good morning i call this hearing on the house small business committee to order in the last few decades information technology has revolutionized virtually every american industry today previously complex on is this more true than the our nation's healthcare sector by the year two thousand and fourteen the national information technology coordinator expects the united states to have a nationwide network of electronic health records today several bipartisan proposals to porting this network are working their way through congress both democrats and republicans recognize the value in h i dean after all it promises to not only control costs but also to improve quality that is an especially appealing prospect given the skyrocketing price and declining value of modern health care in today's hearing we will discuss the value of a strategy and also explore the various going certain surrounding its use if properly implement that haiti can streamline the flaws of complex health care data and doing saw that the knology will improve communication between doctors and hospitals and even the hearing complexities of medicine and well structured communication network is of the utmost importance but this by growing support for health care technology particularly in the form of eighty five hundred dollars a month for small health care providers with limited resources they say up front costs are enough to break the bank in addition to the way the financial obligation files in light of these facts some health professionals worry that h i d holes will thankful for health care fraud at the same time all there are concerned that technology my conflict with appropriate systems oftentimes this technology caters only to mainstream medical practices and even the smaller more specialized businesses behind health information technology has the potential to revolutionize american medicine but unfortunately is series of concerns are blocking large scale implementation there is no silver bullet solution to america's broken health care system that are however in a number of ways to address the issue for one financial incentive to hit to users will help spur uptake so will strengthen in private study regulations for health records as we move forward in the quest to improve health care coverage uncaught costs we can look to current technology future innovation and yet in doing so we must be sure with caution all the wisely risk both small providers and the health and security of their patients with that i would like to take this opportunity to thank all the witnesses for coming here today  this morning i'd like to thank each one of our witnesses who have taken the time out of their busy schedules to provide this committee the testimony that they'll be giving us here this morning i'd like to extend a special welcome to a fellow cincinnati and doctor  board who also happens to be my personal physician so i'm particularly pleased to see him here today and i'll introduce him more formally later over the past thirty years nearly every sector of the american economy has undertaken a sweeping transformation in the way information is collected and managed and transmitted as a result productivity and efficiency consistently has increased yet today healthcare one of the most significant one of the most important sectors of the american economy has not yet made this transfer from ation at least completely although we're certainly beginning that at this time this hearing is an important part of letting congress know what's happening in that area at the present time some of the most serious challenges facing health care today medical errors in consistent quality and rising costs can at least partly be addressed through the effective application of health information technology linking all elements of the health care system improves information available to physicians and boosts quality and and hansen's preventive care and reduces errors on april twenty second two thousand and four the president signed an executive order which established the position of the nash health information technology coordinator within the office of the secretary of department of health and human services and announced his commitment to the promotion of health information technology to lower costs reduce medical errors improve the quality of care and provide better information for physicians as well as for patients in particular the president called for widespread adoption of electronic health records and for health information to follow patients throughout their care seamless and secure manner of september two thousand and five report by the rand corporation estimated that seventy seven billion dollars annually could be saved if ninety percent of physicians adopted health information technology the report also estimated another four billion dollars in savings from reductions in prescription errors a new report indicates that more than thirty five million prescription transactions were sent electronically in two thousand and seven which was  hundred seventy percent increase over the year before despite documented advantages and federal support physician adoption of health information technology has been slow research indicates that concerns about high cost uncertain ever turn on the investment and worry over the usability and obsolescence of new technologies rank highest among reasons surveyed physicians have not yet adopted health information technology doubts about the privacy and security of patient data practice compliance with the health information portability and accountability act of one thousand nine hundred ninety six and the potential for inappropriate disclosure of patient information to third parties ranked just behind the financial concerns that i mentioned previously health information technology is a complex issue the decision to implement health information technology in a small medical practice is considered an act of courage by many physicians it will impact their workflow staff patients and practice finances successful adoption of health information technology including electronic medical records will require evaluation selection planning implementation and effective of technology early adopters agree that there are multiple benefits but recognize a cultural change is required here i look forward to working with you on this important issue and this would be another bipartisan issue that we can work on together as we've done many