[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]

IS ``MEANINGFUL USE'' DELIVERING MEANINGFUL
RESULTS?: AN EXAMINATION OF HEALTH
INFORMATION TECHNOLOGY STANDARDS AND INTEROPERABILITY

=======================================================================

HEARING

BEFORE THE

SUBCOMMITTEE ON TECHNOLOGY AND INNOVATION

COMMITTEE ON SCIENCE, SPACE, AND TECHNOLOGY
HOUSE OF REPRESENTATIVES

ONE HUNDRED TWELFTH CONGRESS

SECOND SESSION

__________

WEDNESDAY, NOVEMBER 14, 2012

__________

Serial No. 112-105

__________

Printed for the use of the Committee on Science, Space, and Technology

Available via the World Wide Web: http://science.house.gov

U.S. GOVERNMENT PRINTING OFFICE
77-035 WASHINGTON : 2012
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing Office,
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center, U.S. Government Printing Office. Phone 202�09512�091800, or 866�09512�091800 (toll-free). E-mail, gpo@custhelp.com.

COMMITTEE ON SCIENCE, SPACE, AND TECHNOLOGY

HON. RALPH M. HALL, Texas, Chair
F. JAMES SENSENBRENNER, JR., EDDIE BERNICE JOHNSON, Texas
Wisconsin JERRY F. COSTELLO, Illinois
LAMAR S. SMITH, Texas LYNN C. WOOLSEY, California
DANA ROHRABACHER, California ZOE LOFGREN, California
ROSCOE G. BARTLETT, Maryland BRAD MILLER, North Carolina
FRANK D. LUCAS, Oklahoma DANIEL LIPINSKI, Illinois
JUDY BIGGERT, Illinois DONNA F. EDWARDS, Maryland
W. TODD AKIN, Missouri BEN R. LUJAN, New Mexico
RANDY NEUGEBAUER, Texas PAUL D. TONKO, New York
MICHAEL T. McCAUL, Texas JERRY McNERNEY, California
PAUL C. BROUN, Georgia TERRI A. SEWELL, Alabama
SANDY ADAMS, Florida FREDERICA S. WILSON, Florida
BENJAMIN QUAYLE, Arizona HANSEN CLARKE, Michigan
CHARLES J. ``CHUCK'' FLEISCHMANN, SUZANNE BONAMICI, Oregon
Tennessee
E. SCOTT RIGELL, Virginia
STEVEN M. PALAZZO, Mississippi
MO BROOKS, Alabama
ANDY HARRIS, Maryland
RANDY HULTGREN, Illinois
CHIP CRAVAACK, Minnesota
LARRY BUCSHON, Indiana
DAN BENISHEK, Michigan
VACANCY
------

Subcommittee on Technology and Innovation

HON. BENJAMIN QUAYLE, Arizona, Chair
LAMAR S. SMITH, Texas DONNA F. EDWARDS, Maryland
JUDY BIGGERT, Illinois FREDERICA S. WILSON, Florida
RANDY NEUGEBAUER, Texas DANIEL LIPINSKI, Illinois
MICHAEL T. McCAUL, Texas BEN R. LUJAN, New Mexico
CHARLES J. ``CHUCK'' FLEISCHMANN, SUZANNE BONAMICI, Oregon
Tennessee VACANCY
E. SCOTT RIGELL, Virginia VACANCY
RANDY HULTGREN, Illinois VACANCY
CHIP CRAVAACK, Minnesota EDDIE BERNICE JOHNSON, Texas
RALPH M. HALL, Texas

C O N T E N T S

Wednesday, November 14, 2012

Page
Witness List..................................................... 2

Hearing Charter.................................................. 3

Opening Statements

Statement by Representative Benjamin Quayle, Chairman,
Subcommittee on Technology and Innovation, Committee on
Science, Space, and Technology, U.S. House of Representatives.. 9
Written Statement............................................ 10

Statement by Representative Hansen Clarke, Acting Ranking
Minority Member, Subcommittee on Technology and Innovation,
Committee on Science, Space, and Technology, U.S. House of
Representatives................................................ 12
Written Statement............................................ 12

Witnesses:

Dr. Farzad Mostashari, National Coordinator for Health
Information Technology, The Office of the National Coordinator
for Health Information Technology
Oral Statement............................................... 14
Written Statement............................................ 17

Dr. Charles H. Romine, Director, Information Technology
Laboratory, National Institute of Standards and Technology
Oral Statement............................................... 30
Written Statement............................................ 32

Mr. Marc Probst, Chief Information Officer and Vice President,
Information Systems,
Oral Statement............................................... 41
Written Statement............................................ 43

Ms. Rebecca Little, Senior Vice President, Medicity
Oral Statement............................................... 53
Written Statement............................................ 55

Dr. Willa Fields, DNSc, RN, FHIMSS, Professor, School of Nursing,
San Diego State University
Oral Statement............................................... 59
Written Statement............................................ 61

Appendix I: Answers to Post-Hearing Questions

Dr. Farzad Mostashari, National Coordinator for Health
Information Technology, The Office of the National Coordinator
for Health Information Technology.............................. 114

Dr. Charles H. Romine, Director, Information Technology
Laboratory, National Institute of Standards and Technology..... 119

Mr. Marc Probst, Chief Information Officer and Vice President,
Information Systems, Intermountain Healthcare.................. 122

Ms. Rebecca Little, Senior Vice President, Medicity.............. 125

Dr. Willa Fields, DNSc, RN, FHIMSS, Professor, School of Nursing,
San Diego State University..................................... 128

IS ``MEANINGFUL USE'' DELIVERING MEANINGFUL RESULTS?:
AN EXAMINATION OF HEALTH INFORMATION
TECHNOLOGY STANDARDS AND INTEROPERABILITY

----------

WEDNESDAY, NOVEMBER 14, 2012

House of Representatives,
Subcommittee on Technology and Innovation,
Committee on Science, Space, and Technology,
Washington, D.C.

The Subcommittee met, pursuant to call, at 10 a.m., in Room
2318, Rayburn House Office Building, Hon. Benjamin Quayle
[Chairman of the Subcommittee] presiding.

[GRAPHIC] [TIFF OMITTED] T7035.001

[GRAPHIC] [TIFF OMITTED] T7035.002

[GRAPHIC] [TIFF OMITTED] T7035.003

[GRAPHIC] [TIFF OMITTED] T7035.004

[GRAPHIC] [TIFF OMITTED] T7035.005

[GRAPHIC] [TIFF OMITTED] T7035.006

[GRAPHIC] [TIFF OMITTED] T7035.007

Chairman Quayle. The Subcommittee on Technology and
Innovation will come to order. Good morning. Welcome to today's
hearing entitled ``Is `Meaningful Use' Delivering Meaningful
Results?: An Examination of Health Information Technology
Standards and Interoperability.''
In front of you are packets containing the written
testimony, biographies, and truth-in-testimony disclosures for
today's witnesses.
I now recognize myself for five minutes for an opening
statement.
Throughout this Congress our Subcommittee has been focused
on advancing U.S. innovation in a constrained budget
environment. We held hearings on cloud computing, start-up
companies, standards development, spectrum R&D, manufacturing,
and innovation policies. Today's discussion is a continuation
of this conversation.
This is also the fourth hearing the Committee on Science,
Space, and Technology has held on health information technology
standards since the 109th Congress.
Effective utilization of information technology in the
medical field has the potential to fundamentally change health
care in our country. Application of health IT could lower
healthcare costs by reducing duplicative and unnecessary tests
and procedures. It could also lead to more effective care by
helping to reduce medical errors and could help to improve
public health outcomes by aiding in clinical decision making.
Given the strain of rising healthcare costs on our budget
and the diverse array of healthcare providers, information
technology will be a critical component of our future
healthcare system. However, while information technology has
become pervasive in our everyday lives, the healthcare industry
has historically been slow to effectively deploy IT.
In 2004, President Bush signed an Executive Order
establishing the Office of the National Coordinator for Health
Information Technology, or the ONC, within the Department of
Health and Human Services to develop, maintain, and direct a
strategic plan to guide the nationwide implementation of health
IT in the public and private healthcare sectors.
The National Institute of Standards and Technology has
worked with industry and other stakeholders to advance
healthcare information technology infrastructure since the
early 1990s.
In 2009, the HITECH Act was passed as part of the American
Recovery and Reinvestment Act to promote the adoption of health
IT products, services, and infrastructure through a series of
discretionary and mandatory funding programs. This legislation
included $2 billion in discretionary funds for the ONC to
invest in health IT architecture and to provide grants and
training programs to encourage health IT adoption.
Furthermore, the legislation provided financial incentives
in the form of mandatory payments through the Medicare and
Medicaid programs to encourage physicians and hospitals to
adopt and use certified electronic health records, or EHRs. To
date, incentive payments under these programs have totaled over
$7.7 billion. It is estimated that CMS will pay out
approximately $20 billion in incentive payments to providers
under this program.
This is a significant Federal expenditure. Given our
current budget situation, it is vital that these taxpayer
dollars are spent effectively in ways that lead to reduced
costs and better health care down the road. Nearly four years
after the HITECH Act, taxpayers should know what we have to
show for it.
While adoption of health IT products and services has
increased since the passage of the HITECH Act, I have serious
concerns about our progress towards greater interoperability of
health IT systems. Without interoperability many of the
potential benefits of health IT could go unrealized.
Interoperability depends on the development and utilization
of strong technical standards. I am interested in hearing from
our witnesses about progress being made towards the development
of these standards and what policy makers can do to advance
interoperability.
Further, I am concerned that the meaningful use
requirements do not effectively take into account the
complexity and diversity of the healthcare marketplace. It is
crucially important that health IT is used to improve care
without burdening certain providers with requirements that
divert valuable time and resources.
Clearly there are key questions that must be answered to
ensure that taxpayer dollars are spent wisely and to ensure
that IT in the healthcare industry is used to reduce costs and
improve care.
We thank all of our witnesses for being here today, and we
look forward to your testimony.
[The prepared statement of Chairman Quayle follows:]

