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HEALTH INFORMATION EXCHANGE: A PATH TOWARDS IMPROVING THE QUALITY AND VALUE 

OF HEALTH CARE FOR PATIENTS 

HEARING 

OF THE

COMMITTEE ON HEALTH, EDUCATION, 

LABOR, AND PENSIONS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

ON

EXAMINING HEALTH INFORMATION EXCHANGE, FOCUSING ON A PATH 

TOWARDS IMPROVING THE QUALITY AND VALUE OF HEALTH CARE 

FOR PATIENTS 

JUNE 10, 2015 

Printed for the use of the Committee on Health, Education, Labor, and Pensions 

( 

Available via the World Wide Web: http://www.gpo.gov/fdsys/ 

COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS 

LAMAR ALEXANDER, Tennessee, Chairman 

MICHAEL B. ENZI, Wyoming 

RICHARD BURR, North Carolina 

JOHNNY ISAKSON, Georgia 

RAND PAUL, Kentucky 

SUSAN COLLINS, Maine 

LISA MURKOWSKI, Alaska 

MARK KIRK, Illinois 

TIM SCOTT, South Carolina 

ORRIN G. HATCH, Utah 

PAT ROBERTS, Kansas 

BILL CASSIDY, M.D., Louisiana 

PATTY MURRAY, Washington 

BARBARA A. MIKULSKI, Maryland 

BERNARD SANDERS (I), Vermont 

ROBERT P. CASEY, JR., Pennsylvania 

AL FRANKEN, Minnesota 

MICHAEL F. BENNET, Colorado 

SHELDON WHITEHOUSE, Rhode Island 

TAMMY BALDWIN, Wisconsin 

CHRISTOPHER S. MURPHY, Connecticut 

ELIZABETH WARREN, Massachusetts 

DAVID P. CLEARY, Republican Staff Director 

EVAN SCHATZ, Minority Staff Director 

JOHN RIGHTER, Minority Deputy Staff Director 

(II) 

C O N T E N T S 

STATEMENTS 

WEDNESDAY, JUNE 10, 2015 

Page 

COMMITTEE MEMBERS

Alexander, Hon. Lamar, Chairman, Committee on Health, Education, Labor, 

and Pensions, opening statement ....................................................................... 1 

Murray, Hon. Patty, a U.S. Senator from the State of Washington, opening 

statement .............................................................................................................. 3 

Burr, Hon. Richard, a U.S. Senator from the State of North Carolina ............... 5 

Warren, Hon. Elizabeth, a U.S. Senator from the State of Massachusetts ........ 33 

Cassidy, Hon. Bill, a U.S. Senator from the State of Louisiana .......................... 35 

Casey, Hon. Robert P., Jr., a U.S. Senator from the State of Pennsylvania ...... 37 

Franken, Hon. Al, a U.S. Senator from the State of Minnesota .......................... 39 

Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode Island ...... 40 

WITNESSES

Payne, Thomas H., M.D., FACP, FACMI, Board Chair-Elect, American Medical Informatics Association, Medical Director, IT Services, UW Medicine, 

University of Washington School of Medicine, Seattle, WA ............................. 6 

Prepared statement .......................................................................................... 8 

Richardville, Craig D., MBA, FACHE, Senior Vice President and Chief Information Officer, Carolinas HealthCare System, Chair, Premier Healthcare 

Alliance Member Technology Improvement Committee, Charlotte, NC ......... 13 

Prepared statement .......................................................................................... 15 

Bechtel, Christine, M.A., Advisor, National Partnership For Women and Families, Chair, Health IT Policy Committee Consumer Workgroup, President, 

Bechtel Health, Olney, MD ................................................................................. 19 

Prepared statement .......................................................................................... 20 

Patterson, Neal L., MBA, Co-Founder, Chairman, Chief Executive Officer, 

Cerner Corporation, Kansas City, MO ............................................................... 24 

Prepared statement .......................................................................................... 26 

ADDITIONAL MATERIAL 

Statements, articles, publications, letters, etc.: 

AMIA, Jeffrey Smith, Vice President of Public Policy, memo ...................... 47 

Response by Thomas H. Payne, M.D., FACP, FACMI to questions of: 

Senator Alexander ..................................................................................... 48 

Senator Murray ......................................................................................... 52 

Response by Craig D. Richardville, MBA, FACHE to questions of: 

Senator Alexander ..................................................................................... 55 

Senator Murray ......................................................................................... 59 

Response by Christine Bechtel to questions of Senator Murray .................. 60 

Response by Neal L. Patterson to questions of: 

Senator Alexander ..................................................................................... 62 

Senator Hatch ............................................................................................ 64 

Senator Baldwin ........................................................................................ 65 

(III) 

(1) 

HEALTH INFORMATION EXCHANGE: A PATH 

TOWARDS IMPROVING THE QUALITY AND 

VALUE OF HEALTH CARE FOR PATIENTS 

WEDNESDAY, JUNE 10, 2015 

U.S. SENATE, 

COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS, 

Washington, DC. 

The committee met, pursuant to notice, at 10:09 a.m., in room 

SD–430, Dirksen Senate Office Building, Hon. Lamar Alexander, 

chairman of the committee, presiding. 

Present: Senators Alexander, Roberts, Burr, Scott, Cassidy, Murray, Casey, Whitehouse, Warren, Franken, Bennet, and Murphy. 

OPENING STATEMENT OF SENATOR ALEXANDER

The CHAIRMAN. The Senate Committee on Health, Education, 

Labor, and Pensions will please come to order. Our hearing today 

is on how to improve the exchange of health information. Senator 

Murray and I will each have an opening statement. Then we’ll introduce our panel of witnesses. After our witness testimony, Senators will have 5 minutes of questions for the witnesses. 

We’re here today to outline our plans to conduct an intensive review of electronic health records. To save a little time, I’m going 

to summarize my comments and put my entire statement in the 

record. 

I have these things I’d like to say as we begin. There is a great 

deal of bipartisan interest in this subject. Senator Murray’s staff 

and my staff have been meeting with experts almost every day, the 

staff of our committee members have been meeting once a week, 

and Senator Murray and I have been working with Secretary 

Burwell and other members of the Administration on this. They 

understand the importance of it. 

Here’s what we’re talking about. The Meaningful Use Program, 

as it’s called, began in 2009 to encourage 491,000 physicians who 

serve Medicaid and Medicare patients and almost 4,500 hospitals 

to begin to adopt and use electronic health records systems, and 

456,000 of those physicians have received some sort of Medicare or 

Medicaid incentive payment. 

All hospitals and most physicians that tried were able to meet 

the early requirements. So far, the government has paid out about 

$30 billion in these incentive payments. The stage 2 requirements 

have been so complex that only about 11 percent of eligible physicians have been able to comply so far, and just about 42 percent 

of eligible hospitals. 

2 

The next step in the program is penalties for doctors and hospitals that don’t comply. This year, according to a CMS statement 

recently, 257,000 physicians who serve Medicare and Medicaid patients have already begun losing 1 percent of their Medicaid reimbursements, and 200 hospitals may be losing more than that. 

Our committee’s goal is to identify the five or six steps that we 

can take, working with the Administration, to improve electronic 

health records. It is a technology that has great promise, but 

through bad policy and bad incentives has run off track. 

To put it bluntly, physicians and hospitals have said to me that 

they are literally terrified of the next implementation stage of electronic health records, called Meaningful Use 3, because of the complexity and because of the fines that will be levied. Our goal is— 

my goal, anyway, is before that phase is implemented, we can work 

with physicians and hospitals and the Administration to get the 

system back on track and make it a tool that hospitals and physicians can look forward to using to help their patients instead of 

something they dread. 

Today we will start a series of hearings that we will hold this 

summer to address various possible solutions. Senator Murray and 

I are announcing the next two hearings in the series, which will 

be chaired by different members of our committee, to examine solutions to the problems we identify. 

The first hearing is on the burden physicians face with these systems. I have asked Senator Cassidy, who is a physician himself, to 

chair that hearing. 

The second hearing is on the question of whether you and I control information about our healthcare, and I have asked Senator 

Collins to chair that hearing. 

The full committee held its first hearing on Meaningful Use on 

March 17. Today, we’ll set the table for this series of hearings by 

discussing how we can solve problems. 

The Precision Medicine Initiative that President Obama has proposed, which we are working on and which I strongly support, will 

only work the way it’s supposed to work if electronic health record 

systems work the way they’re supposed to work. The systems can 

help to assemble and understand the genomes of the 1 million individuals required for the Precision Medicine Initiative. And, second, 

if we want to make genetic information useful to doctors when they 

write prescriptions, we’ll need to get things in order. 

According to medical economic surveys recently published, about 

70 percent of physicians say their electronic healthcare record system hasn’t been worth it. They are spending more time taking 

notes than taking care of patients, and they are spending a lot of 

their own money on systems that have to comply with government 

requirements. 

Today we have invited experts representing various perspectives—medical informatics, a records system vendor, a health system chief information officer, and the perspective of the patient— 

so we can hear these recommendations. I am especially interested 

to hear from our witnesses the recommendations they have to improve the system. 

We’re fortunate that a report was published in late May by the 

American Medical Informatics Association offering several strateVerDate Nov 24 2008 17:35 Jul 20, 2017 Jkt 000000 PO 00000 Frm 00006 Fmt 6633 Sfmt 6633 S:\DOCS\25971.TXT CAROL
3 

gies. They include simplifying and speeding documentation, refocusing regulation, increasing transparency, fostering innovation, 

and supporting person-centered care delivery. 

I look forward to our witnesses’ recommendations, their thoughts 

on the report I just mentioned, and also specific advice on how we 

can make improvements as rapidly as possible. 

Senator Murray. 

OPENING STATEMENT OF SENATOR MURRAY

Senator MURRAY. Well, thank you very much, Chairman Alexander. Thank you to all of our witnesses for being here today. I’m 

especially pleased to have a thought leader from Washington State 

with us, Dr. Payne, who I’ll introduce shortly. 

Thank you for taking the trip today and for everything you are 

doing in Washington State to make our healthcare system work 

better for families and patients. 

As I’ve said before, I really believe strongly that when it comes 

to our healthcare system, we really need to keep building on the 

progress we’ve made so far. We need policies that continue to make 

healthcare more affordable, not less; expand coverage to more families instead of taking coverage away; and improve the quality of 

care patients receive. 

I’m really pleased our committee is focusing on improving our 

Nation’s health IT infrastructure, because effective health information technology is essential to improving quality and cost of care. 

I’m especially pleased that this is a shared, bipartisan priority. 

Members on both sides of the aisle have some great ideas for 

ways we can move forward on these issues. I know that Acting Assistant Secretary Dr. Karen DeSalvo also sees this as a top priority 

as she moves into her new role. 

I’m very hopeful we will be able to reach an agreement on some 

ways to strengthen health IT in our country, because while we 

have come a long way in a short time, there is a lot more to do.

Over the last few years, our healthcare system has made significant gains in terms of adopting electronic healthcare records. 

Today, 78 percent of physicians use some form of electronic health 

records, compared to just 18 percent in 2001. 

The HITECH Act that passed in 2009 was a big part of that 

transformation. I truly appreciate the work that so many doctors 

and hospitals have done to bring our healthcare system into the 

21st century and improve the value and quality of care patients receive. This is really making a difference. 

In my home State of Washington, for example, Virginia Mason 

Medical Center now has more than 100,000 patients who are able 

to look up their own health information through Virginia Mason’s 

medical record. Virginia Mason is also helping patients and their 

doctors keep in touch in more efficient ways. 

Every week, doctors at Virginia Mason exchange more than 

15,000 secure emails with their patients. That means patients can 

get more of their questions answered without making an appointment or being put on hold. It means they are more empowered to 

work with their doctors to find the treatment that is best for them. 

Without question, there is a lot more we need to do to build on 

this progress. Many physicians across the country are facing a 

4 

Medicare payment reduction this year because they are struggling 

to meet requirements for the use of electronic health records. 

I’m very interested in speaking with our witnesses today about 

the major gaps that still exist when it comes to interoperability, because this problem is preventing doctors from sharing information 

in a secure, efficient way. As we find ways to help doctors share 

information across systems developed by different vendors, we also 

need to continue helping patients stay informed about and involved 

in their own care. 