times in the past the rest of congress and not do it but you and i do and again i want to thank you for your cooperation in this hearing today and i want to thank the witnesses we're looking forward to hearing our testimony and i go back about my t for an opening statement thank you madam chair it's great to see that this meeting has been held up before my days here in washington actually ran a company called my health card which was electronic medical records that people care and they're in their pocket a company that we found very difficult to get off the ground very difficult to to get the hospitals to their programs whether it be g e medical or whether it be op ass or whether any of the major electronic medical record groups that to get you to do interface with their systems but we did a company that allowed us to do that and in relationship with the university of tennessee as medical system we actually worked with the geriatric population we we gave them all their cards for free the hospital use it more as a marketing tool but we realized in a very short time that it actually saved lives  so there was a small was in the chain pharmacy but it was actually a pharmacy allowed us to be able to put the database into their system so the person would go to the primary care physician able to only look at the information that the the doctor put on the med sides and we found out we saw jug drug interactions from the primary care physician to a specialist the specials had no idea what the primary care physician had prescribed and we s numerous times of drug interaction it was called by the physician he didn't have the phone number because it was time stamped and dated on the card and they were recognized very quickly that they had a problem and so my and and the geriatric population we saw a decrease in and days in the hospital days in the thompson emergency room was significantly drop the hard part that we had was because the interfaces with the big companies if you will they want to capture that da we had other problems with pharmacies to be able to allow the other pharmacies they want to capture that data they wanted their data for their own personal we didn't look at it we didn't care about the data from the standpoint of what meds were being taken we just want to make sure that that the health and the care of the patient was taken care of first and foremost and then we realized that the hospitals actually had no idea what was happening internally with our hospital when a person comes to the emergency room because the outsource their emergency room that information technology system is different than the one that they have inside the hospital then they go to an operating room although our software is different than the outpatient surgery software and so you had no way to communicate within the hospital so we found ourselves having to implement interfaces with all the systems but the time we got one interface completed we had to start all over because it was time to complete the interface again so we went through this a complete circle of finish an interface with the time we got it done in order to make the court work completely throughout the hospital we were for ever doing an interface and that costs money so i commend you for being here today and talking to some very important subject we actually one of the one of the most important things i was able to do with the company it seems like with our philanthropy work more than anything is kids with foster care the child would go from place to place to place the medical records was never without and so this card they can take with them so medicare i thank you for holding this very important a way to cut down costs of our overall medical crisis that we're in and i think this is going to be a very important part of making a difference on health care thank you madam chair and the  my story and about how we integrated electronic medical records into our practice some of the challenges we face cost we incurred and ultimately benefits that we rate both for our practice and our patients in one thousand nine hundred two our practice was the fifth medical practice in the country and the first inner circle practice to go fully paperless implementing this new system was no easy feat with could not simply plug in the machine and flip the switch because the swift systems are set up in a one size fits all manner it took over a thousand  configure our system and create inertia article templates so if there were no existing specially specific programs all told implementing the first system required about a year of prep time to purchase configure and implement in addition it took about another year to refine it and for our practice to become proficient with it the cost of setting up and maintaining this system were significant we've been about fifty thousand on the initial had a set up the system also required regular maintenance and upgrade which cost us at that time about five thousand a month during the early years our vendor continued to create a new system to upgrade every improvement resulted in some unintended consequence which required a software engineer time to repair implementing the system was particularly difficult on the staff and not everyone was pleased to move to this new paradigm shift in our practice these changes call coupled with the daily stress of working in a nurse surgical practice simply proved too much and we suffered a thirty percent staff turnover a had difficulty in adapting to and learning entirely new procedures and methods this produced problems with continuity of patient care loss of productivity as we went to the process of hiring and training new staff as our practice transition to e m r we also had to keep the paper records for legal reasons inner operability was not even a concept at that point and there was no talking between systems every paper document had to be scanned and transferred into the e m r notwithstanding the challenges of physicians  our staff recognize the benefits go on paperless the efficiency of the practice increased significantly staff no longer had to search for paper charts in order to answer patient phone calls and they could quickly get information to the neurosurgeon our ability to quickly review and create new hundred ninety seven we converted to a windows based system and we went to the same process again incurring a similar cost downtime and lost productivity this new system was