Prepared Statement of Subcommitte Chairman Dan Quayle

Good morning, I'd like to welcome everyone to today's hearing,
which is being held to examine the development of health information
technology interoperable standards, and the implementation of the
Health Information Technology for Economic and Clinical Health Act,
more commonly known as the HITECH Act.
Throughout this Congress, our Subcommittee has been focused on
advancing U.S. innovation in a constrained budget environment. We held
hearings on cloud computing, startup companies, standards development,
spectrum R&D, manufacturing, and innovation policies. Today's
discussion is a continuation of this conversation.
This is also the fourth hearing the Committee on Science, Space,
and Technology has held on health information technology standards
since the 109th Congress.
Effective utilization of information technology in the medical
field has the potential to fundamentally change healthcare in our
country. Application of health IT could lower health care costs by
reducing duplicative and unnecessary tests and procedures. It could
also lead to more effective care by helping to reduce medical errors
and could help to improve public health outcomes by aiding in clinical
decision making.
Given the strain of rising health care costs on our budget and the
diverse array of healthcare providers, information technology will be a
critical component of our future healthcare system. However, while
information technology has become pervasive in our everyday lives, the
healthcare industry has historically been slow to effectively deploy
IT.
In 2004, President Bush signed an executive order establishing the
Office of the National Coordinator for Health Information Technology
or, the ONC, within the Department of Health and Human Services to
develop, maintain, and direct a strategic plan to guide the nationwide
implementation of health IT in the public and private health care
sectors.
The National Institute of Standards and Technology has worked with
industry and other stakeholders to advance healthcare information
technology infrastructure since the early 1990s.
In 2009, the HITECH Act was passed, as part of the American
Recovery and Reinvestment Act, to promote the adoption of health IT
products, services, and infrastructure through a series of
discretionary and mandatory funding programs.
This legislation included $2 billion in discretionary funds for the
ONC to invest in health IT architecture, and to provide grants and
training programs to encourage health IT adoption.
Furthermore, the legislation provided financial incentives in the
form of mandatory payments through the Medicare and Medicaid programs
to encourage physicians and hospitals to adopt and use certified
electronic health records, or EHRs.
To date, incentive payments under these programs have totaled over
$7.7 billion. It is estimated that CMS will pay out approximately $20
billion in incentive payments to providers under this program.
This is a significant Federal expenditure. Given our current budget
situation, it is vital that these taxpayer dollars are spent
effectively in ways that lead to reduced costs and better health care
down the road. Nearly four years after the HITECH Act, taxpayers should
know what we have to show for it.
While adoption of health IT products and services has increased
since the passage of the HITECH Act, I have serious concerns about our
progress towards greater interoperability of health IT systems. Without
interoperability, many of the potential benefits of health IT could go
unrealized.
Interoperability depends on the development and utilization of
strong, technical standards. I am interested in hearing from our
witnesses about progress being made towards the development of these
standards, and what policy makers can do to advance interoperability.
Further, I am concerned that the meaningful use requirements do not
effectively take into account the complexity and diversity of the
healthcare marketplace. It is crucially important that health IT is
used to improve care without burdening certain providers with
requirements that divert valuable time and resources.
Clearly, there are key questions that must be answered to ensure
that taxpayer dollars are spent wisely, and to ensure that IT in the
healthcare industry is used to reduce costs and improve care.
We thank our witnesses for being here today and we look forward to
your testimony.
Chairman Quayle. I now recognize the gentleman from
Michigan Mr. Clarke for his opening statement.
Mr. Clarke. Thank you, Mr. Chair.
First of all, I would like to say, as someone who will not
be returning to Congress, it has been an honor to serve with
you. I also appreciate your diligence on examining this
important need that we have, which is to make sure that we have
electronic health records shared in a way that all physicians
and healthcare providers will be able to exchange this
information.
The Chair laid out the benefits of health IT in terms of
the money that could be saved by eliminating duplicative
testing, and also how health IT could help improve the quality
of health care, especially with diabetics. There have been
studies that have shown that when electronic health records are
used, diabetic patients are able to manage their disease more
effectively.
Now, the Chair mentioned his concern about the value of the
incentives payments, and I acknowledge that, you know, our goal
is to spend approximately $20 billion, I believe, by 2015 on
these incentive payments. I think they are absolutely critical,
because if you look at the fact that most Americans get their
primary care from offices that have five or fewer physicians,
these small offices, they don't have the money or the resources
to be able to set up a health IT system, especially when those
physicians may not be sure if that system is going to really
work in an interoperable way or if it could become obsolete in
a short period of time. So I believe it is critical for us to
move forward on the full implementation of this platform.
I look forward to speaking to the National Coordinator
about his work with NIST since the HITECH Act directs a
partnership--or I should say that this rule that we are now
reviewing establishes a partnership which could help further
develop a health IT platform that could result in the
interoperability of electronic health records.
My one closing statement is this, is that even though this
area is complex, because the healthcare industry is complex and
health IT itself is complex, being able to have these records
in an electronic form that could be shared can make a
difference. Two months ago my first cousin, the closest blood
relative I have here in this country, who is younger than me,
passed away. She suffered organ failure, and I believe that a
combination of prescription drugs may have been a contributing
factor to that. It is likely that with these electronic health
records we would be able to identify that type of prescription
drug interaction before it happens.
So with that, I yield back the balance of my time.
Chairman Quayle. Thank you, Mr. Clarke.
[The prepared statement of Mr. Clarke follows:]

Prepared Statement of Subcommittee Acting Ranking Member Hansen Clarke

Thank you, Mr. Chairman for calling this hearing on health
information technology. Before I begin my opening statement, I'd like
to take a moment to recognize Chairman Quayle for his leadership on the
Subcommittee. It has been a pleasure working with you to address a wide
range of issues. I thank you for your service to the Subcommittee and
Congress and wish you the best in your future endeavors.
Today's hearing is fitting as just a few months ago the
requirements for the second stage in the ``meaningful use'' of
electronic health record technologies were announced by the Department
of Health and Human Services. This morning's hearing provides us with
the perfect opportunity to examine the progress we've made to date and
to discuss what needs to happen in the future to increase the use of
information technology in the healthcare industry.
Over the past 20 years, we have experienced a dramatic change in
the way we share information. Nearly every sector across our economy,
from financial services to entertainment to manufacturing, has embraced
information technology and used it to increase productivity and
quality. Yet the healthcare industry has lagged far behind with many
physicians and healthcare providers keeping track of our medical
information the same way they were 50 years ago.
The use of electronic health records--or EHRs--has real-world
implications for the cost and quality of health care. Right now, a
physician may order a duplicative test because previous test results
from another hospital or doctor are not readily at hand, or they may
miss a harmful drug interaction because a patient's full medication
list is not available and the patient is not in a condition to provide
that information.
Increasing the adoption and use of health IT could help prevent
some of the medical errors that injure at least 1.5 million Americans
each year and lead to an estimated 98,000 deaths annually. For example,
a study of a medical center in Arizona found that the use of EHRs
reduced prescription errors by 88 percent and in a Florida health
system the use of electronic reminders decreased the number of patient
charts that were missing allergy information from 36 percent to 11
percent.
Studies have also shown that the use of EHRs has helped diabetic
patients manage their disease more effectively--lowering their blood
pressure, cholesterol, and glucose levels. In addition to improving the
quality of care and health outcomes, estimates have shown that a fully
interoperable health IT system could save the United States billions of
dollars in health care costs each year.
Given the complexity of our healthcare system, the task charged to
the Office of the National Coordinator by the HITECH Act to promote the
development of a national health IT infrastructure that allows for the
electronic use and exchange of information is a difficult one. However,
in the two years since the Subcommittee last examined this topic, the
National Coordinator, by all accounts, has done an admirable job
meeting tight deadlines and navigating the needs of various
stakeholders. NIST has also played an important role by lending to HHS
its extensive expertise in standards, testing, and certification.
Still, there are a number of factors that have contributed to the
slow adoption of health IT such as the availability of a qualified
workforce or privacy and security concerns. I believe a key barrier to
adoption has been the lack of technical standards to support
interoperability. In order for the full potential of health IT to be
realized, adoption and implementation of EHRs must increase and true
interoperability -meaning the seamless exchange of health information
across vendors and providers must be achieved. Most Americans get their
primary health care at offices with five or fewer doctors. These small
offices are hesitant to take on the considerable expense of a health IT
system that may not work with the system of a neighboring healthcare
provider or may become prematurely obsolete.
However, I am encouraged by the criteria and standards included in
the final rule for Meaningful Use Stage 2 released in August and hope
to gain some insight from today's witnesses about the implementation of
Stage 2. As I understand it, Stage 2 focuses on the challenge of
interoperability in a number of ways. First, it defines a common
dataset, including vital signs, medications, and discharge instructions
that must be a part of a patient's summary of care record. Next, it
details the standards and specifications necessary for the exchange of
typical, but important medical information like laboratory results,
immunizations, and electronic prescriptions. And maybe most
importantly, Stage 2 creates a partnership between the Office of the
National Coordinator and NIST in the development of a rigorous
interoperability testing platform. Such a platform will ensure that
once a physician or healthcare provider has adopted a certified EHR
technology they will be able to send, receive, and use this critical
health information.
However, as I am sure we will discuss today, we still have a ways
to go in promoting interoperability, coordinating the numerous health
IT projects that are underway, and implementing best practices to
address privacy and security concerns.
The widespread use of health IT is imperative for lowering costs
and improving patient care, and I look forward to hearing from our
witnesses about how we can successfully meet the challenges ahead.
Thank you, again, Mr. Chairman, for calling this important hearing
and I yield back the balance of my time.
Chairman Quayle. I now recognize the gentleman from Texas,
Mr. Smith, for his opening statement.
Mr. Smith. Thank you, Mr. Chairman. I do not have an
opening statement, but I did not want it to go unnoticed that
this might be your last hearing that you chair, and I just
wanted to say that all of us who have been associated with you,
whether it be on committees, and in this case you and I serve
on two committees together, that all those who have known you
and worked with you appreciate your service to the
Subcommittee, the full Committee, the Congress, and our
country, and I thank you for that.
Chairman Quayle. Thank you very much. Those are probably
the most important words of this whole hearing today. I thank
the gentleman for those kind remarks.
And I want to thank Mr. Clarke for his opening statement.
If there are Members who wish to submit additional opening
statements, your statements will be added to the record at this
point.
Chairman Quayle. At this time I would like to introduce our
witnesses, and we will proceed to hear from each of them in
order. Our first witness is Dr. Farzad Mostashari, National
Coordinator for Health Information Technology at the United
States Department of Health and Human Services.
Next we will hear from Dr. Charles H. Romine, Director of
the Information Technology Laboratory at the National Institute
of Standards and Technology.
Our third witness is Mr. Marc Probst, Chief Information
Officer and Vice President of Information Systems at
Intermountain Healthcare.
Our fourth witness is Ms. Rebecca Little, Senior Vice
President of Medicity.
Our final witness is Dr. Willa Fields, Professor of Nursing
at San Diego State University and Chair of the Board of
Directors of the Healthcare Information and Management Systems
Society. Thank you all for being here today.
As our witnesses should know, spoken testimony is limited
to five minutes each. After all witnesses have spoken, members
of the Committee will have five minutes each to ask questions.
I now recognize our first witness Dr. Mostashari for five
minutes.

STATEMENT OF DR. FARZAD MOSTASHARI,

NATIONAL COORDINATOR FOR HEALTH INFORMATION

TECHNOLOGY, THE OFFICE OF THE NATIONAL COORDINATOR

FOR HEALTH INFORMATION TECHNOLOGY

Dr. Mostashari. Chairman Quayle, Ranking Member Clarke,
distinguished Subcommittee Members, thank you for the
opportunity to appear today on behalf of the Department of
Health and Human Services. I am Dr. Farzad Mostashari. I am the
National Coordinator for Health IT.
I am delighted to be here today to tell you about the
remarkable progress in health IT the country has made in the
relatively short time since HITECH's passage. Under HITECH,
eligible professionals and hospitals can qualify for incentive
payments from the Centers for Medicare and Medicaid Services
when they adopt and meaningfully use certified EHR technology
as defined by ONC certification criteria and interoperability
standards.
HITECH also funded a number of other supporting activities,
such as 17 beacon communities, community college and
university-based workforce programs, and 62 regional extension
centers that provide hands-on technical assistance to providers
and hospitals transitioning away from paper.
HITECH is working. Between 2008 and 2011, the percentage of
office-based physicians adopting the EHR system has doubled,
and hospital adoption leaped almost threefold. As of September
2012, more than 300,000, or more than half of the Nation's
eligible professionals, as well as over 75 percent of eligible
hospitals have registered to participate in the incentive
programs. More than 154,000 eligible professionals and 3,000
hospitals have earned their first incentive payment.
Achieving meaningful use is meant to be hard, but
achievable. We need to strike a balance between the urgency of
modernizing our healthcare system and the pace of change that
can be absorbed by providers and IT vendors. Each stage of
meaningful use is designed to build increased functionality and
interoperability to improve patient care, enhance care
coordination in population health, increase patient and family
engagement, and protect patient privacy and security.
Recognizing that health IT is a complex and quickly
evolving field, HITECH established two Federal Advisory
Committees. The HIT Policy Committee Members are appointed by
the Comptroller General, the Secretary of Health and Human
Services, the Majority and Minority Leaders of the Senate, and
the Speaker and Minority Leader of the House of
Representatives. The HIT Standards Committee includes
providers, consumers, health plans, vendors, researchers, and
other stakeholders.
As HHS develops the rules for the incentive program, we
fully engage experts in the field, listening to both our
private- and public-sector stakeholders and actively soliciting
input through many mechanisms, including through the thousands
of comments received and reviewed in response to our Notices of
Proposed Rulemaking. One of the key messages we have heard time
and time again is that successful health IT implementation
relies on a predictable roadmap and adequate time.
In 2009, when we were drafting the initial set of
meaningful use criteria and required standards, our plans
necessarily responded to the reality we faced. Different vendor
products used different proprietary or local codes. There were
strong disagreements about how laboratory results or patient
summaries should be packaged. There was simply no consensus on
how the Internet could be used to securely send patient
information. So we took initial steps that put us on the road
to interoperability and focused Stage 1 on functionalities that
support the consistent electronic capture of data and its
effective use within practices.
Over the past two years, we worked with industry to
accelerate the painstaking work of building consensus on these
technical standards that were required. We provided an open,
trusted place where the diverse health IT community can come
together to work, developing and harmonizing the standards and
specifications they need to support interoperability.
Nearly 1,000 people, representing over 300 diverse
organizations, have participated in 1 of more than 10 priority
initiatives. As a result the Stage 2 rules, set to take effect
for hospitals in October 2013 and for eligible professionals in
January 2014, make substantial progress on standards-based care
coordination and health information exchange. For the first
time there is defined a common dataset to be sent securely
during transitions of care, upon hospital discharge, and to be
shared with the patients themselves. It is worth emphasizing
that patients will have the ability to securely access this
same information, download it or share it electronically with
other providers and caregivers as the need arises.
Our good colleagues at NIST continue to play a key role in
supporting the design, implementation, and maturation of the
ONC HIT Certification Program, including the accreditation of
testing laboratories and the test procedures and testing tools
and infrastructure used by them. ONC is working with NIST to
develop an interoperability testing platform for Stage 2 that
will rigorously test that the EHR technology can indeed send,
receive, and incorporate standardized data across vendor
boundaries. Any EHR technology that meets the demanding testing
requirements should be able to send and receive standardized
information with other certified EHRs.
In conclusion, our progress on the road to interoperability
has been steadfast. Working in an open and transparent process,
HHS has developed the meaningful use roadmap in stages to serve
as milestones toward the future. Stage 1 focused on gathering
structured data and basic EHR functionalities, including
privacy and security protections. With Stage 2, HHS is working
to improve care coordination and increase standards-based
health information exchange between providers and with
patients.
We anticipate that future rules will continue to advance
health IT capability and interoperability as the foundation for
better health and better care at lower cost. We look forward to
continuing to work with you to accomplish these goals, and I
would be happy to answer any questions you may have regarding
my testimony.
Chairman Quayle. Thank you very much.
[The prepared statement of Dr. Mostashari follows:]

