quality
monitoring.
To meet these goals, the Office of the National Coordinator for
Health Information Technology (ONC) was created in the Department of
Health and Human Services in response to Executive Order 13335, April
27, 2004. I am pleased that NIST has the opportunity to assist ONC
realize this vision. NIST is contributing through NIST laboratory
activities in measurement and consensus based standards and by direct
collaboration with ONC.
Standards and measurements go directly to the heart of NIST's core
mission. In fiscal year 2005, NIST health related projects encompassed
many areas of the health care sector, including screening and
prevention, diagnostics, treatments, dentistry, quality assurance,
bioimaging, systems biology, and clinical informatics. Also, NIST has a
long and effective history in working with health-related organizations
to improve our nation's health care system. Building on those
collaborations, NIST and HHS signed an interagency agreement in
September 2005 to support ONC in realizing the President's health IT
goals. Since the signing of the interagency agreement, NIST has been
providing technical expertise to the ONC in areas such as standards
harmonization, developing procedures for certifying conformance,
developing performance and conformance metrics, developing the
architecture management system for the nationwide health information
network.
NIST Laboratory Activities in Health IT
NIST works with industry, government, and academia to establish
consensus-based standards, develop associated test metrics to ensure
that devices perform according to the defined standards, and establish
comprehensive certification capabilities for the IT industry. NIST has
for many years focused on developing metrics for the information
technology industry. We develop tests and diagnostic tools for building
robust and inter-operable systems. Applying such tools early in the
life cycle process helps industry determine whether its products
conform to the standard, and ultimately, will inter-operate with other
products. In addition, the development and use of these metrology tools
fosters thorough review of the standards, which will, in turn, aid in
resolving errors and ambiguities.
a.) Standards Harmonization
In accordance with the National Technology Transfer and Advancement
Act of 1995 (Public Law 104-113) and Administration policies, NIST
supports the development of voluntary industry standards both
nationally and internationally as the preferred source of standards to
be used by the Federal Government. NIST collaborates with national and
international standards committees, users, industry groups, consortia,
and research and trade organizations, to get needed standards
developed.
As a matter of policy, NIST encourages and supports participation
of researchers in standards developing activities related to the
mission of the Institute. More than a quarter of NIST's technical
staff--381 employees--participate in standards developing activities of
97 organizations. These include U.S. private sector standardization
bodies, industry consortia, and international organizations. NIST staff
members hold 1,328 committee memberships and chair 161 standards
committees.
NIST is helping ONC in establishing the Health Information
Technology Standards Panel. Supported by an ONC contract with the
American National Standards Institute (ANSI), the Panel is working to
harmonize standards in the health IT arena, the NIST staff also
participates in the following key IT standards-related efforts:
American National Standards Institute (ANSI)
Healthcare Information Technology Standards Panel (HITSP)
ASTM International--Operating Room of the Future
American Telemedicine Association (ATA)
Federal Health Architecture/Consolidated Health
Informatics (FHA/CHI)
Medical Device Communications, Wireless Networks of
the Institute of Electrical and Electronics Engineers (IEEE)
Healthcare Information and Management Systems
Society/Integrating the Healthcare Enterprise (HIMSS/IHE)
Health Level 7 (HL7)
b) Performance and Conformance Metrics for Health Information
Technology
NIST works with industry to establish credible, cost-effective
metrics to demonstrate software inter-operability and conformance to
particular standards. These metrics often form the basis or criteria
upon which certifications are based. Typical NIST metrics include
models, simulations, reference implementations, test suites, and
testbeds.
Specific activities in support of health information technology
include:
Electronic Health Records (EHR): Having access to complete
patient health information is critical to improving clinical
care and reducing medical errors and costs of care. The EHR is
a longitudinal collection of patient-centric, health care
information, available across providers, care settings, and
time. It is a central component of an integrated health
information system. NIST is collaborating with organizations in
both the public and private sectors in achieving the benefits
of EHRs and overcoming the barriers to their acquisition and
use. In particular, NIST leads the effort in HU to define
conformance and develop conformance criteria for EHR systems.
NIST authored the conformance chapter of the draft standard for
trial use and developed guidance (a How to Guide) for writing
conformance criteria, thus teaching the community how to do
this for themselves. The EHR conformance criteria and those
being developed by the Certification Commission for Health
Information Technology (CCHIT) form the basis for HER
certification efforts.
HIMSS/IHE: A key problem today in the realization of
Electronic Health Records for the patient's continuity of care
is the inability to share patient records across disparate
enterprises. To address this problem, NIST is collaborating
with industry to develop standardized approaches to sharing
electronic clinical documents across health care organizations
and providers. NIST staff have built reference implementations
and developed validation tools to demonstrate the feasibility
and correctness of implementations, and worked with
implementers to create integrated solutions based on these
approaches. In particular, NIST is collaborating with the
`Integrating the Healthcare Enterprise' (IHE) project sponsored
by the Radiological Society of North America, Healthcare
Information and Management Systems Society (HIMSS) and the
American College of Cardiology. The goal is to develop an
approach called Cross-Enterprise Document Sharing (XDS). This
standards-based approach provides a mechanism to access a
patient's multi-faceted clinical information, regardless of
where it is physically located, while maintaining local control
and ownership of that information and without compromising the
privacy and security of the patient's health information.
HL7 Messaging Standards: Health Level 7 is a standards
development organization that provides standards for the
exchange, management, and integration of data that support
clinical patient care and the management, delivery, and
evaluation of health care services. NIST is collaborating with
HL7 to improve current and future deployment of HL7 and to
achieve health care information systems inter-operability and
sharing of electronic health information. To achieve this goal,
NIST leads the effort to ensure that HL7 conformance can be
defined and measured at appropriate levels, by: 1) defining
conformance for standards and ensuring that requirements are
precise and testable; and 2) building tools that will promote
consistent definitions and use of messages. Additionally, NIST
is developing a conformance-testing tool that automatically
generates test messages for HL7 Version 2 message
specifications.
Medical Device Information: In a typical intensive care unit
(ICU), a patient may be connected to one or more vital-sign
monitors and receive medicine or other fluids through multiple
infusion pumps. Devices such as ventilators, defibrillators, or
hemodialysis machines may also support more acutely ill
patients. Each of these medical devices has the ability to
capture data. NIST is collaborating with the Institute of
Electrical and Electronics Engineers (IEEE) Medical Device
Communications work group and the IHE Patient Care Device
project, sponsored by IHE and the American College of Clinical
Engineering to develop conformance tests and associated tools
that facilitate the development and adoption of standards for
communicating medical device data throughout the health care
enterprise as well as integrating it into the electronic health
record.
Operating Room of the Future: It is estimated that 10-20
percent of hospital errors occur in the perioperative
environment (before, during, and after surgery). Technology can
play a major role in increasing the overall patient safety in
such situations through the development of the operating room
of the future (ORF). The ORF will consist of a network of
inter-operable plug and play medical devices, where the
utilization of advanced technologies, such as robot-assisted
surgery, sensor fusion, virtual reality, workflow integration,
and surgical informatics, will result in a higher quality of
health care by considerably increasing patient safety. NIST is
working with the Center for the Integration of Medicine and
Information Technology (CIMIT) in the development of an
architectural framework for medical device integration,
development of clinical requirements for device plug-and-play
standards, identification of current interfaces, and
development, testing, and simulation of interfaces.
Clinical Informatics: Building on past experience in
information modeling and research to support interchange
standards for the manufacturing industry, NIST has prepared a
comprehensive report of all clinical information-oriented
standards, their development organizations, their scope, and
the vocabularies/ontologies they employ.\4\ NIST will use the
report as the basis for developing a plan for applying NIST's
experience to assist in clinical information-oriented standards
development and closer harmonization.
---------------------------------------------------------------------------
\4\ Bock, C., L. Carnahan, S. Fenves, M. Gruninger, V. Kashyap, B.
Lide, J. Nell, R. Raman, R. Sriram. Healthcare Strategic Focus Area:
Clinical Informatics. National Institute of Standards and Technology:
NISTIR 7263, 2005.
WPAN's for Health Information: NIST is assisting industry in
the development of a universal and inter-operable wireless
interface for medical equipment, expediting the development of
standards for wireless technologies, and promoting their use in
the health care environment. In close collaboration with the
IEEE and the U.S. Food and Drug Administration, NIST developed
theoretical and simulation models for two candidate Wireless
Personal Area Network (WPAN) technologies including the
Bluetooth and the IEEE 802.15.4 specifications. NIST evaluated
their performance for several realistic health care scenarios
and contributed our results to the appropriate IEEE working
group. NIST contributions will constitute the basis of standard
requirements on the use of wireless communications for medical
---------------------------------------------------------------------------
devices.
c) Certification
NIST has an established history of developing procedures for
certifying conformance to consensus-based standards. Conformity
assessment activities form a vital link between standards that define
necessary characteristics or requirements for software products and the
performance of the products themselves. Conformity assessment
procedures provide a means of ensuring that the products, services, or
systems produced or operated have the required characteristics, and
that these characteristics are consistent from product to product,
service to service, or system to system. Conformity assessment
includes: sampling and testing; inspection; certification; management
system assessment and registration; accreditation of the competence of
those activities; and recognition of an accreditation program's
capability. NIST has been in the certification business since its
inception in 1901 and is well positioned to provide technical guidance
in the development of a technical certification regimen, including
specific certification metrics, software to perform comprehensive
certification tests, and certification procedures.
d) Security
For many years, NIST has made great contributions to help secure
our nation's sensitive information and information systems. Our work
has paralleled the evolution of IT systems, initially focused
principally on mainframe computers, now encompassing today's wide gamut
of information technology devices. Our important responsibilities were
reaffirmed by Congress with passage of the Federal Information Security
Management Act of 2002 (FISMA) and the Cyber Security Research and
Development Act of 2002.
Beyond our role to serve the Agencies under FISMA, our Federal
Information Processing Standards (FIPS) and guidelines are often used
voluntarily by U.S. industry, global industry, and foreign governments
as sources of information and direction for securing information
systems. Our research also contributes to securing the Nation's
critical infrastructure systems. Moreover, NIST has an active role in
both national and international standards organizations in promoting
the interests of security and U.S. industry. Current areas that are
applicable to a Nationwide Health Information Network (NHIN) include:
Cryptographic Standards and Applications
Security Testing
Security Research/Emerging Technologies
Recent activities specifically related to health IT include:
Guidance for Understanding the HIPAA Security Rule: The
Security Rule issued under the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) directs certain health care
entities, known as ``covered entities,'' to comply with
standards for keeping certain health information that is in
secure electronic form. NIST has published a document, An
Introductory Resource Guide for Implementing the HIPAA Security
Rule that summarizes and clarifies the HIPAA Security Rule
requirements for agencies that are covered entities. It also
directs readers to other NIST publications that can be useful
in implementing the Security Rule.
Health Care Accreditation Guidance: NIST in conjunction with
URAC and the Workgroup of Electronic Data Interchange (WEDI)
sponsors the NIST/URAC/WEDI Health Care Security Workgroup. The
group promotes the implementation of a uniform approach to
security practices and assessments by developing white papers,
crosswalks (of regulations and standards), and educational
programs. The group brings together stakeholders from the
public and private sectors to facilitate communication and
consensus on best practices for information security in health
care. Ultimately, these best practices will be integrated into
accreditation criteria used by hospitals and other health care
facilities. The group draws heavily upon information technology
security standards and guidelines developed by NIST.
NIST Collaboration with the ONC
NIST is committed to supporting the ONC in the implementation of
the President's Health IT initiative. Even prior to the interagency
agreement NIST and many other federal departments and agencies provided
assistance to the ONC in serving on the review task force for responses
to a Request for Information (RFI) on implementation of a nationwide
health information network and in assisting with subsequent Request For
Proposals (RFPs) issued by the ONC.
Following are current areas of collaboration:
a.) The American Health Information Community (The Community)
HHS Secretary Leavitt has convened the American Health Information
Community (the Community) to help advance efforts to reach President
Bush's call for electronic health records and a nationwide health
information network. The Community is a federal advisory committee and
will provide input and recommendations to HHS on how to make health
records digital and inter-operable, and to assure that the privacy and
security of those records are protected, in a smooth, market-led way.
The Community agreed to form workgroups in the following areas:
biosurveillance, consumer empowerment, chronic care, and electronic
health records. These workgroups will make recommendations to the
Community that will produce concrete results that are tangible and
offer specific value to the health care consumer that can be realized
within a one-year period. NIST has formal representation on three of
these groups.
b.) Standards Harmonization
HHS has awarded a contract to the American National Standards
Institute (ANSI), a non-profit organization that administers and
coordinates the U.S. voluntary standardization activities, to convene
the Healthcare Information Technology Standards Panel (HITSP). The
HITSP will bring together U.S. standards development organizations
(SDOs) and other stakeholders to develop, prototype, and evaluate a
harmonization process for achieving a widely accepted and useful set of
health IT standards that will support inter-operability among health
care software applications, particularly EHRs. This activity is
fundamental to the success of widespread inter-operability, the
seamless and secure exchange of patient information electronically, and
will overcome today's scenario of many standards for health information
exchange, but with variations and gaps that hinder inter-operability
and the widespread adoption of health IT.
NIST, as with many other federal agencies, is a member of the
Healthcare Information Technology Standards Panel. NIST is helping ONC
in establishing the Health Information Technology Standards Panel. In
addition, NIST is working with HHS to develop a strategy to promote
voluntary consensus standards across both the private and public
sectors. As part of this process towards standardization of health
information, NIST will continue to work with the ONC's Office of Inter-
operability and Standards to develop appropriate implementation
strategies for health care IT standards. This will include
consideration of the development, when appropriate, of Federal
Information Processing Standards and guidance to agencies through NIST
Special Publications for adopted standards. This will help the
government to achieve a greater level of inter-operability of health
data.
c.) Assist in the Development of Procedures for Certifying Conformance
HHS has awarded a contract to the Certification Commission for
Health Information Technology (CCHIT) to develop criteria and
evaluation processes for certifying EHRs and the infrastructure or
network components through which they inter-operate. CCHIT is a
private, non-profit organization established to develop an efficient,
credible, and sustainable mechanism for certifying health care
information technology products. This initiative addresses the problem
that there are more then 200 EHR products on the market, but no
criteria exist for objectively evaluating product capabilities.
Similarly, criteria are not available by which communication
architectures can be standardized in a way to permit two different EHRs
to communicate.
A cross-disciplinary team of NIST researchers serves as a technical
advisory committee to support the CCHIT in tasks including functional
criteria and test methods, general test procedures, accreditation,
security, selection of jurors, and statistical tests of juror bias.
Additional areas for interaction are being defined as the collaboration
continues. In addition, the EHR conformance criteria, developed under
NIST leadership, form the basis for CCHIT's certification efforts.
d.) Develop Performance and Conformance Metrics
In a Nationwide Health Information Network, consumers,
practitioners, researchers, and payers must have tools, systems, and
information that are complete, correct, secure, and inter-operable.
Compliance to specific standards and regulations is the key to the
development and implementation of this network. In addition, there must
be a way to determine that the standards and regulations have been
fulfilled. This is accomplished through conformance testing, a
procedure to provide a means to ensure that products, services, or
systems produced or operated have the requisite characteristics, and
that these characteristics are consistent from product to product,
service to service, or system to system.
NIST is collaborating with the ONC to help enable conformance
testing to provide assurances that health care information technology
products and infrastructure components deliver the functionality
necessary for inter-operability. NIST will work to help the community
understand the current state of conformance testing within health
information technology markets as well as what will be needed to test
conformance of products for suitability, quality, inter-operability,
and data portability so that the risk now assumed by health IT
purchasers will be mitigated and the adoption of robust, inter-operable
information technologies will be accelerated throughout the health care
system of the United States.
e.) Provide Technical Expertise for a Nationwide Health Information
Network
Four groups of health care and health information technology
organizations have been awarded contracts by ONC to develop prototypes
for a Nationwide Health Information Network (NHIN) architecture. These
four consortia will bring together hospitals, laboratories, and health
care providers with technology developers that will lead the health
care industry to develop a uniform architecture for health care
information that can follow consumers throughout their lives.
To manage the content of the four prototypes being proposed, a NIST
team is working with ONC to create an architecture management system
that will serve as a repository for all the final architectural
elements, including but not limited to: user requirements, conformance
testing requirements, functional specifications, and high level
standards used. This system will also help manage the inter-
relationships between all elements, which will aid in the development
of the Nationwide Health Information Network. This architecture
management system can be compared to a blueprint for building a house.
f.) Interagency Health IT Policy Council
Secretary Leavitt has established an Interagency Health Information
Technology Policy Council (the Council) with in ONC to coordinate
health information technology policy decisions across federal
departments and entities that will drive action necessary to realize
the President's goals of widespread health IT adoption. The Council
brings together representatives from various entities within HHS and
elsewhere in the government for the purpose of advancing both short-
term and long-term health IT policy. The initial focus of the Council
is to establish a strategic direction for policy and to identify
accelerators to support the Community breakthroughs. NIST will
participate as a member agency on this Council.
Conclusion
As the Committee can see by the few examples I have cited, NIST has
a diverse portfolio of activities supporting our nation's health
information technology effort. With its long experience as well as a
broad array of expertise both in its laboratories and in its
collaborations with other government agencies and the private sector,
NIST is poised to help facilitate the harmonization of the many ongoing
efforts, which together contribute to achieving the President's goal
for developing both electronic health records and the establishment of
a Nationwide Health Information Network.
Once again thank you for inviting me to testify about NIST's
activities and I will be happy to answer any questions you may have.
Biography for William Jeffrey
William Jeffrey is the 13th Director of the National Institute of
Standards and Technology (NIST), sworn into the office on July 26,
2005. He was nominated by President Bush on May 25, 2005, and confirmed
by the U.S. Senate on July 22, 2005.
As Director of NIST, Dr. Jeffrey oversees an array of programs that
promote U.S. innovation and industrial competitiveness by advancing
measurement science, standards, and technology in ways that enhance
economic security and improve quality of life. Operating in fiscal year
2006 on a budget of about $930 million, NIST is headquartered in
Gaithersburg, Md., and has additional laboratories in Boulder, Colo.
NIST also jointly operates research organizations in three locations,
which support world-class physics, cutting-edge biotechnology, and
environmental research. NIST employs about 2,800 scientists, engineers,
technicians, and support personnel. An agency of the U.S. Commerce
Department's Technology Administration, NIST has extensive cooperative
research programs with industry, academia, and other government
agencies. Its staff is augmented by about 1,600 visiting researchers.
Dr. Jeffrey has been involved in federal science and technology
programs and policy since 1988. Previous to his appointment to NIST he
served as Senior Director for Homeland and National Security and the
Assistant Director for Space and Aeronautics at the Office of Science
and Technology Policy (OSTP) within the Executive Office of the
President. Earlier, he was the Deputy Director for the Advanced
Technology Office and Chief Scientist for the Tactical Technology
Office with the Defense Advanced Research Projects Agency (DARPA).
While at DARPA, Dr. Jeffrey advanced research programs in
communications, computer network security, novel sensor development,
and space operations.
Prior to joining DARPA, Dr. Jeffrey was the Assistant Deputy for
Technology at the Defense Airborne Reconnaissance Office, where he
supervised sensor development for the Predator and Global Hawk Unmanned
Aerial Vehicles and the development of common standards that allow for
cross-service and cross-agency transfer of imagery and intelligence
products. He also spent several years working at the Institute for
Defense Analyses performing technical analyses in support of the
Department of Defense.
Dr. Jeffrey received his Ph.D. in astronomy from Harvard University
and his B.Sc. in physics from the Massachusetts Institute of
Technology.
Mr. Reichert. The Chair recognizes Dr. Jody Pettit.
STATEMENT OF DR. JODY PETTIT, M.D., PROJECT CHAIR, PORTLAND
HEALTH CARE QUALITY CORPORATION, PORTLAND, OREGON
Dr. Pettit. Mr. Chairman and Mr. Wu, my name is Jody
Pettit. Thank you very much for inviting me to provide
testimony on a subject about which I feel so strongly.
I'm a board-certified internist and I've practiced medicine
in Portland for the past 11 years. As a physician, I've had the
privilege to take care of people and to see our medical system
from the front line. There's a glaring problem, and it's the
lack of information flow between systems.
I'll tell you a story about a woman that we saw in a
clinic, who came in with a persistent cough despite treatments.
We ordered a chest X-ray, and it showed a lesion in her right
lung. She'd had a previous chest X-ray several years and
remembered it was abnormal in some way but wasn't sure how.
Luckily, she remembered where she had it done, and so we
ordered the old film for comparison. If the lesion looked
exactly the same, we could feel comfortable and watch it over
time. So we waited. A week later, we still didn't have the
film. We called again, because we could save her the worry, the
radiation exposure, the time, the money that she and her health
plan would pay for more tests. We eventually gave up and
ordered a CT-scan, a chest CT, which cost close to a thousand
dollars. A week later, finally, the old film did show up and,
in fact, the lesion was exactly the same after almost four
years. But by now she had spent the time, her 20 percent co-
pay, she'd missed several hours of work, she'd gotten a hefty
dose of unnecessary radiation, and she spent weeks in fear that
she might have lung cancer.
This story, unfortunately, is not some bizarre exception or
rare occurrence; there are issues of information flow every
day. Experiences such as these have led me to refocus my
energy. For the past three years, I've been one among
hundreds--and they're here, too, today--of Oregonians from the
private and public sector that want to find a better way
through the use of health information technology. We've called
this effort, collectively, the Oregon Health Information
Infrastructure, or OHII for short.
The Oregon Health Care Quality Corporation has provided the
nonprofit multi-stakeholder home for OHII. The State of Oregon
recently created a position in the Office of Health Policy and
Research for health information technology coordinator, and I
will be serving in that role.
The vision is fourfold: A person's health information
available to them anywhere, any time that they need it. It's
private and secure and under their control. Health information
infrastructure is designed with the patient at the center. And
that it's used to assure high-quality, cost-effective, personal
and population-based care. There are many barriers to overcome
and achieve this vision. And I think we're all well-versed in
the EHR adoption issues, the technical issues, standards,
privacy and security, business case, and sustainability
issues--and not the least of which, political will, governance,
stakeholder cooperation, data sharing, and just plain old
trust.
So what are the roles of the Quality Corporation and the
State and the Federal Government in resolving these issues? The
Quality Corporation, with lots of partners, has helped bring
attention to this issue by bringing people together from around
the state and has completed a data sharing project with 12
health plans. We're working on assessment of EHR adoption and
currently engaged in a joint effort with the Oregon Business
Council's EHR and inter-operability committee. The goal of OHII
is to catalyze the formation of a regional health information
organization, or RHIO.