During our last hearing on health IT, Dr. Angela Kennedy of 

Louisiana Tech University shared a story that really showed how 

big a difference electronic health records can make for patients. 

She explained that when she takes her adopted daughter Grace to 

the doctor, she is always quick to note that she does not know her 

daughter’s biological family medical history. 

Last year, the importance of having these kinds of records became very clear when, after Grace failed to respond to allergy 

treatment, genetic testing revealed that she had a rare form of cystic fibrosis. Without access to accurate, thorough medical records or 

the ability to correct errors in medical records, Grace’s illness, one 

that is usually identified right after birth, was not diagnosed until 

she was 11 years old. 

As Dr. Kennedy’s story makes clear, strengthening our health IT 

system is absolutely critical to making sure patients get the care 

they need. There are a few steps I will be especially interested in 

looking at as we continue this effort. 

I know the Meaningful Use provision has caused a lot of frustration among physicians. We need to do more to both set high standards and ensure providers have the support and flexibility they 

need to reach them. 

We should make sure that systems developed by different vendors and used by different doctors are able to speak to each other. 

That way, families like Dr. Kennedy’s will not have to spend countless hours tracking down and comparing documents from different 

sources. Providers will have quick, easy access to information about 

patients’ unique medical needs. 

We also need to continue supporting the development of a network of networks so providers have many options for trustworthy 

information sharing, and they don’t have to reinvent the wheel 

every time they need to exchange information with a new facility. 

Similarly, we should look for ways to make it easier for providers 

to shop for electronic records systems and vote with their feet when 

one isn’t working. 

And, finally, as electronic health records become more integral to 

our healthcare system, we need to look at ways to ensure security 

that stands up to our 21st century challenges. 

These and other steps would go a long way toward improving our 

health IT infrastructure and making our health care system work 

better for the patients and families we serve. 

As I said before, I’ve been truly pleased by the great ideas and 

interest that we have seen so far in this, and I want to thank all 

of our committee members who are so willing to work with us on 

this and for the hard work that everyone has already put in. 

5 

I look forward to our efforts on this, Mr. Chairman, and I’m 

hopeful that we can reach some bipartisan agreements on this really critical topic. 

The CHAIRMAN. Thank you, Senator Murray. 

I’m pleased to welcome our witnesses, and I’ll ask Senator Murray and Senator Burr to introduce the first two. 

STATEMENT OF SENATOR BURR

Senator BURR. Thank you, Mr. Chairman. I thank you and the 

Ranking Member for holding this hearing, and I want to welcome 

Craig Richardville from Carolinas HealthCare System in Charlotte, 

NC. 

Craig, thank you for being here and sharing your expertise with 

us today. 

Mr. Richardville is the vice president and chief information officer overseeing all of the systems for information services and strategies for the Carolinas HealthCare System, a network of more than 

900 healthcare locations. Mr. Richardville also lends his expertise 

to a number of organizations focused on health IT, including serving as a Fellow with the Healthcare Information Management System Society and the American College of Healthcare Executives, as 

well as chairman of the Premier Healthcare Alliance Member Technology Improvement Committee. 

Prior to joining Carolinas Healthcare System in 1997, Mr. 

Richardville spent 12 years with Promedica Health Systems. 

I want to thank Craig for being here and lending his expertise 

to this very, very important hearing. 

Senator MURRAY. Mr. Chairman, thank you. I’m really pleased to 

have a witness today who has come all the way across the country 

from Washington State. Dr. Thomas Payne is the medical director 

of IT Services for UW Medicine at the University of Washington. 

He’s an Associate Professor of Medicine, an Adjunct Associate Professor in Health Services, Biomedical Information, and Medical 

Education at the University. 

He’s also an attending physician in general internal medicine at 

the University of Washington Medical Center and Harborview 

Medical Center. Prior to his current position, he led the installation 

of the Veterans Administration CPRS electronic medical record at 

VA Puget Sound in Seattle, and he’s also the author of over 60 articles in this field, including the recent EHR 2020 Task Force report 

which he wrote as board chair-elect of the American Medical Information Association. 

Dr. Payne, thank you so much for all you’ve done. We really look 

forward to the information you have to share with us today. 

The CHAIRMAN. Thank you, Senator Murray. 

Our third witness will be Ms. Christine Bechtel from Olney, MD. 

She’s a long-time consumer advocate and the president of Bechtel 

Health, a mission-driven organization focused on accelerating innovation in patient and family engagement and patient-centered care. 

She serves as chair of the Consumer Workgroup of the Health IT 

Policy Committee, a Federal advisory committee. 

Our final witness is Mr. Neal Patterson from Kansas City, MO. 

Senator Roberts was here to introduce him to me, so I’ll introduce 

him to the other Senators. Mr. Patterson is Chairman of the Board 

6 

and CEO of the Cerner Corporation, a company he co-founded in 

1979. He has led Cerner to invest more than $4 billion in the research and development of health information technology. Today, 

Cerner’s systems are in use at more than 18,000 healthcare facilities in over 30 countries. 

Dr. Payne, why don’t we begin with you and go down the line. 

If each of you could summarize your remarks in 5 minutes, we 

have lots of Senators who would like to ask you questions. 

Dr. Payne. 

STATEMENT OF THOMAS H. PAYNE, M.D., FACP, FACMI, BOARD 

CHAIR-ELECT, AMERICAN MEDICAL INFORMATICS ASSOCIATION, MEDICAL DIRECTOR, IT SERVICES, UW MEDICINE, 

UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE, SEATTLE, WA 

Dr. PAYNE. Good morning, Chairman Alexander, Ranking Member Murray, and distinguished members of the committee. 

My name is Dr. Thomas Payne. I am the medical director of IT 

Services at UW Medicine and the University of Washington School 

of Medicine, and I am chair-elect of the AMIA board of directors. 

The American Medical Informatics Association represents more 

than 5,000 doctors, nurses, clinicians, researchers, and other 

informatics professionals who develop, implement, and study ways 

to manage information for patients, professionals in their clinical 

practice, public health, and in clinical research. 

It is an honor to appear before you this morning alongside this 

distinguished panel. My comments will focus on positive, near-term 

action items policymakers can take to capitalize on the increased 

adoption of electronic health records and utilize an expanding trove 

of health data to improve the quality and the value of healthcare 

for Americans. 

Recommendations, which I will describe in my comments, are derived from a recent report published by a multidisciplinary task 

force chartered by the AMIA board of directors. The EHR 2020 

Task Force was established to develop recommendations on how 

we, as a Nation, can resolve challenges related to EHRs, challenges 

this committee has examined and will continue to examine through 

a host of recent hearings. This report was developed over the 

course of 12 months by a very diverse group of informatics professionals representing a broad range of perspectives. 

Broadly, the report’s 10 recommendations fall into four categories, which I will briefly summarize as a need to, first, improve 

documentation requirements and functionality to empower patients 

so that all members of the care team can contribute their perspectives and information; second, refocus regulations so that patients 

and their caregivers can derive the most benefit from a networked 

healthcare ecosystem; third, increase transparency to improve 

usability and safety of EHRs; and, fourth, foster innovation so that 

we can build toward the next generation of EHRs and realize the 

benefits of the learning healthcare system. 

Congress can and should play a vital role toward encouraging 

better EHR usability, improved interoperability, and more meaningful patient engagement. For example, relatively simple steps 

could be taken to improve documentation requirements, such as enVerDate Nov 24 2008 17:35 Jul 20, 2017 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 S:\DOCS\25971.TXT CAROL
7 

couraging regulatory guidance that clearly delineates who is and 

who is not eligible to enter data into the record for compliance and 

reimbursement purposes. 

A more impactful and coordinated undertaking would be to include the refinement and adoption of standards meant to integrate 

clinical data from patients, medical devices, and other sources into 

the EHR. Longer term, Congress should develop policies that require CMS to revisit the entire billing and coding system that 

drives documentation for reimbursement and compliance purposes. 

Congress should also continue to promote broad adoption of alternative payment models, such as value-based purchasing, so that reimbursement is contingent on outcome-oriented measures, supported by less prescriptive and more flexible requirements for documentation. 

Documentation and the burdens associated with it are only one 

piece of a larger, more complex puzzle. The EHR 2020 Task Force 

also recommended that policymakers refocus the varied set of regulations and policies shaping the development of the health IT market and its use within healthcare. 

The simple message resonating among the Tasks Force’s recommendations: slow down regulation to accelerate progress. Ensuring CMS does not rush to get to the next stage of Meaningful Use, 

but rather works to help the private sector accelerate optimization 

of the tools and regulations that are already in place; reorienting 

ONC’s certification program to test true interoperability by testing 

how systems both send and receive information are among the key 

steps HHS should take in the near term. Should the regulatory 

pressure continue, stakeholders may look to Congress to intervene. 

While these steps will help the private sector make advancements toward more interoperable, safer health IT systems, Congress would engender genuine and lasting impact by enabling all 

patients to have their medical record, not just a summary of their 

record, available in standardized, machine-readable formats. It is 

unconscionable that in 2015, with the widespread adoption of electronic health records, a patient must still print and scan their medical record when they change to a new physician. 

The future of healthcare will be characterized by an electronic, 

transportable record of care that provides customized views depending on what the care team needs to deliver and according to 

patient preference. The record will have the ability to incorporate 

data from different sources, including patient-generated data, population data, and community context, into an EHR. 

Should this committee take up legislation during this or the next 

Congress, you should focus on the areas described in the EHR 2020 

Task Force report. If so, I am confident that we can turn the page 

from frustrations of today’s technology to realize the promise of a 

truly integrated, modern healthcare experience for all patients and 

their care providers. 

A more detailed explanation of the recommendations and a copy 

of the EHR 2020 Task Force report will be submitted as part of the 

written record. 

Thank you. 

[The prepared statement of Dr. Payne follows:] 

8 

PREPARED STATEMENT OF THOMAS H. PAYNE, M.D., FACP, FACMI 

SUMMARY

Recommendations, which I will describe in my oral and written comments, are derived from a recent report published by a multidisciplinary Task Force chartered by 

the AMIA board of directors. The EHR 2020 Task Force was established to develop 

recommendations on how we, as a Nation, can resolve challenges related to EHRs— 

challenges this committee has examined through a host of recent hearings. This report was developed over the course of 12 months by a diverse group of informatics 

professionals representing a wide range of perspectives. 

Broadly, the report’s 10 recommendations fall into four categories, which are 

briefly summarized as a need to: 

1. Improve documentation requirements and functionality to empower patients so 

that all members of the care team can contribute their perspectives and information; 

2. Refocus regulations so that patients and their caregivers can derive the most 

benefit from a networked healthcare ecosystem; 

3. Increase transparency to improve usability and safety of EHRs; and 

4. Foster innovation so that we can build toward the next generation of EHRs and 

realize the benefits of the ‘‘learning health system.’’ 

The steps Congress should take to help encourage better EHR usability, improved 

interoperability and meaningful patient engagement should focus near-term activities on Reducing documentation burdens for clinicians by clarifying regulatory ambiguity and supporting adoption of standards meant to integrate clinical 

data from patients, medical devices and other external sources of data with the 

EHR. Second, Congress should unleash the potential for every patient to enrich the learning health system by requiring vendors to give patients an electronic copy of their entire record, not just a summary, and require that such information is available in machine-readable formats. Policy development in this area 

will leverage existing requirements of HIPAA and generate a host of positive 

externalities to facilitate health information exchange among patients and their 

caregivers while fueling an ecosystem of modern applications and research. Third, 

Congress should streamline the Federal health IT certification program so 

that the process is more flexible, more transparent, focuses on clinically relevant 

functionality, and tests for true interoperability. 

Finally, Congress should embrace the notion of slowing down regulation to accelerate progress on EHR usability, interoperability and innovation. Federal regulators should not rush to get to the next stage of meaningful use, but should instead 

work to help the private sector accelerate optimization of the tools and regulations 

that are already in place. 

The recommendations developed by AMIA’s 2020 Task Force are inclusive of a diverse group of informatics professionals and we think they are sensible, feasible and 

will capitalize on the progress made to-date. In combination, these recommendations 

represent the most important work Congress can engage to help turn the page from 

our current State problems. Lawmakers have a vital role in determining the next 

evolution in EHRs, and AMIA stands ready to support Congress in this important 

work. 