an improvement and significantly expedited patient care maintaining this system for last ten years has been a challenge hardware has failed servers have been hacked security requirements but ticket hippa are onerous and keeping a full time employee in a competitive job market has been difficult this year we are once again in the process of converting to yet another new program and platform and incurring all the same cost as before even with our practices lengthy history and experience with e m r this upgrade has been a costly and difficult process with considerable loss of productivity furthermore and notwithstanding our experience that after we purchase a system we found flaws in the vendors product madam chairman as you can see our practice has been ahead of the curve in using him arm unfortunately most positions have not shared this experience despite the fact that he mar has the potential to improve the delivery of healthcare most of the sions have been slow or reluctant to adopt these systems a recent study found only four percent of physicians have a fully functional e m r system so we have a very long way to go and a three or four year timetable for name implementation is optimistic at best perhaps a new prescribe and provisions included in the recently passed medicare bill will help encourage physicians to implement this entry level mode of the m r however over seventy percent of the three billion prescriptions written every year are by primary care in america emergency room physicians currently the to grow groups with the lowest rates of e m r adoption significant implementation issues such as the pharmacy familiarity proposed and fatally flawed new rigid da rules for schedule two drugs which will make compliance by most neurosurgical practices only create more resentment among some positions it took over ten years for the stethoscope to become widely accepted as a medical to waddle take time we're on the right path in promoting this general agreement that i will improve patient patient safety  enhanced quality care result in more efficient practice and better health health outcomes should follow we should not deviate from the premise nor should we rush launching a complex system to satisfy political or administrative goals thank you for the opportunity to share q thank you madam chairwoman members of the small business committee i'm dr robert off mic director of the department of quality improvement psychiatric services the american psychiatric association is an honor for the a p a to present this testimony to the committee regarding unforseen charge to small specialty practices the a p a represents more than thirty eight thousand psychiatric physicians nationwide our members work with a variety of systems and care of care including emergency departments in patient settings and small private practices the development of health information technology and corresponding federal and state laws and regulations are a matter of great interest and concern to the a p a our members and their patients the a p a has one committee of members so we focused on various aspects  r's and the second committee so we focused on privacy and confidentiality concerns carefully structured a national national h i t infrastructure has great potential to improve the overall quality of care provided to pay to patients in form health professionals later standards of care and to improve communication of health care information across settings however there are two significant challenges to widespread adoption and implementation of h r systems that the a p a would like to highlight in our testimony today first the assurance of confidentiality is at the core of any effective patient physician relationship electronic health information exchange could erode patient trust and impede clinical care if it's a tila tate's dissemination of sensitive information without sufficient precautions to protect privacy and security second a significant percentage of his members operate in solo private practices in which the upfront cost of implementing an e h r system present a considerable barrier to adoption protecting and strengthening the confidentiality of the patient physician relationship is a critical to providing the highest quality medical care this is particularly true with respect to psychiatric care because of ongoing inequity in insurance coverage employment discrimination and social stigma for people with mental illness and the unintended consequence of me h r is that patients may be discouraged from seeking treatment or sharing information that is critical to their care due to concerns that it will be improperly disseminated treatment of behavioral health and other disciplines medicine often requires patients to share sensitive information such as sexual history drug use pregnancy history and hiv status according to h h s two million americans or seven percent of those with mental illness do not seek treatment specifically due to privacy concerns two thousand and seven harris interactive poll found that seventeen percent of patients withheld information from health professionals because of worries the information might be disclosed these rates are likely to be even greater if information exchange is electronically enabled and the confidentiality and security of health information cannot be assured the trust required for productive therapeutic relationship is undermined by accounts of health care workers who view electronic records of celebrity patients as well as by the loss or theft of laptops and cd containing large quantities of health information apologizing and making improvements one status last is not a sufficient response privacy and security provisions must be keystones to the development of a national uniform has he infrastructure there are many approaches that could help protect the patient physician relationship and optimize the advantages of the e h r environment examples include ensuring the strictest security protections and auditing are employed and giving patients a clinician a degree of control as to who can access sensitive information despite the widespread recognition of the potential t holds to increase efficiency and quality health care delivery system adoption rates remain low a recent study in the new england journal of medicine found that only four percent of physicians had adopted fully functional e h r s and those that had tended to be in larger practices consistently