The state, likewise, has given attention to this issue. The
Oregon Health Policy Commission appointed a subcommittee to
give recommendations to the state; that report is available
here today. The Oregon Office of Health Policy and Research has
committed to resources for coordination. And the Governor's
Office is applying for a federal contract--subcontract to
examine privacy and security laws and practices in Oregon.
With regard to the federal role, the answers for all the
issues are, clearly, not worked out yet; but what we do have is
a forum for discussion and an appropriate framework in the
Office of the National Coordinator for Health Information
Technology. And the good news is, the agenda is moving forward.
National level activities are underway but state levels are not
well supported. Exceptions are communities that have already
received federal funding or have been working on this for well
over a decade.
The expectation is not for the government to fund this
indefinitely. There are RHIO business models being studied in
several communities, but assistance or start-up capital would
be helpful. A good example of this is the federal contract
process. The HISPC, the Health Information Security and Privacy
Collaboration, where RTI serves as a prime contractor and the
states as subcontractors. This allows contract money to be
awarded to states but with some coordination at the national
level. Working through the Governor's Office is an effective
way to gain state leadership. The process takes some leadership
and some followership.
I will close with these points. Number one, there is a
critical need for better information flow for better care.
Number two, real change involves rearranging the system
such that the patient is truly at the center. Until we do this,
the changes are incremental and not transformational. There is
a need for the data holders to share their data for the good of
the patient. We need to resolve these issues regarding--or
arguments regarding data ownership. A person's data needs to be
available to them without question. It's understood that data
holders, i.e., providers, health systems, and health plans,
need to keep a copy for their own records; however, they should
endeavor to make patient centered data sharing arrangements.
Number three, the Office of the National Coordinator is a
vehicle that's working. It has some money for national
coordination but very little to pass through to the states and
communities for RHIO information. Start-up capital could help
to build the infrastructure that's necessary to derive value
and ultimately achieve financial sustainability.
We all need to have courage to make this happen. We're
building something that hasn't existed before, but it needs to
exist as soon as possible, for all of our sakes.
Mr. Chairman and Ranking Member, thank you for coming to
the Great Northwest to listen to our concerns.
Mr. Wu. Thank you.
Mr. Reichert. Thank you, Dr. Pettit.
[The prepared statement of Dr. Pettit follows:]
Prepared Statement of Jody Pettit
Introduction:
Thank you very much for inviting me to provide testimony on a
subject about which I feel so strongly. I am a board-certified
Internist and have practiced medicine in Portland for the past 11
years. As a physician, I have the privilege to take care of people and
to see our medical system from the front line. There is a glaring
problem--and it is the lack of information flow.
Let me tell you a story about a woman that I saw in clinic who came
in with a persistent cough. We had tried several treatment regimens but
her cough continued. We ordered a chest x-ray and it showed a lesion in
her right lung.
She had a previous chest x-ray several years ago and she told us it
was abnormal in some way but wasn't exactly sure how. Fortunately, she
remembered where she had it done, so we called over to that facility to
get the old chest x-ray for comparison. If the lesion still looked
exactly the same after several years then we wouldn't have to worry as
much and we could watch it.
So we waited.
A week later we still didn't have the film. We called again because
we could save her the worry, the radiation exposure of more tests, the
time and the money that she and her insurer would pay for more tests.
We called again, but eventually the resident gave up and ordered a
chest CT. A chest CT costs a little less than $1,000. The following
week, the old film finally made it over and indeed the lesion was
exactly the same after almost four years. But by now she spent the
time, her 20 percent co-pay, missed several hours of work, got a hefty
dose of unnecessary radiation via CT and spent a weekend in fear that
she might have lung cancer.
A chest x-ray + a lack of information could equal a chest CT +
biopsy could = a pneumothorax, a chest tube, an ICU admission, a
hospital-acquired infection and sepsis. And a $50,000 hospital bill. Or
a chest x-ray + timely information = reassurance and prevention of a
hospitalization.
This story is not some bizarre exception, or a rare occurrence--
there are issues of information flow every time I go to clinic.
I could tell you countless stories of scrambling for information--
phone calls to medical records clerks in the wee hours of the morning
while the 50 yo man with chest pain is being wheeled down the hall to
the cath lab--we didn't have an old ECG for comparison or his previous
cath report--we didn't know if the ECG changes were new so he was going
to have a catheter pushed up through his groin into his heart to look
at his coronary arteries.
Any case could follow one of two equations:
Clinical condition + unattainable information = cascade of
unnecessary tests, possible complications and avoidable cost
Clinical condition + timely information = accurate, well-informed
medical decisions and efficient medical care. (cost-effective)
Experiences such as these have led me to refocus my energy.
For the past three years, I have been one among hundreds of
Oregonians from the private and public sector that want to find a
better way with the use of information technology. We call this
collective effort the Oregon Health Information Infrastructure or OHII
for short. The Oregon Healthcare Quality Corporation has provided the
non-profit, multi-stakeholder home for OHII. The State of Oregon
recently created a position in the Oregon Office of Health Policy and
Research for a Health Information Technology Coordinator and I will be
serving in that role.
The Vision:
The vision of better information flow in health care is four-fold:
A person's health information is available to them
anywhere, anytime they need it.
Health information is private and secure and under
the control of the individual.
Health information infrastructure designed with the
patient at the center.
Health information is used to assure safe, high
quality, cost-effective personal and population-based health
care.
The Issues:
There are many barriers to overcome to achieve this vision.
EHR adoption issues--Clinicians aren't adopting EHR because of a lack
of financial incentives, expense, risk of implementation failure and
lack of inter-operability which makes for expensive interfaces and
prohibits migration to different system.
Technical issues--The optimal technical architecture for inter-
operability and health data exchange is still being explored. Vendors
are just starting to create products to perform this function and
engines are operating only in experimental settings.
Standards issues--There are numerous standards organizations in
competition for becoming the standard. There is a need for
harmonization of these standards. EHR vendors have some but not all
data in proprietary formats and new standards would require largely
require retrofitting into their software.
Privacy & Security issues--Inappropriate disclosure of health
information is one of the top concerns for consumers. Fear of
discrimination especially from employers makes people cautious about
sharing their health information. Among the many issues, patient
control over access is a prominent one.
Business case and sustainability issues--It is well-recognized that in
order for the building of information technology systems to be funded
that the investors must recognize some value or return on their
investment. Furthermore, operating expenses of these systems must be
offset by a revenue source in order to be financially sustainable.
Studies of the value of HIT and projections regarding whom benefits and
how much have been published in the past couple of years.
Sustainability models are likewise being devised and tested in some
communities are around the U.S. The answers in this realm are not
readily apparent and the question of who will pay is still largely
unanswered.
Political will, governance, stakeholder cooperation, data sharing and
trust issues--Part of the challenge of moving from an institution-
centric model to a patient-centered model is that it requires that data
holding entities share information. Patients almost never get all of
their medical care in a single location and thus it is inadequate to
maintain walled off silos of data at the various points of care.
However, institutions may view holding onto the records as a means of
holding onto the patient. Thus competitive issues between health care
entities may lead to an unwillingness to share. Establishing a
governance in which the various entities have a seat at the table and
agree to rules for decision-making and data sharing is one of the major
challenges.
Role of the Oregon Healthcare Quality Corporation:
The Oregon Healthcare Quality Corporation (QCorp) has four
initiatives, all of which relate directly or indirectly to the use of
health information technology.
Chronic Disease Data Clearinghouse
This proof-of-concept pilot demonstrated that 12 health plans,
working together, can provide helpful tools that physicians will use to
manage care for patients with diabetes and asthma.
Analysis is providing answers about where people receive their care
to guide decisions about how to reduce fragmentation through common
data systems.
Common Practice Measurements
Providers, health plans and purchasers are working together to
identify a shared set of appropriate out-patient practice quality
measurements. These will be used by multiple stakeholders for
assessing, reporting and rewarding quality care in Oregon.
Advocacy and Education
Legislative testimony, serving on multiple Health Policy Commission
committees and cross-organization board memberships are a few of the
ways that Quality Corporation staff advocate for a collaborative
quality agenda. Sponsoring and participating in numerous conferences
bring Oregonians together for a shared agenda for quality improvement.
Oregon Health Information Infrastructure (OHII)
A strategic plan, developed through stakeholder meetings, is
setting the agenda to encourage adoption of electronic health records
and systems for securely and efficiently getting information to where
it is needed. OHII work (with partners) has included: multiple state-
wide conferences, CIO/CMIO forums, a pilot project proposal, EHR
inventory to establish a baseline. The Quality Corporation is working
to foster the formation of a regional health information organization
(RHIO). The Office of the National Coordinator for Health Information
Technology (ONCHIT), has called for at least one RHIO per state and one
overarching RHIO. In Dr. Brailer's view, a RHIO provides governance and
oversight. He believes it is essential to develop a process for making
decisions in public and RHIOs should have this public governance
process. The OHII effort endeavors to play a role in establishing an
open, neutral, inclusive governance process for Oregon and is engaged
in dialogue with top health care leaders including those in the Oregon
Business Council's EHR and Inter-operability Subcommittee.
Role of the State of Oregon:
The following is taken from the report to the Oregon Health Policy
Commission entitled ``Report to the 73rd Legislative Assembly:
Electronic Health Records & Data Connectivity,'' http://
egov.oregon.gov/DAS/OHPPR/HPC/docs/
EHR-LegReport-March05.pdf
The report made recommendations regarding the State's possible roles:
Convene stakeholders
Assess EHR adoption and community inter-operability
efforts
Sponsor meetings
Examine State laws regarding HIT
Collaborate with Public Health
Engage the public
Coordinate efforts around the state
Provide funding, if possible
Partner with the private sector
Incentivize HIT adoption in role as Payer through
Oregon Medical Assistance Program (OMAP)
Incentivize HIT adoption in role as Purchaser through
Oregon Public Employees Benefits Board (PEBB).
Role of the Federal Government:
The Office of the National Coordinator for Health Information
Technology (ONCHIT) is organized into the following offices:
Office of HIT adoption
Office of Inter-operability and Standards
Office of Programs & Coordination
Office of Policy & Research
They have the following as their major initiatives with the
corresponding roles:
A Recommendation for Action:
We don't have the answers to all the issues but what we do have is
a framework and a forum for discussion in the Office of the National
Coordinator for Health Information Technology (ONCHIT). The good news
is things are progressing in the ONCHIT agenda but the missing piece is
significant money flowing to the states. The activities that need to
take place at the national level are underway but the activities that
need to occur at the state level are not well-supported. Exceptions are
communities that have received funding or have already been working on
this for over a decade. The expectation is not for the government to
fund this indefinitely, but assistance with start-up capital could be
helpful. There are business models being studied and demonstrated in
some communities in the country.
An example of a working model for government funding is the Federal
contract process, e.g., with Research Triangle International (RTI) and
the Health Information Security and Privacy Collaboration (HISPC). RTI
serves as a prime contractor and states as subcontractors. This allows
contract money to be awarded to states in a semi-competitive process
with coordination at the national level. Working through the Governor's
office is an effective way to engage state leadership.
So this process requires some leadership and some followership.
Economic Analysis of Health Information Technology impact:
Several groups have begun to tackle some of the economic issues
relating to the adoption of HIT, the implications for inter-operability
and the use of clinical decision support tools. Below are some high-
level numbers that have been cited as relevant to the discussion.
U.S. health care industry expenditures = $1.7 trillion per year
RAND estimates $81 billion per year savings with EHR implementation
and networking.
The Center for Information Technology Leadership (CITL) estimates
fully standardized health information exchange and inter-operability of
could yield a net value of $77.8 billion per year once fully
implemented. Combined with potential savings from adoption of CPOE in
office EHR of $44 billion, the CITL suggests adoption of HIT could save
approximately five percent of health care expenditure.
A study out of Harvard published in the Annals of Internal Medicine
last year estimates the cost to build the National Health Information
Network at $156 billion in capital investment over five years and $48
billion in annual operating costs. (Annals of Internal Medicine 2005;
143:165-173.)
The Bush Administration has requested $169 million for health
information technology in the 2007 Health and Human Services Department
budget, a $58 million increase from the $111 million allocated for
health IT in the fiscal 2006 budget passed last month. The health IT
funding line includes a requested $116 million for ONCHIT, $50 million
for the Agency for Healthcare Research and Quality and $3 million for
the HHS assistant secretary for planning and evaluation's budget.
(Source: Government Health IT, Feb. 6, 2006)
U.S. health care industry expenditures = 1.7 trillion/yr
Estimated Operating Savings = $124 billion/yr
Estimated Operating Cost = $48 billion/yr
Net Operating Savings = $ 76 billion/yr
The CITL suggests adoption of HIT could save approximately five percent
of health care expenditure.
ONCHIT budget = $169 million/yr
The estimated capital investment is $156 billion, the proposed budget
is $169 million--this is 1/1,000th of the necessary funding.
These figures help to make the argument for federal funding to help
move this effort forward and for CMS in it's role as a payer to
incentivize HIT adoption.
Closing Comments:
I will close with these points:
1. There is a critical need for better information flow in
health care to achieve safe, efficient and high quality care.
2. Real change involves rearranging the system such that the
patient is at the center. Until we do this, changes are
incremental, not transformational. There is a need for the data
holders to share their data for the good of the patient. We
need to resolve the arguments regarding data ownership. A
person's data needs to be made available to them without
question. It is understood that the data holders, i.e.,
providers, health systems and health plans need to keep a copy
for their own records, however they should endeavor to make
patient-centered data sharing arrangements.
3. The Office of the National Coordinator for HIT is a vehicle
already in place for change and to a great degree it is
working. We have a forum for discussion and a framework for
strategic action. The ONCHIT has been able provide some money
for national coordination but very little money to pass through
to the states and communities for RHIO formation. What we're
lacking is the real financial commitment for this effort at a
state level. Start-up capital could help to build the
infrastructure that is necessary to derive value and ultimately
achieve financial sustainability.
4. Support legislation that authorizes the Secretary of Health
and Human Services to make health information technology grants
or contracts for the development of information sharing
infrastructure and collaborative efforts to spur adoption by
small physician groups and others.
ADDENDUM:
Specific examples of issues or barriers:
Solicitation of some health information technology colleagues in
Oregon yielded the following specific examples:
Example of lack of regulatory harmonization: A health IT colleague
`on the ground' implementing systems points to regulation from various
compliance organizations, e.g., JCAHO, NEC, UL, EOC, etc., that result
in layers and layers of regulations. There is apparently a need for
harmonization of these sometimes contradictory and stifling
combinations. It was conveyed that the regulations make sense in
isolation but become nearly unimplementable when several overlap. There
is also a concern that increasing regulation increases the cost of
implementation of systems.
Example of vocabulary standards issue or need: Colleagues at Oregon
chapter of the American Health Information Management Association
(AHIMA) have brought this issue to the fore. They feel that the U.S.
needs to adopt and begin implementing ICD-10 clinical coding systems in
order to improve the quality of health data and patient care. Their
concern it that current classification system, ICD-9-CM is obsolete.
Developed nearly 30 years ago, they assert that it cannot accurately
describe the diagnoses and inpatient procedures of care delivered in
the 21st century. Furthermore, they point out that the U.S. is the only
industrialized country in the world that has not adopted it. Ninety-
nine other countries have preceded the U.S. thus far.
Example of potential legislative need: The U.S. might consider
lengthening the statue of limitations on keeping a medical record from
seven years to 107 years. The rationale is that records need to be
available for the duration of a person's life.
Biography for Jody Pettit
Dr. Pettit is working in a dual role regarding health IT in Oregon.
She was recently selected by the Oregon Office of Health Policy and
Research to serve in the role of Health Information Technology
Coordinator.
She is the Director of the Oregon Health Information Infrastructure
project of the Oregon Healthcare Quality Corporation, a multi-
stakeholder collaborative dedicated to improving health care quality.
The organization has as one of its primary goals to foster the building
of an Oregon Regional Health Information Organization.
She is a Board-Certified Internist practicing part-time as faculty
with the Department of Medical Education at Providence Ambulatory Care
and Education Center, the Department of Medicine Faculty Practice at
St.Vincent's and with Legacy Health Systems in Portland.
She was the Medical Director of the InterHospital Physicians
Association (IPA) in Portland, Oregon from 2001-2005.
Dr. Pettit worked in the role of clinical consultant for the
electronic health records company MedicaLogic in Hillsboro, Oregon from
1999-2001.
She is a Clinical Assistant Professor at the OHSU Department of
Medical Informatics and Clinical Epidemiology.
She has been on the Board of the Oregon Healthcare Quality
Corporation (QCorp) since 2001 and served as the Chairperson of the
Chronic Disease Data Clearinghouse.
Dr. Pettit served as Chair of the Electronic Health Records and
Healthcare Connectivity Subcommittee for the State of Oregon, under the
Oregon Health Policy Commission 2005.
She participated in the State of Oregon Evidence-based medication
review process in three subcommittees, acting as Chair of the Triptan
subcommittee.
She earned her Medical Degree from Medical College of Virginia and
a Master's Degree in Health and Wellness Administration and a BS in
General Science from the University of Iowa.
Mr. Reichert. The Chair recognizes Ms. Diane Cecchettini.
STATEMENT OF MS. DIANE E. CECCHETTINI, PRESIDENT AND CEO,
MULTICARE HEALTH SYSTEM, TACOMA, WASHINGTON
Ms. Cecchettini. Thank you, Mr. Chairman and Mr. Wu.
I'm Diane Cecchettini. I'm a registered nurse and I'm
currently serving as President and CEO of MultiCare Health
System.
To give you a frame of our organization: We're a not-for-
profit, community-governed health care system who operates two
adult hospitals and a pediatric hospital, 593 licensed beds,
six ambulatory care centers, six urgent care, and we employ 200
physicians in our care system.
Over the past eight years, MultiCare Health System has
invested over $50 million implementing an electric health
record in our ambulatory center. Currently, we're implementing
the electronic health record in our inpatient hospitals, and
it's $50 million and counting. One of the huge barriers to the
implementation is the huge training costs of all of our staff,
plus the redesign of work flow so that we really achieve a
transformation of the health care system, centered around
patient, centered around information flow. We believe in these
investments. We are funding this out of operating earnings and
reserves because it's the right thing for the next level of
care.
Our patients are already starting to see the benefit of
this. Our patients now can see--they have access to their
medical records through secure electronic access. They can view
their medical problems, they can see lab work results, make
appointments, review education specific to their disease, and
even refill prescriptions. So we're on that first step of
access.
Since we've been in the ambulatory clinics for so many
years, we looked at what are the results of providing
physicians with information technology tools to really better
manage complex diseases. We've studied the 5,316 diabetic
patients and have seen significant clinical outcome results.
When you're able to provide physicians consistent data in terms
of how they are achieving hemoglobin A1C--and that's how you
manage and control blood glucose, how you manage blood
pressure--we consistently monitor this with our patients and so
it's a continuous stream of measuring outcomes. We know--and
we've extrapolated the data--that we have prevented heart
attacks, we have prevented ED admissions, and we have decreased
morbidity and mortality from this disease.
Our goal is ultimately to establish one health record
across the continuum and decrease the fragmentation that exists
in health care with patients not having the data flow with
redundant imaging tests, by being able to direct the patient at
the right site with the right information needed for care of
the patient. We're already seeing that impact in our emergency
department. When people in our clinics come to the ED, we can
immediately access the history, the medications, and expedite
treatment.
We also see that we're able to recall patients when there
are drug alerts, when we find more information about drugs that
we need to change therapy. So with the recent Vioxx, we were
able to immediately contact our patients and change therapy. We
were able to address our 15,000 women with the hormone
replacement therapy that were issues. With preventative
measures, we're able to achieve a 100 percent childhood
immunization rates in our clinics, and our mammogram compliance
rate exceeds 97 percent.
We believe, with all the barriers and challenges, that
payment incentives are key to the doctors of technology in
order to achieve successful expansion. So we're very interested
in payment incentives. We have concerns about pay for
performance, but my concern is that pay for performance needs
to be tied to clinical outcomes. We have a number of primitive
efforts in Washington state, where the commercial insurers data
is corrupted, and it's from claims history. So it really needs
to be tied to clinical outcomes.
We also have concerns--We're ready to extend our electronic
health records to smaller physician and independent physician
practices and other hospitals. And so we encourage CMS to
continue to examine its interpretation of the Stark Law in
order to encourage connectivity in regional networks at a fair
market value. That will allow us all to get there quicker.
And, finally, I think it's important to consider the
implications of the electronic health record on access to and
recovery of data during a disaster such as Hurricane Katrina.
Of all the lessons learned, area hospitals that already had
electronic health record capacity lost virtually no patient
data. So implementation and inter-operability standards
facilitating safe information exchange and appropriate
redundancy planning in case of another disaster is critically
important.
Thank you, Mr. Chairman. That completes my statement.
Mr. Reichert. Thank you.
[The prepared statement of Ms. Cecchettini follows:]
Prepared Statement of Diane E. Cecchettini
Thank you Mr. Chairman and Members of the Subcommittee. My name is
Diane Cecchettini. I'm the President and CEO of MultiCare Health System
in Tacoma, Washington, and I'm also a registered nurse. Thank you for
inviting me here today to discuss the benefits of Information
Technology (IT) to providers and consumers of health care, the impact
of IT on quality and costs, and the incentives and barriers that exist
to the broader adoption of IT in the health care industry.
MultiCare operates two adult and one pediatric hospital and we
serve as a Level II trauma center for both children and adults. We have
593 licensed beds, five ambulatory surgery centers, six urgent care
centers, and a certified home health agency and hospice program. We
also employ 200 physicians in our MultiCare Medical Group. Over the
last eight years, MultiCare has invested 50 million dollars
implementing an electronic health record in our ambulatory physician
practices. Currently, we are implementing the electronic health record
(EHR) in our three inpatient facilities which will cost another 50
million dollars. We believe this is a critical investment to support
improvements we've seen in patient care, but the costs are truly
monumental. With the EHR we have a much greater ability to track our
care processes using evidence-based guidelines, communicate among
different providers who care for the same patient, and improve patient
outcomes because of our ability to track and study data trends. Our
patients also see specific benefits. Most importantly, they can
participate in their care through secure electronic access to their
medical record to view medical problems, see lab work results, make
appointments, review educational materials specific to their diagnoses
and even refill prescriptions.
In 2001-2002, MultiCare conducted a study of 5,000 diabetic
patients in MultiCare Medical Group and estimated that as a result of
implementing specific physician practice guidelines, which included
tracking and reporting of certain lab values like blood glucose and
cholesterol, along with blood pressure, 33 heart attacks and 28 deaths
were prevented in one year. This of course has the downstream effects
of less Emergency Department (ED) visits, less Coronary Care Unit stays
and fewer cardiac catheterizations to name a few, all of which can cost
tens of thousands of dollars each. The potential annual cost savings in
this group of 5,000 diabetic patients alone had an estimated downstream
savings to Washington State health care of 4.3 million dollars annually
(Reed and Bernard, 2005). The journal article describing the study is
attached to my written testimony. We believe firmly that while terribly
expensive on the front end, EHRs save lives and will save the national
health care system significantly over the long run.