[GRAPHIC] [TIFF OMITTED] T7035.008

[GRAPHIC] [TIFF OMITTED] T7035.009

[GRAPHIC] [TIFF OMITTED] T7035.010

[GRAPHIC] [TIFF OMITTED] T7035.011

[GRAPHIC] [TIFF OMITTED] T7035.012

[GRAPHIC] [TIFF OMITTED] T7035.013

[GRAPHIC] [TIFF OMITTED] T7035.014

[GRAPHIC] [TIFF OMITTED] T7035.015

[GRAPHIC] [TIFF OMITTED] T7035.016

[GRAPHIC] [TIFF OMITTED] T7035.017

[GRAPHIC] [TIFF OMITTED] T7035.018

[GRAPHIC] [TIFF OMITTED] T7035.019

[GRAPHIC] [TIFF OMITTED] T7035.020

Chairman Quayle. I now recognize Dr. Romine to present his
testimony.

STATEMENT OF DR. CHARLES H. ROMINE,

DIRECTOR, INFORMATION TECHNOLOGY LABORATORY,

NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

Dr. Romine. Chairman Quayle and Members of the
Subcommittee, I am Chuck Romine, Director of the Information
Technology Laboratory at the Department of Commerce's National
Institute of Standards and Technology. Thank you for the
opportunity to appear before you today to discuss our roles in
advancing the Administration's commitment to enabling
electronic health records and developing a nationwide health
information network that is reliable, usable, interoperable,
and secure.
NIST has been hard at work fulfilling the mandate of making
our Nation's healthcare system safer, more accessible, and more
affordable through the use of information technology. This
objective remains a priority for the Department of Commerce and
the Acting Secretary. Reaching our common goal of interoperable
EHRs will improve health care for all Americans.
Through direction in HITECH, NIST and ONC are collaborating
with industry, healthcare informatics-related standards
organizations, consortia, and government agencies to develop
consensus-based, complete and unambiguous standards, and to
build tools and prototypes to advance the adoption of IT in
health care. For future stages of meaningful use, NIST is
providing technical leadership in evolving standards for
interoperable EHRs as well as medical devices, genomics,
imaging, and text retrieval and analysis.
The Medicare and Medicaid EHR incentive programs are
successfully increasing the rate of adoption of health IT, thus
enabling the achievement of health and efficiency goals. The
program is designed in a staged approach, with each stage
providing more rigor in what is expected in a certified product
and in meaningful use. Stage 1 standards and criteria, for
example, set a baseline for electronic data capture and
information sharing and were specifically selected to be
achievable by the Nation's providers. Stage 2 takes the next
step by reducing the optionality found in Stage 1 and includes
new standards, including those for electronic health
information exchange between providers.
To support these changes, the 2014 edition EHR
certification criteria included new or updated requirements for
security, usability or safety-enhanced design, and
interoperability.
Each stage of meaningful use advances interoperability.
NIST has developed a conformance test tool that will be used
for the certification and testing program for the 2014
standards and certification criteria that will also be an
initial tool in a test bed that simulates exchange between a
test EHR technology and a standards-compliant EHR technology.
This will eventually allow for all levels of interoperability
to be assessed in the electronic exchange of transition-of-care
and referral summaries. This capability will also provide a
platform for testing more comprehensive forms of
interoperability between EHR technologies.
The HITECH Act calls for ONC, in consultation with NIST, to
recognize a program for the voluntary certification of health
IT as being in compliance with certification criteria for EHR
technology that can support meaningful use requirements. Under
this program testing organizations authorized by ONC, use the
NIST test methods and tools to evaluate EHR systems so
healthcare providers have confidence in the systems they
purchase. NIST's National Voluntary Laboratory Accreditation
Program has been acknowledged by ONC in regulation, as the
accreditation body for private-sector labs that perform the
testing.
Some lessons learned about why these programs are
succeeding and have received positive feedback from all sectors
of the healthcare enterprise, including clinicians, consumers,
developers, standards develop organizations and others:
following a staged approach, allowing vendors and providers
adequate time to transition to more advanced health IT;
engaging the community throughout the process; relying on a
consensus-based standards-development process that actively
engages industry; soliciting and incorporating broad public
comment; engaging the Federal Advisory Committees; and
transparency in the process. We will continue to be guided by
these lessons learned and are prepared to meet the challenges
as each stage becomes more rigorous in its requirements.
In addition to its collaborations on standards, testing,
security, usability, interoperability, and certification for
meaningful use, NIST's cutting-edge research, advanced
measurement science, and participation in standards development
are building the infrastructure for a future that offers even
more promise for emerging healthcare breakthroughs in the
United States.
NIST initiatives are examining the best ways for humans to
interact with next-generation health IT. They are significantly
improving medical device interoperability and making health
care safer in the process. NIST researchers are exploring
innovative techniques by which critical patient diagnostic and
treatment information can be collected and transmitted
continuously in a safe and secure manner, which addresses
patient privacy concerns.
NIST is pleased to contribute to making our exciting vision
of health IT a reality. Thank you for the opportunity to
testify today on NIST's activities in health IT, and I would be
happy to answer any questions you may have.
Chairman Quayle. Thank you very much.
[The prepared statement of Dr. Romine follows:]

[GRAPHIC] [TIFF OMITTED] T7035.021

[GRAPHIC] [TIFF OMITTED] T7035.022

[GRAPHIC] [TIFF OMITTED] T7035.023

[GRAPHIC] [TIFF OMITTED] T7035.024

[GRAPHIC] [TIFF OMITTED] T7035.025

[GRAPHIC] [TIFF OMITTED] T7035.026

[GRAPHIC] [TIFF OMITTED] T7035.027

[GRAPHIC] [TIFF OMITTED] T7035.028

[GRAPHIC] [TIFF OMITTED] T7035.029

Chairman Quayle. I now recognize Mr. Probst for five
minutes.

STATEMENT OF MR. MARC PROBST,

CHIEF INFORMATION OFFICER AND VICE PRESIDENT,

INFORMATION SYSTEMS, INTERMOUNTAIN HEALTHCARE

Mr. Probst. Chairman Quayle, distinguished Committee
Members, thank you for inviting me to testify today. My name is
Marc Probst. I am the Chief Information Officer at
Intermountain Healthcare, a nonprofit, integrated health system
in Salt Lake City, Utah. I am also an appointed member of the
Health Information Technology Policy Committee.
Nationally, Intermountain is known for providing high-
quality care at sustainable costs. One way we achieve this is
by identifying best clinical practices and applying them
consistently. Research reviewed by Dr. John Wennberg of
Dartmouth showed that Intermountain is the best model in the
country of how you can actually change health care for the
better. Dartmouth estimated that if health care were delivered
nationally in the way it is provided at Intermountain, the
Nation could reduce healthcare spending for acute and chronic
illnesses by more than 40 percent.
Absolutely essential to Intermountain's ability to deliver
high-value, coordinated patient care is the effective use of
information technology.
As requested by the Subcommittee, I will address the
question, has progress been made as a result of the HITECH Act
towards greater health information technology interoperability?
My answer is yes. Progress has been made, but it is only a
beginning. We must commit ourselves as a Nation to set a clear
roadmap and support an exchange infrastructure and the adoption
of standards that will make it easier to share health
information so clinicians and patients have the information in
the form and at the time they need it to make appropriate
healthcare decisions.
The Australian railroad provides a useful example of the
importance of standards. In Australia, railroads developed
independently, one by one. While trains and tracks did get
built, the railroad system was constructed with many different
gauges of rail, preventing railroad cars on one set of tracks
from running on others. After many years of subpar train
service, expensive workarounds, and increasing costs, Australia
defined a standard gauge system. The process of standardizing
the gauges was expensive and disruptive, but efficiencies
continue to be realized today for those decisions.
There are parallels between the Australian railroad
experience and America's HIT experience. On the HIT Policy
Committee, work began almost immediately, and requirements were
created with the goal to increase the meaningful use of EHRs
across the country. The vast majority of these meaningful use
requirements deal with functions that any EHR should be able to
perform and requirements for what functions or data should be
shared between EHRs.
The existing HIT systems, be they vendor-developed or self-
developed, also were built one by one and applied differing
standards. Although very effective for each institution,
heroics are required to share even basic data between them.
Applying standards is really hard. This is why we now
essentially have our own Australian railroad, and fixing it
will require leadership and investment.
Numerous market-driven and private efforts have recognized
the value of standards, and significant funds and efforts have
been applied toward defining standards. Clearly there are
examples of open markets which have achieved a set of standards
that have yielded tremendous benefits to the citizens of our
country, such as the financial industry and ATMs. However,
health care is more complex than financial transactions. The
vast quantity of data and the requirements for painstaking
accuracy set health care apart. Further contributing to the
complexity surrounding health data is both the overlay of
regulations and the absolute need for privacy of health data. I
simply do not believe that the current voluntary approaches to
standard definition work.
In my opinion, what is needed is a mandate to: one, define
the set of information system-related standards which will be
applied to health care; two, ensure accountability to
appropriately develop and document these standards; three, set
a time frame in which to define and document the standards
measured in months, not years; and, four, establish a realistic
time frame in which the HIT community must adopt a federally
supported set of standards, say 10 to 15 years.
I realize this is a long time, but like the Australian
railroad analogy, there is much infrastructure to be aligned,
and we cannot stop providing health care or HIT services during
the transition. In this way, we will achieve a nationwide
health information technology infrastructure as called for in
ARRA.
In conclusion, I believe that with true leadership and a
commitment for long-range planning and support for transitions,
appropriate standards and exchange infrastructure can be
defined and implemented. If this is done, innovation in HIT
will skyrocket, health-related data will be more secure, costs
for technology and access to knowledge will be significantly
reduced, and quality care across the country will be improved.
If this is done, all ships can rise.
I look forward to working with you to achieving these goals
and would be pleased to answer any questions you may have.
Chairman Quayle. Thank you very much.
[The prepared statement of Mr. Probst follows:]

[GRAPHIC] [TIFF OMITTED] T7035.032

[GRAPHIC] [TIFF OMITTED] T7035.033

[GRAPHIC] [TIFF OMITTED] T7035.034

[GRAPHIC] [TIFF OMITTED] T7035.035

[GRAPHIC] [TIFF OMITTED] T7035.036

[GRAPHIC] [TIFF OMITTED] T7035.037

[GRAPHIC] [TIFF OMITTED] T7035.038

[GRAPHIC] [TIFF OMITTED] T7035.039

[GRAPHIC] [TIFF OMITTED] T7035.040

[GRAPHIC] [TIFF OMITTED] T7035.041

Chairman Quayle. I now recognize Ms. Little for her
testimony.