Good afternoon, Chairman Alexander, Ranking Member Murray, and distinguished members of the committee. My name is Dr. Thomas Payne. I am medical 

director of IT Services at UW Medicine and the University of Washington School 

of Medicine, and I am chair-elect of the AMIA board of directors. The American 

Medical Informatics Association represents more than 5,000 doctors, nurses, clinicians, researchers and other informatics professionals, who develop, implement and 

study ways to manage information for patients, professionals in their clinical practice, public health and clinical research. 

It is an honor to appear before you today, alongside this distinguished panel. My 

comments will focus on positive, near-term action items policymakers can take to 

capitalize on the increased adoption of electronic health records, and utilize a burgeoning trove of health data to improve the quality and value of healthcare for 

Americans. 

Recommendations, which I will describe in my comments, are derived from a recent report published by a multidisciplinary Task Force chartered by the AMIA 

board of directors. The EHR 2020 Task Force was established to develop recommendations on how we, as a Nation, can resolve challenges related to EHRs— 

challenges this committee has examined through a host of recent hearings. This reVerDate Nov 24 2008 17:35 Jul 20, 2017 Jkt 000000 PO 00000 Frm 00012 Fmt 6633 Sfmt 6621 S:\DOCS\25971.TXT CAROL
9 

port was developed over the course of 12 months by a diverse group of informatics 

professionals representing a wide range of perspectives. 

Broadly, the report’s 10 recommendations fall into four categories, which I will 

briefly summarize as a need to: 

1. Improve documentation requirements and functionality to empower patients so 

that all members of the care team can contribute their perspectives and information; 

2. Refocus regulations so that patients and their caregivers can derive the most 

benefit from a networked healthcare ecosystem; 

3. Increase transparency to improve usability and safety of EHRs; and 

4. Foster innovation so that we can build toward the next generation of EHRs and 

realize the benefits of the ‘‘learning health system.’’ 

Congress can and should play a vital role toward encouraging better EHR 

usability, improved interoperability and more meaningful patient engagement. For 

example, relatively simple steps could be taken to improve documentation requirements, such as encouraging regulatory guidance that clearly delineates who is and 

who is not eligible to enter data into the record for compliance and reimbursement 

purposes. A more impactful and coordinated undertaking would include the refinement and adoption of standards meant to integrate clinical data from patients, medical devices and other external sources into the EHR. Longer term, Congress should 

develop policies that require CMS to revisit the entire billing and coding system 

that drives documentation for reimbursement and compliance purposes. Congress 

should also continue to promote broad adoption of alternative payment models, such 

as value-based purchasing, so that reimbursement is contingent on outcome-oriented 

measures, supported by less prescriptive and more flexible requirements for documentation. 

Documentation—and the burdens associated with it—are only one piece of a larger, more complex puzzle. The EHR 2020 Task Force also recommended that policymakers refocus the varied set of regulations and policies shaping the development 

of the health IT market and its use within healthcare. The simple message resonating among the Tasks Force’s recommendations: slow down regulation to accelerate progress. Ensuring CMS does not rush to get to the next stage of meaningful 

use, but rather works to help the private sector accelerate optimization of the tools 

and regulations that are already in place; reorienting ONC’s certification program 

to test true interoperability by testing how systems both send AND receive information are among the key steps HHS should take in the near-term. Should the regulatory pressure continue, stakeholders may look to Congress to intervene. 

While these steps will help the private sector make advancements toward more 

interoperable, safer health IT systems, Congress would engender genuine and lasting impact by enabling all patients to have their medical record, not just a summary 

of their record, available in standardized, machine-readable formats. It is unconscionable that in 2015, with the widespread adoption of electronic health records, 

a patient must still print and scan their medical record when they change to a new 

physician. The future of healthcare will be characterized by an electronic, transportable record of care that provides customizable views and varied amounts of context 

depending on what the care team needs to deliver care, and according to patient 

preference. The record will have the ability to incorporate data from different 

sources, including patient generated data, population data and community context 

into an EHR. Once the complete medical record is available in an electronic form, 

patients can more fully participate in clinical research, precision medicine, and 

other activities in which they control who can use their data. The first step toward 

this future is to enable patients to have access to their entire record in a computable, electronic form, not just a summary of their record. The electronic standards 

are ready, and this is perhaps the single, most important work Congress can engage 

to help turn the page from our current State problems. 

Should this committee take up legislation during this or the next Congress, and 

should you focus on the areas described in the AMIA EHR 2020 Task Force report, 

I am confident that we can turn the page from the frustrations of today’s technology 

to realize the promise of a truly integrated, modern healthcare experience for all patients and their care providers. 

A more detailed explanation of recommendations and a copy of the EHR 2020 

Task Force report will be submitted as part of the written record. 

Thank you. 

The remainder of my comments will detail the action items policymakers can take 

to improve the quality and efficiency of care delivery, optimize patient safety, and 

improve interoperability of health IT. 

10 

Recommendation 1: Improve documentation requirements and functionality to empower patients so that all members of the care team can contribute their perspectives and information. 

For the last two decades, documentation requirements for reimbursement and 

compliance purposes have increased dramatically in healthcare. Rather than diminish the burdens associated with documentation, as information technology has done 

for countless other industries, EHRs have magnified the amount of time physicians 

and nurses spend away from the bedside, increasing their workload and contributing to worsened professional satisfaction. Because EHRs are expected to serve the 

dual purpose of capturing data for clinical and billing purposes, as well as envisioned to fulfill a myriad of quality reporting requirements, EHRs do not inherently 

promote sensible workflows. Quite the contrary, in many cases EHRs dictate 

workflows to users in order to generate reports and satisfy documentation requirements, creating a classic ‘‘tail wagging the dog’’ situation. 

The EHR 2020 Task Force concluded that much of the information relevant to the 

diagnosis and treatment of a patient could more effectively be entered by other 

members of the care team, captured automatically by devices or other information 

systems or captured and entered by patients themselves. Further, the Task Force 

noted that moving away from the current evaluation and management (E/M) billing 

structure would free EHR developers to support more novel methods to collect important data. In order to help the care team get back to the bedside, Congress 

should: 

• Encourage regulatory guidance clearly delineating who is and who is not eligible to enter data into the record for compliance and reimbursement purposes; 

• Adopt standards meant to integrate clinical data from patients, medical devices 

and other external sources with the EHR; 

• Encourage and support Federal agencies, such as AHRQ, NIH, NLM, NSF and 

NIST to study alternative approaches to documentation using different media and 

data sources to identify more efficient documentation; 

• Finally, Congress should support and encourage further adoption of alternative 

payment models, such as value-based purchasing, so that reimbursement is contingent on outcome-oriented measures, supported by less prescriptive and more flexible 

requirements for documentation. This will focus attention on documenting outcomes 

and clinically relevant information (rather than processes and procedures), and will 

speed the adoption of better ways of capturing and documenting clinical care. 

Recommendation 2: Refocus regulations so that patients and their caregivers can derive the most benefit from a networked healthcare ecosystem. 

Over the last 5 years, the Federal Government has been much more proactive in 

shaping the market for health IT and informatics. The Federal Government’s centerpiece legislation, the HITECH Act, has driven significant efforts by public and private stakeholders, resulting in undeniable gains for the public good. The CMS EHR 

Incentive Program has enabled a remarkable rise in the adoption of EHRs and 

ONC’s certification program has provided a long-overdue framework to identify, harmonize and drive the adoption of health IT standards across the fractured 

healthcare landscape. The impact of HITECH is undeniable, but so too are the burdens associated with compliance—and not just to meaningful use, but a host of 

other programs dependent on the use of IT and informatics tools. The growth in 

adoption and use of health IT has not been without its challenges. 

Following completion of meaningful use Stage 1 and adoption of the 2011 Edition 

of Certified EHR Technology, many developers struggled to produce upgraded 

versions—2014 Edition CEHRT—and many providers struggled to meet Stage 2— 

more rigorous—requirements for meaningful use. Seeing these challenges, policymakers turned to a flurry of regulatory responses with exceptions, flexibility, and 

extended attestation periods. The challenges faced by healthcare stakeholders has 

also led to proposed legislation to increase flexibility in the program. These changes 

suggest that the EHR incentive programs should take a different approach to leverage the gains already made and prevent further erosion of the program. Further, 

the Federal Government needs to refocus the wider set of health IT and informatics 

policies across agencies and programs. 

The EHR 2020 Task Force recommended Federal health IT regulations focus on 

(1) clarifying and simplifying MU regulations for providers and vendors; (2) improving data exchange and interoperability; and (3) Reducing duplicative quality measurement while prioritizing patient outcomes over new functional measures. 

11 

CLARIFY AND SIMPLIFY MU REGULATIONS FOR PROVIDERS AND VENDORS

In order to provide vendors with clarity on how to meet the MU certification criteria, ONC provides precise instructions for each MU functional objective. The advantage of this approach is that vendors know with certainty how to qualify for MU 

certification. An unintended consequence is that vendors believe their customers 

must follow the workflow they programmed into the certified function and built into 

the automated calculation of the MU threshold determination. This predetermined 

workflow built into EHR products significantly affects usability of the products, 

often in a negative way. The goal of certification should be to assure that standards 

are consistently used in vendor products, in how systems interact with each other, 

and how quality is measured. Properly used, standards can lead to more flexibility 

as best of breed and modular products allow customization. The certification program, however, has led to preprogrammed workflows that are intended only to meet 

the conditions of certification, and not the needs of health care providers. Near-term 

action items for Congress include: 

• Ensuring CMS does not rush to get to the next stage of MU, but rather works 

to help the private sector accelerate optimization of the tools and regulations that 

are already in place; 

• Create flexibility in the certification program by encouraging vendors to develop 

testing methods that focus on demonstrating a functional capability instead of adherence to a predetermined, prescriptive test procedures. 

IMPROVE DATA EXCHANGE AND INTEROPERABILITY

New certification requirements should focus on technical requirements that will 

improve interoperability and data exchange, support better quality measures, and 

provide for safer and more secure care. To do this Congress should: 

• Engage with HHS to ensure that ONC’s certification program tests not just conformance to the standards, but true interoperability. This means testing both how 

systems send information and making sure that they are flexible in how they receive information. 

• Require that health IT vendors provide all patients with their entire medical 

record in a standards-based computable format. 

REDUCING DUPLICATIVE QUALITY MEASUREMENT WHILE PRIORITIZING

PATIENT OUTCOMES

Quality measurement and reporting has become the primary focus of many FTEs 

within any given healthcare system due to a proliferation of quality reporting programs, such as the Physician Quality Reporting System (PQRS) Program, Inpatient 

Quality Reporting (IQR) Program, meaningful use quality reporting requirements 

and a host of quality reporting regimes applied by State-level health officials or 

private-sector insurers and accreditation bodies. Many, if not most of these quality 

reporting requirements befall providers simultaneously and call for slightly different 

specifications of quality measures, rendering multiple uses of the same measures 

impossible. As Federal legislators look to quality measures as the basis for future 

reimbursement models and consumer comparison efforts, Federal regulators are 

looking to require submission of electronic clinical quality measures, which are incomplete and inaccurate without the addition of manual abstraction with current 

EHR systems. 

The EHR 2020 Task Force recommended that quality measurement should focus 

on outcomes that are consistent with national priorities while also being relevant 

to patients, their communities and clinicians’ specialties. And, again, working with 

payers and other stakeholders to develop payment alternatives that depend less on 

documentation and more on quality and value is likely to promote EHR innovation 

and uses that support these goals. In order to reduce duplicative quality measurement and prioritize patient outcomes over functional measures, Congress should: 

• Develop a special committee dedicated to harmonizing quality measurement 

across Federal, State and private sector stakeholders. 

• Encourage development of accurate, complete and reusable electronically specified electronic CQMs, by building quality measures from a consistent set of data 

‘‘building blocks’’. 

• Study the value of complex versus simple quality measures, and use the results 

of those studies to simplify data collection and quality measure calculations. Complex quality measures will lead to complex data collection requirements, and simple, 

high quality measures may achieve the same goal at a lower cost. 