Our mission is quality patient care. Because, ultimately, it is the
patient who owns their clinical data, our goal is to establish one
health record that spans the continuum of our services. Physicians in
our EDs have access to medications and past medical history via the
ambulatory record. Our ambulatory physicians and home health nurses are
able to see the course of treatment when a patient is in the hospital.
Our community physicians are able to remote into our system using a
secure connection. Now, instead of relying on just faxes and mail, our
medical records department is beginning to work with physician offices
to access patient information electronically. This is much more
efficient to the physician and to our hospital. Secure access for our
providers can even be extended to them at home, meaning they can see
important lab and radiology results as soon as they are available, even
at night or on weekends. This is good for care continuity and it also
saves money because duplicate lab tests or other interventions that
might be repeated, are not. Another real advantage of an EHR is the
ability to contact patients quickly when a drug is recalled or found to
have ill-effects for certain populations. For example, as soon as we
learned of the potential problems with the drug Vioxx, we were able to
immediately contact our patients receiving the drug and schedule them
to talk with their doctor. When concerns arose about hormone
replacement therapy in 2002, information was targeted to 15,000 women.
With traditional paper systems this would be extremely time intensive,
if not impossible.
Our prevention programs have also seen tremendous improvements with
the EHR. Childhood immunizations have reached 100 percent in some of
our clinics. Our mammogram compliance rate exceeds 97 percent. In 2003,
influenza administration reminders were mobilized in seven days for new
CDC recommendations.
We feel strongly that Information technology provides our health
system with several specific benefits. In particular, it allows us to:
Practice evidence-based medicine;
Implement disease management programs that focus on
prevention and care of the chronically ill;
Lengthen lives and allow patient participation in
care;
Prevent costly hospitalizations; and
Support public health and biosurveillance.
We equally believe that payment incentives are key for the adopters
of technology in order to achieve successful expansion throughout the
country. Specifically, we would encourage the State and Federal
Government to:
Adopt a common set of operating standards to support
inter-operability;
Provide payment incentives for adopters of
technology;
Ensure protection of consumer privacy by enforcing
encryption, user authentication and audit trails;
Encourage a common set of measures to audit
performance among all of the payers for health care; and
Support a common, agreed-upon, and detailed
vocabulary for all medical terminology, such as SNOMED.
A significant barrier will continue to be how to pay for
information technology, especially for small hospitals, rural
providers, and individual physician practices. While some federal and
private grant money has been available for Health Information
Technology (HIT) adoption, there simply is not enough to go around. We
would like to extend the use of our EHR to smaller physician practices,
and even to hospitals through application service provider arrangements
(ASP). I would encourage CMS to continue to examine its interpretation
of the Stark Law, in order to encourage connectivity in regional
networks at a fair market value. We would also encourage CMS and other
payers to ramp up efforts to expand pay for performance and
reimbursement incentives for organizations that adopt information
technology. Once payment is tied to the use of technology, the urgency
of adoption will increase. However, hand in hand with these efforts
need to be a uniform set of standards that vendors must adhere to in
order to achieve the inter-operability needed to ensure patient records
are always available when and where they are needed.
It is also important to consider the implications of the EHR on
access to and recovery of data during a disaster such as hurricane
Katrina. Hospitals, clinics and other care settings, along with the
paper medical record information in those facilities were literally
destroyed. As evacuees crowded into shelters with many in need of
medical attention, doctors who treated the patients had to do so with
only a rudimentary knowledge of their past treatments. However, area
hospitals that already had electronic health record capacity lost
virtually no patient data. Implementation of inter-operability
standards facilitating safe information exchange and appropriate
redundancy planning in case of another disaster can ensure that
electronic patient information can be available much sooner,
alleviating many of the challenges faced by care givers in difficult
circumstances.
I have the honor of currently serving as the Chairperson of the
Washington State Hospital Association. As a state, the health systems
in Washington have actively embraced the Institute for Healthcare
Improvement's 100,000 lives campaign. We firmly believe that technology
can improve care quality in our hospitals and save money. While the
return on investment is not immediate, EHRs are key to achieve the
efficiencies and care management so crucial to patient safety in the
hospital, and to address the needs of the chronically ill. The task of
developing a National Health Infrastructure is extremely difficult and
complex--it is a long-term endeavor. However, it is imperative that it
be done and I appreciate the leadership of the Subcommittee.
Thank you. Mr. Chairman, this completes my statement. I will be
happy to answer any questions that you or other Members of the
Subcommittee might have for me.
Biography for Diane E. Cecchettini
Ms. Cecchettini has served as President and Chief Executive Officer
of MultiCare Health System since 1999. Prior to the CEO role, she
worked in various capacities at MultiCare Health System--Executive Vice
President, and Vice President Patient Services.
Ms. Cecchettini's previous experience includes multiple leadership
positions in 11 years at Sutter Health in Sacramento, and direct
clinical experience at UCLA Medical Center in Los Angeles, California.
Ms. Cecchettini received a Bachelor's degree in Nursing in 1970 from
the University of California, Los Angeles, and a Master of Science
degree in Human Resources Management in 1976 from the University of
Utah.
In 1993, Ms. Cecchettini retired as a Lieutenant Colonel from the
Air Force Reserve, having served 21 years as a Flight Nurse in
Aeromedical Evacuation--serving in the Vietnam era and as a Troop
Commander in Desert Storm.
Mr. Reichert. And the Chair recognizes Mr. John Kenagy.
STATEMENT OF MR. JOHN JAY KENAGY, CHIEF INFORMATION OFFICER,
OREGON HEALTH AND SCIENCE UNIVERSITY
Mr. Kenagy. Thank you, Mr. Chairman and Mr. Wu. I'm pleased
to be here to present testimony.
We have a lot of people coming from very different
perspectives, and what I'd like to do--I have a longer
testimony, but I'd just like to highlight some of the things
from my perspective as an IT professional.
I am the chief information officer for Oregon Health and
Science University and have been in that role since 2001, and
also serve as the Chair of the CIO council for the university
health system consortium of academic medical centers around the
United States. In 21 years' experience in health care IT, it's
been a wild ride over those 20 years.
OHSU, as Oregon's only academic and research center, has
sort of a unique perspective. We're really in the business, at
its core, of knowledge--creating it through advanced research,
imparting it to students through education, using it in the
delivery of health care, and sharing it through our community
service mission. What we feel is information is really the
currency for knowledge. It is the way that it is developed and
analyzed and used and stored. And as an institution, we've
spent a lot of money, time, and resources into developing a
very comprehensive IT architecture. Are we there yet? Far from
it.
Since year 2000, we've spent about $25 million on different
IT solutions. In 2003, we embarked on an electronic health
record, like MultiCare, $50 million and counting. And I
appreciate that comment. I think one way to express sort of
what we deal with on a day-to-day basis, I brought a graphic,
that you cannot see and cannot really read, but that's somewhat
of the point I want to make. At OHSU, we have not one
electronic health system or, like banking, where you have a
core system; we have a significant interaction of about 100
different disparate islands of information that, every day, day
in and day out, patient records are actually not in an
electronic health record--it's sort of a misnomer in our
industry; we actually have a significant number of these
systems--that are woven together by people who work on my staff
and, fundamentally, by paper. So what we've been--what we have
been using in terms of our information system is an attempt to
use these different islands of information.
The health care IT industry, for all intents and purposes,
is a 40-year-old industry; but, still, the products are
extremely immature, especially around a comprehensive
longitudinal electronic record. In the paper environment, this
situation is not bad; in fact, it is the way--This is not
atypical; it is the way most health care organizations in the
United States run--certainly, academic medical centers, in what
we call a best of breed approach. As we approach the
marketplace or approach a need, we actually look at the niche
that is needed and buy an application that meets that niche.
A number of us were in San Diego for the national HIMSS
conference, the annual health care IT marketplace. There were
over 800 vendors there on the floor, showing their wares,
showing different products. In many ways, that's a great--
there's a lot of interest in this field, there are a lot of--
there's a lot of progress being made in IT. On that floor, I
could see systems that did diabetes care and cardiology care
and intensive care and home care; but as an institution, we
have patients who come in--a woman comes into our ED with chest
pain complicated by diabetes, who needs to go to the ICU and
then eventually be followed up at home. Is it really
reasonable, logical, smart for us to have her record in four
different systems, or six or eight? It's what we deal with
every day, where standards and inter-operability is an issue.
So one of the barriers, I would say, in adopting electronic
health records is not the dearth of choice; it is the plethora.
It is what we face all the time as an IT professional trying to
pull these together.
A couple other barriers, finances and resources, of course,
are mentioned all the time. We were both saying that we're
investing $50 million of our own institution's money to put
this in. Do I think the health care IT will make health more
cost effective? I think that's debatable. It will certainly
replace a lot of low paid file clerks with a lot of high paid
IT professionals.
One--certainly some of the issues around the barriers of
resources, one is clinician time, and I want to stress that
point. As we implement our electronic health record at OHSU,
and as research has shown throughout the U.S., the active
involvement of physicians and nurses and members of the health
care team to be involved in changing the work flow--it's not a
deployment of a technology, but it's really the change in the
way we practice medicine--requires their time and attention. As
we've been implementing EPIC electronic health records, we're
actually requiring physicians to spend 14 hours in classroom to
learn how to use the tool effectively. That's just to use the
tool, let alone designing and implementing the system.
As Medicare, Medicaid, the insurance company, who works
towards cost containment and tries to deal with what is
considered from the outside, run-away health care inflation, we
have no extra time of our clinicians to engage in the change of
their practice to adopt this system. That is a significant--I
think it's the--what's under the tip of the iceberg is this
clinician time.
The other one that I'm facing right now is the lack of IT
professionals--few IT professionals who have this knowledge and
experience to come into our field. As a provider organization,
I and many of my colleagues, we sort of look at the
consulting--consulting businesses to go to different companies
to bring those resources. But they also face the same problem,
to bring in qualified IT professionals in order to do this.
The final barrier I would highlight, again, as maybe a
defensive CIO, is what I would call the expectations gap. I
think there's an expectation, certainly within our industry as
well as outside, that IT in health should cost less and should
be more effective, it should be easier and cheaper. Frankly, it
isn't. And we face that all the time, trying to explain--going
to the board to explain cost overruns and to explain why we are
so far behind.
Congressman Wu, I appreciate your mentioning the point
about the investment health care makes. And you'll see, we at
OHSU spend a little bit less than three percent of our--as most
institutions in this industry do, three percent in health care;
but banking and finance, which are used as hallmarks of IT
investment, are at 10--eight to 10 to 12 percent. It's my
recommendation.
I think there are a lot of roles that the Federal
Government can play. I think one is to continue and expand
research in health care IT. We do a lot at OHSU, through our
Department of Medical Informatics, which is a leading research
institute for this field. I think there's a lot of additional
study that needs to take place on how can these be effectively
implemented successfully.
I think the other thing that the Federal Government can do
is expand training programs for clinicians and for IT
professionals, to really create the understanding and the body
of the pipeline of people who can help. I think there are many
economic disincentives to doing health care IT--like I said
earlier, the lack of spare clinician time to be able to invest
in this; and cost containment pressures from other parts of the
Federal Government make that even more difficult.
Finally, I do think that there is a requirement for inter-
operability. I could make comments about my sense of what the
priorities are. I certainly think inter-operability between
institutions is a critical priority; inter-operability within
an institution, I think, is better served by integrated
information systems and not a continuation of a hundred
different disparate systems.
Thank you for letting me testify.
[The prepared statement of Mr. Kenagy follows:]
Prepared Statement of John Jay Kenagy
Chairman Ehlers and Members of the Committee on Science:
On behalf of Oregon Health & Science University (OHSU), I submit
the following written testimony to the Environment, Technology, and
Standards Subcommittee of the U.S. House of Representatives' Committee
on Science. I serve as the Chief Information Officer (CIO) for OHSU, a
position I have held since 2001. In that role, I am responsible for
information technology (IT) strategy and implementation for all
missions of OHSU, including health care, education, research, and
community service.
As Oregon's only academic health and science center, OHSU provides
high-quality health care to more than 150,000 patients each year. The
OHSU health care system offers the most comprehensive health care
services in Oregon, including many innovative clinical care and
diagnostic services. It is nationally recognized for clinical research
and education, helping to develop tomorrow's health professionals.
At its core, OHSU is in the business of knowledge: creating it
through advanced research, imparting it through excellent teaching,
using it in effective and safe clinical care, and sharing it in service
to the community. Information serves as the currency for knowledge-the
method to develop, analyze, store, and distribute it. Effective IT
solutions therefore are fundamental to our organization. In 2003, OHSU
adopted the Strategic Information Plan that establishes a compelling
vision for the IT-enabled organization and sets forth goals and
objectives in ten key strategic areas. Among the key strategic areas
are health care, business intelligence, information security and
privacy, and technology and infrastructure. OHSU has an extensive IT
infrastructure requiring significant, on-going investment to sustain
and grow. The organization invests just under three percent of its
operating budget in IT.
Health care IT has gained significant national attention since the
beginning of the decade. The health care sector, one of the largest in
the U.S. economy, lags other industries in the use of IT to enhance
efficiency, improve effectiveness, and achieve quality. President Bush
included it as one of his administration's goals in the 2004 State of
the Union address: ``By computerizing health records, we can avoid
dangerous medical mistakes, reduce costs, and improve care.'' Landmark
studies by the Institute of Medicine [To Err Is Human: Building a Safer
Health System in 2000 and Crossing the Quality Chasm: A New Health
System for the 21st Century in 2001] called for widespread adoption of
IT solutions to enhance patient safety.
While calls for enhanced automation have increased, landmark
research from OHSU demonstrates the lack of progress nationwide. In a
2002 study published in the Journal of the American Medical Informatics
Association, Joan Ash, Ph.D., and the Provider Order Entry Team
surveyed hospitals and found that fewer than ten percent had a fully
implemented CPOE system. Of those, only one-third achieved a high
penetration with more than 90 percent of orders entered through a
health care IT system.
As a health care CIO, I believe that in the absence of a
comprehensive health care IT infrastructure, our industry will be
unable to achieve its goals of patient safety, clinical effectiveness,
and operational efficiency. Health care is highly information-
dependent. Clinical decisions are made minute by minute and require
access to patient-specific data and expert clinical knowledge. An
objective that resonates with our role as an academic health
institution, we need to implement systematic tools so that all of us
know what the best of us knows.
From my perspective within a provider organization, the health care
IT sector is beginning to deliver comprehensive IT solutions that
effectively meet our needs as users. Our industry traditionally has
developed niche systems (patient financial, patient management/
scheduling, laboratory, pharmacy, etc.) that were interfaced where
possible and practical. While much attention is being paid to sharing
information across institutional boundaries and among community
providers, many systems have been limited in their ability to exchange
information within the hospital's four walls. The goal of a
comprehensive, patient-centered, paperless electronic health record
(EHR) remains a futuristic goal for the vast majority of health care
providers.
1. How does OHSU use health care-specific information technology? What
benefits has OHSU realized so far? What future benefits are expected
from this kind of technology?
OHSU's health care IT infrastructure supports its patient care
functions (ancillary testing and reporting, pharmacy, digital
radiology, order entry); safety and quality functions (infection
control, data warehousing, trend monitoring); and administrative and
business functions (admitting/discharge/transfer, scheduling, patient
billing). OHSU has been a long-standing user of health care IT dating
back to early internal development efforts in the 1970s. In the mid
1980s, OHSU became one of the first sites in the country to implement
Shared Medical Systems' (SMS, now Siemens Health Services) Independence
system, a platform we continue to rely on today. Through the Integrated
Advanced Information Management System grant from the National Library
of Medicine, we developed a physicians' workstation as an early attempt
to combine disparate sources of information into one portal. In the mid
1990s, OHSU deployed the Siemens Lifetime Clinical Record which has
grown to be one of the vendor's largest longitudinal repositories of
clinical data. OHSU also implemented clerical order entry and
communication, effectively eliminating paper order transmittal from
outpatient clinics and inpatient units.
The Information Technology Group (ITG) maintains this extensive
health care IT infrastructure. Roughly two-thirds of our annual $30
million budget supports the hospital's IT services. Nearly 120 IT
professionals are dedicated to our health care mission. These
individuals maintain over 100 different IT applications on a multitude
of hardware and database technologies; design, code, and manage over 80
different interfaces that exchange critical clinical data among the
disparate systems; install and support over 5,000 personal computers
deployed throughout the institution; manage over 400 active health care
IT projects; and train many hundreds of physicians, nurses, and other
members of the health care team.
OHSU continues to make considerable investment in health care IT
solutions building upon the core patient administrative and clinical
repository system. Our model remains to implement commercially
available software solutions (``buy'' versus ``build'') and to make
limited but necessary local modifications and customizations. Since
Year 2000, OHSU has invested over $50 million in capital for both
enterprise and departmental health care IT solutions. As is common with
academic health centers, we historically have been ``best of breed'' in
our approach to commercial software, seeking the optimal solution for
each unique application and interfacing it to the common core.
Supported by positive industry developments, however, OHSU is embracing
a strategy that minimizes data interfaces and strives for integration.
Early this decade OHSU make the strategic decision to invest in an
electronic health record (EHR), starting with ambulatory care and then
proceeding to inpatient care and the emergency department. This
strategy contemplates a fundamentally different use of IT in health
care--rather than being a passive repository of clinical and
administrative data, the delivery of health care itself will be
transformed using IT. Members of the interdisciplinary health care team
will document, order, and plan treatment on line. As significant as
OHSU's past IT investments have been, health care practice is still
based on paper charts. A single stay in the hospital may generate
upwards of 100 pages of documentation, orders, vitals, and other
relevant clinical data. To eliminate filing and improve ready access to
information after the fact, OHSU implemented a document imaging
solution to scan every piece of paper after discharge, but active
inpatient care still relies on paper.
OHSU selected Epic Systems to provide our ambulatory EHR and have
now deployed this advanced clinical IT solution in seven outpatient
practices. Before the $22 million investment was approved, an extensive
return on investment calculation was performed. The project showed a
positive net present value considering only hard benefits. These
benefits included transcription savings, staff savings (reduced charge
entry, medical records, and support staff), supplies and storage
savings. So far, the results have validated--and in some cases,
exceeded--the anticipated benefits. For instance, Family Medicine
showed a reduction in transcription lines per month from a pre-live
high of 94,093 to post-live of 1,743.
Quality outcomes are difficult to quantify as hard financial
savings, but present the real strategic benefits of EHR. As OHSU moves
to implement an enterprise EHR across inpatient, outpatient and ED, we
anticipate significant benefits to patient care. We will provide
direct, secure, on-line access to records by patients. Clinical
decision making will be supported by best practice guidelines. Decision
support rules will provide timely, data-driven input to physicians when
ordering tests and treatment.
A personal story (note: no HIPAA implications) may illustrate the
real benefits to patient care of this IT investment. Not only am I
OHSU's CIO, I am also a patient. Since 2000, one focus of our
investment has been diagnostic imaging services, with advanced
technologies such as an entirely digital enterprise repository (Picture
Archiving and Communication System), voice recognition, digital
radiography, and secure external communication. Each was a major IT and
clinical re-engineering project. Overall, they have taken multiple
years and countless hours of work. After all this effort, the results
for patient care are clear. When I was recently referred for an X-ray
exam, my physician was able to review and share with me the completed
results just 11 minutes after the study (all digital capture and read,
voice recognition transcription, and secure e-mail transmission of
final results). Eighteen months prior, this normal exam would have
taken at least 48 hours to be completed.
While OHSU's investments have been successful and the benefits
real, we have yet to achieve what should be possible with a
comprehensive EHR at OHSU. As early as 1970, Morris Collen, M.D.,
published a seminal paper on the characteristics of a medical
information system. A third of a century later, our industry has yet to
witness widespread adoption of IT.
2. What incentives and barriers exist to the broader adoption of
information technology in the health care industry, and are these
financial, technical, or of some other nature? What has been OHSU's
experience with these incentives and barriers?
From my perspective from helping craft our strategic vision for
health care IT, the most significant incentive to a broad adoption of
IT is the strongly held belief that IT is essential for the practice of
medicine in the 21st century. As this institution planned to build
health care facilities for the future, there was near unanimous
approval for significant investment in an EHR solution. A compelling
question was posed as we began to design the space: Should we really
carve out clinical space in 2006 for a large paper file room in each
practice setting? The EHR also was seen as vital to patient-centered
care. Our tech-savvy customers in the Pacific Northwest are starting to
expect the ability to e-mail their physicians, schedule an appointment,
review their child's immunization record, and pay their bill on line.
This was an important incentive for OHSU's strategic decision to direct
scarce capital dollars into IT.
While not an incentive per se, another source of support for
widespread health care IT adoption comes from our role as an academic
health center. Today's medical, nursing, and dental students were born
after the invention of the personal computer and have grown up in the
high-speed information age. In fact, to our X-box-generation residents,
our systems sometimes feel as antiquated as Atari PONG. A tech-savvy
workforce makes IT-enabled clinical practice an expectation.
To date, there have been few financial incentives to adopt EHRs
within an institution or share data through Regional Health Information
Organizations (RHIOs). While health care IT may enhance clinical
quality and effectiveness, cost containment continues to be a driving
factor in health care. Pay for performance, Federal Government funding,
and other programs have been debated, but nothing to date has
translated into an economic support for this IT investment.
As studies have shown, only pioneering institutions have
implemented comprehensive health care IT solutions--and some have
resulted in significant failure. An article in the LA Times in 2003
reported the suspension of the multi-million-dollar computerized system
for doctors at Cedars-Sinai Medical Center after significant physician
complaints. A number of practitioner articles and scholarly studies
have attempted to address barriers to successful implementation of EHR
and health care IT solutions. I would propose that the major barriers
include the expectations gap, technology barriers, and resource
barriers--though the latter two may not be the traditional definition
of these type of barriers.
In my opinion, a serious issue facing health care CIOs is an
expectations and perception gap between the IT department and IT users
and their senior leadership. Hospital leaders often believe IT should
cost less and deliver more. It simply ought to be much easier; it is
not. Complicating this gap is the extent of IT project failure or cost
overruns. Any IT project has inherent risks and challenges; enterprise
health care IT projects are extremely complex with competing
requirements, multiple users, different data types, and complicated
work flows and information needs. Looking broadly at all IT projects in
the public and private sector, the Standish Group reported that only 16
percent of IT projects completed on time, budget, and scope. They
estimated that U.S. companies and government agencies would spend $81
billion on canceled software projects in 1995 alone. Health care
organizations may not recognize their extent of investment (time,
resources, and capital) required or may not trust their IT department
to deliver successfully.