STATEMENT OF MS. REBECCA LITTLE, SENIOR VICE PRESIDENT,
MEDICITY

Ms. Little. Good morning, Chairman Quayle and Members of
the Subcommittee. Thank you for inviting me to participate in
today's discussion. My name is Rebecca Little, and I am here on
behalf of Medicity, a health information exchange, commonly
referred to as an HIE technology company, headquartered in Salt
Lake City, Utah. Medicity is a wholly owned subsidiary of
Aetna.
The software Medicity provides facilitates health
information exchange. What that means is we supply the
plumbing--the intelligent plumbing rather--that allows
electronic medical records, electronic health records, lab
services, pharmacies, hospitals, doctors' offices, and other
providers to connect to one another.
To continue with the metaphor, it doesn't matter what
electronic medical record or fixture a provider uses, whether a
provider is using health information technology for the first
time or has been using it for years. We can accommodate their
needs at any state of readiness or sophistication. The Medicity
HIE plumbing can connect any type of fixture to another so that
health information and patient data can be safely and securely
transmitted.
This matters to you as policy makers because Medicare and
Medicaid costs are unnecessarily greater when the lack of
information leads to bad outcomes or repetitive testing and
procedures. The results can translate directly into lower
healthcare costs. Improved use of diabetes medicine can cut
risk of hospitalization by half. Diabetics who take their
medicine less than 80 percent of the time were 2-1/2 times more
likely to be hospitalized for a diabetes or cardiovascular-
related condition in the next year. In total, poor adherence
results in 33 to 69 percent of medication-related
hospitalizations at a cost of roughly $100 billion per year.
These are costs that are absorbed by taxpayers in Medicare and
Medicaid and cannot be addressed effectively without robust
patient information. This is why interoperability across
providers is so important.
Our plumbing is truly interoperable, allowing for the safe
exchange of patient information across public and private HIEs,
across multiple provider systems, between small and large
physician practices, and across and within hospital systems.
True HIE interoperability, the seamless flow of patient
data in a secure framework, is the necessary ingredient to
transforming patient care and creating a more effective,
efficient, and ultimately less costly healthcare system,
because once the electronic connections are established across
providers and networks, and the patient data begins to flow,
other health information technologies can be put to work to
turn that data into useful information for physicians and
patients, saving lives, reducing medical errors, and
substantially lowering costs.
These successes are happening today. A recent Health
Affairs article demonstrated the success of a Medicare
Advantage pilot in Maine where the provider collaboration
relied on shared patient data in conjunction with patient
coordination. The result of using patient data to improve
patient outcomes and lower costs could not be clearer.
The result of the study of the population had a 50 percent
fewer hospital days, 45 percent fewer admissions, and the
corresponding costs were 16-1/2 to 33 percent lower than costs
for patients not included in this pilot, but these types of
successes could not be achieved without robust standards for
interoperability and data sharing.
Even though health information exchange is a requirement
for demonstrating meaningful use under the HITECH Act, health
information exchange is really about preparing providers and
healthcare organizations for the future of health care as
delivery models and reimbursement constructs continuously
evolve. This exchange of health information across providers,
hospital networks, between different HIEs holds the power to
improve care and improve efficiency by fostering care
collaboration and lowering administrative costs. We are already
seeing encouraging outcomes of how patient data can be turned
into actionable information for physicians to use--to improve
clinical outcomes for patients.
The rest of my written testimony provides examples around
how Medicity and Aetna are meeting providers at their stage of
readiness to employ cost-effective technology solutions that
will drive towards efficient, low-cost, high-quality patient
care.
Thank you again for the opportunity to testify in front of
you.
Chairman Quayle. Thank you very much.
[The prepared statement of Ms. Little follows:]

[GRAPHIC] [TIFF OMITTED] T7035.043

[GRAPHIC] [TIFF OMITTED] T7035.044

[GRAPHIC] [TIFF OMITTED] T7035.045

[GRAPHIC] [TIFF OMITTED] T7035.046

Chairman Quayle. I now recognize Dr. Fields to present her
testimony.

STATEMENT OF DR. WILLA FIELDS,

DNSC, RN, FHIMSS, PROFESSOR,

SCHOOL OF NURSING, SAN DIEGO STATE UNIVERSITY

Dr. Fields. Chairman Quayle, Members of the Subcommittee,
thank you for the opportunity--whoops, excuse me. I knew that.
Chairman Quayle, Members of the Subcommittee, thank you for
the opportunity to testify before you today. I am Willa Fields,
a professor in the School of Nursing at San Diego State
University in San Diego, California. Additionally, I was
honored to be selected as the Chair of the Board of Directors
of HIMSS, the Healthcare Information and Management Systems
Society, as of July 1st this year.
I am honored to have the opportunity to provide you the
perspective of HIMSS as well as my own on the status of health
information technology adoption, some of the challenges we
still face as a Nation, and recommendations on selected issues
requiring Congressional attention in the coming years.
HIMSS is a cause-based, not-for-profit association
exclusively focused on providing global leadership for the
optimal use of health information technology for the betterment
of health care. Founded 52 years ago, HIMSS is headquartered in
Chicago, with additional offices in the United States, Europe,
and Asia. We represent 50,000 individual members, of which more
than 2/3 work in provider, government, and not-for-profit
organizations. We also have 570 corporate members and more than
225 not-for-profit organizations that share our mission.
As you recognize, health IT is an essential foundational
element of any meaningful transformation of the Nation's
healthcare delivery system. Robust nationwide adoption of
health IT, including electronic health records, health
information exchange capabilities, and mobile health devices,
all of these are essential to achieving safe, effective care
delivery, payment reforms, and engaging patients in their care.
Health IT also enables timely, accurate, and appropriate
collection and dissemination of patient information in a
private and secure manner.
While there is still much work to be done, adoption of
interoperable health IT systems continues to expand thanks to
the incentives provided by the HITECH Act. We are only two
years into the program, and there has been a great shift toward
electronic health records throughout the Nation.
HIMSS Analytics has performed a cross-reference of
hospitals achieving Stage 1 meaningful use against their scores
on the Electronic Medical Records Adoption Model, or EMRAM,
which is a HIMSS analytic tool to track U.S. civilian hospitals
on their progress toward a mature, paperless, electronic
environment. The results demonstrate that hospitals are rapidly
evolving to higher stages on the EMRAM scale. Such results are
clear indicators that government incentives are achieving their
mission at accelerating the widespread implementation and
meaningful use of certified electronic health records in the
United States. More importantly, the top-ranked EMRAM Stage six
and seven hospitals reflect the rapidly escalating move of
United States hospitals toward interoperability, which will
lead to information exchange. The EMRAM system and its findings
are explained further in my written statement.
The evidence, including data from the Centers for Medicare
and Medicaid Services, the Centers for Disease Control and
Prevention, and HIMSS Analytics suggests that as a result of
the HITECH Act and the substantial investment the public and
private sectors have made, a groundswell has been achieved in
the adoption of health IT and specifically electronic health
records.
We believe the time is very near when informed patients
will use adoption and meaningful use of health IT as a key
factor in selecting a caregiver and a care setting because of
the opportunities these systems provide for access to
information. Without the HITECH-authorized meaningful use of
Electronic Health Record Incentive Program, the Nation would
not be realizing adoption and implementation of these systems,
which includes the rapidly expanding ability to exchange
information privately and securely across systems and regions.
HIMSS strongly encourages the continued bipartisan support
of Congress for the earliest nationwide adoption and
implementation of electronic health records and the Meaningful
Use Program.
In conclusion, in order to improve the quality of health
care for all Americans, while also controlling costs, HIMSS
recommends seven strategies for Congress: One, continue your
strong bipartisan support for the adoption and meaningful use
of electronic health records; two, continue to support and
sustain the Meaningful Use Electronic Health Records Incentive
Program; third, direct the Administration to initiate
collaboration with the private sector on an appropriate study
of patient data matching and the adoption of a nationwide
patient data-matching strategy; fourth, support harmonization
of Federal and State privacy laws and regulations to encourage
the exchange of health information across systems, payers, and
vendors; continue to support programs and services to educate
providers and provider organizations on how health IT can and
should be used to engage patients in their health care;
continue to support and sponsor pilot programs addressing the
collection, analysis, and management of clinical data and
quality for reporting purposes; and, seven, preclude any
additional delay in the nationwide implementation of ICD-10,
the International Classification of Diseases that is set to be
implemented October 1, 2014.
Let me reiterate, electronic health record adoption and
implementation has passed the tipping point in America. The
evidence, including HIMSS' own analysis, indicates continued
process--I am sorry, continued progress on the implementation
of health-information technologies. My written statement citing
evidence of these upward trends in health IT adoption and
discussing the rationale for these recommendations in more
depth--in more depth has been provided for the record.
Clearly the Nation would not have made the significant
progress toward electronic health record adoption and health
information exchange that it has without the Meaningful Use
Program authorized by the HITECH Act. Perhaps in many years
health care might have caught up with other industries in the
adoption in information technology, but in the meantime quality
of care and access to care have continued--would have continued
to suffer, and the Nation would have continued to pay much more
for health care than necessary.
There is more work to be done, especially in
interoperability, health information exchange, privacy, and
security. HIMSS recommends that in order to improve the quality
of your constituents' health care while also reducing its
costs, Congress should continue its strong bipartisan support
for health information technology. I and my 50,000 professional
colleagues stand ready to work with Congress and the
Administration.
Thank you for the opportunity to speak with you today, and
I would be happy to answer your questions.
Chairman Quayle. Thank you very much.
[The prepared statement of Dr. Fields follows:]