12 

Recommendation 3: Increase transparency to improve usability and safety of EHRs. 

Currently, purchasers of EHRs often do not have visibility into how applications 

work. This lack of transparency inhibits an effective, competitive marketplace. 

Those choosing EHRs need clear knowledge of what commercial EHR systems offer 

and, importantly, what workflows are incorporated into their use for frequent tasks 

such as creating notes, entering data, reconciling medications, responding to decision support, and extracting data for reports or research—so they can make more 

informed choices. 

However, transparency in how EHRs perform during certification conformance 

testing is only one aspect of transparency. Users of health IT also need transparency 

in how systems perform after they’re deployed in a live environment. Moreover, patients and their care providers should have a clear understanding of the safety performance of health IT and informatics tools. In order to improve usability and safety 

and to foster innovation, health care organizations, providers and vendors should be 

fully transparent about unintended consequences and new safety risks introduced 

by health information technology systems, including EHRs, as well as best practices 

for mitigating these risks. In order to create the most transparent market for health 

IT, Congress should: 

• Encourage ONC to modify its certification program to streamline the certification process—as outlined previously in my comments—and better convey the process by which developers program common functionality and frequent tasks; 

• Make all the results of testing and how each vendor satisfies the certification 

requirements open to the public for review. This should include not just summaries, 

but videos, screen shots and details of the workflow used to satisfy the certification 

requirements; 

• Move forward with recent Food and Drug Administration Safety and Innovation 

Act (FDASIA) report recommendations to develop a public-private Health IT Safety 

Center that would promote health IT as an integral part of patient safety with the 

ultimate goal of assisting in the creation of a sustainable, integrated health IT 

learning system; and 

• Encourage a more inclusive ‘‘culture of safety,’’ by affording similar safe harbors 

to vendors that are afforded to providers that participate with Patient Safety Organizations (PSOs). 

Recommendation 4: Foster innovation so that we can build toward the next generation of EHRs and realize the benefits of the ‘‘learning health system.’’ 

Given the complexity of our healthcare system, the incomplete State of several national efforts to modernize care, harness health data and empower patients, a clinician could be forgiven for being overwhelmed. But the future is bright and the possibilities are great. As a Nation, we are closer than any other point in history where 

every patient encounter could present an opportunity for patients and clinicians 

alike to contribute to our understanding of health care and participate in research 

and clinical trials. This is the essence of the learning health system. 

In addition to enabling the incorporation of research knowledge into practice to 

support evidence-based medicine, EHRs can enable evidence generating medicine 

thereby creating a virtuous cycle of rapid evidence generation and evidence-based 

care delivery, an essential element needed to create a learning health system and 

to advance precision medicine. 

Although we don’t know what the next generation EHR will look like, we know 

that it will likely be very different than the systems that we have now. If we want 

to have the same successes that we’ve seen in the internet, we need a stable base 

of standard building blocks that allows us to create new technology to benefit patients. Unfortunately, there is a disconnect between the promise of what we can do 

and the real-world infrastructure required to actually make it operational and scalable. 

In order to foster innovation so that we can build toward the next generation of 

EHRs and realize the benefits of the learning health system, Congress should: 

• Support the adoption of standards for connecting different systems together, 

such as Application Program Interfaces (APIs), 

• Require standards that allow patients to have a copy of their entire medical 

record, not just a summary as previously described; 

• Fund research on how to best capture data, integrate data and design new user 

interfaces utilizing the best computer and human-computer interaction science 

available; and 

• Support innovation in precision medicine by making it easier to get information 

out of the electronic health records and into the hands of patients who wish to participate in precision medicine. 

13 

We know that the IT sector has in many other domains driving significant economic development and job growth. We believe the same is possible in Health IT, 

but we must create the innovation ecosystem that will allow everyone, not just the 

largest companies thrive in the expanding marketplace. 

Together, we are confident these recommendations will improve the landscape for 

better, more usable EHRs that will lead to greater interoperability, more engaged 

patients and improved clinical outcomes. Congress can take tangible steps toward 

the improved future of health IT by reducing documentation burden, requiring vendors to give patients an electronic copy of their entire record, and by streamlining 

certification so the process is more flexible and transparent. These actions will enable advances in population health, precision medicine and capitalize on the 

progress made to-date. 

Lawmakers have a vital role in determining the next evolution in EHRs, and 

AMIA stands ready to support Congress in this important work. 

The CHAIRMAN. Thank you, Dr. Payne. 

Mr. Richardville. 

STATEMENT OF CRAIG D. RICHARDVILLE, MBA, FACHE, SENIOR VICE PRESIDENT AND CHIEF INFORMATION OFFICER, 

CAROLINAS HEALTHCARE SYSTEM, CHAIR, PREMIER 

HEALTHCARE ALLIANCE MEMBER TECHNOLOGY IMPROVEMENT COMMITTEE, CHARLOTTE, NC 

Mr. RICHARDVILLE. Thank you, Chairman Alexander, Ranking 

Member Murray, and the members of this committee, for your leadership in holding this hearing today, and to you, Senator Burr, for 

your gracious introduction. 

I appreciate the opportunity to testify today on behalf of Carolinas HealthCare System and the Premier Healthcare Alliance, 

where I serve as chair of Premier’s Member Technology Improvement Committee. 

Carolinas HealthCare System is one of the largest health systems in the country. We have a diverse network that includes more 

than 900 care locations, 3,000 physicians and ACPs, 39 hospitals, 

behavioral health centers, home healthcare, nursing homes, hospice, and palliative care. In 2014, we touched the lives of 11 million 

patients living throughout North Carolina, South Carolina, and 

northeast Georgia. 

Premier is a leading healthcare improvement company, uniting 

an alliance of approximately 3,400 hospitals and 110,000 other providers to transform healthcare. 

Improving health information exchange and achieving true interoperability is one of the key challenges of our time, especially given 

the drive from volume-based care to value-based care, to increase 

the quality, efficiency, safety, and well-being of our citizens. As this 

committee has heard earlier this year, the current HIT ecosystem 

continues to be challenging for healthcare providers due to the lack 

of interoperability among various HIT systems. 

Efficient, easy to use, and the integration of health information 

is foundational to advancing and providing excellent care in this 

country. The cost to build, test, and maintain those integrations 

and interfaces is significant. At Carolinas HealthCare System, we 

have had success in these integrations. To date, we’ve integrated 

more than 125 different systems into our EMR. 

More than the impact on providers and hospitals is the impact 

on the patients that we serve. In order to truly engage our patients 

in the management of their care and to give them the tools that 

14 

they need to manage and understand their health status, we must 

provide them with this clinical information. 

Take, for example, a patient who has diabetes and other chronic 

conditions. This patient may be receiving care from multiple providers who are documenting their care in multiple systems. In 

order that the care be coordinated, up-to-date, and based on reliable current information, providers need to have the information 

readily available. 

The lack of easy exchange of this data amongst all providers and 

patients is the challenge. The goal should be to design and implement a secure HIT ecosystem that enables an easy exchange of 

health information. 

To accomplish this, we ask for a combination of congressional 

leadership and administrative actions that promote policy principles that further open health IT infrastructures. These include: 

Governance: Private-public partnership on HIT interoperability 

governance should be established to provide clear rules of the road. 

Functional standards: The governance mechanism should focus 

on the development of functional data and transport standards in 

key areas including patient identifiers, terminologies, clinical data 

query language, security, open APIs, and clinical decision support 

algorithms as well as business practices and policies. 

Measures: Transparent and public measures of interoperability 

should be developed in collaboration with the Federal Government. 

Transparency: Secure data should flow freely and easily. 

Compliance enforcement: The Federal Government should be enabled to enhance its enforcement tools to ensure functional data 

and transport standards and measures are compliant in vendor 

partners through its certified technology programs. 

The impact of having true interoperability achieved through the 

functional standards, metrics, and innovative technologies, such as 

open and secure APIs, would be transformative in terms of care, efficiency, safety, and patient engagement. 

Let’s go back to our patient with diabetes. With a more robust 

and open system, the patient could securely send to his or her provider daily glucose readings from a mobile device. Those readings 

would be easily posted and translated to a care management system where a coordinator is monitoring for fluctuations. 

During the visit, either in person or a virtual visit, the physician 

sees all the data from the patient and the various clinical systems. 

This allows the provider to understand not only today’s clinical 

data, but also the information that the patient voluntarily shares 

from outside the office. 

Thank you again on behalf of the providers at Carolinas 

HealthCare System and Premier Healthcare Alliance members and 

the patients that we serve for this considerable transformative 

work that you are doing for the benefit of the communities that we 

serve. 

[The prepared statement of Mr. Richardville follows:] 

PREPARED STATEMENT OF CRAIG D. RICHARDVILLE, MBA, FACHE 

SUMMARY

Chairman Alexander, Ranking Member Murray and members of the Senate 

Health, Education, Labor, and Pensions (HELP) Committee, I appreciate the opporVerDate Nov 24 2008 17:35 Jul 20, 2017 Jkt 000000 PO 00000 Frm 00018 Fmt 6633 Sfmt 6621 S:\DOCS\25971.TXT CAROL
15 

tunity to testify today on behalf of Carolinas HealthCare System and the Premier 

healthcare alliance, where I serve as the chair of Premier’s Member Technology Improvement Committee (MTIC), which consists of member CIOs that advise Premier’s 

leadership and the Board on health information technology (HIT) matters. 

HIT INTEROPERABILITY IS FOUNDATIONAL TO IMPROVING QUALITY AND VALUE

OF HEALTHCARE TO PATIENTS

As this committee heard earlier this year, the current market incentives are not 

aligned with open exchange of necessary healthcare data in cost-effective ways. The 

sharing of data that sits in software systems across the care continuum is not only 

technically complex, it also is expensive. Data resides in many systems, not just 

electronic medical records. Registration, billing, lab, pathology systems, medical devices, sensors and monitors, to name just a few, all have vital data that can and 

should be integrated and accessible across the care spectrum, no matter what the 

underlying software system is. 

More than the impact on providers and hospitals is the impact on the patients 

we serve. In order to truly engage our patients in the management of their care and 

to give them the tools they need to manage and understand their health status, we 

must provide them with this clinical information. 

PATHWAY TO ACHIEVING INTEROPERABILITY

The goal should be to design and implement a secure HIT ecosystem that enables 

an easy exchange of health information in timely and cost-effective ways. To accomplish these goals, we ask for a combination of congressional leadership and administrative actions that promote policy principles that further open health IT infrastructures. In creating these structures, we need clear rules of the road for providers and 

vendors alike through establishment of functional data and transport standards and 

methods to measure and test functionalities, with enhanced enforcement tools for 

regulatory bodies to drive compliance in the marketplace. 

• Governance: Private-public partnership on HIT interoperability governance 

should be established to provide clear rules of the road on interoperability. This 

should be done in consultation and coordination with Federal agencies, such as HHS 

and ONC, and the private sector. Providers, vendors, patients and payers should be 

consulted. The government entities should provide regular reports to Congress and 

the Administration on current standards development status as well as ready to 

market timelines and assessments for their applications. 

• Functional data and transport standards that promote interoperability and innovation: The governance mechanisms should focus on the development of functional data and transport standards in key areas including: patient matching, 

terminologies, clinical data query language, security, open application program 

interfaces (APIs), and clinical decision support algorithms as well as business practices and policies. 

• Public interoperability and cost efficiency measures: Transparent and public 

measures of interoperability should be developed in collaboration with the Federal 

Government, including HHS and ONC, and standard-setting bodies in consultation 

with the private sector and be required as part of ONC’s certified technology program. 

• These measures should be validated and tested in terms of functional standards, processes, and their maturity for application in the marketplace in a 

timely way, and within specific use case scenarios. 

• Measures should include business and implementation approaches that deliver functional interoperability outcomes and include operational processes 

and implementation practices. 

• Measures should also include assessment of cost efficiency metrics achieved 

through incorporating innovative technologies, such as existing API, which is 

an open source code that enables third party applications to exchange data. 

• Transparency: Data should flow freely and easily. Determinants of transparency 

should include: 

• Availability of ‘‘free’’ (no cost) export of publishable EHR domains. 

• Prohibition of specific fees for access to necessary data through API or other 

functional standard callable methods. 