OHSU is addressing this barrier in our ambulatory EHR deployment,
though it is an on-going effort requiring continual dialogue. We have
faced budget challenges--underestimating the complexity of system-to-
system interfaces and the resources required to support such dramatic
clinical practice transformation. We have built trust and mutual
understanding, but this takes attention to sustain the relationship.
Another major barrier relates to technology. It is evident in the
focus on inter-operability standards and data exchange. I argue however
that this focus addresses the symptom and not the underlying condition.
From the perspective of a provider organization CIO, our industry
suffers from too many ``choices'' rather than too few. Hospitals and
physician groups face a staggering array of options for health care IT.
IT units are often confronted with the Herculean task of trying to tie
together these islands of information. At the Health Information and
Management Systems Society (HIMSS) exposition in San Diego last week,
there were over 800 different vendors showing IT software. You could
purchase individual systems tailor-made to support diabetes care,
cardiology care, intensive care, and home care. But what about the
patient admitted with chest pain and complications from diabetes who
requires an ICU stay and follow-up back at home? Should her record
really be in four different systems (at best)? Can I guarantee that
relevant clinical data from each is readily available to all?
With the paper record as the common denominator to all, this
situation was not uncommon or particularly troublesome. Each system
printed final documents and these were all filed in the integrated
paper chart. (Relevant documents from outside providers were handled in
the same manner.) Yet as we embrace the EHR, we are faced with the
option of implementing a comprehensive, integrated platform or managing
and interfacing multiple disparate solutions. Both paths have their
challenges. As I stated earlier, OHSU is now starting to support the
concept of global optimization, though sometimes sacrificing local
customization. Changing our health care IT paradigm, however, is
difficult--clinical users can make strong cases for their targeted,
niche solution. Fortunately, the vendor marketplace is now producing
products where integration does not require significant trade-offs in
functionality.
Resources present another significant barrier to adoption and
diffusion of health care IT. On the surface, one barrier is simply the
cost of the software and hardware itself. Health care organizations
face the challenge of diverting funds from facilities and clinical
technology to invest in IT--often with a significant leap of faith.
This investment is indeed significant. For OHSU, it was over $7
million.
The more significant resource barrier in my opinion is human
resources: the clinician time to help design, develop, and implement a
successful tool and the IT professionals to build and maintain the
technology. Many studies of health care IT successes and failures have
pointed to the need to engage clinicians in all aspects and phases of
the project. EHR represents a significant modification to the work of
all clinicians; they must be actively engaged to adopt the new tools.
At OHSU, physicians must participate in 14 hours of classroom training
just for the ambulatory EHR. We have found that this participation
alone is not adequate. It requires a rethinking of the outpatient
clinic encounter, their interaction with data, and their workflow. Each
clinical specialty also requires up front design and build effort as
well. Extensive work also will be required for our inpatient
implementation, especially around nursing care.
With constant pressures to cut costs, there is little spare time
for physicians, nurses, pharmacists, and other members of the health
care team to engage in designing and implementing health care IT
solutions. This may be a major hidden cost of implementation. As OHSU
deploys our EHR to more ambulatory practices, we continue to find this
barrier to success.
The other human resource barrier is finding IT professionals to
assist with implementation. With more organizations planning for major
EHR implementations, I have personally witnessed a growing shortage of
qualified health care IT professionals to fill vacancies and hit the
ground running. Hospitals turn to vendors and consulting firms to help,
though they appear to face the same problems with recruitment and
retention. OHSU's role as an academic health center may help--our
department of medical informatics and clinical epidemiology can build
the staff pipeline and I hope to develop with them some innovative
programs to train individuals for advanced health care IT roles.
However, I see a very significant problem looming as the industry at
large embraces IT solutions.
Finally, I would like to make a comment about the barrier to RHIOs
and sharing data across organizational boundaries. There are a host of
technical, financial, legal, and regulatory barriers. Who benefits and
who will pay? Is funding a duplicate, though clinically necessary, CT
scan a disincentive to sharing clinical data? How do we ensure patient
security under HIPAA's generally defined guidelines? How do I know that
this ``John Kenagy'' is the same as that ``John Kenagy''? With the
right attention, priority, investment, and perseverance, these barriers
can be overcome.
The more critical barrier today is that I cannot exchange what I do
not have electronically in the first place. While the Portland market
(and the Pacific Northwest in general) represents some of the most
advanced IT systems in the U.S., we each have major EHR projects
underway that will last through the end of the decade and serve as the
core foundation piece for extensive data interchange. We need to
proceed with our internal IT implementations in order to have the data
to share. Nonetheless, the health care CIO community here is engaged in
active dialogue to take demonstrable steps forward.
3. To what extent have the Department of Health and Human Services and
the National Institute of Standards and Technology reached out to
institutions like yours in an effort to develop a national strategy on
Health IT?
OHSU has contributed significantly to the body of knowledge in
health care informatics research and our Provider Order Entry Team
(www.cpoe.org) has been awarded a number of grants for evaluating,
interpreting, and disseminating evidence of computerized provider order
entry success.
Apart from these research programs, OHSU's ``production IT unit''
with responsibility for implementing and maintaining our health care IT
infrastructure has had little direct input into HHS or NIST efforts.
Through a partnership with the Oregon Chapter of HIMSS, OHSU has been
involved with several local efforts to understand and contribute to
efforts such as the Certification Commission for Healthcare Information
Technology (CCHIT) and other initiatives. However, these have mainly
focused on education and awareness.
As a CIO who relies on the commercial marketplace for health care
IT solutions, I believe that HHS and NIST needs to focus attention on
the vendor community for standards adoption. As an institution, OHSU
will not adopt the standards per se, but will look toward our product
suppliers to be compliant and take advantage of the functions.
Nonetheless, I recognize my power as a consumer--vendors are more
likely to adopt standards if they feel it is an important requirement
that makes a difference in product sales.
From my perspective at a major tertiary referral site, I am most
keenly interested in basic data exchange between disparate information
systems, especially as more hospitals and physician groups adopt EHRs.
OHSU needs to receive relevant clinical data that led to a referral to
our site and we need subsequently to transmit the results and follow-up
plan of care to the referring physician. Exchange standards should be
set to a lowest common denominator--even using Adobe portable document
format and a manual process to match patients to enable information
exchange now. My concern is that our industry will attempt to design
the ``perfect'' IT solution that either cannot be implemented or
assumes too much technology overhead (e.g., a regional or national
patient index).
Developing standards for inter-operability of health care data is
an unbelievably complex undertaking and is fundamentally driven by
expectations and requirements. For instance, does inter-operability
mean that I can begin my nursing documentation in a stand-alone ED
system, continue it in an OR system, and add to it in an inpatient EHR?
Is the allergy I document in one system replicated to everything else?
Is that the desired level of inter-operability? In implementing OHSU's
ambulatory EHR, I face this problem today. Interfacing systems for
simple demographic information (e.g., keeping patient address in synch)
has been challenging and a resource drain. We were unable to address
data exchange for patient allergies and stepped back to paper
documentation on the inpatient side. With this experience, I have
strongly encouraged OHSU to move toward a single integrated system.
Even between sites with the same core vendor (Kaiser Northwest, OCHIN,
and OHSU all have Epic) we cannot exchange data electronically. I am
challenged to think that complete inter-operability is possible, even
if desirable.
It would be worthwhile for provider institutions like OHSU to play
a more active role in establishing requirements and priorities, sharing
our perspectives from the front line of dealing with multiple systems.
I suggest that our involvement with HHS and NIST is not due to their
lack of interest or mechanisms for input, but our time constraints and
challenges at the local level. Standards seem so far off and I have end
users needing attention now. Piqued by this question, however, I
encourage HHS and NIST to make a greater concerted effort to seek
provider CIO input. I will do my part to share my perspective as well.
4. What specific measures can the Federal or State governments take to
help the broader adoption of health information technology?
The Federal and State governments play many roles in the health
care sector. I suggest several important steps to enhance incentives to
adopt health care IT.
Continue and expand research funding in health care
informatics. As EHRs and CPOE become more prevalent, these
offer unparalleled opportunities to study the antecedents of
and barriers to success.
Expand support for training programs to develop
clinical and IT professionals in the field of health care
informatics. If the 90 percent of U.S. hospitals that do not
have CPOE start to implement these systems, I fear we do not
have the human resources to meet the need.
Address the economic disincentives to invest in
health care IT. The constant pressure to cut health care costs
by reducing payments to hospital and doctors stands in direct
opposition to requiring these entities to invest millions of
dollars of capital and, more importantly, scarce clinical time
in designing, testing, implementation, and using advanced IT
systems.
Work in partnership with the vendor community to
address exchange of data among disparate EHRs and with emerging
standards of personal health records (PHRs). I personally do
not think strong government regulation of this industry is
needed (e.g., FDA regulation of EHRs), but believe the market
cannot and ultimately will not sustain the number that
currently exist.
Thank you for the opportunity to share my perspectives as a
provider-institution CIO. With 20 years experience in health care IT, I
am very encouraged by recent developments. There is increasing
attention and awareness of the important role IT must play in health
care quality, safety, effectiveness, and efficiency. At the same time,
the marketplace is maturing and products are emerging that can deliver
comprehensive, patient-centered electronic health records. Barriers and
challenges remain, but the ultimate goals compel us to strive ahead.
Biography for John Jay Kenagy
John Jay Kenagy, MHA, FHIMSS, is Chief Information Officer at
Oregon Health & Science University (OHSU), in Portland, Oregon, serving
in this role since July 2001. His responsibilities include developing
the information technology strategy and directing the IT department for
the health care, academic, research, and community service missions of
the university. From 1999 to 2001, John served as Associate CIO for
OHSU. The Information Technology Group has an annual operating budget
of $30 million and a capital budget of $10 million. The department of
325 staff maintains a complex information technology and
telecommunications environment.
As an academic health system CIO, John has served on a number of
national and regional IT bodies. He serves as the Chair of the
University HealthSystem Consortium Chief Information Officer Council
(2005-2006). He was elected as president of the Oregon Chapter of the
Healthcare Information and Management Systems Society (2003-2004). He
has served on the board of Siemens Customer Health Information
Executive Forum.
In 2003, John was appointed to Fellow status in the Healthcare
Information and Management Systems Society. He is also a Certified
Professional in Healthcare Information and Management systems.
John is pursuing a Doctor of Philosophy degree from Capella
University's School of Business. His doctoral research is focused on
health care information technology implementation success. John earned
his Bachelor of Science degree in electrical engineering at Stanford
University. He was awarded a Master's degree in Healthcare
Administration at University of Southern California and received the
Alexander Cloner Outstanding Student Award at graduation.
In addition to the IT operational responsibilities, John has
enriched his experience and knowledge through teaching and mentoring.
He has an appointment as Assistant Professor in the Department of
Medical Informatics and Clinical Epidemiology in the OHSU School of
Medicine. John has taught at the University of Oregon and University of
Southern California.
Prior to joining OHSU, John worked for thirteen years at the
Department of Veterans Affairs, most recently as Chief Information
Officer for the VA Desert Pacific Healthcare Network in Long Beach,
California. John directed major IT projects and strategy for this
extensive network of health care facilities and served on several
national IT committees.
Notable awards include a U.S. Department of Veterans Affairs
Commendation and American Legion Medal of Valor for deeds following the
1994 Northridge Earthquake and the 1999 Emerging Leader Award by the
USC Health Services Administration Alumni Association.
Mr. Wu. Thank you.
Mr. Reichert. Thank you. Now we're going to just pause for
a minute while we play musical chairs. The Chair recognizes Dr.
Chin.
STATEMENT OF DR. HOMER L. CHIN, MEDICAL DIRECTOR, CLINICAL
INFORMATION SYSTEMS, KAISER PERMANENTE; NORTHWEST CHIEF
INFORMATION OFFICER, OREGON HEALTH AND SCIENCE UNIVERSITY
Dr. Chin. Good afternoon, Mr. Chairman and Congressman Wu,
ladies and gentlemen.
My name is Homer Chin. I'm the Medical Director for
Clinical Information Systems for the Kaiser Permanente
northwest region.
Kaiser Permanente serves over eight million members in
eight separate regions. My comments today about our experience
relate specifically to the northwest region.
In 1998, Kaiser Permanente Northwest completed the
implementation of a comprehensive electronic medical record
that allows physicians to document, prescribe, order, refer,
and to message other health care providers. We no longer
create, move, or file paper medical records. We also provide
patients direct, secure Internet access to parts of their
medical record and the ability for them to directly message
their physicians.
Along with the usual benefits of IT systems that were
mentioned by Diane earlier, our system embeds clinical decision
support to help guide physicians as they deliver care, provides
a comprehensive database that allows us to monitor and to
provide care across the population, and allows for modalities
of care such as self-service appointing and additional ways for
patients to access care and communicate with their physicians.
What distinguishes Kaiser Permanente from other health care
organizations is, number one, our integrated comprehensive
health care system where all services for our members, both
inpatient and outpatient, are delivered under one umbrella;
and, number two, prepaid capitated health insurance. These two
aspects of Kaiser Permanente provide both a structure and
incentive for us to fully leverage information technology in
the delivery of health care services.
In my view, there are two significant barriers to the
adoption of IT in health care. The main barrier is the lack of
incentives to be efficient and effective at producing the
product, health. Organizations may be efficient at producing
office visits, radiology tests, laboratory tests, procedures
and prescription, but they're not incented to produce health
and they're certainly not incented to work with other
organizations that they compete with, to reduce the overall
cost of health care.
A second barrier is the information intensive and complex,
subjective and changing nature of health care itself. Unlike
other industries that are relatively more static, medical
knowledge, practice, regulation, and technology are constantly
changing, making it necessary to build complex yet flexible and
modifiable systems to meet the different and constantly
changing environments. As a consequence, there are few well-
charted paths to implementing health care IT, at least in the
clinical arena. Unlike installing a refrigerator, where you buy
it, you bring it home, plug it in and derive refrigeration,
implementing health care IT is still more of an art than a
science.
Although health care IT holds great promise, we must
remember that the systems are not ends in and of themselves.
A good implementation will improve things; but a bad
implementation may fail, may yield few benefits, or make things
worse. We must remember that health care IT is just the
enabling means and not an end in and of itself.
Finally, what can the federal and state governments do?
Number one, and I would say most importantly, they should--they
should provide incentives for health care organizations to
implement IT and to share that information between
institutions. And, number two, they should require standards or
at least facilitate the means to allow the identification of
individuals between health care entities; that will allow you
to aggregate information between individuals, across
organizations. Any further standards should be evaluated in
terms of the benefits and costs of developing and imposing that
particular standard. At a minimum, standards that require each
piece of information to be indexed by date and the type of
information, will allow at least the merging of information
between separate entities into a single view.
Thank you for allowing me to testify today. I'd be happy to
answer any questions.
Mr. Reichert. Thank you, Doctor.
[The prepared statement of Dr. Chin follows:]
Prepared Statement of Homer L. Chin
Introduction:
Good afternoon, Mr. Chairman and Members of the Subcommittee. My
name is Homer Chin. I am the Medical Director for Clinical Information
Systems for the Kaiser Permanente Northwest Region, which is one of
eight Kaiser Permanente Regions that together make up the Kaiser
Permanente Program.
Kaiser Permanente is the Nation's largest nonprofit health plan.
Over 140,000 employees and 11,000 physicians serve 8.4 million members
in over 30 hospitals and 430 medical office buildings.
Kaiser Permanente is actually made up of two separate but closely
aligned entities: Kaiser Foundation Health Plan and Hospitals, which is
responsible for administering the prepaid insurance and for running
much of day-to-day operations, and The Permanente Medical Groups, who
are responsible for the delivery of professional medical services.
What distinguishes Kaiser Permanente from most other health care
organizations is:
1. Integrated comprehensive health care where primary care,
specialty care, inpatient outpatient and ancillary services are
delivered under one umbrella, and
2. Prepaid health insurance--which encourages us to keep our
members healthy, prevent disease, and improve the effectiveness
and efficiency of our care delivery system.
These two aspects of Kaiser Permanente--comprehensive integrated
care and prepaid health insurance--provide both the structure and
incentive for us to fully leverage information technology in our
delivery of health care services.
Kaiser Permanente Northwest and Health Care Information Technology:
Although some of my comments today are about the Kaiser Permanente
Program as a whole, many of the more specific examples and comments
relate specifically to our experience here in the Kaiser Permanente
Northwest Region.
In 1994, KPNW embarked on the implementation of a single integrated
EMR for all members of this region. This system is not only an
electronic version of the outpatient medical record, it also automates
all information transmission processes in the outpatient setting.
Physicians use this system to document, prescribe, order, refer, and to
message other health care providers. By 1998, we had completed our
implementation of an entirely electronic medical record throughout our
region, and from that point forward we no longer created a paper
medical record for members that joined our program. In 1999, we created
an Internet portal for members to provide them with a wealth of health
information along with the ability to request appointments and refill
their medications on-line. In 2002, we provided patients direct access,
through a secure Internet connection, to parts of their medical record
along with the ability for them to directly electronically message
their physicians. That system, KP HealthConnect Online, is now being
used by over 100,000 members in this region--roughly 20 percent of our
membership.
Over the years we have studied and published results of the many
benefits of having an integrated electronic medical record. Benefits
can be general classified into:
1. Integrated and Comprehensive Lifetime Clinical Record. All
medical information from all sources is accessible
electronically in an integrated system.
2. Multiple users in multiple locations can simultaneously
access the chart.
3. Time and location independent interaction between
providers, and between providers and patients.
4. Embedding of best practices and guidelines into the
processes of care.
5. Embedding alerts and reminders into the care process.
6. Identifying patients for specific interventions, such as
identifying all patients that were given Phen-Fen weight loss
treatment, and requesting that they come in for a screening
cardiac ultrasound.
7. Ability to carry out systematic population care strategies,
such as notifying all patients who are overdue for screening
mammography, or identifying all patients with diabetes that
need more aggressive treatment of their cholesterol.
8. Improved new modalities of care, such as self-service
appointing and electronic methods of communication.
9. Databases that can effectively monitor and improve overall
organizational performance.
In 2003, The Kaiser Permanente Program embarked on the
implementation of an integrated health care information system called
KP HealthConnect, at an estimated cost of over $3 Billion over ten
years. This system is envisioned to be a comprehensive integrated
system covering practice and hospital management, inpatient and
outpatient electronic medical records, data warehousing, health plan
administration, and patient self-service and communication systems. All
eight Kaiser Permanente Regions have already implemented significant
portions of this system.
Incentives and Barriers to the Adoption of Information Technology in
Health Care:
There are three significant barriers to the adoption of IT in
Health Care.
One of the main barriers to the adoption of information technology
in health care is the lack of incentives for organizations to be
efficient and effective at producing the product ``health.''
Organizations may be effective at producing office visits, radiology
tests, operations, prescriptions, but they are not incented to produce
``health,'' and are certainly not incented to work with other
organizations that they compete with to reduce the overall cost of
health care.
A second significant barrier to IT adoption is the relative
immaturity of the field of health care IT. There are few well trodden
paths that organizations can follow to get from here to there in the
implementation of electronic medical record systems.
A third significant barrier is the inherent complex, subjective,
and changing nature of health care. Unlike other industries that are
relatively more static or certain, medical knowledge, practice,
regulation, and technology are constantly changing. The implementation
of an Electronic Medical Records is not like installing a refrigerator,
where you buy it, plug it in, and derive the benefits. The
implementation of an EMR is currently still more of an art than a
science. A good implementation will improve the efficiency of a
functional process, but a bad implementation may fail, have unintended
negative consequences, or worsen existing processes. Because medicine
is inherently uncertain, changing, and not well defined, a good
implementation of IT in health care requires a certain skill-set and
the right conditions. Although there are many instances of health care
IT systems that have been successfully implemented with significant
benefit, there are also many instances of implementations that failed
or resulted in little or no benefit.
Reasons for Successful Health Care IT Implementation at Kaiser
Permanente Northwest:
KPNW was successful because it had:
1. Aligned incentives to maximize effectiveness and efficiency
in maintaining health.
2. One unique patient identifier (the insurance number is also
the health record number), allowing for the easy aggregation of
information across systems.
3. Minimal issues with terminology or data standards. In most
cases, KPNW had a single instance of most systems--for example,
a single Pharmacy System, Radiology System, Lab System, etc.
The terminology that the particular single system used became
the defacto standard for the enterprise. There was no need to
impose a terminology or data standard or translate data between
the various systems.
4. An integrated implementation team partnering physicians,
project management staff, and IT professionals.
Implications for other health care systems:
There must be incentives for health care organizations to share
information. KPNW has contracts with several non-KP hospitals in the
community where we hospitalize our patients. All transcribed
information on our patients in those facilities is electronically sent
to us and integrated with other information in our Electronic Medical
Record. The incentive for organizations to send us this information is
clear--it is a requirement for us to do business with them.
A minimum requirement to support the interchange of health care
information between entities is to be able to identify specific
individuals between health care entities. This implies either a unique
patient identifier, or demographic standards that will allow the
identification of the same individual between health care entities with
reasonable certainty.
The optimal level of information standardization, beyond that
minimum requirement of patient identification, is unclear. At one end
of the spectrum, scanned images of the paper record could be
electronically transferred from one health care entity to another. That
would require minimal changes in each system but would not allow for
any significant integration of data between the two entities. At the
other end of the spectrum, a very rigid and detailed standard at a very
atomic level could be defined that would allow for complete integration
of information between entities, but would require significant work in
each organization, and would require significant on-going maintenance
and organizational adaptation.
Such a rigid detailed atomic standard for all data in medical care
is unlikely to be successful because of the changing nature and
variation in the practice of medicine between locations and over time,
and the enormous cost involved in migrating existing systems and
terminologies into a rigid standard and the cost required to adapt to
ongoing changes. Because of the inherent uncertainty and subjective
``fuzzy'' judgment involved in health care, requiring adherence to a
rigid detailed standard in all areas may also introduce more problems
than it will solve.
On the other hand, imposition of higher level standards will
greatly increase the ability to integrate information between health
care entities at a relatively low cost. For instance, the requirement
to date stamp and label pieces of information into broad categories
such as: Lab Result, Radiology Report, Progress Note, Medication, etc.,
would allow the merging of the information between institutions into
separate electronic ``tabs'' and display that information in
chronologic order.
Within each area of medical data, there are varying levels of cost
and benefit to the various levels of standardization, so the optimum
level of standardization will vary depending on the specific area and
situation.