[GRAPHIC] [TIFF OMITTED] T7035.047

[GRAPHIC] [TIFF OMITTED] T7035.048

[GRAPHIC] [TIFF OMITTED] T7035.049

[GRAPHIC] [TIFF OMITTED] T7035.050

[GRAPHIC] [TIFF OMITTED] T7035.051

[GRAPHIC] [TIFF OMITTED] T7035.052

[GRAPHIC] [TIFF OMITTED] T7035.053

[GRAPHIC] [TIFF OMITTED] T7035.054

[GRAPHIC] [TIFF OMITTED] T7035.055

[GRAPHIC] [TIFF OMITTED] T7035.056

[GRAPHIC] [TIFF OMITTED] T7035.057

[GRAPHIC] [TIFF OMITTED] T7035.058

[GRAPHIC] [TIFF OMITTED] T7035.059

[GRAPHIC] [TIFF OMITTED] T7035.060

[GRAPHIC] [TIFF OMITTED] T7035.061

[GRAPHIC] [TIFF OMITTED] T7035.062

[GRAPHIC] [TIFF OMITTED] T7035.063

[GRAPHIC] [TIFF OMITTED] T7035.064

[GRAPHIC] [TIFF OMITTED] T7035.065

[GRAPHIC] [TIFF OMITTED] T7035.066

[GRAPHIC] [TIFF OMITTED] T7035.067

[GRAPHIC] [TIFF OMITTED] T7035.068

[GRAPHIC] [TIFF OMITTED] T7035.069

[GRAPHIC] [TIFF OMITTED] T7035.070

[GRAPHIC] [TIFF OMITTED] T7035.071

[GRAPHIC] [TIFF OMITTED] T7035.072

[GRAPHIC] [TIFF OMITTED] T7035.073

[GRAPHIC] [TIFF OMITTED] T7035.074

[GRAPHIC] [TIFF OMITTED] T7035.075

Chairman Quayle. And I want to thank all the witnesses for
their testimonies.
Reminding Members that Committee rules limit questioning to
five minutes, the Chair will at this point open the round of
questioning, and I recognize myself for five minutes.
Dr. Mostashari, I want to start with you. One of the
things--I had a lot of inquiries and comments from constituents
leading up to this hearing about the meaningful use
requirements and how they might not be applicable to their
practice. They were more specialists in different fields, and
Stage 2 provided a temporary hardship exemption. But we need to
ensure that the criteria is going to be applicable for these
types of physicians, and so my question is, is it appropriate
to have the same core and menu requirements for different types
of physicians? Are there steps that the Administration is
taking to ensure that the requirements take into consideration
the unique nature of different medical fields and practices?
Because what I have been hearing is that the various meaningful
use requirements in different specialties do not match up, make
it more difficult for them to actually fulfill these
requirements, and then if they are going to be punished for not
actually doing this, it is going to have a detrimental effect
on their own practices.
Dr. Mostashari. That is an issue that we have been working
on with stakeholders in the Policy Committee for the past two
years. The Stage 1 rules did set in place a kind of common
infrastructure and common core set. So the assumption was that
if we are going to be able to exchange information, there
should be a common set of information around medical diagnoses,
or smoking status, or blood pressure. And we heard a lot, and
since the implementation of Stage 1, that that may not be
relevant; this is a national program, and it may not be
relevant for all practices.
So the challenge is how do we get to a place where there
is, for the things that really--at the planning level, the
things that really we want interoperability on, we get that
sort of interoperability across all practices, and yet allow
for the differences in practice and what is relevant to
different specialists.
In Stage 2 we made a number of accommodations to that
reality. So we, for example, provided guidance and in the rule
said if it is really not--if collecting blood pressure is not
relevant to your practice, you are a pathologist, then you can
have an exclusion from that requirement.
And we also heard from Stage 1 that many of the quality
measures were--the ones that were available at the time were
not relevant to all specialists. So for Stage 2 we said, okay,
you don't have to report on the quality measure for smoking if
that is really not relevant to your practice, although it is
hard to imagine; you know, there is not that many practices for
whom smoking status is not relevant, but----
Chairman Quayle. So will all these kind of kinks be ironed
out prior to the temporary reprieve where people will start
getting penalized for not actually complying with this when in
certain specialties smoking would not be extraordinarily
useful? So will that all get ironed out? That is one of the big
things that I am trying--those will get ironed out before the
penalties will be put into place?
Dr. Mostashari. So all of the flexibilities that I
mentioned, there are many more, are part of Stage 2, which is
going to be in effect before the penalties.
Chairman Quayle. Okay. Okay, great. Thank you very much.
And Mr. Probst, I want to get to your testimony, because in
your testimony you stated that, you know, voluntary
consistent--consensus-built standards don't work within the
healthcare industry. And in previous hearings, you know, we
have had NIST here a lot, and that was one of the main things
with NIST--is it is very consensus driven with the
stakeholders, and it has worked very well.
Why do you not think in the healthcare industry that that
is the best way to go and instead come up with a set of
standards from basically kind of more of a top-down approach
rather than the voluntary consensus? I just want to get your
take on that.
Mr. Probst. Well, I think the very fact that we are having
this conversation suggests that it hasn't worked. They have
been doing it for a long time. And that is not to slam HL7 or
DICOM or any of the groups that have been working towards
standards. There are varying incentives in those groups. The
people that formed those groups have different rationales for
why they want standards or what standards they might like.
But, again, I think the fact that we haven't come to some
basic standards, like the gauge of rail that they did in
Australia, we are dealing with all the discussions around
health information exchange, what kind of contraptions can we
put together to move data from one system to another that loses
fidelity and costs time. So I just think history is a good
educator for the future, and I don't see how we are going to
get to standards without some direction on some basic core
standards.
Chairman Quayle. If we are going to have that direction,
how, in your estimation, do we set those standards so that we
can still have the flexibility for technological innovation
going forward, since that seems to be--from past testimony on
the consensus building, that seems to be where we have had some
really good innovation? But in the way that you are kind of
seeing this in the outlook, how do we leave that flexibility in
place so that the innovation can continue to progress?
Mr. Probst. I think what we don't want is standards that
suggest everything that we have to do. But we do need
standards, and I listed several of them in my written
testimony, basic core foundational IT standards toput in place.
If those are put in place, then innovation happens. Then you
have Internet kind of innovation that can occur ubiquitously
across large groups of people. So that is the gist of my
testimony.
Chairman Quayle. So you basically--you put the trunk, and
then the tree--you know, the limbs of that trunk can go up, and
that is where the innovation would be able to take place,
something--I mean, to use a----
Mr. Probst. Exactly, if you get the foundation in place.
Chairman Quayle. The foundation. Okay, great. Thank you
very much.
I now recognize the gentleman from New Mexico Mr. Lujan for
five minutes.
Mr. Lujan. Thank you. I yield to Mr. Clarke.
Mr. Clarke. Thank you, Mr. Lujan, for yielding me time.
In order to implement these health information technologies
and to operate them on a day-to-day basis, you need an adequate
workforce. I represent the City of Detroit, the metro Detroit
area. We have very high unemployment, but also we have got some
great hospital systems. The potential for job growth in that
region and also nationally, because of the complexity of our
healthcare delivery system and the growing number of people who
need health care--we are going to need a lot of people in this
workforce area. An interoperable health IT system will create
jobs.
The HITECH Act directed your Office, the Office of National
Coordinator, to establish education programs, which I think is
great. Now, one thing that causes me concern, though, is this
eHealth Initiative survey that indicates that nearly a quarter
of the health information exchanges are not hiring students
from ONC-funded workforce development programs.
You know, Dr. Mostashari, or anyone who would like to
comment on that, I mean, is this survey accurate? Is there some
fundamental basis for concern about the adequacy of the
training programs that your office is funding? And if that is
the case, what can we do to correct that? My assumption is that
this is a whole new industry that can be created that could
transform our entire workforce nationally and even
internationally. How can we get people prepared to operate
these health IT systems?
Dr. Mostashari. Your concern is very well put. There is
going to be a lot of jobs in--and there are a lot of job
openings, huge increases in job openings, for skilled health IT
workforce, even as we have many students and others who would
wish to fill those jobs. So to meet that we have established a
curriculum that is openly available, we have created a
competency exam working with AHIMA, we have funded university-
based training slots as well as 81 community colleges that have
graduated over 15,000 students to meet the expected need of
50,000--a shortage of 50,000 jobs in health care IT.
As you say, one of the things we have learned is if you
don't have experience in health care, it is hard to get into
health care IT and get a job. So one of the things we are
working with, for example, in Ohio at the community college
there is working with a hospital association to have
internships and placements and apprenticeships. Those are, I
think, some of the answer to meeting--making these two sides
connect up with each other.
Mr. Clarke. Thank you, Doctor.
Anybody like to comment on this?
Dr. Fields. I actually would----
Mr. Clarke. Dr. Fields?
Dr. Fields. Thank you.
I would like to expand on the program through ONC. I
personally use some of the slides that have been posted to
teach my students, graduate students in informatics in nursing.
So what that says-- you don't capture that in your numbers of
the benefits. So I am using the materials that ONC has funded
through work done by others. I then have up-to-date information
that I can incorporate into my classes, which makes the
graduate students in nursing more capable of taking these
complex HIE jobs. And then when they move into the health care
IT positions, it opens up less experienced types of positions,
which the survey that you quoted in the information, Dr.
Mostashari, that you talked about, this information, these data
don't get captured.
Mr. Clarke. Thank you, Dr. Fields.
And I yield the balance of my time to the gentleman from
New Mexico, Mr. Lujan.
Mr. Lujan. Thank you very much, Mr. Clarke.
A lot of conversation as to what we need to get done here
with the implementation of this, and I think in the end what we
can all certainly agree on is that we all want to make sure
that we have more consistent treatment, better outcomes, cost-
saving measures as well.
And with the limited time that I have left, one thing I
just want to point out is as we implement medical records, and
we hopefully will find a way to do this as effectively and
efficiently as possible, the importance of partnerships between
the Federal Government, local governments, and private entities
to be able to implement this, the importance of standards.
And I just want to highlight one project that has come out
of New Mexico. It is Project ECHOTM, which is the Extension for
Community Health Care Outcomes, led by Dr. Sanjeev Arora out of
the University of New Mexico Hospital, who are now partnering
with the VA as well, a program dependent on the implementation
of distance medicine, and we are seeing huge, huge benefits and
positive outcomes there. So I look forward to talking about
that a little bit more throughout this hearing and getting your
perspective on that.
Thank you, Mr. Chairman, and with that I yield back.
Chairman Quayle. Thank you very much.
I now recognize the gentleman from Illinois, Mr. Hultgren,
for five minutes.
Mr. Hultgren. Thank you, Mr. Chairman. Thank you all very
much.
A question for all of you. Interoperability--I can't speak
this morning--is critical to realizing the many potential
benefits for health information technology. So far the Federal
Government, I know, has spent approximately $2 billion in
appropriated funds for HIT infrastructure and $7 billion in
mandatory incentive payments for HIT adoption. Wondered if each
of you could give thoughts, given this investment, have we made
appropriate progress on interoperability, and why have we or
why have we not made the progress that you all think we should?
Dr. Mostashari. I believe that we have made substantial
progress on both the adoption and the meaningful use of
electronic health records, which includes the interoperability.
And this is a long road. As Marc pointed out, these are
complex. It is much more complex than saying 4 feet, 8-1/2
inches should be the width of the railway gauge, which the U.S.
Congress did in 1853.
These are quite complex, but I think we have a roadmap, and
we have, through meaningful use, a phased approach to being
able to bring the whole country, bring the floor up and create
that infrastructure in stage after stage after stage to help
increase that journey towards interoperability.
Dr. Romine. I would certainly like to agree with my good
friend and colleague Dr. Mostashari about this. I think we have
made substantial progress. NIST has a long history of working
on both conformity assessment and also interoperability, and I
think the steps that we are taking, and particularly the
emphasis on this phased approach that allows us to sort of
bring the community along in an aggressive but achievable
manner, is absolutely essential to doing this.
Mr. Probst. Yes, I believe meaningful use has made good
progress forward toward the exchange of information and the
ability to use it, you know, between organizations. Although it
was 4 feet, 8 inches for the rail gauges, and that is pretty
simple, this is incredibly complex, and therefore
interoperability is way more complex than the rail system, and
it needs to be taken care of.
So I agree with what we are doing around meaningful use
because we have an infrastructure we need to leverage and we
are providing better care, I believe, because of the efforts
that are happening. But I still would stand on the fact we need
to divine a--define--maybe divine, but define a core set of
standards that would allow for true interoperability, because
the way we are saying interoperability right now, what is
really happening is information exchange. Interoperability, to
me, is far deeper, with a far greater capability to save lives
and money.
Ms. Little. We would also agree that substantial progress
has been made, and we certainly agree that meaningful use Stage
1 began the proliferation of adoption of electronic health
records, and without robust standards for interoperability, the
spread of electronic health records will be stifled or limited.
We encourage HHS to adopt standards that would support the
clinical needs of coordinated care, such as requirements for
accountable care organizations, medical homes, and hospital
readmission programs.
Lastly, I would observe that occasionally Federal programs
and program rules are not aligned. Providers must comply with
different standards for different programs, which make them
less attractive. We are pleased to see HHS proposing alignment
of rules across meaningful use, accountable care organizations,
physician quality reporting, and medical homes.
Dr. Fields. And, yes, I am going to agree also, but with
that I am going to tell you some data that I personally
collected on a research study at a hospital in San Diego.
So I look at interoperability not only across
organizations, but within organizations, and this particular
hospital had been digital for decades. The emergency department
had one system, critical care had one system, women services
had another, pharmacy was on another, and on and on and on. And
so this is--yes, it was the railroad gauge absolutely. So each
group of practitioners had the best system for them, but they
couldn't share easily information across systems.
We implemented an integrated--I wouldn't call it
interoperable because it doesn't go across organizations except
within our healthcare system. And in this research study when I
surveyed the nurses on the use of the system before we went
live with the integrated one and then one year after
implementation with the one system or with the sharing of the
information, that they clearly were using the new system much
more. They were accessing it for information, for patient data,
for patient engagement.
I then interviewed the nurses one year after to find out
what did the transition go like, how was the system, what were
the changes they found, and without a doubt the nurses
resoundingly said that they were able to provide better care
because they had all of the information in front of them. They
had the emergency department information in front of them. With
the click of a button, they would be able to look up past
hospitalizations.
So we have improved care in this one organization where
they can look at the physician office patient episode, they can
look at previous hospitalizations, they can look at the
information from throughout that hospitalization, yet if that
same patient goes to another hospital within our community,
that information is not available.
But I will also compliment ONC because San Diego is
fortunate enough to be one of the beacon communities, and so
money has been invested so that in San Diego we can have that
same type of sharing of information not only within Sharp
Healthcare, but we can have it throughout San Diego.
Mr. Hultgren. Thanks. I see my time has expired. I yield
back. Thank you.
Chairman Quayle. Thank you very much.
I now recognize the Ranking Member, the gentlelady from
Maryland, Ms. Edwards, for five minutes.
Ms. Edwards. Thank you, Mr. Chairman, and I want to thank
my colleague Mr. Clarke for sitting in for me today, I really
appreciate that. And Mr. Chairman, thank you as well for your
service. We have had some great hearings in this Subcommittee,
and I really do appreciate your leadership.
To our witnesses today just a couple of questions. Dr.
Mostashari, in your testimony you indicate that any rulemaking
includes some compromises between the aspirational goals we
want to achieve and the reality of where the market is, really
important questions for us today. And I wonder if you could
elaborate on that and additionally what the impact on small or
rural practices is if the expectations of meaningful use are
set too high.
Even in my own State of Maryland, we are a small state, 5.5
million people, a lot of people live in our metropolitan areas,
but a lot of folks don't. And so even in a small State you
could have a two-tier system if we are not really careful about
this.
Dr. Mostashari. Thank you, Ranking Member Edwards, for the
question. It is absolutely true that one of the fundamental
challenges we face in setting the meaningful use policy is this
is an escalator that we want people to get on and continue to
advance through the different stages. How fast up that
escalator can we push? What is the rise and the run so that
people don't fall off the escalator? Because we could set the
standards very, very high, and, you know, only a few
institutions, signal institutions, across the country would be
able to qualify for those standards, and we would not have
succeeded in improving health and health care for all
Americans. So it becomes really important for us to not set
them so low that we are not changing the intrinsic capabilities
and interoperability of the systems, but not set them so high
that only a few can participate as well.
The issue around the rural providers and small practices
are particularly important because historically those have been
the kinds of providers who haven't had the resources to
implement health IT effectively, and they have consequently the
lowest rates of adoption of EHRs. So when we took our Regional
Extension Center Program funded through HITECH, we said focus
on the small practices, focus on the primary care providers,
focus on the critical access hospitals, the rural health
clinics, the community health centers. And I think it is in
part due to these efforts that we have seen, for example, rural
adoption of electronic health records now among office space
providers is 38 percent higher than the national average of 34
percent. So it can be done, but we have to make sure that we
set the rules appropriately and we provide them with the
services they need to be able to get there.
Ms. Edwards. I want to ask you a question that is somewhat
related, and it is regarding the issue of upcoding. The New
York Times recently profiled and wrote about some instances in
which hospitals, particularly those Medicare providers, in
using these IT systems actually were billing at much higher
rates. And I have a question just about the design, whether it
is--and maybe NIST can comment on this, too--we can have some
way of testing these, the designs of IT systems, so that we get
a more intelligent design that might factor in the potential
for abuse or the potential for upcoding when it doesn't result