casas cited as the largest barrier to wider adoption although estimates vary widely studies report the caught the total cost for implementing office based e h r s range from twenty five thousand to forty five thousand dollars per patient per physician and subsequent annual cost for maintaining the system range from three thousand to nine thousand dollars per physician per year these senators are amplified for smaller practices where there are fewer physicians to share the costs psychiatrists involved in solo practice a significant percentage of a p a members often have little or no administrative support staff further increasing the physician's responsibilities with regards to selection implementation and maintenance of the system and decreasing the time available for clinical care the a p a appreciates the effort for small the small business committee has made to address confidentiality concerns while developing a chatty infrastructure which a great potential to raise the overall quality of care provided to patients this goal can be met without breaching privacy protections and can assure patient trust if privacy is made a cornerstone of hiv to haiti development the a p a further recommends the use of financial incentives such as grants or other support to help practitioners and fellow or small group practices cover the cost of hardware and software again we thank you for the opportunity to testify today and we hope the members of the committee will consider the a p a as a resource at this process continues thank you mis a pediatrician in private practice at the pediatric center in stone mountain georgia he is a fellow both of the american academy of pediatrics and the society adolescent medicine he has served as the chair of the policy committee for the academy's steering committee on clinical information technology now the council on clinical information technology on the academ committee on adolescents and is the past chair of the georgia a p chapters committee on adolescents the american academy of pediatrics is a professional organization pediatricians with more than sixty thousand members trained to deal with the medical care of infants children and adolescents and we welcome you today to this committee sir of practicing physician pediatrician in stone mountain georgia and you've heard my credentials let me tell you that pediatric sixty percent of pediatricians practice in small businesses pediatricians are asked by industry to pay extra for electronic health capabilities to deal with the complexities of pediatric care you're reimbursed by the government less well to provide these services then i don't care a colleague's let me explain pediatricians are different from other doctors because the major government program pays for the health care of children is medicaid not medicare medicaid has a major major impact on children's care paying for forty percent of births in the united states and i believe sixty percent in georgia medicaid faces physical problems but not because of them more than thirty million children that are covered by the program these children account for more than fifty percent of medicaid population but only twenty five percent of its cost pediatricians find it very costly to purchase health information systems a real factor in our inability to afford these expensive technologies is the payment rates that pediatricians receive under medicaid under medicaid payments for providing the same medical services every sixty nine percent of what medicare pays so the margins under which most pediatricians practice up to practices operate a much more severe than those of our adult colleagues furthermore if incentives for adopting health information technology are structured to flow through the medica program as is now largely the case in sixty thousand practicing pediatricians would be excluded from the opportunity to qualify for these and so on it's the already an equitable system of funding programs for children will only be worse and this is not a good investment in our future unfortunately even if we do receive help to adapt health information systems in our practices we face special constraints because a special needs child care and the rules governing governing privacy for  patient population electronic health records are frequently designed for adult care and did not take into account the specific needs of children there are a number of special functions that a pediatric health record requires that must be implemented in  we pediatricians are hampered you know ability to properly document care yet the vendor community frequently asked us pediatricians to pay extra for these capabilities even if they're willing to provide them at all major areas in which these needs arise documentation in news asian registry management growth tracking medication dosing privacy privacy for special pediatric populations and in providing normative data by age body mass index a developmental stage a particular concern in today's discussion of health information technology incentives or advice and privacy concerns the help of privacy law and its implementing regulations defer to the state and other applicable law on the issue of adolescent privacy laws about age of consent vary from state to state and according to the patients presenting problem the electronic health records need to be able to reflect this as an example in many states adolescents who present for the outpatient treatment of mental health disorders made c sent to their own treatment before they become eighteen years old pediatric practices typically have policies in respect with respect to what portion of an adolescent care should be handled with special privacy protections e h r are should be flexible enough to handle these practice level or sees the recording of patient and parental consent chowed asset and the permission to treat are frequently less straightforward for children and adolescents then for the care of adult separation of the patients can stand  parents or guardians consent is particularly important in the areas of testing for drugs screening for surgery transmitted illness or in the case of abuse remember also that our privacy concerns are not limited to minors we pediatricians continue to care for young people throughout through age twenty one in some cases beyond my written testimony also focuses on other special cases children in foster a custodial care consequence sent by proxy children in for