Summary:
In summary, the key to improving information sharing between
entities is to provide incentives for organizations to share that
information.
At a minimum, a mechanism to identify specific individuals between
entities is needed. Beyond that, minimal further standard specification
will allow the merging of clinical information between entities in a
useful way at minimal cost.
Thank you for allowing me to testify today. I would be happy to
answer any questions.
Limited Bibliography
Chin HL. The Reality of EMR Implementation: Lessons from the Field. The
Permanente Journal Fall 2004; 8(4):43-48.
Chin HL, Dworkin L, Krall MA, et al. The Comprehensive Computer-Based
Patient Record (CPR). The Permanente Journal Summer 1999;
3(2):13-24.
Chin HL; Wallace P. Embedding guidelines into direct physician order
entry: simple methods, powerful results. Proc AMIA Symp
1999;:221-5.
Chin HL; Krall MA. Successful implementation of a comprehensive
computer-based patient record system in Kaiser Permanente
Northwest: strategy and experience. Eff Clin Pract 1998 Oct-
Nov;1(2):51-60.
Chin HL, Brannon M, Dworkin L, et al.: The comprehensive computer-based
patient record in Kaiser Permanente Northwest. In, 4th Annual
Nicholas E. Davies Award, CPR Recognition Symposium Proceedings
(Edited by: Overhage JM). McGraw Hill 1998, 69-129.
Marshall PD, Chin HL. The effects of an Electronic Medical Record on
patient care: clinician attitudes in a large HMO. Proc AMIA
Symp 1998:150-4.
Chin HL, Krall MA, Lester S. Adapting clinical coding systems for the
computer-based patient record. Proc AMIA Annual Fall Symposium
1997:849.
Chin HL, McClure P. Evaluating a comprehensive outpatient clinical
information system: A case study and model for system
evaluation. Proc Annual Symp Comput Appl Med Care 1995:717-21.
Mr. Reichert. The Chair recognizes Mr. Machuca.
STATEMENT OF MR. LUIS MACHUCA, PRESIDENT AND CEO, KRYPTIQ
CORPORATION, HILLSBORO, OREGON
Mr. Machuca. Mr. Chairman, Mr. Ranking Member, and
colleagues, good morning--or afternoon, I guess. I'm honored to
offer my thoughts on health care IT adoption. I'm particularly
grateful to you and your committee staff for taking on this
very important topic.
My testimony will illustrate three major points: That the
lack of data mobility in health care is at the heart of the
cost and quality issues there; that the standards-based
clinical messaging represents the best opportunity to modernize
the system; and that the technologies to accomplish this are
neither complex nor expensive.
Locally, we have recently witnessed a media frenzy
regarding the theft of medical records, but where are the
voices of outrage regarding the errors that occur due to the
lack of timely patient information? Preventable medical errors
are a greater risk to patient health than car accidents, breast
cancer, or AIDS. The average Medicare patient sees more than
six physicians per year, and their care is not coordinated. And
chronic conditions now account for a majority of health care
expenditures, yet 70 percent of patients who have hypertension,
diabetes, or severe asthma are not in treatment compliance. We
get e-mails from our car dealer about our car needing an oil
change, but where are the e-mails from our doctors saying we're
overdue for a blood pressure check? The price we pay for not
having data mobility is unsafe care, high cost, and
productivity loss.
And we created Kryptiq to solve that problem.
In just three years, our customer base has grown to over
700 organizations in 48 states. More significantly, the number
of secured clinical messaging customers grew by more than 200
percent last year alone. Every one of those clinics that
purchased connectivity software did so with a specific intent
to collaborate with other clinics, and did so in some cases to
collaborate in sharing information also with their patients.
And we also know from the CITL, the Center for Information
Technology Leadership, study that two thirds--that at least two
thirds of the potential savings from IT adoption can only be
realized through collaboration, as opposed to internal office
automation.
Much attention has been given to the President's goal to
enable EHR adoption; however, EHR adoption alone does not
result in collaboration. In fact, experience suggests that most
EHR implementations create islands of automation no more
capable of sharing information than the paper records they
replaced. We really need to look at how we move the data, not
just how we store it.
As highlighted by Forrester Research, efforts spearheaded
by ONC to create RHIOs for information sharing have largely
stalled, and largely stalled on issues regarding governments,
infrastructures, standards, and sustainability. We believe
there's a smarter approach. The concept of an organic and
incremental RHIO, which is defined as the exchange of data
between providers, using e-mail and the Internet, enables
immediate data mobility in a self- sustaining model. Forrester
has coined this concept ``managed clinical messaging.'' This
approach includes any clinic that has e-mail access, not just
those that have EHR; and collaboration begins on day one, not
in a multi-year program.
Personally, I know this model will succeed. I spent 15
years in Intel at the critical time of PC adoption, and I can
tell you that the transition from early adoption to widespread
business use really happened because of e-mail. More
importantly, I know that the organic approach works because I
see our customers doing it every day.
Oregon has been the home to many health care IT
breakthroughs. Continuing this tradition, Providence and the
Oregon Clinic recently transitioned to electronic referrals,
saving a combined $10 per referral. And further, a
comprehensive study at Providence revealed a 58 percent
improvement in diabetes clinical outcomes through increased
patient interventions, with no additional staffing costs.
There are dozen examples--dozens of examples of Kryptiq
customers like these across the country, realizing the gains of
the organic approach. Some are informal RHIOs and some are just
RHIOs without telling anybody about it. Examples such as these
illustrate that the market is creating the standards for
baseline inter-operability; the next step is a common
interchange standard for patient medical records, such as CCR
or CDA, clinical data architecture. This standard should be
accessible by both health care providers and patients, and
should also work in both an EHR and in a non-EHR environment.
This should help mediate between these approaches.
We want to continue to build the success that will drive
collaboration. To this end, we recommend the government's
funding for health care IT address the following among more
recommendations that we have in our full testimony.
Number one, prioritize organic RHIO expansion while
limiting any additional spending on centralized or federated
models.
Number two, the government is in the business of public
health, and as such it should fund the implementation of
electronic collaboration technologies in the public health
settings.
Number three, mediate a standard--a standard for patient
medical records as above.
And number four, combine any changes in Stark laws with
collaboration mandates that ensure the technology recipients be
in an open network.
We have shown that the benefits of electronic collaboration
are real. We are on the eve of a major breakthrough of
technology adoption to make health care industry safer, most
cost-effective, and more competitive.
Thank you very much.
Mr. Reichert. And thank you.
[The prepared statement of Mr. Machuca follows:]
Prepared Statement of Luis Machuca
My name is Luis Machuca and I am the CEO of Kryptiq Corporation
based in Hillsboro, Oregon. I am honored to offer my thoughts and
perspectives on the opportunities and barriers for health information
technology adoption. This testimony will illustrate that secure
clinical messaging represents the single biggest opportunity to quickly
and cost effectively modernize our health care system.
As residents in the Portland metropolitan area we have just
witnessed the media frenzy regarding the theft of medical records. We
have heard the raised voices of outrage that personal data may have
been exposed due to this incident. An Oregonian editorial indicted the
health system for its failure to manage health data appropriately.
But where are these voices of outrage regarding the errors in
clinical judgment and decision-making that occur in every health system
in every city, in every state, every day of the year, due to the lack
of clinical information being available at the right time. Why is this
not the target of our outrage and concern as a society?
To cite the Institute of Medicine (IOM) Report published in 2000
``To Err is Human,'' our U.S. health system, which is capable of the
most miraculous acts of life-saving, is frequently the source of
patient harm. Between 44,000 and 98,000 patients die in hospitals each
year from preventable medical error. Preventable, but unprevented,
medical errors are a greater risk to patient health than motor vehicle
accidents, breast cancer, or AIDS. In terms of lives lost, patient
safety is as important an issue as worker safety. Every year, over
6,000 Americans die from workplace injuries. Yet this number is
exceeded by the 7,000 Americans who die annually from errors in
medication prescription or administration.
In addition, our health care system is overwhelmingly expensive.
Health care in the U.S. is estimated to cost up to $2 trillion per
year, consuming 13 percent of the GDP. Centers for Medicare and
Medicaid Services (CMS) estimates predict this will rise to $3 trillion
and close to 20 percent of GDP within the next 10 years, or an average
of $10,000 per American resident. Employers will not be able to afford
health benefits approaching $40,000 per year for a family of four,
while remaining competitive in a global economy--nor can they continue
to afford the staggering (yet unmeasured) productivity loss from
subjecting workers to an inefficient health care system.
The decentralized and fragmented nature of the health care delivery
system contributes to unsafe conditions for patients, and serves as an
impediment to efforts to improve safety. Even within hospitals and
large medical groups, there are rigidly-defined areas of specialization
and influence. The average Medicare patient sees more than six
physicians in the course of a single year, but their care is frequently
``silo-ed,'' and lacks coordination and communication. At the same
time, the loose affiliation of most provider groups makes it difficult
to implement improved clinical information systems capable of providing
timely access to complete patient information across all providers.
Unsafe care, high cost and productivity loss is the price we pay for
not having data mobility in our health care system.
The IOM followed their 2000 report with a 2001 report that boldly
stated that between the health care we have and the care we could have
lies not just a gap, but a chasm.
A highly fragmented delivery system that largely lacks even
rudimentary clinical data mobility results in poorly designed care
processes characterized by unnecessary duplication of services and
delays. There is substantial evidence documenting overuse of many
services--services for which the risk of harm may outweigh the
potential benefits.
Meanwhile we are stuck in a health system that pays for quantity
not quality and is centered on a 400 year model of treating patients
when they are acutely sick, rather than ensuring the services needed to
maintain their health. For the last four decades, the needs of the
American public have been shifting from predominantly acute, episodic
care to care for chronic conditions. Chronic conditions are now the
leading cause of illness, disability, and death; they affect almost
half of the U.S. population and account for the majority of health
care. Yet these conditions are seriously under managed when it comes to
ensuring Americans get the most appropriate evidence-based care that
they should expect.
For example, hypertension affects nearly one in three American
adults. It is called ``the silent killer'' due to the strong link
between unmanaged hypertension and later incidents of coronary vascular
disease. Yet only 23 percent of diagnosed hypertensives have their
blood pressure under control, despite readily available and cost-
effective medications. Diabetes was referred to in a recent New York
Times article as a disease of epidemic proportions, and yet more than
70 percent of diabetics have unmanaged cholesterol levels, despite
readily available cholesterol management treatments. Diabetes is the
leading cause of non-traumatic lower limb amputations in the U.S., but
barely one in five patients with diabetes receive the recommended
annual foot exams that can expose loss of sensation. Additionally,
almost 70 percent of our children with severe asthma are not receiving
appropriate medications.
A 737 stays grounded due to safety risks if a tray-table won't stay
in it's locked and upright position, but the equivalent of a 737 load
of people die every day from preventable medical errors.
Many of us would not dream of letting our cars go more than 7,000
miles without an oil change, and in fact get regular notifications
about servicing so they don't break down on the side of the road.
However, we may go years without a blood pressure or cholesterol check,
and the first sign of coronary heart disease is when our bodies break
down and we are rushed to hospital with a heart attack or stroke.
As a society, we are outraged about a single occurrence of data
being stolen, but ignore the daily health care crisis when
opportunities for continuous and appropriate care are missed due to the
lack of basic information systems with data mobility.
The relevant technologies to address these problems are neither
complex nor expensive. We don't need 4-D CAT scanning devices to ensure
children receive immunizations and the elderly receive flu shots. We
don't need to solve the genome code to notify patients in a timely and
traceable manner when their lab results are normal or abnormal.
We created Kryptiq to solve these problems.
Today, more than 100 employees at Kryptiq Corporation are focused
on enabling secure connectivity in health care. Last year alone our
customer base grew 120 percent to over 700 health care organizations in
48 states. More significantly, the number of secure clinical messaging
customers grew by more than 200 percent in that same time frame. Every
one of these clinics who purchased Kryptiq connectivity software did so
with the specific intent to collaborate with other clinics and in many
cases also with their patients. The primary application of Kryptiq
software is ``provider-to-provider'' communication for referrals, lab
results, consultations, admissions, and prescriptions. These products
also allow ``provider-to-patient'' communication to deliver secure
online access to medical record summaries, lab results, and
administrative data. They enable patients with chronic diseases to ask
questions and provide home monitored data to their physician office,
and support eVisits to provide necessary care without the patient
coming into the practice. The growth and adoption of Kryptiq software
tells us that connectivity is not just a ``nice to have'' capability--
it is the best way to unlock the value that is trapped in the
information silos of health care.
Much attention has been given to President Bush's goal to enable
Electronic Health Records (EHR) for nearly all Americans by 2014. The
creation of the Office of the National Coordinator for Health
Information Technology (ONC) has advanced the cause and awareness of
EHR. Among other tangible benefits, Dr. David Bralier's efforts have
been a positive and significant step forward in moving us away from
paper and establishing a foundation for data storage and management.
EHRs are of great value in organizing and maintaining the accuracy of
patient information, while eliminating the burdens inherent in a paper
system. However, EHR adoption alone does not result in collaboration.
In fact the evidence to date suggests most EHR implementations create
islands of automation, no more capable of sharing information than the
paper records they replace.
Efforts spearheaded by the ONC to create Regional Health
Information Organizations (RHIOs) for information sharing have largely
stalled. Yet Kryptiq customers are delivering significant and
measurable gains by combining the EHR systems that already exist with a
readily available and affordable messaging infrastructure to share
information across their communities. Secure clinical messaging
represents the greatest opportunity to modernize and improve health
care. Therefore, we believe that in order to truly lower costs and
improve quality, we need to look at how we MOVE patient information,
not just how we STORE patient information.
We all know about the growing cost of health care and the burden it
is placing on our citizens, our businesses and our economy. Several
studies have shown the tremendous potential for cost savings and
qualitative improvements that can be realized through health care IT
adoption. A recent study by the Center for Information Technology
Leadership (CITL) at Partners HealthCare reported that if all
information exchange between physician, hospitals, pharmacies,
radiology centers, and public health facilities were fully automated in
a standardized way, the U.S. health care system could save in excess of
$77 billion dollars each year. The study specifically, and in my
opinion rightly, points out that 70 percent plus of the savings
opportunities exist through inter-office collaboration as opposed to
internal office automation.
The recent RHIO initiatives are an attempt by the government to
address the data mobility issue. However, the ``typical'' RHIO (not
unlike it predecessor, the CHIN) has a fatal flaw--it essentially
requires that all infrastructure, governance, funding, and standards be
agreed to and deployed BEFORE it can be of any use. This is analogous
to building an entire road system before anyone can drive. In addition,
questions about their sustainability have yet to be answered. This
leads me to conclude that the current RHIO concept will require ever-
increasing and ongoing financial support from the government.
There is a smarter approach. The concept of an ``organic'' or
incremental RHIO fueled by secure messaging technology provides
immediate data mobility in a self-sustaining model without the
centralized high cost infrastructure and bureaucratic governance.
Forrester Research, reflecting on the early and modest results from
initial RHIO efforts, has coined this concept as Managed Connectivity
and it is gathering support among industry leaders. Dr. Brailer
illustrated this point in a recent article in Health Data Management,
``Most [people] will want to make local decisions on how data will be
shared. . .the less centralization there is, the more value people will
see. . ..'' The Managed Connectivity concept is predicated on peer-to-
peer workflow-based collaboration. The technology foundation is e-mail
and the Internet, which is already universally available at a minimal
cost.
By definition, this approach includes any clinic that has e-mail
access as opposed to only those that have EHR. At the same time, it
will serve to stimulate EHR adoption because electronic records are a
place to store and manage data that is sent and received. The big
benefit however is that collaboration begins on day one--there are no
multi-year implementation projects.
I know that this model will succeed. I spent 15 years at Intel at
the critical time of Personal Computer adoption. As many of you may
recall, the transition from early adopters to widespread business use
occurred because of e-mail. Collaboration drove PC adoption, which in
turn drove richer applications, and created the industry that made
every industry more competitive and productive. This was referred to as
a ``virtuous technology spiral.''
More importantly, I know that the ``organic'' approach works
because I see our customers doing it every day.
Oregon has been the home to many health care breakthroughs, both in
the private and public sector. The Oregon Health Plan, the early
electronic medical record developed by Dr. Mark Leavitt, and the wide
deployment of EHRs by both Providence Health System and Kaiser
Northwest Permanente are examples of national leadership in health
care.
Recently, in partnership with our customers, Kryptiq has
established that connectivity solutions significantly improve care
delivery and reduce costs. For example, by transitioning patient
referrals from paper-based systems to secure electronic communications,
Providence Health System and The Oregon Clinic were able to save an
approximate combined $10 per referral. Faxes and phone calls were
replaced by electronic messaging in a matter of weeks. This was
achieved without the need of external forces or government subsidies or
multi-agency committees arguing about every last technical and business
detail. In addition to reducing costs, moving to electronic referrals
eliminated the time lag inherent in paper systems and ensured that
relevant information was where it needed to be when it needed to be
there.
Meanwhile Providence Medical Group recently released the results of
a comprehensive one-year study of significant improvements in patient
outcomes using Kryptiq's CareManager Diabetes Module. Their ability to
unleash the data stored in their EHR and use it to proactively
communicate with chronic patients regarding their health status,
instead of waiting for the next office visit, has lead to remarkable
improvements in treatment compliance. They have demonstrated a 58
percent increase in the number of patients with diabetes who achieved
control of their cholesterol and blood pressure levels, significantly
reducing the risk of disease complications. They also documented a 250
percent increase in foot screenings, helping to stem the rate of later
amputations. All of this was achieved without any additional staff
requirements, and the extra revenue from providing necessary and
medically appropriate care in a timely manner allowed the medical group
to pay for the necessary IT investment, while undoubtedly saving the
economy many millions of dollars in hospital visits and other longer-
term care costs.
Similar examples exist throughout the country in physician offices
adopting connectivity solutions at their own investment to improve
their care services and generate additional revenue at a lower overall
cost. Family Medical Specialists of Texas (FMS) believed that their
busy patients would receive better care if they could have online
consultations with their primary care physician to resolve medical
questions and issues without an office visit. Rather than waiting on
all the local health plans to support ``eVisits,'' FMS now charges
individual patients $40 per year for their eCare program. Patients
believe it pays for itself by avoiding co-pays; employers and employees
save time by avoiding unnecessary office visits; FMS generates
additional revenue without increasing staff costs; and the health plans
save money by shifting office visits to more cost-effective and
efficient forms of care.
Memorial Hermann Healthcare System (MHHS) in Houston, Texas has
adopted messaging technology for similar reasons. Dr. David Bauer,
Residency Director for The Family Medicine Residency Program, cites a
typical pre-messaging scenario of a patient calling in with a question
regarding a medication she had been prescribed the previous day. ``She
left me a message to call her back. But when I called her back she was
in a meeting so I got her voicemail. When she returned my call I was
busy seeing patients. Over the next 24 hours she spoke to three of my
nursing team without reaching me, having to re-explain her issue each
time, and we left each other seven voicemail messages.'' Dr. Bauer's
scenario is a common one, happening all over the country every day, but
for him it's now a thing of the past. ``Now we use secure messaging,
which allows me to communicate with patients and other providers
without our needing to be available at the same time.''
Examples such as these illustrate that the market is creating the
standards for baseline inter-operability. The next logical step in the
evolution of such standards is a common interchange structure for
patient medical records that is simple to deploy such as the ASTM
Continuity of Care Record (CCR) or the HL7 Clinical Document
Architecture (CDA). The standard should be accessible by patients and
health care providers and work in both EHR and non-EHR environments. By
contrast, emerging concepts, such as Cross Enterprise Document Sharing
(XDS), promote collaboration but require significant infrastructure,
are more complex to deploy and assume certain market outcomes that are
still in question.
Because there are competing definitions of a common interchange
structure for patient medical records, health care IT vendors are
reluctant to develop inter-operability solutions based on either
standard. We believe that it is time for the government agencies such
as NIST to help mediate between these competing approaches. We are also
encouraged by NIST's involvement in developing reference
implementations for the XDS standards. These efforts help promote the
validity of standards and their applications.
A common interchange structure for medical records will be a great
leap forward for everyday collaboration. However, other standards will
need to be developed to address more specialized health care-related
homeland security needs such as the aggregation of emergency room data
to identify pandemics.
We've made great progress in a short period of time and this has
led us to a solid foundation for the critical work that remains to be
done. Clearly, we want to continue to build on the successes that will
drive collaboration and improve the quality and delivery of care, while
achieving critical cost savings. To this end, we recommend that the
Government's continued and future funding for health care IT follow
this direction:
1. Prioritize ``organic'' RHIO expansion while limiting any
additional spending on centralized or federated models unless
they demonstrate scalability and broad community participation.
2. Fund the implementation of electronic collaboration
technologies in public health settings. Public health is
largely funded by the government at a federal, State and local
level. To preserve the viability of the public health clinics,
they should be the recipients of targeted resources
specifically for this purpose.
3. Mediate a definition of a common interchange structure for
patient medical records to facilitate collaboration.
Specifically, settle the debate between CDA and CCR. CMS could
provide incentives for the adoption through its reimbursement
processes.
4. Combine any contemplated changes in Stark laws with
collaboration mandates that ensure that any recipient of
technology can participate in a fully collaborative and open
community-wide network.
5. Continue work towards differential reimbursement to
physicians who can prove better outcomes of care for their
patient population.
As we have shown, the benefits of secure electronic collaboration
are undeniable. We are on the eve of a major breakthrough of technology
adoption that will make the health care industry safer, more cost-
effective and more competitive. We advocate a network of collaboration
that maximizes provider and patient participation, and provides
immediate and secure data mobility in a self-sustaining model without
the high cost and complexity of a centralized system.
Thank you.
Biography for Luis Machuca
Luis Machuca is the President and Chief Executive Officer of
Kryptiq Corporation, the leading provider of inter-operability and
workflow connectivity solutions for health care. Mr. Machuca received
his BSEE in 1980 and MSIE in 1981, both from Purdue University. In
1981, he joined Intel Corp., where over a 15-year career, held a
variety of roles in management before becoming co-General Manager of
the OEM Products & Services Division where he established Intel as the
number one motherboard supplier in the world. In 1996, he became the
Executive Vice President of the NEC Computer Services Division of PB-
NEC Corp. In 1999, Mr. Machuca joined eFusion Corp. as President and
COO and subsequently merged the company with ITXC. Mr. Machuca
currently serves on the Oregon Health & Science University Foundation
Board of Trustees, Lifeworks NW Board of Directors, the Boy Scouts of
America Cascade Pacific Council Executive Board, Catholic Charities of
Oregon and the Jesuit High School Board of Trustees. Mr. Machuca has
also served on the Portland Metropolitan Family Services Board of
Directors, and was a finals judge for the 2005 NewVenture Championship
business plan competition sponsored by the University of Oregon's
Lundquist Center for Entrepreneurship. In 1999, Mr. Machuca received
the Outstanding Industrial Engineering Award in from Purdue University.