in a better patient outcome or a better quality of care so that
we can actually guard against increases in costs in a system
rather than seeing more efficiency in the system because of the
implementation of the technology.
Dr. Mostashari. I would note that the article you mentioned
examined trends in billing leading up to 2010, which actually
predates the implementation of the EHR incentive program, which
is moving electronic health records industry away from just
being documentation and billing machines and towards things
that, as Ms. Little commented, help us do the new payment
models of the future with accountable care, and bundled
payments, and shared savings and so forth.
That said, I want to assure you that HHS is taking the
appropriate steps to investigate and correct any possible
improper billing associated with EHRs. The Centers for Medicare
and Medicaid Services is conducting a comprehensive review of
potential improper billing through the use of electronic health
records. We also plan to convene a summit of stakeholders to
develop those potential policy and EHR design responses, as
well as conduct a pilot of hospital audits using EHR technology
functionality that supports fraud enforcement and investigation
so that EHRs are used as tools to combat fraud, not encourage
it.
Ms. Edwards. And is it possible, though, that in testing
for standards that NIST actually might come up with a design
that looked more intelligently at these systems so that, you
know, if there were system prompts or the software was coded in
such a way that it would automatically kick out things that,
you know, looking at an entire record, might actually indicate
that there was that upcoding going on, as opposed to coding
correctly for a given medical condition or circumstance.
Dr. Romine. So from this perspective--thank you for the
question.
Our role has really been in trying to ensure that we
provide the best technical advice to get the best technical
standards from the community with regard to interoperability,
security, privacy, and so on. But that also includes usability.
And one of the things that may be related to this issue is
ensuring that the usability of these systems are testable in a
way that might prevent I would call inadvertent, mistaken
coding, or things of that nature where the usability of the
system can help avoid those kinds of issues.
With regard to the policy issue of trying to prevent
intentional fraud, I think that would really kind of be beyond
our scope. I'm not sure how we would contribute to that.
Ms. Edwards. Thank you, Mr. Chairman.
Chairman Quayle. Thank you very much.
I now recognize the gentlelady from Oregon, Ms. Bonamici,
for five minutes.
Ms. Bonamici. Thank you very much, Mr. Chairman. And thank
you for calling this hearing today.
Thank you for all of our panelists for sharing your
thoughts and ideas about this important issue. Many people in
my home State of Oregon are talking about the importance of
increasing access while reducing costs. So this is certainly an
important topic.
I represent a district that includes an area that's known
as the Silicon Forest; it's like the Silicon Valley, only with
trees.
And we have a lot of technology companies, Intel, doing a
lot of great work in developing our health IT infrastructure.
The Oregon hospital systems have been early adopters of using
common IT systems, and they have been working through informal
collaboration.
I recently hosted a roundtable discussion that brought
together many of the stakeholders. We had the Oregon Office of
Health Information Technology, the Medical School, Oregon
Health Sciences University, the Oregon Healthcare Work Force
Institute, community colleges, software developers, the Oregon
Center for Aging and Technology, and many others, to talk about
where we were going, the development so far, and some of the
challenges.
One of the interesting issues that came up, and I believe
you touched on, Dr. Mostashari, was the importance of having
some medical knowledge in the actual software and systems
development phase. The medical workflow is really important in
the initial design of the software and the developments. So
that's an issue that we feel really needs to get addressed.
And also there was a discussion about involving providers
at every level from, you know, hospitals to home care and in
many cases to completely fulfill the use of the medical
records. You have patients and caregivers who are involved, and
they need to be comfortable with the technology as well.
So could Dr. Romine, and perhaps Dr. Mostashari, I know
there has been some discussion about how you go about engaging
healthcare professionals in the actual development of the
technology. But would you also comment, please, about the work
that you've done in engaging healthcare professionals in the
implementation as well?
Dr. Romine. The way that NIST works most effectively in
working with the community to develop standards, particularly
in a space where historically we don't have a lot of expertise
in medicine. We do a lot of life science research, but that's
quite different from clinical practice, for example.
And so we have to engage the communities. Most effectively,
we do that with the standards development organizations that do
have the various technical background that we need. So
standards development organizations such as--we've worked with
ASTM and HL7 and other organizations that are involved in this
arena specifically to look at the ways that we can help develop
the standards necessary in this space to be the most effective.
And that does include looking at the workflow associated with
this.
We also could not actually contribute to this without the
very strong partnership with ONC, where a lot of that expertise
resides. And so I'm very pleased that the partnership that we
have with ONC is as strong as it is.
Dr. Mostashari. The issue you raise is of critical
importance. The software, and there are--and it is wonderful.
There are hundreds of new vendors, hundreds of new products.
And 60 percent of those vendors have 50 or fewer employees.
They are small companies. And it's critical that as we have
technological innovation, those technologies are more usable
and work for the frontline clinical staff, the nurses and
doctors. And the usability issue here is something absolutely
critical.
We've been doing a lot of work with our stakeholders,
including our Chief Medical Officer, with many of the providers
groups within the usability space.
I do, though, having been in the space for some time now, I
might be interested in hearing Willa's perspective on this as
well. The products are a lot more usable today. If you look at
products that came out four or five years ago, it's really
night and day in terms of how usable they are, you know, iPad
applications, and a whole host of new innovations around
usability are now coming to the forum. As it should be,
competition between vendors for the most useful product I think
is going to be yielding us tremendous results in the future.
Ms. Bonamici. Thank you. Dr. Fields, did you want----
Dr. Fields. Yes. The usability is an issue. They are more
usable than they used to be, and hopefully they aren't as
usable as they will be, that we aren't where we need to be.
That said, we need to continue with the implementation. And one
of the barriers in the United States, if you look at the
literature, clearly a major barrier to implementing these
systems is cost. And thanks to our Federal government, the cost
barrier is being lessened because of the incentive program.
So with that we'll have the--what Dr. Mostashari talked
about, all the new vendors. We're having the increased
competition in the innovation. And the users, the nurses I talk
to, the physicians I talk to, they want systems that are easy
to be used.
And we as a public are very computer savvy. I looked up
some data--80 percent of the households have computers. And of
that 80 percent, 70 percent of adults--so that's not kids--it's
70 percent of the adults, are using the Internet, and 80
percent of that 70 percent are getting health information. So
that means that the majority of your constituents in getting
their health care, the number one thing is looking for
healthcare information. They know how to use the systems. They
are going to be demanding that our clinicians know how. And the
usability is getting better, but it's not written in slate.
Ms. Bonamici. Thank you. My time has expired. Thank you.
Chairman Quayle. Thank you very much. Now recognize the
gentleman from Maryland, Mr. Harris.
Mr. Harris. Thank you very much, Mr. Chairman.
And I have a couple of specific questions, and then a more
general, I guess.
Dr. Mostashari, it's good to see you again.
As you know, last time we met, we'd talked about the
difficulties that some different specialties have, which I
think you appreciated, with regard to meaningful use.
Now, as an anesthesiologist, you know I know that hospital-
based physicians a lot of times lack face-to-face interactions
and other things. And I--so that I think Stage 2 granted the
hardship exemptions to at least three categories--radiologists,
pathologists, anesthesiologists. But in the absence of
meaningful--of developing meaningful use criteria for those
specialties, is it the intention of the Administration to
continue a hardship exemption until those are worked out, you
know, some kind of meaningful use parameters are worked out? I
mean, to my understanding, this is kind of a one-time, one-year
hardship exemption. That doesn't provide consistency long term.
Dr. Mostashari. Yes. As you know, the--particular issue for
those three categories, anesthesiologists, pathologists, and
radiologists, was not only that they practiced, in some cases,
where they have less patient interaction, it's also that the
systems that they use are oftentimes provided by the hospital
where they practice rather than purchased by the providers
themselves within their private practice.
So the exemptions, we asked about whether there should be
more blanket exemptions for those categories, and in Stage 2,
we find that it can be up to five years.
Mr. Harris. Okay.
Dr. Mostashari. So I think that given the current
legislation, I think that is the means that are available to
us.
Mr. Harris. Thank you very much.
Dr. Romine, is that how I pronounce it? Okay.
I have a very specific question. It has to do with one of
these things that I think NIST is involved with, which is the
prescription, the drug-to-drug interactions and drug allergy
checks. And this is very specific to anesthesiology.
And when I was in the operating room last week, on one
patient, I had a list of 10 drugs, if you count two inhalation
agents. Only one of those was one where another provider was
involved, which is the prophylactic antibiotic, which a nurse
had requested from the pharmacy, which an electronic system in
use could have picked up a drug-to-drug interaction or an
allergy. But of the other nine drugs I administered, all of
them are documented really after the administration. That's
just the way the workflow occurs. So software in a health
information technology system really wouldn't pick up drug-to-
drug interactions or drug allergy interactions in that setting.
Do you think that--and anesthesiologists are kind of unique
in the number of times we--the number of drugs we use and the
fact that we are doing it on a momentary basis. So there's no--
it's hard to prospectively identify and write an order, check
it in the computer, things like that.
Should they be exempt from the requirement until such time
that we can figure out how to work that into an electronic
system?
Dr. Romine. Congressman, I'm a mathematician, but I'll try
to address that.
I would say--I don't know the system that you used in to
obtain the nine drugs that you did apply.
Mr. Harris. No, they sit in a cart in the room.
Dr. Romine. I see. Okay.
Mr. Harris. We have access. They sit in a cart. That's the
problem. And that's the way anesthesiologists practice in most
settings. You have access to a variety of drugs. You make a
decision sometimes on a momentary basis which drug you have to
administer without time to prospectively enter it into a
system.
Dr. Romine. From this perspective, we're happy to work on
developing the standards. But the expertise with regard to
where certain interactions might take place, or working with
ONC, for example, on drug-to-drug interaction, allergies, and
so on, all of the guidance with respect to the kinds of issues
that you're just talking about would not come from NIST. We
don't have that expertise.
Mr. Harris. All right. We have to work with Dr.
Mostashari's office, I guess, with that.
One final thing is, I guess the question of
interoperability, and Ms. Little kind of suggested, I guess
Medicity is kind of a translator system. No matter what
language a given group speaks, you're the translator between
these.
And I guess interoperability can occur two ways, it can be
by declaring that everybody speaks the same language, or that
everybody has access to a translator that works.
Which is the system that we're going to go to? Because a
lot of institutions, as Mr. Probst indicated, a lot of
institutions invested heavily in a proprietary scheme. And it
would seem that the easiest way to get a broad--if it's
technologically feasible--broad acceptance at this point is
just to allow translators to exist. Is that the scheme?
Dr. Mostashari. I think the answer is yes. We need both.
Mr. Harris. But both is not specific. I mean--and, again,
if you're going to tell a provider, why don't you go--you know,
you got to go ahead and invest in a system now. But we might
down the road change the rules and say that you actually have
to have a system has these qualifications and too bad if yours
didn't, as opposed to saying, okay, you have now invested in
this now we're going to actually spend our energies on making
sure translators exist that accurately translate.
Dr. Mostashari. Let me be more specific. I think it is
important to, as much as possible, make sure that two different
certified EHR systems can talk to each other without the need
for requiring that a translator be present, particularly since
the availability of such, you know, health information exchange
organizations throughout the country are still limited. It's
growing, but it's still limited. So I think it's important for
us to have, as much as possible, the precoordination and have
those national standards at the electronic health record in
place so that the systems can talk to each other.
It also greatly, I think, reduces the work of the
translators if the people speaking the languages at least speak
them consistently instead of having to translate. And much of
the cost on the information exchange side is doing all those
variations on all the different languages that people are
speaking.
So I think the reality is that there are translators in
place today. And we've made--I think we've encouraged the
development of information exchange at the state level and
others. And it's a reflection in reality. But we can't give up
on the idea that we're going to get to the point where the EHRs
can speak to each other without the need for translators.
Ms. Little. I would agree with Dr. Mostashari. I think the
need for the middle-ware, the translator or the plumbing, as
you called it, is particularly important now as standards are
relatively nascent.
We see--and Dr. Romine and Dr. Mostashari may have a
different statistic than I--but dozens if not hundreds of
permutations of the continuity of care document today.
And so, for us, it's an important part of making sure that
the right information gets to the right person at the right
time within their workflow. I do also agree that over time
systems will be better able to communicate with each other.
Dr. Fields mentioned that the systems we have today are
better but hopefully not as good as the ones we'll have in the
future.
The other, I think, important component part that the
translator provides for, as to the point you made, sir, whereby
changes evolve and standards evolve, the middle-ware, the
translator oftentimes can buffer and provide a little bit of
runway as systems become more operable and then adopt those new
standards. So I agreed with Dr. Mostashari, I think we need
both.
Mr. Harris. Thank you very much, Mr. Chairman.
Chairman Quayle. Thank you very much. Now recognize the
gentleman from Michigan, Mr. Clarke, for five minutes.
Mr. Clarke. Thank you, Mr. Chair.
And I wanted to thank the Ranking Member from Maryland, Ms.
Edwards, for giving me this opportunity. Back two years ago
when I served as Ranking Member of the Michigan Senate
Committee on Health Policy, I actually convened an informal
hearing on the health information exchanges to see how we could
get those set up. So this is an issue that's important to me.
And thank you again.
With that, I yield my time to the gentleman from New
Mexico, Mr. Lujan.
Mr. Lujan. Thank you very much, Mr. Clarke.
And, Mr. Chairman, I also, as our Ranking Member, Ms.
Edwards, want to commend you for your work on this
Subcommittee, Committee as a whole, and your time in the House.
It's been great to get to know you. Appreciate your leadership,
and I know that it won't be too long before we see you again,
sir. So it's always an honor, Mr. Quayle. Really appreciate
that, sir.
Dr. Mostashari, all of us as Representatives represent
about the same population, plus or minus a few hundred or maybe
a few thousand people. The difference between our districts is
some of us represent a few square blocks, others represent
47,000 square miles, like my district in New Mexico. The
longest drive I have is about 8-1/2 hours drive time. Out here,
we can go through about six, seven States in that amount of
time.
The reason I bring this up is when we talk about the stages
of the implementation versus urban, metro, and rural areas,
what sensitivity is paid attention when we start talking about
the smallest of clinics, smallest of communities, that need
more assistance or time as we talk about the implementation of
the stages and the requirements associated inherently therein
and the capital necessary to be able to do that?
Dr. Mostashari. You're absolutely right that we need
different approaches in different parts of the country.
This is why the regional extension center program is based
out of local institutions that understand the local needs and
the local resources.
So a program like the one I ran in Brooklyn and the Bronx
in New York City is going to be structured differently than the
program in New Mexico. Both are successful, but they take
different approaches to the issue. And I think it's been that
sensitivity to what the local needs are that has made the
success that we've enjoyed in making sure that a digital divide
does not develop. Because as one rural provider said to me,
``My patients now come to me knowing that the best technology
that they could get anywhere in the world is in their doctor's
office here in my rural practice.''
He also said it's very important on the telehealth side,
that you mentioned earlier, ``that if my patient drives 300
miles to go to a specialist that I referred them to that when
they get there they have the information that they need instead
of having the patient turn around or be told, `sorry, we're
going to have to repeat all those tests,' or, `sorry, we didn't
get the paperwork on you.'' So we have to pay particular
attention to the rural areas and we are doing that.
Mr. Lujan. I appreciate that.
If anyone else would like to weigh in and in addition to
the impact as we talked about the standards on telemedicine as
well.
Mr. Probst. Yes. And I think I come from a geography in
Utah very similar to yours.
And I can assure you that our smallest hospital, which
probably consists of about eight beds, very small, serving a
rural population, has the exact same level of sophistication as
our Salt Lake City based hospitals. That comes down to using
standard technologies and the ability to train across the
organization and move those things out.
If we had to do something independent in each of those
rural areas, the costs would be prohibitive and the value to
the organization would be very slim. So I guess I'm stuck on
the standards route. But, again, by applying good, solid
standards with good technology, if I get in an accident in
Panguitch, Utah, which hopefully none of you know where it is,
they have exactly the same information and can provide me just
the exact level of care.
Mr. Lujan. Appreciate that, Mr. Probst.
Dr. Romine. I appreciate that. I also agree that standards
actually can help to drive the adoption more readily in all
sectors, including rural sectors, because of products that are
affiliated with those standards or that conform to those
standards are well understood.
I will also say some of the testing infrastructure that
NIST is developing in partnership with ONC is publicly
available. In fact, all of our testing infrastructure is
publicly available, our test tool kits are publicly available.
We try to make them as friendly as possible for providers to be
able to use.
And so we pay close attention to that.
Mr. Lujan. I appreciate that.
And as my time expires, Mr. Chairman, just again, as we
look to programs across the United States, again to highlight
what's happening in New Mexico with Project ECHOTM, the
extension for community healthcare outcomes, now providing
opportunities with our veterans as well, where via telehealth
they are able to reach out across rural parts of the country
now. And through the communication they actually have a series