• Publication of technical instructions on how to interact with APIs, interface 

standards or other callable methods. These should be published either publicly or broadly to any authorized third party. 

• Technology and devices that generate health information be required to publish clinical data to any other authorized consuming applications, including 

16 

EHR/EMRs, to create interoperability. Consuming applications’ ability to develop methods to ingest information from other HIT assets, including devices, 

should adhere to current and future medical device interoperability standards. 

• Enforcement of functional data and transport standards and measures of HIT 

interoperability: The Federal Government should be enabled to enhance its enforcement tools to ensure functional data and transport standards and measures compliance of vendors through its certified technology program. 

Chairman Alexander, Ranking Member Murray and members of the Senate 

Health, Education, Labor, and Pensions (HELP) Committee, I appreciate the opportunity to testify today on behalf of Carolinas HealthCare System and the Premier 

healthcare alliance, where I serve as the chair of Premier’s Member Technology Improvement Committee (MTIC), which consists of member CIOs that advise Premier’s 

leadership and the Board on health information technology (HIT) matters. 

To start, I applaud the leadership of Chairman Alexander and Ranking Member 

Murray for holding this important hearing today. This is a vital topic, important to 

the well-being of our citizens and our Nation. 

Carolinas HealthCare System is one of the largest health systems in the country. 

We have a diverse network that includes more than 900 care locations, 3,000 physicians and advanced clinical practitioners, 39 hospitals, behavioral health centers, 

home health care, nursing homes, hospice and palliative care. For 11 consecutive 

years, we have been named one of America’s Most Wired Hospitals by Modern 

Healthcare. We are the only health system in North or South Carolina to have received HIMSS Analytics Stage 7, the highest level, for adoptions of electronic medical record (EMR) technologies in both outpatient and inpatient settings. We also 

are a member of Healtheway, a founding member of Carequality and being certified 

for the national eHealth Exchange. Just last month, Carolinas was named by Forbes 

magazine as one of the Nation’s best employers. 

Our mission is clear—to create and operate a comprehensive system to provide 

healthcare and related services, including education and research opportunities, for 

the benefit of the people we serve. In 2014, we had more than 11 million patient 

encounters, touching the lives of those that live throughout North and South Carolina and northeast Georgia. Each day, our 60,000 teammates dedicate themselves 

to providing the best medical care possible. Much of the care they deliver each day 

is extended, buttressed and enhanced by the advances in technology. 

Premier, Inc. is a leading healthcare improvement company, uniting an alliance 

of approximately 3,400 U.S. hospitals and 110,000 other providers to transform 

healthcare. With integrated data and analytics, collaboratives, supply chain solutions, advisory and other services, Premier enables better care and outcomes at a 

lower cost. Premier, a Malcolm Baldrige National Quality Award recipient, plays a 

critical role in the rapidly evolving healthcare industry, collaborating with members 

to co-develop long-term innovations that reinvent and improve the way care is delivered to patients nationwide. 

HIT INTEROPERABILITY IS FOUNDATIONAL TO IMPROVING QUALITY AND VALUE

OF HEALTHCARE TO PATIENTS

Despite its potential, the current HIT ecosystem continues to be challenging for 

healthcare providers because of a lack of interoperability between systems. Cost-effective, efficient, and easy to use and integrate health information is foundational 

to advancing and providing excellent care in this country. Patients and care providers are missing opportunities to improve people’s health and welfare when information about care or health status is not easily available. It is critical for us, all 

of us, to fully use and leverage the health data that is vital to improving patient 

care. Doing so will help us discover and develop better treatments while improving 

safety and quality in the delivery of that care. 

As this committee heard earlier this year, the current market incentives are not 

aligned with open exchange of necessary healthcare data in cost-effective ways. The 

sharing of data that sits in software systems across the care continuum is not only 

technically complex, it also is expensive. Data resides in many systems, not just 

electronic medical records. Registration, billing, lab, pathology systems, medical devices, sensors and monitors, to name just a few, all have vital data that can and 

should be integrated and accessible across the care spectrum, no matter what the 

underlying software system is. The difficulty in achieving this has an impact not 

only in care quality but also in cost. 

17 

The cost to build interfaces and test and maintain those interfaces is not insignificant. At Carolinas HealthCare System, we have been successful with many of these 

integrations. In order to meet the needs of our patients across our geographies and 

throughout the care continuum, we have interfaced with more than 125 systems to 

get data into our EMRs. One critical factor to our success has been with our patient 

matching biometric program which uses palm vein scanning. Patients scan their 

palms, and we are able to match them to the data in many of our systems, ensuring 

that the right information about the right patient is available. Using this system, 

which 99 percent of our patients do voluntarily, results in less than .11 percent failure rate. That means 99.9 percent of our patients are correctly matched in our systems. The national average for this is 8 to 10 percent, while a best practice is 5 

percent. 

Achieving this integration has not been easy or inexpensive. Today, in order to 

build the bridges that connect disparate data sets necessary to provide comprehensive and informed decisions or care, providers must either pay their original system 

vendors thousands and sometimes millions of dollars to custom code linkages so 

they can ‘‘talk’’ to other systems, or they often find paper-based workarounds that 

are fraught with potential for both errors and wasted resources and expense. 

The costs of sharing this critical data among other health systems is not just in 

dollars. It creates an environment of inefficient use of some our most valuable resources, our people. Having care providers faxing or mailing information to other 

providers is not the best use of these highly skilled clinical people. 

More than the impact on providers and hospitals is the impact on the patients 

we serve. In order to truly engage our patients in the management of their care and 

to give them the tools they need to manage and understand their health status, we 

must provide them with this clinical information. Take for instance a patient who 

has diabetes and other chronic conditions. This patient may be receiving care from 

multiple physicians who are documenting their care in multiple systems. In order 

that the care be coordinated, up to date and based on reliable current information, 

those physicians need to have the information readily available when they are making clinical decisions. The lack of easy exchange of these data amongst all providers 

and the patient is the challenge. 

PATHWAY TO ACHIEVING INTEROPERABILITY

The goal should be to design and implement a secure HIT ecosystem that enables 

an easy exchange of health information in timely and cost-effective ways. The system should promote collaboration among all stakeholders, from patients to providers 

to vendor partners and payers. We need a system of standards that focuses on improving healthcare quality, efficiency, safety, affordability and access through government and market incentives, while encouraging innovation and competition. 

At Carolinas, for instance, we care for more than 60,000 people with diabetes. 

Continuing to manage their care through today’s methods is not optimal. The shift 

from volume-based care, where we are paid for the numbers of things we do or the 

number of patients we see, to value-based care where we are compensated for the 

quality of the care, leads us to this new care delivery model. Population health programs like we are implementing at Carolinas will advance the delivery of this valuebased care where providers and patients are linked and partners in the care. 

To accomplish these goals, we ask for a combination of congressional leadership 

and Administrative actions that promote policy principles that further open health 

IT infrastructures. In creating those structures, we need clear rules of the road for 

providers and vendors alike through establishment of functional data and transport 

standards, and methods to measure and test functionalities, with enhanced enforcement tools for regulatory bodies to drive compliance in the marketplace. These include: 

• Governance: Private-public partnership on HIT interoperability governance 

should be established to provide clear rules of the road on interoperability. This 

should be done in consultation and coordination with Federal agencies, such as HHS 

and ONC, and the private sector. Providers, vendors, patients and payers should be 

consulted. The government entities should provide regular reports to Congress and 

the Administration on current standards development status as well as ready-tomarket timelines and assessments for their applications. 

• Functional data and transport standards that promote interoperability and innovation: The governance mechanisms should focus on the development of functional data and transport standards in key areas including: patient matching, 

terminologies, clinical data query language, security, open application program 

interfaces (APIs), and clinical decision support algorithms as well as business practices and policies. 

18 

• Public interoperability and cost efficiency measures: Transparent and public 

measures of interoperability should be developed in collaboration with the Federal 

Government, including HHS and ONC, and standard-setting bodies in consultation 

with the private sector and be required as part of ONC’s certified technology program. 

• These measures should be validated and tested in terms of functional standards, processes, and their maturity for application in the marketplace in a 

timely way, and within specific use case scenarios. 

• Measures should include business and implementation approaches that deliver functional interoperability outcomes and include operational processes 

and implementation practices. 

• Measures should also include assessment of cost efficiency metrics achieved 

through incorporating innovative technologies, such as existing API, which is 

an open source code that enables third party applications to exchange data. 

• Transparency: Data should flow freely and easily. Determinants of transparency 

should include: 

• Availability of ‘‘free’’ (no cost) export of publishable EHR domains. 

• Prohibition of specific fees for access to necessary data through API or other 

functional standard callable methods. 

• Publication of technical instructions on how to interact with APIs, interface 

standards or other callable methods. These should be published either publicly or broadly to any authorized third party. 

• Technology and devices that generate health information be required to publish clinical data to any other authorized consuming applications, including 

EHR/EMRs, to create interoperability. Consuming applications’ ability to develop methods to ingest information from other HIT assets, including devices, 

should adhere to current and future medical device interoperability standards. 

• Enforcement of functional data and transport standards and measures of HIT: 

The Federal Government should be enabled to enhance its enforcement tools to ensure functional data and transport standards and measures compliance of vendors 

through its certified technology program. 

Let’s go back to our patients with diabetes. With a more robust and open system, 

the patient could send to his or her care provider, their daily glucose readings from 

their mobile device. At Carolinas, they soon will do that through MyCarolinas 

Tracker, which integrates data from 60 consumer-based medical devices. Those 

readings would be easily posted and translated in a care management system, 

where a coordinator is monitoring for fluctuations. In the meantime, the coordinator 

is scheduling the patient for a check-up with the physician. Before the patient goes 

in for the visit, they log in to look at the latest lab and test results on them. During 

the visit, the physician sees all the data from the patient and all the data from the 

clinical systems in the EMR. The physician can also view when the patient had an 

ER visit at another hospital while on vacation. This allows the physician to understand not only today’s clinical data, but also the life of the patient outside of the 

office visit. 

The technology is now available to realize the goals of what the Institute of 

Healthcare Improvement calls the Triple AIM—improve the health of the population 

served, improve the experience of each patient, and improve the affordability of the 

care. 

Thank you again for the opportunity to testify today. As this committee continues 

its work on improving HIT infrastructure and data exchange, we urge the Members 

to require HIT interoperability as foundational to facilitate research, storage and 

use of health data to advance patient care, quality and safety, while reducing costs. 

Thank you on behalf of the providers at Carolinas HealthCare System and Premier 

healthcare alliance and the patients we serve for this considerable transformative 

work you are doing for the benefit of the communities we serve. 

The CHAIRMAN. Thank you, Mr. Richardville. 

Ms. Bechtel. 

19 

STATEMENT OF CHRISTINE BECHTEL, M.A., ADVISOR, NATIONAL PARTNERSHIP FOR WOMEN AND FAMILIES, CHAIR, 

HEALTH IT POLICY COMMITTEE CONSUMER WORKGROUP, 

PRESIDENT, BECHTEL HEALTH, OLNEY, MD 

Ms. BECHTEL. Good morning, Mr. Chairman, Ranking Member 

Murray, and distinguished committee members. I’m Christine 

Bechtel. I’m a consumer advocate, and I’m an advisor to the National Partnership for Women and Families. Thank you for having 

me here today. 

As you’ve just heard, the healthcare system is struggling to foster the kind of exchange that will drive better care and smarter 

spending. We’re making progress, but many organizations still 

treat health data as a close-hold business asset when it should be 

treated as a public good. 

I’m here to talk about how consumers can be a force for change. 

The role of consumers in healthcare is changing rapidly, thanks to 

emerging information technologies, evolving economic incentives, 

and rising consumer expectations. 

If we harness these forces, consumers can play a major role in 

beginning to dramatically reshape the way we share information in 

healthcare today. Simply put, if I can gather my data electronically 

from all of my healthcare entities that hold it, use a safe and secure app to store it, then I could share it with any one of my 

healthcare providers for my care or for other purposes, like precision medical research. 

As the only one present at all of my healthcare encounters, I can 

potentially amass more data more quickly and more comprehensively than any single healthcare entity can today, because I know 

where it is, and I have a legal right to it. 