Mr. Reichert. Lastly, we recognize Mr. Urali.
STATEMENT OF MR. PREM URALI, PRESIDENT AND CEO, HEALTHUNITY
CORPORATION
Mr. Urali. Thank you, Chairman Congressman Reichert,
Congressman Representative Wu, ladies and gentlemen.
My name Prem Urali. I am the founder and CEO of HealthUnity
Corporation, a 17-month old health information technology
company based in Bellevue, Washington.
First let me start by thanking you for giving me the
opportunity to present our company's views in front of the
Subcommittee and in front of the general public here today.
HealthUnity was founded with the singular vision of
providing the solution for getting the right clinical
information to the right person at the right time. We had two
earlier deployments underway: One in the Seattle east side,
namely, Bellevue, Washington; and another one in Baltimore,
Maryland. In both of these locations, we have had early
successes in enabling health information exchanges to flourish.
HealthUnity's approach and early success can be summarized
in the following key points: Our approach is targeted at the
grass roots, namely, we target the clinicians first. They are
the knowledge workers who need to be introduced to health
information technology right from the outset. If the clinicians
are not on board, we will not achieve the national vision we
seek, despite the involvement of others, so that's why we
started the grass roots with the clinicians.
Secondly, we provide an affordable solution that is also
the best in its class.
And, thirdly, we take care of all the external integration
and communication needs, which is a critical piece, as Luis was
pointing out, in our national health IT strategy.
Finally, we believe we have a business model that is
scalable and sustainable.
Now, let me summarize my thoughts on what role health
information plays in improving care. Health care is essentially
a local, at best a regional, activity; hence, any approach to
solving health information sharing, it should start at the
local or regional level.
There are three goals which are central if any of this is
to happen. The first goal is improving quality of care. Now, I
will limit my--the value proposition discussion from a
clinician's perspective. And I'm sure there are various other
perspectives on value and how a network could be beneficial.
But, you know, like I said, we have to start at the grass roots
level; and unless the clinicians are up to it, it doesn't
matter who else is interested in it.
The often quoted figure is that 96,000 avoidable deaths
happen, in the U.S. Alone. By electronically recording,
communicating, and archiving health information and then
analyzing de-identified information--meaning the patients
identify information that has been removed from it--we can both
benefit the patients as well as the community and the
population health needs and how we can improve quality of care.
The second goal is addressing provider inefficiencies.
Information technology has the power to reduce cost of doing
business for all the providers involved. Today there is still a
ton of paperwork, papers, faxes, phone calls, that keep passing
between care providers. At HealthUnity, we have recognized this
as another important area where our solutions should help
improve those inefficiencies.
The third goal is to improve patient experience. We--in our
earlier--in other testimony, it came out that we all go through
the frustrating experience where we go see a doctor and we have
to--the first thing we do is we have to fill out the clipboard.
Additionally, the patients who see multiple providers have to
take it upon themselves the act of coordinating the health
information, and, physically, in many cases, transporting data
between the various care providers.
Now, let me turn to the topic of incentives and barriers.
The key barriers hampering technology adoption in the physician
practices. Deployment of IT systems requires up-front capital
and it also causes short-term disruption in practice
efficiencies. So any solution should address squarely, number
one, how to help physician practices raise the capital they
need in order for deploying and operating such; and then,
secondly, how do you promote the mass education of our general
public and the IT people so that adopting these systems can be
very inexpensive and the talent to do that is ubiquitous and
it's widely available.
Here are some practical suggestions on how incentives can
be targeted at these two barriers. Number one, let any
interested party finance physician practice adoption of
technology, with no strings attached. So far, we have had a lot
of discussion on why physicians do not have technology; but any
solution or every policy solution keep coming back has strings
attached to it, and hence the adoption is not being what it
needs to be.
Number two, we need to fund education and training so the
best practices on how to implement these technologies become
affordable and common knowledge: So we can walk to a community
college and get the graduates that are coming out or have been
through the program, and they have the knowledge how to help
the physicians implement the IT solution in their practice.
Now, let me turn to the topic of Federal Government
departments and agencies and the role that they have played in
health IT. HHS, the Health and Human Services Department, as
well as the Office of the National Coordinator, have done a
phenomenal job in raising the awareness in the industry and
setting a national agenda in terms of the appropriate goals and
strategies. This was done in record time. We commend them for
serving the Nation well in doing so.
In the area of execution we believe we can share some of
our experience which might help all of us achieve national
goals in a capital as well as time efficient manner.
Our nation owes much of its economic success to its
numerous entrepreneurs, inventors, and workers. Equally
importantly, our nation owes its success to the right policies
enshrined in our Constitution, in our laws, and in various
administrative and legislative bodies. Government intervention
in the free market should be one of last resort. We are all for
government incentives and removal of barriers, but we are not
for government picking winners and losers in the health
information technology market. We are not that particular about
government massively spending and indirectly funding health IT
projects, either from Washington, D.C., or the state capitals.
We understand the urgency within our government and public
officials to get things done quickly. We also think there has
not been sufficient progress in creating the right policy
environment and right incentives environment and then letting
the private sector innovate. I think that is where we have had
deficiencies and we can definitely use a lot of help from
Washington, D.C. We would also like to see more of the Health
and Human Services Department as well as the Office of National
Coordinator's resources targeted towards addressing these
policy and incentive issues.
Addressing the topic of standards in the health care
environment, the scenario that is most important at the
national level may be quite different than what is most
important at the regional level. And we've only seen that based
on some of the recommendations and incentives that are coming
from Washington, D.C. Our focus needs to be at the regional
level, the regional scenarios, the barriers, the incentives,
and the policy and legislative needs, at the grass roots level.
We thank you for the opportunity, and I look forward to
answering some questions. Thanks.
Mr. Reichert. Thank you.
[The prepared statement of Mr. Urali follows:]
Prepared Statement of Prem Urali
Good afternoon, Chairman, Members of the Subcommittee, ladies and
gentlemen.
My name is Prem Urali. I am the Founder and CEO of HealthUnity
Corporation, a 17-month-old health information technology company based
in Bellevue, Washington.
First, let me start by thanking you for giving me the opportunity
to present our Company's views in front of this subcommittee.
HealthUnity was founded with the singular vision of providing a
solution for getting the right clinical information to the right person
at the right time. We have two real-world deployments underway: one in
Bellevue, WA, and the other in Baltimore, MD, where we have had early
successes in enabling regional health information exchanges to
flourish.
HealthUnity's approach and early successes can be summarized in the
following key points:
1. Our approach is targeted at the grass-roots--we start with
clinicians. They are the knowledge workers who need to be
introduced to the health technology world right at the outset.
If the clinicians are not on board we will not achieve the
national vision we seek, despite the involvement of others.
2. Secondly, we provide an affordable solution that is also
the best in its class.
3. Thirdly, we take care of all of the external integration
and communication needs--a critical piece that has been missing
till now. Clinicians want to communicate electronically with
other clinicians, labs, radiology centers, hospitals and
patients. Facilitating this communication is what we do best.
4. Finally, we have a business model that is scalable and
sustainable, and which produces the best solution for the
clinical communication and collaboration problem.
Let me now summarize my thoughts on the role health information
plays in improving care.
Health care is essentially a local, or at best regional, activity.
The patients and their providers (hospitals, labs, physician practices,
etc.) are all located within a given locale or region. Hence any
approach must start at the regional level. There are three goals that
are central to regional care providers that also align perfectly with
the national vision. I am limiting my analysis to goals that are
relevant from a provider's view-point because that is where I believe
all discussions around information technology adoption in health care
should begin.
The first goal is improving quality of care:
The often quoted figure is that 96,000 avoidable deaths occur in
the U.S. each year. By electronically recording, communicating, and
archiving health information and analyzing de-identified health
information, we can help reduce the incidence of errors and improve
quality of care. This can be achieved by providing patient-specific, as
well as population-wide, interventions.
The second goal is addressing efficiencies:
Information technology has the power to reduce the cost of doing
business for all the providers involved. Today, there is still a ton of
papers, faxes and phone calls passing between care providers. At
HealthUnity we address inefficiencies by automating major workflows,
such as patient demographics exchange between health care entities,
automation of the referral process, clinical information sharing,
distribution of lab and radiology results, and several other frequently
recurring processes. These savings lower the operating costs for care
providers and help them run their businesses better. In addition, by
making historical data seamlessly available to care providers, we
reduce the practice of defensive medicine. If prior data is available
and easily accessible, providers are less likely to reorder tests and
procedures. This reduces the level of waste in the system. Providers
need not be concerned about overall revenues falling. We need to keep
in mind that there is no dearth of growth in demand for health services
with our aging population. By reducing wastage and reducing the unit
cost per visit or procedure, providers can treat and meet the needs of
more of our citizens at a lower unit cost to the system.
The third goal is to improve the patient experience:
Today, as patients, we often have frustrating experiences when we
visit our doctors and the dreaded clipboard is handed over for us to
fill out. Often patients who see multiple providers may have to fill
out the same form multiple times over the course of a single day.
Additionally, patients who see multiple providers appreciate what it
takes to transport medical data between their various care providers,
and consequently they themselves act as coordinators of their own care.
Technology can help the system do what it is supposed to do and make
the care delivery process considerably more patient friendly.
Clinicians would love to see this happen at an affordable cost to them.
I hope I was able to illustrate the core benefits of a connected
health care environment. Now, let me turn to the topic of incentives
and barriers.
The key barriers hampering technology adoption are in physician
practices. The other health care providers are typically larger and can
easily afford new investments or have already made investments in
health information technology. Deployment of an electronic medical
record system, or EMR, requires up-front capital and causes a short-
term drop in practice productivity. Furthermore, an EMR, coupled with a
practice management system, or PMS, does not completely address the
three goals I spoke of earlier. The third missing piece is the
bidirectional external communication solution. Any real solution should
squarely address: 1) How to help physician practices raise capital for
deployment and operation of an IT solution that addresses EMR, PMS and
the bidirectional communication need. And 2) How to promote the
education of the market on the best practices for adopting those
solutions in a way that minimizes disruption in practice productivity.
In summary the barriers are 1) Capital for deployment and
operations and 2) Practice disruption during implementation. Here are
some practical suggestions on how incentives can be targeted at these
two barriers: 1) Let any interested party finance physician practice
adoption of technology, with no strings attached or with only a minimal
requirement that the physician practice match the interested party's
funds with their own funds, or match the funds in kind. 2) Provide
incentives for standardization and commoditization by implementing the
solution such that there are hundreds of people who have the expertise
to implement these technologies for a low price.
Let me now turn to the topic of the Federal Government departments
and agencies, such as the Department of Health and Human Services and
NIST, and the role they currently play and could play in the future.
HHS and the Office of the National Coordinator have done a phenomenal
job in raising the awareness in the industry and setting a national
agenda in terms of appropriate goals and strategies. This was done in
record time and we commend them for serving the Nation well. In the
area of execution, we believe we can share some of our experience,
which might help all of us achieve the national goals in a more capital
and time efficient manner.
Our nation owes much of its economic success to its numerous
entrepreneurs, inventors, and workers. Equally importantly our nation
owes its success to the right policies enshrined in our constitution,
our laws and the various administrative and legislative bodies. When a
major challenge such as the adoption of Health IT stares at us, we go
back to the formula that has worked for over 200 years, and that is
that the Government does what it is best at--setting the right legal
and policy environment, and the private sector does what it is best
at--innovating and creating the best health information infrastructure
in the world, one that is constantly innovating and keeping us at the
fore front. Government intervention in the free market should be the
last resort. We are all for Government incentives and removal of
barriers. But we are not for Government picking winners and losers in
the free market by massively spending the public's money on direct
Health IT projects managed from our national and state capitals. We
understand the urgency within our government and public officials to
get things done quickly. We also think there has not been sufficient
progress in creating the right policy environment and the right
incentives environment and then letting the private sector innovate. We
would like to see more of HHS' and the Office of the National
Coordinator for HIT's resources targeted towards solving the policy
deficiencies and the incentives for private sector development.
Addressing the topic of standards, NIST has a role to play as
standards emerge. Standards make sense when a value proposition can be
clearly articulated and there is strong consensus around that value
proposition. Let me give you the example of my ATM card. When I travel
to Europe, I can withdraw cash from most ATM machines there. However, I
cannot call up my bank statement from Europe. The value proposition
here is very clear. When traveling out of your home country, you want
to be able to get cash. However, you don't particularly care if you are
able to get your last month's bank statement. Translating this analogy
to the health care environment, the scenario that is most important at
a national level may be quite different than what is most important at
the regional or local level. Our first goal is to set in motion a
policy and incentive framework that will identify the scenarios that
are important at the regional level. When a clear picture emerges at
the regional level, we can then identify a subset of the regional
scenarios that would be important at the national level. At this stage
our focus needs to be on the regional scenarios. When a clear value
proposition emerges for a given regional scenario then we can move
forward to standardize it at the national level. NIST can play a key
role in this process.
Our observation is that the national standards are being worked on
without first letting the local and regional standards sufficient time
to emerge. Again, I clearly understand the urgency of our government
and public officials to achieve tangible progress. We want to help by
providing our candid feedback so that the national debate includes the
voice of a firm which is making progress on the ground at the regional
level.
We thank you for the opportunity again. I look forward to taking
some questions.
Biography for Prem Urali
Prior to founding HealthUnityTM Corporation, Prem was a Group
Manager in the BizTalk Server division of Microsoft, responsible for
the BizTalk Accelerator line of server products including the HL7 and
HIPAA Accelerators (integration engine). Prem incubated these
initiatives from concept to $10 million in incremental revenue in three
years. Prior to Microsoft, he founded a B2B software company Commercia
Corp, which was acquired by Microsoft in 2000. Prior to that Prem held
the position of CTO of Petopia, now a division of Petco Animal Supplies
(NASDAQ: PETC). Under his leadership, Petopia was ranked by InfoWorld
in its e-Business 100 list in 1999. Previously, Prem worked for four
years in the consulting services division of Microsoft, where he was
one of the youngest persons to be elevated to the position of Principal
Consultant in 1998. In this capacity, Prem lead the program that
launched the very first electronic commerce presence for Gap, Baby Gap
and Gap Kids. Prem, has founded companies in India and U.S. in the
software consulting and product areas.
He earned a Master of Science degree from Iowa State University in
Computer Engineering. He also earned an MBA from the Wharton School of
the University of Pennsylvania. Prem has three patents pending in the
area of message-oriented middleware systems.
About HealthUnity Corporation
HealthUnity was founded with the singular mission of providing the
right clinical information to the right person at the right time.
HealthUnity is the ``RHIO in a box'' company. HealthUnity's affordable
solution can be used to build regional health information networks that
support organic growth from as little as two entities to hundreds of
entities. Our tag line is ``Trust is Earned'' which reflects our
commitment to protecting security and privacy of patient data.
Discussion
Mr. Reichert. Would the other witnesses come up and try to
find a seat? I know it's a little crowded.
You know, these hearings, when I--this is my first term, by
the way, in Congress. I was a law enforcement officer in the
sheriff's office in Seattle, and I was a sheriff in Seattle for
eight years. And I find these things to be very formal and
people are a little bit nervous.
Are you nervous out there? Are you nervous up here?
See, we can relax a little bit now. You've got your
testimony out of the way, and Mr. Wu and I will ask a few
questions.
I, personally, am not an IT expert and I'm not a health
expert, but what I've noticed is some similarities in the field
that I came from, my 33-year career in law enforcement. When
you talk about inter-operability--and I think, you know, you
were mentioning that, first, hospitals and doctors' offices
need to build sort of a system within their own operation
before they can kind of reach out and be inter-operable. Law
enforcement has the same problem. I think back to--oh, by the
way, I'm supposed to say, before I start to talk, that I'm
recognizing myself for five minutes. That's part of the rule.
So I've now recognized myself, and I've used up some of my
time. Since there are only two of us, we'll be liberal with our
time today.
Mr. Wu. Absolutely.
Mr. Reichert. I would just like to draw a couple of
comparisons to law enforcement, because we're all going through
this struggle of just this massive increase in technology and
the number of vendors mentioned, 800 vendors. We all are
dealing with the fastest moves.
But in 1982, I was 31 years old, I started to work on the
Green River murder investigation, which brought me to Portland,
back to the Oregon area again. Do you know that in 1982, when I
started to work that case, there were no computers? And what we
used--and I've talked to young children about this in grade
school and junior high, and even high school students, they
will raise their hand and say, when I say, ``This is on Rolodex
file,'' they'll say, ``What is a Rolodex?'' And that's so far--
and then DNA and automated fingerprint identification systems,
all those things.
So what's exciting, though, is the Northwest is really
leading the way in a lot of these areas, and in the health IT
area, the Northwest once again is leading the way. What you've
heard from the expert witnesses today is that we are far ahead.
I've had the opportunity to travel to New Orleans and
Houston, and after Katrina and Rita, and interact with the
people there. They are making progress too, don't get me wrong,
but--you know, we're a little bit biased here in the
Northwest--we are doing a great job, but there's so much more
we can do. And I'm just happy to see that all of these bright
people are on this problem, because it is one that needs to be
solved.
The other thing that I find very interesting in these
discussions within the Federal Government and state government
are all these acronyms. Let's see, I just jotted a few down. So
we're just going to have a little bit of fun.
HHS. NIST, N-I-S-T. ONC. IEEE. HITS. PCC. IH. IT. EHR. OPI.
RTI.
Does everyone know what all those mean? You do? That is
scary.
Well, you know, it's good that you all know what they mean.
Mr. Wu. What we have is an inter-operability issue.
Mr. Reichert. Exactly right.
Mr. Wu. It's a new language.
Government Role in Health IT
Mr. Reichert. But what I've--What my question, now, I lead
up to is: I recognize that some of the problems that were
listed were turf wars, partnerships, and standards, incentives;
those are some things that have been talked about.
What I'd like to know, first of all, what are the three
most important things that the Federal Government can do to
help? Now, I've heard a lot of suggestions; but if we can just
maybe--anyone in the panel, the three most important things
that we can do. I know there's a lot.
Dr. Pettit. I think, as a start, this was a great
experience trying to figure out in writing this testimony,
really, and I think everyone is nodding their head. What can
the government do to help us.
Mr. Reichert. Yeah.
Dr. Pettit. And I see bringing attention to the matter has
done a tremendous amount in the past year, I believe. Funding
is another thing. Supporting legislation is another. And one
more--what was it? Nancy, help me. Programs.
Yeah. Those are the--Those are the four things I see. Oh,
and providing incentives through the government's role as a
payer.
Mr. Reichert. Yeah.
Mr. Machuca. If I could, I'm just going to give you one. I
really believe that embracing an organic approach not only has
the benefits that we stated, but I think there's a paralyzing
effect when clinicians and professionals in health care think
that somebody else is figuring out, somebody else is going to
pay for it, and in ten years we're just going to plug our PC
into the wall and all the health information is going to come
out. Not only is that a fallacy, but it's a paralyzing and
chilling effect. And people moving in an incremental way to get
the great benefit they can go with immediately, and so I would
focus very much on incremental, high yielding steps as opposed
to the big vision in the sky ten years from now.
Dr. Chin. I would--You know, I would agree with that. And
one of the big things in health care IT is ``don't let perfect
be the enemy of the good.'' You know, we've got to start
somewhere; and rather than trying to develop the perfect system
and the perfect standards, we've got to start somewhere.
The number one thing for the Federal Government is really
incentives to incent people to put their information into an
electronic form and to be able to share that information. One
of the examples of that is Kaiser Permanente, here in the
northwest region, actually contracts out services, hospital
services, to four or five hospital organizations. And we do get
that information back, we do get that information back
electronically. And the incentive for those organizations to
provide that information is that, unless they provide that
information, we do not use their services. And so that's
certainly a big incentive for them to provide that information.
The issue is not a technological one; the issue is one of
incentives and making it attractive and reward organizations
for engaging in this behavior of sharing information.
Ms. Cecchettini. I agree on the--I agree on the incentives
for early adoption, but also sharing the best practices of
early doctors, because it is about the work flow and how we do
change practice within health care.
Mr. Kenagy. I just want to add, though, the point earlier
about highlighting the issue is important. I think the Federal
Government plays a huge role in educating itself, educating the
industry, and educating consumers about how complex this is.
And I think that's critically important. I agree with the
incentives.
I think the focus on inter-operability between institutions
is a huge--you know, we have keen interest within OHSU to
automate our records, to improve care, to improve quality, to
improve efficiencies; but as was said by many of the people
here today, there are few incentives to sharing the
information.
I think Dr. Chin mentioned it great. There's a lot of
incentive around being effective in one area, but around
health. So I think that focusing the incentives around sharing
information, being able to export it to the patient themselves,
who are ultimately the greatest beneficiaries of this, and
between institutions, is a good focus area.
Mr. Reichert. Dr. Jeffrey.
Dr. Jeffrey. Well, as the Federal Government representative
here tasking ourselves, I'd like to echo some of the things
I've heard, which I completely agree with.
One is the leadership role that the Federal Government can
have in terms of exactly what you just said, increasing the
awareness and the importance of issue at all levels.
Second, it was mentioned the need to provide incentives for
technology adoption in policy, especially sort of market-based
policy incentives. And one of the things that the Department of
Health and Human Services--I'll try to avoid the acronyms--
under. Dr. Brailer's leadership, they just put out the contract
recently to George Washington University, Massachusetts General
Hospital, and I think it's the Harvard Institute for Health
Policy, to specifically examine government policies and how
they may be used to more effectively help the adoption of some
of these technologies. So, hopefully, that would be one
mechanism to try to get more of this kind of input.
And then the third area is on the same obstructions to
inter-operability, I agree, across institutions is a critical
piece. And that's a place where the Federal Government is not
mandating but working with the private sector and plays sort of
a little bit of the referee and a little bit of the convenor
(unintelligible) to try to get to the right answers.
Mr. Reichert. Great. You noticed I asked for three and I
think I counted about eight, so that's good.
The Chair recognizes the ranking member, Mr. Wu.
Mr. Wu. Thank you very much, Mr. Chairman.
You know, I tend to be a ``glass is half full'' kind of
person; but after the challenges that we've heard today, I
think the glass is kind of a quarter full. But I think that we
have some success stories here, or at least some good starts,
with Kaiser based here in the Pacific Northwest, with our local
V.A. Hospital, and with the efforts at OHSU. And I'd like to
get into some of the specific reasons for that, and it'll
probably take several rounds of discussion to get into that.