of physicians that can enter into any of these diagnoses and
they can work together collectively. They can also come out and
talk about the best-case scenarios or mistakes that were made.
So they are learning together, they are keeping their
certifications up together. But they are also making sure that
they are delivering the best possible care, especially when it
comes to the shortage that we have of family care specialists
in some areas, that even in the most remote parts of the
country they are able to get that.
So thank you very much, Mr. Chairman.
Chairman Quayle. Thank you, Mr. Lujan.
Now recognize the gentleman from Texas, Mr. Neugebauer.
Five minutes.
Mr. Neugebauer. Thank you, Mr. Chairman. Mr. Mostashari,
Mr. Romine--Dr. Romine.
Authenticating the patients is an important part of the
critical health IT part and setting up security parameters to
protect that. And how--what are we doing in the IT world to be
able to make sure we got the right patients being matched up
with the records?
Also, what are we doing to allow patients to look at and to
use those records and to, you know, verify them that those
records are correct? And can you kind of share a little bit
about what's going on in the next phase?
Dr. Mostashari. Absolutely. When we talk about being
patient centered, we have to take that very seriously. And one
of our most important principles is not just having the patient
be at the center of the care, but the patient literally being
able to access their own information and to participate in
their care as partners. Someone said if we want to get better
care at lower cost, we've got to use every resource we have.
And the patient is the most underutilized resource in
healthcare.
So we've actually been big advocates for and pushing on the
standards side as well as on the policy side for patients to be
able to exercise their legal right to get access to their own
health records online and to be able to view it, to be able to
download it, to be able to store it securely.
That all requires, as you point out, that there be means of
authenticating the patient. And many of the organizations who
have implemented this at a large scale are able to--whether
it's the Veterans Administration, which has had a million
downloads among veterans of the blue button of their health
record, whether it's other organizations, healthcare
institutions that have found that by engaging with their
patients online, they help have patients keep their
appointments, take their medications, and be more active in
their healthcare. It's a high priority for us.
Dr. Romine. I'd like to make mention of three quick things.
One is we're working in the area of patient identification
matching and our researchers have developed a tool that
supports the testing of patient identifier cross-reference and
patient demographic query, test cases for both HL7 versions 2
and 3.
The second thing is NIST is the home to the program office
for the National Strategy for Trusted Identities in Cyberspace,
which is a major program for identity management, broadly
speaking, but I think will have serious implications with
regard to helping in this context.
And, third, we have a National Cyber Security Center of
Excellence that we have just stood up. And our first use case
is going to be on health IT and patient records, particularly
focused on small providers' ability to transfer secure and
private records.
So all of those things I think will contribute.
Mr. Neugebauer. I think someone--did you?
Dr. Fields. Yes. I wanted to comment on your question
patient matching. The lack of patient matching is a major
health safety issue. You can imagine if we merge records that
shouldn't be merged.
Congress actually prohibited the use of appropriated
funds--I'm going to quote here--``to promulgate or adopt any
final standard for unique health identifier for an
individual.''
You may remember that part of HIPAA, back in 1996 or '98,
there was the request for a unique patient identifier. And it's
been prohibited by Congress to actually evaluate that.
And one of the tasks that HIMSS had when we were on the
Hill in the fall was not that we dictate what type of
identifier we have, but that Congress have a consistent,
nationwide patient data matching strategy that we start to look
into, that Congress actually authorized the ability for us to
look into a patient data matching strategy. Because without
that, we are at risk for patient safety.
Mr. Neugebauer. Yes.
Mr. Probst. Might I second Dr. Fields.
We spend about $5 million a year trying to do patient
identification accurately for our patients. You talk about
waste in the system, that's a significant amount of waste and
it seems to be something--it's one of the seven standards I
wrote in my written testimony--that we need to tackle because
it's incredibly frustrating and unsafe.
Dr. Fields. And it takes time and delays care. What happens
from a practical point in a hospital, when the computer
doesn't--when the computer is programmed to say these two
patients, these two records may not be the same patient, but
maybe they are, then that data goes into a holding zone where a
human being then looks at it to determine what happens to it.
So while it's in that holding zone, that data is nowhere near
available for clinicians to be able to give care.
So each organization has come up with their own strategy,
because we as providers recognize the importance that the data
that goes into the computer has to be for the patient that we
think it is. So we have these complex algorithms and complex
human processes that eat up time and actually interferes with
the ability to give care.
So I really plead with you to promote this investigation
for a national strategy for patient identification. We have it
for the clinicians, we have it for the insurers. We do not have
it for the patients. And that's where the risk is.
Mr. Neugebauer. I would make a suggestion that--you say
Congress hasn't given that permission. I'm pretty sure that the
patients would be better off if Congress didn't make that
decision.
But if the industry would come forward with, you know, a
recommendation where you've actually had some experience,
what's working, what's not working, but, you know, for Congress
to set those standards----
Dr. Fields. Oh.
Mr. Neugebauer. --I think we would rather hear from you
than--I'm pretty sure I've got some really smart colleagues,
but I feel a lot of them don't really know a lot about this
particular issue.
Dr. Fields. Thank you. Let me correct myself. I don't mean
for Congress to in any way set the standard. What I am asking
for Congress is to take away what had previously been stated
and that we come up with a strategy that Congress allow the
investigation, that Health and Human Services, ONC, the
appropriate government agency, bring together the private
sector, the government sector in to study the situation and
come up with a strategy. Because from my understanding that
Congress prohibits the use of appropriated funds to be able to
look into this.
Ms. Little. I think I would just like to add and agree with
Dr. Fields. What I think we would really like to see is an
opportunity to collaborate on a strategy and see a strategy
come forward.
As a technology supplier who provides software that
connects things together, we also provide software that
provides patient matching. And once you get outside of an
individual healthcare organization, even a large delivery
network like Intermountain Healthcare, and you complicate that
with a regional implementation or a statewide health exchange
implementation, those complexities and algorithms become even
more important and the accuracy of them become more important.
So we would also value and look forward to participating in the
opportunity to see a strategy.
Chairman Quayle. Thank you very much.
Now recognize the gentleman from California, Mr.
Rohrabacher, for five minutes.
Mr. Rohrabacher. Thank you very much, Chairman Quayle, and
to our witnesses as well.
I'm the first one to admit that I have limited knowledge
into the area that we are talking about. So I guess I have to
ask some fundamental questions.
We seem to be talking about interoperability and privacy is
some of the issues, but as the discussion has gone on, it seems
that we are talking about more than electronic health records.
It seems to me that we're morphing into a discussion at some
point into setting up a system of medical cooperation that will
ensure that any hospital has the best technology available to
it. That's different than medical records.
So far, I take it the original goal was to have a national
system where we could easily exchange information. That seemed
to be a goal that people could actually accomplish within a
certain budget.
I mean, I know people have apps right now. My wife actually
invented an app over the Internet. And it's relatively--a lot
of people are utilizing the Internet in a relatively
inexpensive way. But we've already spent $2 billion on this
information sharing, which does mirror some of the things that
I think I've seen on the Internet.
But are we now morphing this into something that's far
beyond just medical records that's going to cost more money
that we may not ever have?
Dr. Mostashari. The payments authorized under the CMS
Medicare and Medicaid Health IT Incentive Program are
specifically for the meaningful use of certified electronic
health records.
Mr. Rohrabacher. Just for the records----
Dr. Mostashari. Certified----
Mr. Rohrabacher. I'm not saying that we can't do a lot of
other things in the healthcare arena that are--that will be to
the benefit of our people. But I do know that when people try
to do everything, they generally don't get anything done.
And so we're just focused on the records. This program is
still focused on just setting up a system so that if someone
goes into a hospital his medical records can immediately be
available?
Dr. Mostashari. The Medicare and Medicaid incentive
payments are specifically for the meaningful use of electronic
health records that are certified to meet interoperability and
functional standards.
Mr. Rohrabacher. How much has been spent for that already?
You said it was $2 billion?
Dr. Mostashari. There's $2 billion in appropriated funds
for the grant programs and to establish the infrastructure like
the regional extension centers is the examples I gave. And then
there are mandatory payments, as Chairman Quayle described in
the beginning, for eligible professionals and hospitals, and
approximately 7--a little bit over $7 billion has been spent to
date out of an estimated $20 billion.
Mr. Rohrabacher. That's to come up--that money was spent to
come up with a basic set of standards or to set up a system?
Dr. Mostashari. Those payments are for individual eligible
professionals and eligible hospitals who earn those mandatory
payments if they adopt a certified a health record and they use
them in these certain ways, check for drug, drug allergies,
collect information needed, and exchange it.
Mr. Rohrabacher. So what we have spent the $2 billion on is
to encourage people to participate in a system that is a
standard system for the country. Is that right?
Dr. Mostashari. The incentive payments, which is the--the
44,000--up to $44,000 over five years for eligible
professionals and the 2 million-plus for hospitals is payments
to them for whatever system they choose, but the systems have
to meet the national standards.
Mr. Rohrabacher. And so but the point is to establish the
national standard?
Dr. Mostashari. The goal is to get widespread adoption and
meaningful use of the electronic health records, which include
the standards.
Mr. Rohrabacher. Let me just suggest that $20 billion to
set up a standard is a big price category.
Dr. Fields. May I jump here?
Mr. Rohrabacher. Chairman Quayle will----
Dr. Fields. May I speak?
Chairman Quayle. Go right ahead.
Dr. Fields. Further, the point I want to make is that the
goal is to have tools to help clinicians provide care. The
ultimate outcome is improved patient care and health outcomes,
a healthy American population.
Mr. Rohrabacher. Okay, that's different than what he just
said.
Dr. Fields. No, it's the same.
Mr. Rohrabacher. No, I'm afraid it's not. That's your
opinion on that. He just said it was medical electronic
records, not what you just said.
Dr. Fields. And what I am saying is the medical electronic
record is imperative for us in the United States to be able to
give high quality care, which ultimately will be healthy
people. Without these tools so we can go through research study
after research study that those organizations that have
standards based electronic health records, and they are using
it in a meaningful way, like Intermountain Healthcare, and many
other organizations, because of the data that is available to
them to give care to individual patients and then to their
population, it's because of that information that we're able to
have healthier populations, which I believe is something that
everyone in this room wants.
Mr. Rohrabacher. No one has any argument with the fact that
we need to have the ultimate amount of information available to
anyone who's a health provider for the person that comes in for
treatment. There's no doubt about that.
It seems to me, however, Mr. Chairman, that billions of
dollars were to set a standard that would permit that type of
availability. As I say, I see people setting up businesses
every day on the Internet that provide information on a global
scale to various businesses and various enterprises. And it
just doesn't seem to take that much money. And at a time when
we're trying to bring down the level of deficit spending so we
can actually provide the medicine, provide the x-ray, that it
seems like to me the $20 billion expenditure is an awfully high
price tag for something that the private sector seems to be
doing and offering at a much lower rate.
Thank you very much.
Chairman Quayle. Thank you.
Now recognize the gentleman from Michigan, Mr. Benishek,
for five minutes.
Mr. Benishek. Thank you, Mr. Chairman.
I have a question. I'm a physician as well. And I've been
familiar with several different electronic medical records. And
some of them work better than others. I mean, I worked at the
VA system, and that's a pretty good system as far as they go,
as far as I'm concerned.
My biggest concern really is this mandating the
implementation of electronic medical record that doesn't work
as well as the VA system. Because many of the systems I've seen
in the private sector are expensive, they are costly to
maintain, and they don't do what we want them to do, which is
provide, you know, sort of a universal access to information.
You know, I know in my practice we have electronic medical
records but we're still sending or trying to get a fax of an x-
ray report because it's not available on this electronic
medical record that I have.
And there's a lot of people in private practice that simply
can't afford to spend, you know, 65,000 or $150,000 dollars on
a electronic medical record system for their practice, plus a
$5,000 a month maintenance fee for a system that doesn't
produce.
So I have a real problem with, you know, mandating
implementation of a system that doesn't do, you know, what
result that we want.
And I think that, frankly, this implementation or
interoperability, you know, when you can't get a lab test
because it was done in another hospital that your system does
not talk with, it wasn't worth that $150,000 for me to tell my
girl to have to get, you know, get this test. You know.
So explain to me why are we implementing it before it's
universally interoperable.
Dr. Mostashari. So I think you're raising the issue of
upfront costs and not just the costs for purchasing the system,
but also implementing it and changing the work flows and the
challenges that are there.
And you mentioned, you know, for a practice with a few
physicians, it can cost tens of thousands of dollars. That has
been what has held back the adoption of the electronic health
records in the U.S.
And Congressman Rohrabacher's question about what are we
paying for, what we're paying for is providers like yourself to
be able to be receiving the payment over a period of several
years if they choose to adopt and meaningfully use the
technology.
Mr. Benishek. Payment doesn't cover those costs. Okay. I've
talked to, since I've been here in Congress, I've been talking
to many small hospital administrators. And they say, we got
this one-time payment to implement this electronic medical
record, but, you know, it's not going to cover what it's going
to cost us. So I don't know what we're going to have to cut in
order to comply with this rule. But, you know, our budget is
not getting bigger, you know, with reimbursement. It's getting
smaller. And this is a one-time payment we got but now we have
an ongoing cost associated with it that we're not being paid
for.
It's really frustrating to me to hear, you know, a small,
critical-access hospital telling me this.
Dr. Mostashari. Sure.
Mr. Benishek. Because, you know, they don't have any extra
places to find money.
Dr. Mostashari. There are--one of the approaches that
Congress took in HITECH was not to have the Federal government
procure the software, but to really leave it to the market-
based approach to let the hospitals and providers be the ones
to choose what system works best for them. And there are a
greatly expanded range now of software products each with their
own usability and the cost structures, lease models, web-based
models and so forth that providers can now choose from.
And what we're seeing in practice is that the amount of the
incentive payments has been sufficient to produce this great
acceleration in the adoption of electronic health records.
Mr. Benishek. Well, the people have implemented them
because they are sort of terrified of the Federal government,
you know, cutting their reimbursement. The people I've talked
to said they had to do it because the rule came in. But they
are finding that their costs exceed, you know, what they're
getting reimbursed. So to me, that's a problematic issue.
And I didn't hear any answers in any of your testimony to
this part of the problem. Because I have seen it in real life
myself and, you know, I visit lots of hospitals. What I just
mentioned to you, you guys didn't talk about at all in any of
your testimony.
So it's a great concern to me.
I mean, it all sounds great. I mean, I want great medical
records. And, you know, it's great to have the medical record
in your hand. But if the hospital goes broke, that access to
care is not there either.
I think my time is up. Thanks.
Chairman Quayle. Doctor, you want to answer that?
Dr. Mostashari. The program is designed and legislation
passed by Congress in HITECH does not have a mandate, that it's
a voluntary program. And if providers sign up for the program,
as 75 percent of the hospitals have already done and more than
half of providers have done, then they can earn the incentive
payments. And if they don't, it basically says that the
Government feels that Medicare is not getting 99 cents on the
dollar value for the care that we are buying from the
providers.
So it is the way that the legislation was set up. And I
believe that it is an important step towards getting a national
infrastructure that can help public health, that can help
research, and that can help patient care.
Chairman Quayle. I want to be real quick.
But it is true that if you don't participate, you get cut
in your Medicare and Medicaid reimbursements. Is that correct?
Dr. Mostashari. Yes.
Chairman Quayle. I do want to thank all of the witnesses
for their valuable testimony, and the Members for their
questions.
Members of the Subcommittee may have additional questions
for the witnesses, and we will ask you respond to those in
writing. Record will remain open for two weeks for additional
comments and statements from members.
Before we gavel this closed, this is more than likely going
to be the last Subcommittee hearing of this Congress. And I
just want to thank all of the Members of this Subcommittee for
their valuable input. I really want to thank the Ranking
Member. She has been a great partner to work with. And this
Subcommittee has been very bipartisan. We want to focus on the
technological and innovation in this country.
And I also do want to thank all of the staff both on the
majority and the minority side for making sure that this whole
Subcommittee runs so smoothly.
And, Ms. Edwards, would you like to say anything?
Ms. Edwards. Mr. Chairman, I want to echo that. And I just
want to say to you that I know a lot gets said about how
Congress works or it doesn't. And I just want to say to you
that it has actually been a real joy to be on this Committee
with you as Chairman because we've had some incredibly
thoughtful discussions with great witnesses and exploring areas
that you don't often get to do in the Congress and looking for
the future. And this panel today was more evidence of that.
So I really do appreciate your leadership, appreciate your
service in the United States House of Representatives
representing your Congressional district in Arizona. And I wish
you incredibly good luck, good fortune into the future. Thank
you.
Chairman Quayle. Thank you very much. And I echo those
sentiments to you as well. This has been a great two years on
this Subcommittee.
And I want to thank you, the witnesses, again. This was a
great hearing today. And you are excused. Thank you all for
coming. Hearing is now adjourned.
[Whereupon, at 11:45 a.m., the Subcommittee was adjourned.]