We’re close to achieving this vision. Both the policies and the 

technologies exist, but we aren’t there yet, and my personal experience demonstrates that we have work to do. 

Eight weeks ago, I tried to gather my health records from the 

patchwork of providers that hold it, and I started with my primary 

care practice. Because the practice participates in Meaningful Use, 

I should have been able to download my data directly from the patient portal. Unfortunately, the portal was broken, and the practice 

had no plan to fix it. 

Instead, I asked for an electronic copy of my record, which I now 

have a legal right to under HIPAA. The practice was unaware of 

my right, and they had no established process for complying. I had 

to drop off a copy of the Federal register to demonstrate my right, 

and then the staff had to work through how to meet my request. 

After a lot of back and forth, they put two files on this lovely 

CD–ROM, and I physically went to the office to pick it up. The 

process took about 2 weeks, and then once I looked at the CD’s contents, I learned that the files alone aren’t very useful. I researched 

and I downloaded an app, as anybody would, to display my medical 

record in a way that I could understand. 

This simple medical records request was a lot of work. Most consumers will not have the resources or the expertise to persist as 

I did. They should, because my experience produced results. My 

doctor’s office is now changing their process so that all patients can 

have an electronic option when they want it. 

20 

If consumers writ large can do what I did, if they can really ask 

for and demand their health information right now, then I believe 

that this can enable systematic change. To do that, there are several actions that we need to take in the next 12 months to make 

this process easy, private, and secure. 

Good news—none require legislation, but a little nudge from 

Congress would certainly help. There’s more detail in my written 

testimony. In summary, we need to start by raising consumer 

awareness and provider awareness about our rights to our electronic health information and the use of patient portals for 

downloading health data. HHS has many mechanisms for doing 

this. 

We should also use the Federal EHR certification program to create the capacity for EHRs to receive consumer-generated data and 

make it easy for providers to analyze it and act on it. 

Next, we need to preserve the Meaningful Use patient access requirement, including the requirement that a small percentage of 

patients use their online access at least once. We can argue over 

the exact percentage, but the fact remains that CMS’s proposal to 

drop this threshold to just a single patient will completely undermine efforts to make consumer access to healthcare data the norm. 

Finally, we do need advancements in consumer privacy. Consumers don’t realize that once they download their data from a provider into an app, most often, HIPAA no longer protects them. 

We need to do three things in the short term. One is to encourage HHS to finalize best practice guidance for app developers on 

privacy and security. The Federal Trade Commission can enforce 

voluntary best practices for those who adopt them. 

Second, we need to incentivize more app developers to use ONC’s 

model PHR notice for consumers. That’s a Personal Health Record 

notice, and it enables quick and easy comparison of otherwise complex privacy policies. 

Finally, we should shorten the timeframe for meeting medical 

records requests under HIPAA to less than 30 days. When the data 

is digitally available, the law should not give us a basis for delay. 

The challenge before us is simple and straightforward, and success, I believe, is within reach. The steps I outlined will move us 

toward the day when consumers no longer have to use the sneaker 

net, where we walk our medical records around from doctor to doctor, and instead leverage the internet to drive quality, value, and 

patient-centered care. 

Thank you. 

[The prepared statement of Ms. Bechtel follows:] 

PREPARED STATEMENT OF CHRISTINE BECHTEL, M.A. 

Our health care system is struggling to foster the kind of exchange that will truly 

drive better care and spending. But consumers can be a force for change. Namely— 

if consumers could leverage their legal rights and gather data electronically from 

all of the health care entities that hold it, then use a safe and secure app to store 

it, it would enable us to share that data with health care providers and give them 

a much better view of health and care. Yet my own personal experience does not 

bear this out. My simple medical records request required multiple trips to the doctor, several aggravating phone calls, legal and technical knowledge, and persistence. 

Most consumers won’t have the resources to persist and succeed. My case is not 

unique; it illustrates the challenges of our current system. 

21 

1 Engaging Patients and Families: How Consumers Value and Use Health IT. National Partnership for Women & Families, December 2014. www.nationalpartnership.org/patientsspeak. 

There are a range of actions we can take over the next 24 months to achieve 

change. A little nudge from Congress can help: 

• Better educate consumers about their legal rights and about the use of patient 

portals for downloading and using health data. HHS has many mechanisms for 

doing so, including the Office of Civil Rights (OCR). 

• Develop and disseminate tools to help consumers understand how/where/what 

and what format to request, what to do with the data, where to securely store it, 

and how to navigate roadblocks along the way. Make the data request process 

frictionless for consumers. 

• Work through HHS to educate providers about how to meet the demand for digital health information. 

• Use the Federal EHR certification program to create the capacity for EHRs to 

incorporate consumer-generated data and make it easy for providers to analyze and 

act on. 

• Finalize the proposal to include open Application Programming Interfaces 

(APIs) in the Federal EHR Certification program. APIs will help break down information silos in health care. 

• Preserve the Meaningful Use view/download/transmit requirement: both the requirement that the technology is in place, and the requirement that a percentage 

of patients use it at least one time during the reporting period. Regardless of whether the number is 5 percent or something else, CMS’s recent proposal to drop this 

threshold to just a single patient will completely undermine efforts by consumers 

who want to have and use their data. Requiring providers to actively engage with 

a percentage of patients is an essential mechanism for changing consumer expectations and enabling consumers as a force for change. 

• Privacy protection—consumers want and support greater online access, and consumers also care about privacy. We must encourage ONC, FTC and OCR to finalize 

best practice guidance on protecting privacy and security for app developers (most 

of whom are not covered by HIPAA). The FTC can enforce voluntary best practices 

for those who adopt them. 

• Incentivize more app developers to use ONC’s model PHR notice for consumers. 

It enables consumers to quickly and easily compare privacy policies across apps, including whether or not the developer sells consumer data for marketing or to employers and/or insurance companies. 

• Shorten the timeframe for meeting records requests under HIPAA from 30 days. 

Patients should have the data as soon as doctors do, and where digital records make 

that possible, the law should not provide a basis for delay. 

• Require providers to offer an ongoing data feed so patients don’t have to submit 

requests again and again. There are technical standards that already enable this. 

• Establish that it is willful neglect to deny a patient access (or even claim 

HIPAA precludes it), unless the provider in good faith is relying on one of HIPAA’s 

exemptions. 

Good morning Mr. Chairman, Ranking Member Murray and distinguished committee members. I’m delighted to be with you today to talk about driving progress 

toward quality and value through health information exchange. 

The notion of ‘‘health information exchange’’ has been around for decades, and we 

have tried many approaches. Yet our health care system is struggling to foster the 

kind of exchange that will truly drive better care and smarter spending. Entrenched 

payment policies that do not reward better health outcomes or coordinated care continue to hold us back. We are making progress, but many health care organizations 

today still treat health data as a close-hold business asset, when it should be treated 

as a public good. 

I’m here to talk about how consumers can be a force for change. 

We know that consumers want health information technology (IT). According to 

a nationwide survey released by the National Partnership in December, patients 

overwhelmingly believe that electronic health records (EHRs) are essential to making sure providers have timely access to information that can help avoid medical 

errors and repeat tests.1 Consumers also want and use online access to their own 

health information, largely through patient portals. Almost 9 in 10 patients who 

have such access use it, and it has a significantly positive impact on patient engagement, better care and improved outcomes. Notably, individuals who use patient porVerDate Nov 24 2008 17:35 Jul 20, 2017 Jkt 000000 PO 00000 Frm 00025 Fmt 6633 Sfmt 6621 S:\DOCS\25971.TXT CAROL
22 

tals with some frequency are dramatically more likely to say it motivates them to 

improve their health. 

We also know that the role of consumers in health care is changing rapidly, facilitated in part by these emerging technologies, along with evolving economic incentives and rising consumer expectations. 

These forces are converging, positioning consumers as a potentially potent force 

for change that can dramatically reshape the way we share and use information in 

health care—if we can make the process of downloading, managing and sharing 

health information easy, private and secure. 

What does it take to unleash this consumer potential? Let’s look at how our system works today. In my case, I have a primary care physician (PCP) who uses an 

EHR. I also have a high-deductible health plan, which means that I often seek out 

care from places that have published price lists and are convenient—like a webbased service that, earlier this year, allowed me to ‘‘see’’ a doctor online on a Sunday 

morning for just $49. As a result, health care data about me exists in several different places—with my doctors, my health insurer, MinuteClinic, my web-based doctor service, and more. This is not usual for most Americans—all of us have data 

spread across a patchwork of providers and systems. 

Few if any of these systems talk to each other, which means that no single provider can see a complete picture of my care. So how can I, and the millions of consumers like me, become a force for change that drives health information exchange 

in the marketplace? 

If I could gather my data electronically from all of the health care entities that 

hold it, and use a safe and secure app to store it, then I could share it with any 

one of my health care providers, giving them a much better view of my health and 

my care. 

The fact is, as the patient, I am the only one present at all of my health care 

encounters—so I can potentially amass more data, more quickly and more comprehensively than any single health care entity can today, because I know where 

it all is. And, in theory, I know how to get it. If I have the data, I can spot errors, 

avoid repeat tests, detect fraud, help facilitate coordinated care, and much more. I 

can be the curator of my own health record, sharing it where and when it is needed 

to improve my care, and for other important purposes like research into precision 

medicine. 

We are close to achieving this vision; both the policies and the technologies exist. 

But we aren’t there yet. I learned this the hard way when I requested my data from 

my PCP 8 weeks ago. Because the practice participates in Meaningful Use, I should 

have been able to download my data directly from the patient portal. That is due 

to an important Federal requirement that stipulates patients must be offered online 

access to view, download or transmit their health information to a third party. Unfortunately, the patient portal was broken and the practice had no plan to fix it. 

I decided on another approach that few consumers—and it turns out, few providers—know about. Under the HIPAA amendments made by the HITECH law, I 

now have a legal right to an electronic copy of my health information. I can exercise 

this right with any covered entity that holds data about me, as long as they can 

produce the data electronically. And if they have a Meaningful Use-certified EHR, 

they can. So I asked my PCP’s office for an electronic copy of my health record. 

After convincing them that I wasn’t trying to change doctors and just wanted my 

record electronically, they told me they ‘‘don’t do that;’’ they only offer paper copies. 

I told them about my legal right to an electronic copy since they have a certified 

EHR, and they again simply said they don’t do that. 

I returned a few days later with a copy of the Federal Register, demonstrating 

my legal right under HIPAA to an electronic copy. Over the course the following 

week, and many phone calls back and forth, the practice staff figured out how to 

meet my request. They created a text file, and a second file in a format called CCR, 

which stands for Continuity of Care Record, and placed both files on a CD–ROM 

that they left at the front desk for me to pick up. 

I quickly learned that having my record on a CD–-ROM wasn’t very useful. I 

could read the text file (once I bought an external CD–ROM drive), but text files 

aren’t very actionable. So I did what anyone would when faced with a problem— 

I downloaded an app. The app used the CCR file to summarize and display my medical record in an organized way that I can understand. 

This simple medical records request was a big hassle—it caused a lot of friction 

even though I was simply requesting information to which I am legally entitled— 

information that is an essential part of my health and care. It required multiple 

trips to the doctor, several aggravating phone calls, legal and technical knowledge, 

and persistence. Most consumers won’t have the resources to persist and eventually 

succeed. 

23 

My case is not unique, and it illustrates the many challenges of our current system: 

• Many providers and their staff members don’t know we have a right to an electronic version of our records. • They don’t have workflows to accommodate it—for example, their medical 

records request forms don’t ask if the patient wants paper or an electronic copy. • Consumers don’t know about this right. And if we do, we don’t know the best 

ways to ask for the data—that we should avoid PDFs in favor of structured data, 

and what our options are to get structured data. Many also don’t know about their 

ability to download data via their portals. • Most of us don’t know what to do with the data once we get it. Which app 

should we use? What are that app’s policies and practices on privacy and security? 

We also don’t know that once we download data from my doctor, hospital or other 

covered entity, and upload it into an app like a Personal Health Record (PHR), that 

data is no longer covered by HIPAA unless the app developer is itself a covered entity. That means the developer could sell my identifiable health information. • And finally, to drive heath information exchange, EHRs need to be capable of 

ingesting data from consumers, and making it actionable. 