But we really have a critical mass of providers, payers,
innovators, suppliers, quality organizations, here in the
Northwest--in the Portland metro area in Oregon, in the Puget
Sound area in Washington state; and it's not just because the
businesses exist here and the health care providers exist here,
but because, I think, there's a spirit of innovation.
And before we let other folks get too far out ahead, as Mr.
Reichert referred to the loss of memory of Rolodexes, which
were so important to us in our prime, you know, in my
intellectual property practice, we represented all different
sorts of folks, including financial institutions. And I
remember helping financial institutions transition from their
in-house IT service to outsourcing their out--this is before
``outsourcing'' was a bad word; this was outsourcing to a nice
company in the Puget Sound--and this transition was typically
done over a weekend. That is, you shut the bank down on Friday
afternoon and you click over from your in-house service to this
new service provider. And the theory was that you did all of
that work over the weekend and you open up on Monday and nobody
notices the difference. And just in my legal career, I've got
to tell you that one of these transitions, well, you know, the
client shut the service down on Friday afternoon and on Monday
morning the tellers were using shoe boxes and paper records. So
there have been a lot of challenges to a lot of different
industries, just in our very short professional life, and so I
think that there's real room for optimism.
And focusing on the positive first, with Dr. Chin.
Kaiser is an integrated operation. You've gone to a
paperless system. There have been tremendous problems in giving
incentives to health care providers. My understanding is that
at Kaiser it's a bit tough. It's basically, if you want to work
here, you're going to use this paperless system.
But, Dr. Chin, as the designer of the system, you must have
made many decisions to try to make your system more provider
friendly. Could you talk about some of those things in addition
to the stick of ``if you want to work here,'' what are some of
the carrots that you offer.
Training on IT Systems
Dr. Chin. There is a learning--certainly a learning curve
for clinicians to learn how to use systems. And I would say,
initially, number one, is the amount of training that we
provide them. So we've provided them with 20 hours of training
in order to get them to be used to the system, and then we
actually reduced their schedules, initially, when they started
using the systems, to enable them to really learn how to use
the system effectively.
After you do that, once you get 90 percent of the
clinicians on board and using the system pretty effectively,
then it's relatively easy to get the other 10 percent on board
and to make--and to mandate the use of the system; otherwise,
they don't work for Kaiser Permanente.
And one of the interesting things is that we did send a
survey out after we implemented the system, and we said, ``If
we gave you the opportunity to go back to a paper record
system, would you take that opportunity?'' And over 90 percent
of the clinicians said no, they would not, because they could
see the advantages of the information system.
So I would say, Congressman Wu, that, initially, you do
sort of need a stick and you need to coach people and you need
to train them and you need to make it part of their job; but
once they convert over to the electronic systems, the
clinicians see the advantages of doing that, and they naturally
continue to use it rather than fall back into paper. So that's
the approach that we've taken.
And then, also, if you develop these systems intuitively
and well enough, it can actually make their lives easier,
because, number one, they have access to all the information to
all of their patients, not only in their practices but from
other people's practices. And physicians recognize the benefit
of doing that. And then, secondly, if you make the system
intuitive enough, you can actually build in things, automated
things, that actually make it easier for them to practice
medicine and easier for them to practice good medicine. And
physicians will appreciate that as well. And so those are the
different approaches we've taken.
Mr. Wu. Your training was about 20 hours per clinician. Mr.
Kenagy mentioned 14 hours at OHSU. So we're beginning to get a
bracket, if these hours of training did work, and you also
reduced clinical hours.
And, Mr. Kenagy, did you want to add something to this.
Mr. Kenagy. Yeah. Just one thing, before, sort of, I think
one key element to our success, I think, was involving
clinicians at every phase of the selection process. I think you
need a tool--to be successful, you need a tool that will work
for physicians and nurses. They need to be involved in
selecting what that is. You need to buy and implement a product
that is good. And I would argue that our industry is only now
emerging with three or four or five vendors that can actually
meet the needs. And then have clinicians involved every step of
the way.
So to answer your question about, you know, what has been
successful--and I think the Pacific Northwest is remarkably
successful in adopting EHRs. We sort of say, ``We're very
wired, and it's not just the coffee.'' I think that--but
having--and I'm a non-clinician, and so having the clinicians
engaged throughout that process has been absolutely critical to
our success.
Mr. Wu. Well, both of you talked about training the health
care providers and training folks up on the system. I wanted to
ask a follow-up about training in general, training both for
the clinicians and the providers, but also of--I think someone
referred to a shortage in personnel in health care IT--because
you need to be proficient not just in IT but in health care;
and if you're proficient in health care, you need to be
proficient not only in health care but in IT.
Do you see a role here--there was a parallel situation, I
believe, in data security, several years ago, and the Federal
Government provided some sprinkling of funding to train IT
professionals in security protocols and to develop an
additional personnel in that. Is there a federal role here to
work on that crossover between health care and IT.
Mr. Kenagy. I would say absolutely, first on just what
we're facing in trying to find good professionals.
I think it's a good sign that the Pacific Northwest economy
is recovering, that when we have positions--I mean, two years
ago or three years ago when I had a vacancy, it was easy for us
to have 100 or 150 people looking for that vacancy sort of just
saying, ``Well, I never really wanted to work in health care
because it's such a backwater of technology, but it's a job.''
Now we're having the problem that people--we don't have that,
we don't have that lecture anymore. I think people, good
people, have jobs now.
At OHSU we do have a program where we are training health
care IT professionals for the future. It's part of the pipeline
development that, as the operational side of OHSU, I want to
work with the academic side of OHSU to continue that. I think
that is a problem. I think understanding the nuances of health
care IT.
What can the Federal Government do? I think, as you
mentioned, incentives. It's expensive to train computer
professionals. I think recruiting them, retaining them, and
understanding that health care is an unbelievable career for a
health care--for an IT professional. I think that we just need
to have more programs.
The American Medical Informatics Association has a program
called ``Ten by Ten'' to train 10,000 clinicians by 2010.
Again, OHSU is a part of that effort. I think that's great. We
need a significant number of people in our industry, both to
support it--the ongoing support and the like.
Dr. Chin. You know, as part of my written comments, not my
spoken comments, one of the things that I mentioned is the
reason for our success was really the partnership of
physicians, IT professionals, and project managers working
closely together. Certainly, if you have somebody who's got
medical knowledge and the IT knowledge, that will go a long way
to ensure the success of a project. And I think that's very
important.
One of the problems with health care IT is, it is a very
specific body of knowledge and it's not really acknowledged as
such. Unlike medical care, where you have neurosurgeons that
are board-certified, internists that are board-certified in
internal medicine, within health care IT, it's difficult to
know who's qualified and who's not qualified. And just like you
wouldn't have neuro--an internist do neurosurgery, you
shouldn't get somebody who's knowledgeable only in IT in a
certain area, necessarily, involved and feel that they're going
to be completely competent in health care IT; because there are
a lot of issue in health care IT that are very specific to that
field, that are not specific to other IT fields.
Mr. Urali. Again, kind of representing sort of the small
clinician practices. I'd like to kind of narrate a recent story
we heard from one of our customers.
We had a big storm about a month back, in the Seattle area.
The DSL connection--basically, the Internet connection--failed
for this physician, and she couldn't get the connection back up
and running for almost four days. And she had to get the
consultant to come in and spend almost like $150 an hour to get
something as basic as an Internet connection back up again.
That just goes to show how expensive it is to even get
something basic as an Internet connection going.
One of the benchmarks should be that, you know, I can open
my community college, you know, class schedule and see a ton of
courses there that I can go take for a hundred dollars that,
you know, I can gain the expertise over a two or three week
period, maybe it's three evenings for a four-week period or
like or something like that.
You know, health IT is not that difficult, you know,
honestly. I mean, I come from a technology background--used to
work for Microsoft for eight and a half years, did not have
that much of a health care IT background up until about four or
five years back. And, you know, we built two products within
Microsoft within a literally short time to pick something up.
It is possible to get that knowledge out there in a pretty
common manner, and I do certainly believe that. And the more
people we have trained that way, I think it's going to bring
down the cost of that option. We cannot have $150 consultants
coming in just to fix my Internet connection. Physicians cannot
just afford that sort of expensive services. They've got to be
able to have their own office staff trained, or maybe they
should be able to hire people who they can pay $20 or $30 an
hour and have them full time on staff and maybe help them run
most of the technology infrastructure.
Role of Patient in Health IT
Mr. Reichert. Okay. Now we're back to recognizing the
Chair. Thank you, Mr. Wu. And I have a couple of questions.
I've noticed, Dr. Pettit, in your testimony, you referred
to--and this might be kind of a commonsense statement, but an
answer would be a commonsense answer. What do you mean by ``put
the patient at the center''? I know what it means to me, but
what does that really mean, when we try to bring that into the
whole health IT world?
Dr. Pettit. I'm glad you--I'm glad you asked that.
Mr. Reichert. We need somebody with some IT experience.
Dr. Pettit. I really am very, very glad you asked that
question, because it's something that's been--a definition
that's been sort of elusive, and I think you will find
different answers from different people.
Some say, ``Well, we offer a portal to our information, and
that's patient-centered.'' But I think the way that I'm
defining ``patient centered'' is illustrated by this: A friend
of mine just today said, you know, ``Where is my medical
record?'' Where is my medical record? And then he realized, he
goes, ``Well, I don't have it.'' So he said, ``Is it at this
clinic and that clinic and that clinic.''
And I said, ``Yes. It's in fragments in different places.''
And so that's really sort of institution-centric, meaning the
record exists there, and if you want it, you need to retrieve
it, as opposed to having the patient be able to see it, in its
entirety, either, you know, virtually or directly.
I mean, even as I start to explain this, it does get kind
of confusing in a hurry, because there are technical ways to
bring the information together even though it might exist in
different places, and then there are other ways where you can
put it all in a single database and then it's essentially right
there.
Did I answer your question?
Mr. Reichert. So is this part of your--because you followed
up in your testimony with a comment about shared data
ownership, so is that kind of what you're talking about when
you talked about ``patient centered'' when you share the--that
the patient has ownership of the shared data? Am I following
you right?
Dr. Pettit. Yes. Yes.
Mr. Reichert. Okay.
Dr. Pettit. What we don't want to do is just make what
we're already doing just a little bit quicker, you know,
because to get a record from one place to another, you know, we
can mail it or we can fax it or we can e-mail it. But we need
to rearrange things so that you don't have to go out and get it
every time you need it, so that it's in a single nonredundant
structure, you see.
Because when you seek health care, you have, generally, a
history and physical. And in the emergency department, when
you're admitted to the hospital, in the outpatient setting,
there's a ton of redundancy in that. I mean, how many times are
you asked, ``Have you had any surgeries? Are you allergic to
any medications?'' You hear the same thing over and over. That
should be documented one time, and one time only, in her life.
If you had an appendectomy in 1972, document that once; and
then it will save health care people unbelievable amounts of
time in reasking all those questions.
Privacy Issues
Mr. Reichert. Of course the follow-up question to that
would be, and, again, to the entire panel: When you document
that once and the record goes out to all these other entities,
then there certainly is this concern about the whole HIPAA and
privacy issue.
Do you feel that the technology that's out there today is a
technology that does protect the privacy of patients?
Dr. Pettit. I would say not adequately at this point. And
there are other issues that the--the record is still so
undifferentiated, if you--if I dictate a note on a patient, it
might include issues about their depression and their prostate
and their hypertension. It's just all in one thing and you
can't really separate it out. But, you know, the ultimate goal
in this patient-centered way is that the patient can control
it, item by item. I mean, we're a long ways from this, believe
me. But, you know, a person should really be able to say,
``Don't share the results of that test with this person.''
Because your orthopedist may not need to see some embarrassing
things you had, you know, across town.
Unique Patient Identifier
Dr. Chin. And the technology certainly exists to secure it
and make it private, so the technology isn't an issue.
The technology is there. But the first step--building on
what Dr. Pettit said, the first step is really being able to
identify a person as the same person in another institution.
And even that basic functionality does not exist. So I don't
know whether the John Smith that I admitted at Providence is
the same John Smith that was admitted at OHSU the day before.
And that would really be the first step, is to say, ``Okay.
I'm seeing somebody in my institution. What other
institutions does this person have information about? And if I
pull that information, is it the same person or is it a
different person.''
Some people have called this the unique patient identifier.
And I would say it doesn't really have to be a unique patient
identifier; you just need a mechanism to be able to clearly
identify a person as the same person across institutions. Now,
whether it's a unique patient identifier or some other
functionality, it doesn't make any difference as long as you
have that functionality to be able to identify that person. And
that's the basic thing that we do not have.
Mr. Reichert. A follow-up, then, with one other question.
If I've heard correctly, Doctor, you've said that a unique
patient identifier is a first step in this process.
Mr. Machuca, you talked about, in your statement, making
incremental high yield steps. So would this be one of those
incremental high yield steps?
Or anyone else on the panel, is there an incremental step
that you see as a high yield, other than this patient
identifier? I would see that as one. What would be some others?
Mr. Machuca. Well, along those lines, I think we tend to
look at this through the prism of acute care, which is a 400-
year-old model, and maybe we should start looking at this
through the prism of chronic disease management and chronic
care, which is an entirely different growth path in terms of
consumption of resources and health care.
And through that model, identification and data--the
incentives for the publication of data, whether they're coming
from the patient or another provider, are based on the value
associated with that activity, as opposed to some financial or
regulatory incentive I have to post or publish my data to some
unified place. In other words, if you look at this through the
point of view of--through the prism of acute care, you now have
to solve also the problem of you created a burden, yet another
burden, on an already overburdened health care system and a
clinician, to not only take the data down for their own benefit
but to publish it to--I don't know how many entities, but let's
just assume there's one that collects all of that. And so you
at least have to solve that incentive.
And I'm much more at looking into this problem from the--if
you look at it just as an example from the prism of chronic
disease management, where the data that you're going to enter
into the system of managing that has a very immediate and
relevant step on how you get to compliance, whether it be in
your blood pressure or whether it be in cholesterol or whatever
it be in, whatever the parameters are.
I think the other issues, the notion that I have to have
all the data at my fingertips, all the time, for any possible
reason, is a notion that, in my experience so far, I have found
as many clinicians rejecting as too much information is worse
than not enough information. And so I would be very careful of
trying to wrap everything around a unified patient identifier.
I think the efforts that are being taken to that are adequate
and should move forward, but I would much more focus on the
value associated--what is the data that needs to be there and
what's the value associated with that data.
Mr. Reichert. Sounds like that was Dr. Pettit's point a
little bit earlier.
Are there other steps that--incremental steps that are high
yield steps? Anyone?
Dr. Pettit. I will just say one thing about patient
identification. I think that is definitely one of the first
steps. There are a couple of ways to accomplish it and it
doesn't have to be done through the use of a unique personal
identifier, in the fact that I know that's been politically a
very difficult discussion for a long time.
Mr. Reichert. Yes.
Dr. Pettit. I think there was unique patient identifiers
options done like in 1997 and it was shut down practically in
the afternoon after it was presented. But there are technical
ways to accomplish the same thing.
There's a lot of discussion about record locator services
and matching algorithms and all that sort of thing. So the good
news is that even in the past year, going to HIMSS, seeing real
progress in the technology to do these sort of things, and
things that were more of a theory a year ago are now becoming
at least sort of real in the exhibition booth. But it's a step.
I think someone here described it as a concept car: You can see
them but you can't drive them yet.
Mr. Reichert. Yeah.
Dr. Pettit. But they're on their way.
Mr. Reichert. Good. Thank you.
Dr. Chin. You know, the next incremental step would be to
simply take information, medical information, on a patient and
label each piece of information as to the date the information
was generated and the type of information. So if it was a
medication, label it as a medication; if it was a radiology
test, label it as a radiology test. And that way, when you
download information from one institution to another, and you
say, ``Well, I want to take a look at all the radiology tests
somebody had,'' you could then filter that information and look
at all the radiology tests in reverse chronological order. That
would be relatively easy to do in terms of developing a
standard for that and yet produce enormous benefits. So I would
say, next to being able to identify the patient as the same
patient across institutions, that would be the next step, is to
label each piece of information as to date and the type of
information.
Mr. Reichert. Mr. Kenagy had a comment.
Mr. Kenagy. Just a couple things. One, I think, I can't
exchange anything electronically if I don't have it
electronically in the first place. And I think the earlier
point that only 10 percent of hospitals and 5 percent of
physicians' offices have anything electronic in the first place
is a much more significant barrier to exchange.
When we--This panel represents very different views.
We do not share the same idea that either a very large
national database of all patient information is either a good
or a wise objective or technologically feasible. I don't know
if I think--actually, I do know that I don't think an
electronic--a unique patient identifier would be the first
step. I do think we need incremental ways to get information
out of our systems. That is a significant--even if it were just
a PDF, the ability to extract what is either in paper or
electronically, at first, would be important. Right now, it's
an extremely manual process. Some technology would help that.
Mr. Wu. Would the Chairman yield to me for a moment.
Mr. Reichert. Yes, Mr. Wu.
Mr. Wu. I wanted to go back to the subject of a patient
identifier.
Are we overthinking this a little bit? I mean, you know, if
you get the patient in the loop, you know, there may be 50
David Wus in the United States but I can look through that--I
mean, if you say, you know, ``Is this you?'' If you have a
conscious patient, you know, ``Well, I never had a hospital
visit in Des Moines.'' I mean, a lot of this can be simplified,
can't it? I mean, am I missing something here?
Dr. Pettit. Well, when you look at Denmark, they've had a
universal patient identifier since 1963.
Mr. Wu. Yeah, but they're Danish.
Dr. Pettit. I know. That's the issue. You know, that's--
yeah, and we're not. Yeah.
Mr. Kenagy. Your earlier point--your earlier point, Jody,
about putting the patient at the center, I think, is the key of
what you're talking about. And I think in Oregon where we are
very individualistic, and the like, if we look at the patient--
Intel is very interested in the digital--the personal digital
health record. If there was a way that I could identify that
this is, ``I am John Kenagy, I give you access to this
information,'' and I collate it, I'm the arbiter, whether
that's the same, I think, is potentially a better way to
approach it than thinking of a large national repository.
Mr. Urali. If I can question that a little bit further from
my viewpoint.
There could be 50 David Wu's, but once you start looking at
the date of birth and the gender and maybe some other types of
information such as your current address, you can actually
narrow it down to potentially even just one person. And there
are certain other identifying information that are already
available like, for instance, the state in which your driver's
license was issued and the driver's license number is pretty
unique. And then, again, maybe social security number is
another additional piece of information that can help hone in
on that.
One of the things we have done is we have, you know, looked
at those types of information and we've also tried to make it
much more automated. In other words, if there are five
institutions that want to start automatically sharing
information based on those criteria that I mentioned, where we
can uniquely identify David Wu's data residing in three of
those 15 institutions and automatically share the data.
So that's the sort of technology that's already available.
And then so, you know, now we are looking at how, you know,
what are the adoption barriers and just going through the
process of implementing it in the Seattle area.
Mr. Reichert. Mr. Wu.
Questions From the Audience
Mr. Wu. I just wanted to follow up on the earlier
discussion about adoption of technology and the personnel that
it takes. I want to recognize Dr. Bill Hirsch there who's
training a lot of folks. And as we talk about adaptation and
flexibility, I have to note that instead of having our table
adapt to our people, we've had our people adapt to the table
that we have available.
And the other thing that's happened here--and, Mr.
Chairman, I don't know if there's anything that we can do at
this point, although we do have multiple microphones and I'd be
willing to, you know, flip one of ours out into the audience.
We have a lot of experts in the audience; and instead of
adapting this the Northwest, we've done the classic Washington
thing where there's a panel of members of the House of
Representatives asking an expert panel to testify, rather than
having a more interactive process. And most of you all know
more than Mr. Reichert or I do about this field. You're also
learning something by looking at our learning curve right here.
And while that might be an interesting experience for you, if
there is some way that we can quickly work out a way of sharing
microphones, I think that it would be very valuable to get all
of you all participating in this.
And while we're spreading that out, I just wanted to
comment that in two other adoption arenas, banks and schools,
they both had this experience initially of having a box on a
desk. Initially, when banks computerized, they shoved a box in
front of employees, and they probably didn't spend enough on
training, and they didn't integrate it into their core
operations.
When schools first, quote, unquote, computerized, again, a
box on the desk. And the curriculum was not integrated around
the computer--or, actually, the computer system wasn't
integrated into the curriculum. And over time, banks have
changed, schools are changing, and I think that what many of
you all have addressed is the challenge of having the health
care system and this technology integrate with each other. And
that is a great challenge of every transition.
Are there folks who--I think the microphone is back there;
we'll bring it up here momentarily.
Unidentified Speaker. Chairman Reichert, Congressman Wu,
and panelists----
The Court Reporter. Excuse me. Excuse me, sir. Would you
mind coming down here and stating your name?
Mr. Reichert. We want to make sure you're on TV.
Unidentified Speaker. I don't go for that.
Chairman Reichert, Congressman Wu, and panelists, I thank
you for your presentation----
The Court Reporter. Would you please state your name?
Mr. Bouchard. My name is Mike Bouchard, a former IT wonk,
as it were, and also a patient consumer of health services.
I think the gentleman here who mentioned about the recent
loss of data--it's an old media that was actually lost, with
poor security applied. Trust is an issue for patients. I didn't
see anyone here advocating patient rights. I think that is very
important. The patient is actually the grass roots person being
involved here, other than the health care providers.
Secondly, OnStar. You push a button, someone contacts you,
they have all your data, it's kind of a centralized database.
With Katrina, we had loss of a lot of information. There's no
hardened infrastructure if something happens, like the person
who lost their DSL contact, how to back it up. We have wireless
technologies. We have jump drives. We have many new cards with
data chips embedded in them. Biometrics is a big thing.
You mentioned the 50 David Wu's. Now, with biometrics,
encryption, and other such stuff, other than addresses and
social security numbers--which I lost recently, with
Providence, thank you--it is not always secure. Data security
is probably going to be the biggest thing that will also get
the patient involved.
Now you have baby boomers--I'm a late stage, not an early
stage, baby boomer--generations X, Y, Z, and Aa, Bb, you know,
they'll be coming down the road. You have to have ease of
operation scalability, vertical as well as lateral use. That's
going to be very important. Because my seven year old son is
going to be able to out-Blackberry me and yet I can outdo how
to turn on a computer and double-click, right-click with
computers better than my grandparents were. So that has to be
scalable also, ease of use.
And, lastly, one of the barriers I'm finding is, there is
lack of budgeting. I have contacted many health care
operations. I do e-waste and computer destruction. One of the
things that we focus on is how to get rid of the data in a
manner that does not pollute our environment or in whole drive
form being sent to foreign countries, dumped in their
landfills, or accidentally falling into the ocean. If one hard
drive has 365,000 records--and I think it was a tape or a drive
or something of that nature--any enemy can garner that
information through data mining and computer forensics. Big
business right now. So I would not want OHSU's information to
be garnered and then used against me.