Appendix I

----------

Answers to Post-Hearing Questions

Responses by Dr. Farzad Mostashari

[GRAPHIC] [TIFF OMITTED] T7035.076

[GRAPHIC] [TIFF OMITTED] T7035.077

[GRAPHIC] [TIFF OMITTED] T7035.078

[GRAPHIC] [TIFF OMITTED] T7035.079

[GRAPHIC] [TIFF OMITTED] T7035.080

Responses by Dr. Charles H. Romine

[GRAPHIC] [TIFF OMITTED] T7035.081

[GRAPHIC] [TIFF OMITTED] T7035.082

[GRAPHIC] [TIFF OMITTED] T7035.083

Responses by Mr. Marc Probst

[GRAPHIC] [TIFF OMITTED] T7035.084

[GRAPHIC] [TIFF OMITTED] T7035.085

[GRAPHIC] [TIFF OMITTED] T7035.086

Responses by Ms. Rebecca Little

[GRAPHIC] [TIFF OMITTED] T7035.087

[GRAPHIC] [TIFF OMITTED] T7035.088

[GRAPHIC] [TIFF OMITTED] T7035.089

Responses by Dr. Willa Fields, DNSc, RN, FHIMSS

[GRAPHIC] [TIFF OMITTED] T7035.090

[GRAPHIC] [TIFF OMITTED] T7035.091

[GRAPHIC] [TIFF OMITTED] T7035.092

[GRAPHIC] [TIFF OMITTED] T7035.093