These are challenges, to be sure, but they can be addressed in the very near term. 

And if we overcome them, the potential of consumers to unravel the knot that binds 

our health data in silos is enormous. If consumers can make a concentrated tug on 

the rope and demand their data, starting right now, it can enable systemic change. 

To do that, we need to take the friction out of the process for consumers. There 

are a range of actions we can take in three broad areas over the next 24 months 

to achieve change. The good news is that none require legislation. They can all be 

done by administrative action, by the private sector or with public-private collaboration. However, a little nudge from Congress can help: 

1. Equip consumers with the tools and awareness they need to exercise 

their rights to their digital health data. 

• Better educate consumers about their legal rights, and about the use of patient 

portals for downloading and using health data. The U.S. Department of Health and 

Human Services (HHS) has many mechanisms for doing so, one of which is the Office of Civil Rights (OCR). OCR has a Web page to help consumers understand and 

exercise their privacy rights. Content should be updated to emphasize electronic requests over paper-based ones. • Develop and disseminate tools to help consumers understand how/where/what 

and what format to request, what to do with the data, where to securely store it, 

and how to navigate roadblocks along the way. • Make the process of requesting data easier. How can we automate it? A small 

group of leading experts, consumer advocates and former policymakers are catalyzing action in this area right now. Developers are working on tools such as the 

Vocatus tool, which enables consumers to request their health data online. Others 

are working to fix problems with patient portal download features. 

2. Give providers the tools and incentives to make consumer use of digital data the norm in health care. 

• Work through HHS to educate providers about how to meet the demand for digital health information—through patient portals and through other means of 

downloading data such as Blue Button (which Medicare and the Veterans Administration already use), or the Direct protocol—a secure email link between patients 

and providers. • Use the Federal EHR certification program to create the capacity for EHRs to 

incorporate consumer-generated data and make it easy for providers to analyze and 

act on. 

3. Advance Federal policies that enable consumers to routinely request, 

download and use their own health data in private, secure and valuable 

ways. Focus on two areas. 

1. First, support policies that drive more information sharing by: 

• Finalizing the proposal to include open Application Programming Interfaces 

(APIs) in the Federal EHR Certification program. APIs will help break down 

information silos in health care. • Preserving and strengthening the Meaningful Use view/download/transmit requirement, most commonly met by offering patient portals which deliver functions patients want like secure messaging with their providers, online medication refills and data downloads. We must preserve both the requirement that 

the technology is in place, and the requirement that a percentage of patients 

use it at least one time during the reporting period. Regardless of whether 

24 

the number is 5 percent or something else, CMS’s recent proposal to drop this 

threshold to just a single patient will completely undermine efforts by consumers who want to have and use their data. Requiring providers to actively 

engage with a percentage of patients is an essential mechanism for changing 

consumer expectations and enabling consumers as a force for change. 

2. Second, privacy protection—there is no question consumers want and support 

greater online access to their own health information. Consumers also care about 

privacy. Now that health data is increasingly accessible in digital form, an app market is rapidly emerging, bringing with it both benefits and risks. We need to enable 

the market and protect consumers who are using apps to manage their data. 

To do so, we should: 

• Encourage the Office of the National Coordinator (ONC), the Federal Trade 

Commission (FTC) and OCR to finalize and widely disseminate best practice 

guidance on protecting privacy and security for app developers. Under its existing authority, the FTC can enforce voluntary best practices for those who 

adopt them. 

• Ask the public and private sectors to come together and explore how to evaluate apps on a range of aspects, including privacy, security and usability. My 

own research into the privacy policies and data sharing practices of the apps 

I considered for my record required hours of reading and the ability to decipher a lot of legalese. We should incentivize more app developers to use 

ONC’s model PHR notice for consumers. It enables consumers to quickly and 

easily compare privacy policies across apps, including whether or not the developer sells consumer data for marketing or to employers and/or insurance 

companies. But it should be promoted much more aggressively by the Federal 

Government. 

• Shorten the timeframe for meeting records requests under HIPAA from 30 

days. Patients should have the data as soon as doctors do, and where digital 

records make that possible, the law should not provide a basis for delay. 

• Require providers to offer an ongoing data feed, at least where it is feasible, 

so patients don’t have to submit requests again and again. There are technical standards that already enable this. 

• Establish that it is willful neglect to deny a patient access (or even claim 

HIPAA precludes it), unless the provider in good faith is relying on one of 

HIPAA’s exemptions. 

If all that sounds technical, the challenge before us really is quite simple and 

straightforward. More than that, success is within reach. By taking some of the 

steps I have outlined, we can make it possible for consumers to finally stop being 

the ‘‘sneaker net’’—patients who have to walk our records around to different doctors—and start leveraging the Internet to drive quality, value and patient-centered 

care. 

The CHAIRMAN. Thank you, Ms. Bechtel. 

Mr. Patterson. 

STATEMENT OF NEAL L. PATTERSON, MBA, COFOUNDER, 

CHAIRMAN, CHIEF EXECUTIVE OFFICER, CERNER CORPORATION, KANSAS CITY, MO 

Mr. PATTERSON. Thank you, Senator Alexander and Senator 

Murray. This is a privilege and a pleasure, and I was told yesterday it would be fun to testify. This is my first. 

Just to give you a quick thumbnail of Cerner, there’s about 

21,000 Cerner associates around the world. I had the privilege of 

being the co-founder of it in 1979. The first thing I want to do is 

thank you for the opportunity to be born in such a great country 

that a poor farm boy from Oklahoma that went to a land-grant college actually could go and create something that is significant. 

It was pure fortune that I found the intersection of healthcare 

and IT. That is the world I live in. I wake up every morning and 

I go to sleep thinking about that. I think it is the most—I think 

information technology is the greatest lever we have to change our 

healthcare system. I also have the privilege of basically agreeing 

25 

almost wholeheartedly with everything that has been said here 

today. 

My lift is relatively small. My biggest challenge as an entrepreneur is to talk within 5 minutes, and the clock is running. 

We have a huge opportunity. We’ve invested as a country to 

digitize the entire content of the most important and largest sector 

of our economy. That’s healthcare. Information technology is the 

biggest lever to create change. 

We are, I believe, at the dawn of a new era, and I think there 

is huge opportunity for it to be a golden era. There are significant 

things, though, in front of us that are barriers to realizing all of 

those benefits, and the fact that you are having these hearings, the 

fact that you are as informed as you are about the issues, I think 

is a very, very good deal. 

One thing that we say at Cerner about healthcare is that 

healthcare is too important not to change, and also healthcare ultimately becomes personal. My wife has stage 4 cancer since 2007. 

I have my version. My version of this with Jeanne are bags and 

bags, and you continuously update these. You do go to see doctors 

that are outside of the organization, and you need all that information in those bags. 

I think it is a crime. I think that—I shouldn’t say crime here. I 

think it is a failure of all of us to have in 2015 the fact that Jeanne 

carries bags to her doctors’ appointments where she’s going to see 

a new doctor or a specialist if she wants specific opinions. We have 

to fix that. 

Interoperability is high on my list, both professionally and personally, to fix. From the role, I guess—what’s your role as government in interoperability? I hold up this card. This is my ATM card. 

I’m old enough to basically remember when that was issued by my 

bank, and I had to use the bank’s machine. 

I’m old enough to remember that I was so excited when I could 

go to other banks in other cities. As long as I had a network—my 

card had the network that was on the machine—I could get money 

out of it, and today, we go—my youngest son just flew last night 

to Sri Lanka, and he will get currency out of an ATM machine 

there. 

We, as an industry, are behind around access to information, enabling the person, the patient, to have that. I believe industry 

should solve that. I think all of my associates up here believe that, 

too. It takes, frankly, my part of the industry to solve that, and we 

have to work together to do that. 

That has not happened to date. I’m moderately optimistic it will 

happen. I commit—I will do everything I can to make that happen 

so that we collaborate as an industry, and our networks that we 

build as companies, where we have our clients connected—that 

those private networks connect, and it will work like the ATM, I 

hope, by the end of this decade, so that you can expect to go to any 

physician anywhere in the country, and they can push one button 

and the relevant part of your lifetime record would appear on that 

screen. 

I think what you—one other quick thought on your role. Make 

sure when you do regulations and you do legislation that you put 

rounded edges on it. One of the issues with Meaningful Use is it 

26 

was defined specifically, and physicians felt like they had to follow 

the specifics every time for every patient, and, in reality, that was 

not—and they felt like they had to do it, and their assistants could 

not do it. 

We need thoughtful regulations coming from here. Thank you 

very much. 

[The prepared statement of Mr. Patterson follows:] 

PREPARED STATEMENT OF NEAL L. PATTERSON, MBA 

Dear Chairman Alexander, Senator Murray, and members of the HELP Committee, thank you for inviting me to share my ideas about how to improve health 

information exchange for the benefit of every American. I appreciate your openness 

to ideas and action from the private sector as well as administrative and legislative 

change. 

My name is Neal Patterson. I am co-founder, chairman and CEO of Cerner. We 

are a leading health information technology company with a projected $4.7 billion 

in revenues in 2015. We will spend more than $650 million on research and development in 2015. We employ 21,000 associates who operate in more than 30 countries 

worldwide. 

The intersection of health care and IT is one of the most important in modern 

society. Every citizen touches and depends on both. 

I appreciate the opportunity to share Cerner’s perspective on what can be done 

to create a more interoperable health system. We believe that every individual has 

a right to access their complete health record, regardless of where it’s located or 

what system contains the data. It is immoral for any organization to block the flow 

of information that could help individuals—and their providers—make better-informed decisions about their care. 

In other industries beyond health care, from retail and entertainment to banking 

to manufacturing and distribution, information technology has wrought massive 

change and materially improved our lives. It is not simply the efficiencies of IT. 

When things are digitized, they change. 

Digitizing content drives transformation. Digital music recording paved the way 

for file sharing and iPods to change our music collections. The movement of news 

online changed how quickly we receive the news. ATM cards changed how we bank. 

Social media has enabled political mobilization against dictatorships. The secondorder effects of content digitization are profound. 

You don’t always see these effects coming. They happen when data liquidity allows innovators to use information in new ways. 

In health care, HITECH and Meaningful Use are not perfect, but they are helping 

move health care onto a digital platform. As a society, we may be closer than we 

think to a golden era when science, intelligence and insights from big data can become a natural, unforced part of health care. 

Two qualities are important to enable this type of transformation. Health IT platforms must be open, and they must be interoperable. 

The quality of being open is what allows independent developers to build ‘‘apps’’ 

and extensions that work with existing health IT platforms. After years of little 

movement, our industry is finally making real progress toward being open to outside 

development. It will fuel an entrepreneurial wave of novel health IT apps and services that will address particular needs of providers and patients. 

For all the progress and promise, however, our current efforts are insufficient if 

they still serve a bunch of disconnected digital silos. Current health IT systems lack 

true interoperability, and the lack of true interoperability is failing patients. Without it, we risk missing the moonshot transformation that has positively changed 

other industries and lives. 

My wife has been fighting breast cancer since 2007. I have her permission to 

share her story. She has had procedures in the last 8 years ranging from mastectomy, radiation and chemo to brain surgery and genome sequencing. Her diagnostic 

and treatment journey has taken her to multiple providers, and her records have 

wound up in more than 20 different health organizations’ EHRs. Everyone has a 

piece of Jeanne’s record, but no one has the whole picture. 

Because there is not widespread interoperability, Jeanne carries printed copies of 

her records around in shopping bags. Each record she carries represents a phone 

call, a wait in a line at a records desk, a fax or a photocopy. The burden of assembling those records is what she calls the ‘‘train wreck.’’ 

27 

1Practice Fusion survey conducted by GfK Roper, 2010. 

It’s, of course, not just cancer patients who live this reality. It’s almost all people 

with chronic conditions who have to see specialists—and people who move—and people who rely on emergency rooms for their care. In reality, everyone in the chamber 

today has experienced this issue. In the United States, the average person has seen 

18 different doctors. If you’re over 65, the number increases to 28.1 It doesn’t matter 

if the records are across the country or across the street. If the systems are not 

interoperable, the result is the same. 

Here is my litmus test and vision for real, patient-centered, true interoperability. 