And, also, with the NSA issues--you have other acronyms,
CIA, FBI, et cetera, et cetera--how is that information going
to be protected from privacy issues, as well? You guys have
opened up a panoply of--a veritable cornucopia of subjects
that, as an entrepreneur, I'm seeing many opportunities that
they use as--that also has to be opened. How can the small
business entrepreneur get involved in this, become a part of
the process, as well as capitalize on it to actually generate
new incomes, make new jobs, and actually reap some of the
rewards. Thank you.
Mr. Reichert. Thank you. And back to the kind of the
Washington, D.C., format--the Chairman thanks the gentleman for
his statement.
Anyone want to ask a question, we would ask that maybe you
limit yourself to a question, two minutes, so that we can have
a number of people ask questions.
Yes.
Ms. Schoene. Sir, go ahead and come down. I'll meet you
right down here. And, again, please state your name for the
record.
Mr. Leahy. My name is Mike Leahy. I'm with a group called
the Oregon Community Health Information Network. And we do have
a common community health record that we're building, so I was
hopeful that maybe some of our friends, like my board member,
Dr. Chin, or my buddy, Luis Machuca, or Jody, or John, could
comment on this, because I think there are some specific things
we could be doing.
And then just the general statement, in Oregon we have
about 3.6 million people, and while I appreciate all the
private initiative type stuff, the reality is we have about a
million people that are either Medicaid or uninsured. And so,
eventually, we have to talk about kinds of patients and what--
who's covered and who isn't.
And then regarding the reluctance of the governmental
leadership, I would only say that there's another 800,000
people who are either Medicare or who get their, quote,
commercial insurance paid for by local, State, and Federal
governments. That's about half of the folks in this state
you're currently talking about, already depend in some way with
leadership or the lack of leadership in terms of coherent
federal, State, and local policies.
So I guess my question to, maybe, your experts is if you
could comment about efforts like what we're trying to do with
common community health record, where we already have 15 Oregon
organizations. Most of them are small organizations in rural
clinics in this area. And if you could maybe comment about some
of the ways that the representatives could help us build the
common community health record. Thank you.
Mr. Reichert. Thank you.
Dr. Chin. Certainly, organizations like OCHIN provide a
great opportunity, because OCHIN provides services for the
medically indigent, for the medically underserved. And the
interesting thing about OCHIN is that institutions that treat
members that are medically indigent actually lose money on
those patients, and so there's an incentive--there's a built-in
incentive for them to actually share that information.
If they see a patient that comes in, for whom they are not
going to be able to bill and get any revenue, the incentive for
them is to review all the other information and review all the
other medical records that the patient has, so that if the
patient needs a radiology test and they've had one at another
institution, they don't have to repeat that test and therefore
lose money. And so that's one of the big promises, I think, in
terms of incentives, is in organizations like OCHIN that serve
the medically indigent.
The way the Federal Government could promote that is really
to support organizations like OCHIN, that are providing
services to the medically underserved. And it's a win-win
situation, because, in the end, it will cost the government
less money to do so.
Dr. Pettit. Just a brief follow-on comment. But as a
clinician, I can say pretty unequivocally that the patients
that OCHIN serves, the people that are on and off insurance,
that suffer the most from discontinuity and those handoff
misses/errors occur routinely; because when people don't have
insurance, they often don't seek medical care. They don't get
primary care. They might get care, intermittently, through an
emergency department; and we all know that's not a good way to
care for patients.
Mr. Machuca. If I could expand, I think, on the earlier
point. I think it's problematic to think of patients as a
single persona in only one context. And I think that's where we
get our head wrapped around the asphalt on this issue.
I may be a member of Dr. Chin's practice, I'm also an
employee. My employer may want to have a community of its
employees who have diabetes participate in a diabetes
compliance improvement. So in that context, I'm a different
person than the person I may be at Kaiser. I'm going to present
myself as a patient to multiple places.
And to follow up Mr. Leahy's question, who's doing an
admirable job with a set of that community: Those folks are
going to be moving in and out of that community, and at times
they're going to be employees of somebody else who may have a
program to help them move along. And so our emphasis and the
incremental approach of the collaboration in making sure the
information gets to establish at least some level of secure
electronic continuity--maybe not in a record, but the ability
to know, at a context level, who are all those people that--who
is the network of this patient and who's involved in the care
of this person, and you have access to those people and those
resources. I think it's a much more real-life approach than
sort of say, ``Take everything else out of your desktop and
just leave Google. And just put your name in, and out comes
everything else.'' And so I think we need all the tools in our
desktop, not just Google.
Mr. Reichert. Thank you.
Top-down or Bottom-up Approach
Mr. Wu. Mr. Chairman, if I may, I wanted to shift to one
topic that I think we may be at a fork in the road, and it's
pretty important that we get some discussion on this topic so
that we guide the Federal Government down what I hope many of
us believe to be a proper choice at that fork in the road.
Many of you mentioned the temptation to develop an
overarching or perfect IT solution, and we might have
difficulty implementing that because it assumes too much
technology or too much training or too much overhead. And I
just wanted to throw open to you all the discussion of, is this
the direction that you see HHS headed in? Are they looking at a
perhaps overarching solution that will someday look like
Esperanto in the rear-view mirror? Or is the effort, you know,
sensitive to the bottom-up approach which Mr. Machuca is
advocating, an incrementalism and adaptive approach? And I
would like the panel to address that, and I would also invite
Dr. Jeffrey to address what NIST has been doing since signing
the memorandum of understanding with ONC in September of 2005.
Mr. Machuca. Thank you. To be candid, there are mixed
signals coming from HHS. If you analyze them on a trend basis,
Dr. Brailer and the office seem to be much more embracing of
the incremental approach of late. But if you also look at the
work of the four contracts that were awarded for the large
national infrastructure, if you look deeper into that, as to
the output that is expected and the consultants that have been
engaged, it is troubling in that effect, because it looks like
more of the same will get the big consultant-driven needs, so
we can spec out something that costs a lot more and has an
unlimited thirst of funding before it can be seen.
And so, to be quick to your question, is that there are
mixed encouraging signals in this direction.
Dr. Chin. You know, I would definitely support an
incremental approach, because our experience is that an
overarching approach that solves every problem is, for the most
part, not successful. And if you map out the key things that
are needed, and I think members of this panel had discussed
this, one of the key things is to make that information
accessible electronically. If you don't have it accessible
electronically, it's very difficult to move it.
The second thing is that you have to identify a particular
person in one organization as the same person in another
organization. And however you do that would be fine; it doesn't
necessarily have to be a single patient identifier. You could
use other pieces of information.
And then the third thing that would be useful, that would
be relatively low tech and easy to do, is to label each piece
of information with the date in which it was generated and the
type of information it was. Once you have those three
standards, then you can pull information together and integrate
it into a single medical record, and that's all you really
need. All the other stuff is good to have, but there's a cost
associated with implementing those standards. So those are the
three things that I would emphasize.
Mr. Kenagy. Maybe a different perspective on this. At the
ground, grass-roots level, I don't have time to pay attention
to what HHS does.
When you asked--one of the questions that was asked in this
testimony is: Has NIST or HHS contacted us at OHSU to get
engaged? And the answer is no. And the first thing I was going
to say was, ``Well, it doesn't really matter, because it will
be so long before it has any impact on me, positively or
negatively.'' But I think that it's a great--it was a very
thought provoking question. I think all of us reflected on all
the questions that you asked for the testimony. But I'm not--
there are many people who are directly engaged.
I'm not a commercial, off-the-shelf deployer of technology,
so I look to my vendor to have the standards or whatever. And
the inter-operability that they're working on, I don't know if
it's going to have a positive impact or not.
I don't know if it's well directed or not. I just know that
day in and day out, we have serious concerns.
I do want to make one positive comment about the point that
Mike Leahy made. One of the things that they have addressed
sort of in trying to get all these systems together is not
doing that through inter-operability but actually one single
database. And we are working on integrating that large database
with ours, but a lot of the efforts around inter-operability, I
don't know if they're correctly addressed. I think there would
be a lot more input from providers to see if HHS is moving in
the right direction.
Dr. Pettit. Do you have time for one more comment.
Mr. Reichert. Yes. Go ahead.
Dr. Pettit. I think I've been criticized as being an
idealist at times, but when you think about how you spend your
energy and what you're working towards, you want to make sure
you're working towards something that is really going to change
the way we do things. And to avoid all this redundancy, I still
believe you have to work towards a unified--and that doesn't
mean a single, but a unified collection of information about a
single person, that is accessible and controllable by them.
I think an analogy in this case might help. Because our
world is changing and we--let's say, for example, you go to a
class reunion and you take pictures with your digital camera.
And now you've got a picture of each of your 150 classmates and
you have given them your e-mail address. And you go back home
and you get e-mails from all of your friends, saying, ``Hey,
could you send me that picture that you took?'' Instead, how
about if I have--we have sort of a shared workspace. You've
probably dealt with some of those shares--Ofoto, Shutterfly,
Snapfish--all of these different services, where you can post
your photos and then you're out of the loop and they can get
what they want when they want, and you don't have to respond
all the time.
So I think shared workspace is kind of analogous to a
shared chart. I mean, right now in this hospital, we use a
shared chart. If you're--every inpatient here has a single
chart, and if you want to know what the pulmonologist thinks or
the cardiologist thinks or the home health person thinks, you
read the chart, because it's--you have this singular sort of
point of contact. And so we don't have that in the outpatient
setting.
I think that there's absolutely a place for the work that
both of these gentleman do. I mean, there's always going to be
a need for encryption and sending information in a safe,
unidentifiable way. And some of the--some of the models that
are being promoted, the (unintelligible) models, include that
sort of point-to-point contact--I think the Markel model, for
example.
Anyway, I could--I'm sort of going off. But I just want to
say I think there's room for all of us in this workspace. I
mean, there's so much to be done and there's room for all of
our work.
Mr. Reichert. Thank you. Dr. Jeffrey was going to respond
to this question, and Mr. Wu has another follow-up question or
two, and then we'll conclude.
Dr. Jeffrey. A quick answer to the first part of the
question, which is, basically, ``is better the enemy of good
enough,'' on that.
One of the purposes of Secretary Leavitt's setting up the
American Health Information Community, which was actually to
get the representatives from the community, including not--it's
not just government, but private sector at all phases of the
health care industry, in there to help set the priorities, to
help identify some of these issues. And so I think that's a
very important mechanism by which people in this room and
others can interface and make sure that we're getting a good
enough solution and not waiting for perfection. So I applaud
Health and Human Services for that.
In terms of what is NIST doing specifically, since the
September '05, so now just about six months into the memorandum
of the agreement. We're working on several specific issues that
have been identified as potential impediments. And one of them
has been mentioned already, that physicians can't
electronically share information, and it's both internally and
externally across that. And so that's where all of the usual
things that NIST does--the standards, the conformance,
harmonization between different standard setting
organizations--so that you don't have to worry about which one
your vendor picked, so that all the vendors will work together.
Those are important areas that we're working on, and that's
something that's sort of our bread and butter.
The second is something that we haven't yet mentioned yet
today, which is the issue on medical terminologies. There are
inconsistencies and ambiguities in the way that some of the
medical terminologies are recorded, and that's actually a very
hard problem in getting that consistency. So it's, essentially,
not just a thesaurus and a dictionary equivalent, but it's
functionally getting the equivalent.
And you don't want all of the--again, in terms of training,
you don't want every clinician to have to be forced to a very
specific set of terms. And so one of the things that we're
working on is a program to automatically identify ambiguities,
cross-correlations, and the like, that would eventually be able
to band into that. And, obviously, we talked a lot about
securing privacy. And we're supporting Dr. Brailer in a lot of
the programs that he's put together and the contractors that
he's put forward to ensure that a lot of the security and
privacy features are being incorporated in the validation of
those.
Mr. Reichert. Mr. Wu.
HIPAA
Mr. Wu. Thank you very much, Dr. Jeffrey.
I just wanted to assure our previous commentator that the
issues of privacy and security are not at all ignored by those
of us in Congress, or I doubt that they are ignored by anyone
on this panel.
I did want to follow up on that, because--besides the
incident that we all know about here in the Portland Metro Area
about loss of records, Consumer Reports this month also ran an
article on some of the hazards of electronic health records.
And Consumer Reports was actually quite critical of HIPAA for
being inadequately protective of patient records, primarily
because of the potential for sending health care information to
health care affiliates.
You all have talked about changing the Stark Law, doing a
couple of other things. I'd be very interested in your views on
the concerns about HIPAA, any potential loopholes.
My understanding is that HIPAA is actually much less
protective of American patients than, say, European law is,
European privacy. At least that's been the assertion. I'd be
interested in your comments about consumer and patient
protection and privacy.
Mr. Machuca. Well, I would start by--make sure everybody
understands that paper is not the stalwart of security and
everybody let's just stay on paper because it's secure, kidding
themselves every time something goes in a fax machine.
Mr. Wu. Well, the thing is that it's inconvenient to look
in all those files.
Mr. Machuca. Right.
Mr. Wu. And the inconvenience is--it's like inefficiency in
the Federal Government, it guarantees our liberties.
Mr. Machuca. And that's true as long as the paper stays in
the chart.
Mr. Wu. That's right.
Mr. Machuca. But the moment it gets in a fax machine, you
have no idea what's at the other end.
Mr. Wu. That's right.
Mr. Machuca. And that--And let me say also for the record,
and I don't have a precise number of this, but we have, in a
little bit over three years, tens of thousands of clinicians
sending secure electronic e-mail--which, actually, Providence
doesn't get enough credit for this.
They were the first provider to provide secure, encrypted
e-mail, in the Greater Northwest, which is now followed by
everybody, and I echo your point.
But in millions and millions of e-mails--and we don't have
a precise count--we have yet to have a single incidence of any
kind of a problem along those lines. So we take this issue
very, very seriously, but we reject the notion that people
should be afraid and use privacy and security as the reason to
not implement technology. That--I think it's going away, but it
has been resonant in the early days. And so I think the
technology is absolutely there to ensure, far beyond paper and
far beyond anything we have, with very low cost means, absolute
privacy and security, provided, of course, that there's the
will in the organization to implement it.
I'll say one more thing on this topic. Sometimes we trip
over the pedestrian to look at the big thing with the shiny
lights. I got the call from your staff about testifying, and we
had our meeting. And immediately, within hours, I had two e-
mails from your staff, one with a full charter of the hearing
and another one with an attached Power Point of the work
between NIST, ONC, and the other organizations. I had that on
my desktop. I took off, I started preparing. I left for San
Diego. I came back on Thursday of last week. On my regular mail
was the letter inviting me to the hearing, with the charter--no
presentation on what NIST is doing.
So had I gone to--had I lived in that system, where I
reject the use of e-mail for business productive use, I would
have prepared--I would start preparing for this hearing on
Friday of this week, probably ruined my weekend, and it would
have been an entirely different situation, than the context and
the information being readily available.
And when you asked--I think you asked a very, very profound
question. I don't think we've really given you a sharp, crisp
answer. If you wanted to hang on to one thing that could
modernize the system tomorrow and make a quantum leap--not
solve all the problems that we have, but do the quantum leap--
look at the physician use of e-mail in the routine part of
their practice. And that, in and of itself, as every other
industry would suggest, and as your own, I would bet,
experience in your daily work flow would suggest, could move
that step forward. That first little baby step would give you a
tremendous amount of benefit. So I would leave that as my
comment on that.
Dr. Chin. I would just say that it's a very, very complex
area. You know, Kaiser Permanente does take privacy very
seriously and we do monitor access to the medical record, and
we've had to let people go in some cases because of breaches of
privacy. So we do take it very seriously.
But it is a very complex question, and I think the only
solution to this would be to give individuals control over
their medical information and somehow say, ``Okay. You can see
this, you can't see this; you can see this, you can't see
this.'' And one of the reasons why there is this issue with
privacy in the United States is precisely because of payment
mechanisms: In order for payers to pay, they need to know what
they're paying for; and because of that, there are issues where
payers can see information that otherwise would be private in
other organizations. And that's one of the key reasons why
there is this issue with HIPAA and the lack of security around
HIPAA.
Dr. Pettit. You bring up a very good point about--and
someone had mentioned to me last week at HIMSS about how people
are compelled to share their information, whether they really
want to or not; because if they don't, they don't get services.
And it's like we all have done on the Internet, where you sign
that EULA, the end-user's licensing agreement, that you don't
want to sign because you can't read it, but you scroll through
it and you hit ``agree,'' even though you have no idea what you
just signed. And there are some analogies to that in health
care. Because you come into the emergency department and you
sign because you want service or--and if you want a health plan
to cover you, you sign what you need to sign. But I really do
believe that the American public has no idea how many people
see their information; and I think when they do find out, that
there's going to be some change.
Mr. Reichert. Now they all know.
Mr. Urali. I tend to take privacy and security very
seriously. In fact, we came up with a tag line, ``Trust is
Earned,'' to indicate that we take it very seriously, and
through our actions we will show that we will honor the trust
of the public in how we approach it.
It fundamentally boils down to a central principle we have,
which is the part of the network that we make it available is
only accessible to the clinicians; and so right there, we are
restricting access to information, even in the community
setting. And then we give hundred percent opt-out capability
for any patient that has not consented. So I can say I don't
want to be part of the network, and hence none of my data will
be electronically shared.
The problem with having patients decide which piece of
information that they want to share or which piece they don't
want to share is that they can make very serious mistakes. None
of us are experts at health care. We've talked to literally
hundreds of doctors, and they say a certain psychiatric
condition may be important even for treating the foot. And it's
not something that I can personally understand, but we've had
those types of conversations. So having nonsophisticated
patients making decisions as to which medication information
they will share, or which problem they will share, and who's
the physician--that is going to build a very complicated
system.
I think we're all looking for simple systems that work. If
you think about your banking system, the ATM card, you know,
how simpler could it get? I just get a card, I can go into a
machine, put it in, I put a four-digit PIN code and I can get
my money out. That is a simple system. That system works. Of
course we can't use the banking standards for health care data.
We have to come up with a lot more security and privacy
solutions; but at the same time, we can make it so difficult
that the system doesn't actually work.
Mr. Reichert. Go ahead.
Mr. Urali. So in our model, the first step we took is
restrict data access to only clinicians. We saw some survey
that said more than 95 percent of patients trust their primary
care provider and their doctors, you know, to do the right
things in terms of protecting their privacy.
Mr. Reichert. The Chair will recognize Mr. Wu for the final
question.
Mr. Wu. Mr. Chairman, I think that, given the tremendous
forbearance and attention of both--well, all of our guests and
panelists here, I'm going to forego this last question, because
there are--there's never a last question; there's just so many
more to ask.
I'll just take a moment to thank--Mr. Reichert, you, and I
always get the honor of being the talking face and being in
front of the microphone; but there are many, many people who
work very hard to make these things happen, and work behind the
scenes.
And first and foremost, I want to thank Marshall Jeffrey
from our office, who has taken the lead in organizing this
field hearing today.
From the Science Committee staff, the majority side, Jamie
Brown has really done heroic work. And supervising Jamie's work
is Olwen Huxley. On the minority staff, Mike Quear. Thank you,
all, for making the long trip from Washington, D.C. and our
Science Committee.
Staffers Stella Ma, who has also worked very, very hard on
this, along with Dan Whelan and John Wykoff of our district
staff. And I'd also like to recognize Kevin from the NIST
congressional liaison office, who was so helpful with
information about Dr. Jeffrey. Ralph Hall's Legislative
Director who has joined us from Texas and Washington, D.C., and
Chairman--Mr. Chairman, I believe that your district director
is also here today.
Mr. Reichert. My deputy district director, Sue Foy.
Mr. Wu. And I want to thank you all for attending. And I
thank the staff for their very, very hard work to bring this
together. As we all know, for every person who's in front of
the microphones, there are probably five or ten people who are
behind the microphones or behind the camera, making the system
work.
And with that, Mr. Chairman, I yield back to you for a
closing.
Mr. Reichert. Thank you, Mr. Wu.
Well, it's been a pleasure being here this afternoon. We
have a little bit of a drive back now to Seattle, and I'm also
on the Transportation Committee, and so we'll have a chance to
have firsthand experience with the commute between Portland and
Seattle, which I've experienced in the past. Today will be
special.
I just, too, want to echo the words shared by Mr. Wu.
All of you in the audience, thank you so much for
everything that you do. And the panelists, thank you for being
here. I know it's not just appearing for two or two and a half
hours, responding to questions and giving testimony, but there
is preparation time. And, fortunately, you were fully informed
with the e-mail service and better able to prepare.
One of the things that I think that a forum like this
provides, certainly for those of us who can't--some who can't
travel back and forth to Washington, D.C., and attend a forum
like this, you kind of get a flavor for what it's like back in
D.C. and how business is sort of conducted. It can be a little
bit awkward and formal, I'm discovering. But it also, I think,
more importantly, provides an opportunity for all of us to
visit, person to person, to have a discussion, to interact with
each other on a personal level and to hear from people who are
involved every day in trying to solve our health care IT
problems.
And so, you know, when you talk about e-mail and you talk
about IT and you talk about the changing world that we're
living in, you know, a year ago, I used to reach and I would
have my badge. Now I have a--this is, yeah, I'm stuck with this
Blackberry, but----
Mr. Wu. It will respond to all functions.
Mr. Reichert. Right. I think it has a ``beam me up'' button
on it.
Mr. Wu. Right.
Mr. Reichert. The point I want to make here is that--and
Dr. Pettit, you know, I appreciate your comments on the
personal issue. Because doctors can look at a record, you can
read the record--and I was wondering, and somebody did mention,
I think--Doctor, I think you mentioned the inconsistency of
recording data and information. And so as you read data and
information, as you read e-mails and you don't know what you're
signing and the data is inconsistent, there is this importance
for us to interact as human beings; we can never let that go.
And so I just want to leave us with that thought. We all have
that access to e-mails and technology; but, please, never
hesitate to pick up the telephone or walk down the hallway and
knock on someone's door and have a little visit with someone.
So there's a closing statement I need to read. Before we
bring the hearing to a close, again I want to thank everyone
for being here. This has been highly educational, and our
witnesses have given this committee a lot to consider about the
potential role of information technology in the health care
industry.
And if there is no objection, the record will remain open
for additional statements from other Members and for answers to
any follow-up questions the Committee may ask of the witnesses.
Without objection, so ordered. The hearing is now
adjourned. Thank you.
[Whereupon, at 2:32 p.m., the Subcommittee was adjourned.]
Appendix:
----------
Additional Material for the Record