It is when you as a patient can go to a new doctor who hasn’t seen you, sign your 

name electronically giving your consent, and then the doctor can click a button in 

the EHR and compile what is most relevant from your lifetime record that you want 

to be shared, pulling information from many places. We actually are quite close to 

being able to realize this vision, and the issues in realizing it are largely not technical ones. 

Over the past decade, there has been some good progress on interoperability. 

Standards have progressed that define how and what information is shared to whom 

and when. Governance and privacy standards are also progressing. We are members 

of Carequality, an industry coalition focused on governance. I think Congress’s recent focus and sensitivity to the behavior of data blocking (intentional or inadvertent) is a good thing. There are current efforts to create the concept of ‘‘semantic 

interoperability,’’ which is extremely powerful and has the potential to unleash enormous innovation that will interact with the EHR platforms. But it is my testimony 

that, while this progress is good and necessary, it will not realize the vision I shared 

above. I want Jeanne’s doctors to have access to her full lifetime record. That vision 

requires a system for national patient identification, for record location tracking and 

for patient-driven consent. 

There is a tendency to use isolated interoperability success stories as the poster 

children for progress and defense of the status quo. Some regard largely single-vendor networks or ‘‘intra’’-operability as equivalent to interoperability. It’s a form of 

progress, but it’s not the same, because your records and Jeanne’s records are not 

all on one vendor’s system. They’re spread out across every vendor in the industry. 

It’s just not enough. If we remain satisfied with this progress, patients could wait 

decades to see real interoperability. It will leave too many patients carrying too 

many bags for too long. 

As a health IT industry, the electronic health record community has grown up 

alongside each other—Meditech, Cerner, Epic, McKesson, Allscripts and many others. We were out conquering the map. Each of us has had our own version of building our core capabilities. Competition has been healthy, and it has driven a lot of 

innovation. But too often these competitive instincts led to technological silos. 

Outside of health care, there are plenty of examples where competing business interests, spurred by consumer pressure, came together to solve interoperability problems. Apple and Android phones can talk nationwide. The Verizon network connects 

with the Sprint Network. My Microsoft Outlook email communicates seamlessly to 

Google Gmail. My ATM card works at nearly every machine worldwide. Government 

may have helped, but industry played the biggest role. 

In 2013, in an effort to augment the standards and governance work playing out 

in Washington, our industry sought to take on a set of big issues that are impeding 

true interoperability and data liquidity. Along with some other vendors, we created 

a non-profit called CommonWell with an eye toward addressing three barrier issues 

to true patient-centered interoperability: patient identification, record location and 

patient-driven consent. CommonWell invited all electronic health record vendors to 

come together. 

To solve for the needs of patients, we wanted an approach that was national in 

scale. The service it offered had to be available at a very low, utility-like cost to providers. And it goes without saying that it had to safeguard privacy and the trust 

of individuals and providers. 

Achieving this level of interoperability in health care requires a virtuous cycle of 

product innovation and standards development and evolution. It also requires all 

the players in the industry to agree that patient-centered interoperability needs 

shared networks between vendors, not just a trickle of individually negotiated connections. Waiting around to fulfill the next request to connect two hospitals to each 

other or to a local HIE meets the letter of the law. But getting to full interoperability requires active cooperation among all the vendors, and their acceptance that 

once technological silos are eliminated, they will have to compete on innovation, 

quality and cost. We do not have this yet in health IT, but this kind of dialog at 

the national level has a chance of creating real change. 

28 

What we do have is CommonWell, a non-profit vendor-to-vendor network, national 

in approach, which providers and hospitals can access on behalf of individual patients. It is open to the entire industry, and its members include Allscripts, 

Athenahealth, Brightree, Cerner, Evident (formerly CPSI), Greenway, McKesson, 

Medhost, Meditech, Merge Healthcare, Sunquest, and other companies—which includes every major acute care EHR company in the industry with the exception of 

one. Cerner is committed to any effort to advance true interoperability, and the 

CommonWell network is in my opinion our industry’s best cooperative effort so far. 

I have made it clear that if someone establishes another open network that has a 

reliable method of patient identity management, record location tracking and patient-driven consent, it will also have my support and participation. 

As for Washington’s role, it must be clear to all that the policy of this country 

is true interoperability. The Office of the National Coordinator (ONC) must continue 

pressing its framework for interoperability, convening, facilitating and evolving important standards work. Vendors and providers must enable sufficient transparency 

around data sharing to allow keeping a watchful eye on behaviors in our industry. 

Congress should not be afraid to act. Whether intentional or unintentional, behaviors that restrict patient choice, throw up roadblocks to true interoperability, or use 

control over data to further market share should be challenged. None of us have 

a perfect record, and we can all do better. 

The subject of interoperability can quickly become blurred into an alphabet soup 

of acronyms, nomenclature, standards, governance and use cases—so much so that 

we lose the point. In the end, you will know it when you see it. It’s when you can 

go to your doctor and they can push a button and assemble the relevant parts of 

your lifetime record that you want to be shared with your doctor. 

We all can cite how the rising cost of health care is consuming more of our resources as a family, community and country. I am convinced that information technology is the single greatest lever for creating value in health care by eliminating 

waste, variance, error, delay and friction. It can put a system into health care. 

We have a chance to deliver a golden era of health care. It’s a system where consumers not only have a right to their data, but also have the ability and the financial incentives to mobilize it in pursuit of better health. 

We have a chance to make Jeanne’s shopping bags a thing of the past. 

I look forward to working with the industry, as well as members of the committee, 

to advance that vision. 

The CHAIRMAN. Thank you, Mr. Patterson, and thanks to all the 

witnesses. We’ll now begin a round of questions. I’ll call on the 

Senators in the order they were here at 10 a.m. Senator Murray 

after me, and then Senator Burr, Senator Warren, Scott, Casey, 

Cassidy, Bennet, Franken is the order that I have. 

Dr. Payne, in March, the department released proposed rules for 

Stage 3 of Meaningful Use and the 2015 edition of the Certification 

Program for Electronic Health Record Technology. The comment 

period ended in May, and we expect the Administration to release 

the final rules this fall. Meaningful Use 3 will go into effect in 

2018. Parts of 2015 certification could go into effect later this year. 

A hospital that should know what it’s doing has told me it’s terrified by Meaningful Use 3. Do you think that it would be a good 

idea to delay some or all of these proposed rules until Congress and 

the Administration have a chance to work on the five or six things 

that seem to be the biggest impediments to making our electronic 

healthcare records something people look forward to instead of 

dreading? 

Dr. PAYNE. Thank you for the question. The answer is yes. We 

think Stage 3 needs some improvements. There are many elements 

to it. A good example of an improvement would be that it tests 

whether a vendor conforms to a standard, but it doesn’t test whether the vendor systems are truly interoperable. 

We should be sure that the record can be sent and that it can 

be received and used. The certification program also needs to be 

29 

improved so it can make certain that both the sending and receiving is possible. Some of the standards in it are in a draft state. 

The CHAIRMAN. My question is do you think it should be delayed 

or not, in part or in whole? 

Dr. PAYNE. We think it should be delayed until it’s improved. 

The CHAIRMAN. Mr. Patterson, in your comments earlier, you 

seem to think that physicians are being asked to do some things, 

or they think they’re being asked to do some things that’s not necessary for them to do. Senator Cassidy is going to chair a special 

hearing on physician documentation. 

As I understand your position, you feel that physicians—there is 

some documentation that physicians certainly should do. There are 

other things that an aid could do. To some extent, the billing system has gotten mixed up with the electronic healthcare records and 

made it even more onerous on physicians. Is that a fair summary? 

Mr. PATTERSON. I would agree with your summary. 

The CHAIRMAN. Would you be able to suggest to us or perhaps 

to Senator Cassidy’s work the specific things that you think doctors 

should do and other things that others shouldn’t do—or aren’t necessary for them to do, and how we might change the regulations 

or the law to make that clear? 

Mr. PATTERSON. Yes. We certainly can provide some followup to 

that in writing. 

To give you an example, meds reconciliation, I think, as written 

and the intent of the regulation is that the physician is to do the 

meds reconciliation. I think that’s appropriate in many cases, but 

that was—but I think in many cases, that function could be done 

by a nurse or an aid to the physician under their supervision. They 

review the work and basically accept it. That’s the, if you will, 

rounded corners, rounded edges on the regulation. 

The physician’s time is one of and if not the most critical resource inside of the healthcare system, and then the person they’re 

serving—the patient’s time is the other part of that. We need to 

preserve the physician’s time with the patient, and I think, current 

state, we have impacted that amount of time that they can spend 

negatively. 

The CHAIRMAN. Mr. Richardville, all of you have mentioned the 

importance of having agreed upon standards by the various participants in healthcare, and it’s critical to enabling real interoperability, the kind of ATM card that Mr. Patterson talked about. To 

what extent would you propose that the Federal Government get 

involved in mandating or otherwise requiring health information 

technology standards to be adopted? 

Mr. RICHARDVILLE. A couple of points, and thank you for the 

question. There are current initiatives out there today that help 

promote—that are trying to promote some of this interoperability— 

Carequality, CommonWell, Epic Care Everywhere, Argonaut—and 

there are successful—— 

The CHAIRMAN. My question is on standards. To what extent 

should the Federal Government get involved? 

Mr. RICHARDVILLE. Well, I think what the Federal Government 

needs to do is to come in from a governance perspective and help 

define what those rules of the road are so that these organizations 

can all abide by those rules. I think, as Senator Murray talked 

30 

about, that the ability for the network of networks, which is similar 

to Neal’s point, like the Cirrus network that connects the ATMs, 

would be a viable opportunity for the healthcare industry. 

If those rules are set up—— 

The CHAIRMAN. Do you want the Federal Government figuring 

out the standards? 

Mr. RICHARDVILLE. No. 

The CHAIRMAN. Or do you want it encouraging the development 

of standards developed by private industry? 

Mr. RICHARDVILLE. Encouraging the development of—I think it’s 

a multidisciplinary team of payers, patients, vendor partners, and 

providers that should get together and develop what those standards are. We do need regulation to help define what the timelines 

are, the aspects of defining what those rules of the road are that 

we all need to play into so we can participate in a very multidisciplinary approach and allow that network of networks to develop. 

The CHAIRMAN. Thank you. 

Senator Murray. 

Senator MURRAY. Thank you. Our hearing today is focused on 

health IT because of its potential to improve the quality and value 

of healthcare for our patients. Health IT can support research that 

unlocks innovative new treatments. It can support better coordinated care at critical times like when a patient is being discharged 

from a hospital. To achieve any of those objectives, patients themselves need to be engaged in this work. 

Ms. Bechtel, I want to ask you: How does health IT enable better 

partnerships between patients and families and their doctors? 

Ms. BECHTEL. Health IT does quite a lot to enable those partnerships. It lends a lot of transparency, so I can see what’s in my medical record. I can correct errors. I can add to it and complete information. It also helps me engage more in not just managing my 

care, but in managing my own health. There’s a lot of data that 

shows us the many ways, from reading my physician’s notes to 

looking at lab results, that health IT really supports and enables 

that. 

I think the one thing that is essential to also think about—and 

this is going to point back to Senator Alexander’s question about 

delaying Stage 3. There are aspects of patient engagement that we 

would give up if we delayed Stage 3 wholesale. I just want to note 

that we would also, ironically, give up requiring a greater percentage of doctors to share information electronically, not just with patients but with other doctors. 

We would also lose a technical fix that would help us to unlock 

the data that is currently siloed in patient portals. It’s called an 

API, an application programing interface, where we would be able 

to download that. We would give up some gains on patient-generated health data. 

I just want to recognize that wholesale delay of Meaningful Use 

Stage 3 should be very thoughtfully considered in light of the items 

that we would impact, give up, that I know we all support. 

Senator MURRAY. OK. Great. 

Dr. Payne, in your testimony, you talked about enabling patients 

to receive an electronic copy of their entire medical record, that 

that would have the most genuine and lasting impact on smoothing 

31 

the flow of electronic health information. I’m really proud that in 

our home State of Washington, including the University of Washington, we are pioneering the Open Notes Project, which is working 

to give patients access to the visit notes written by the doctors and 

nurses that Ms. Bechtel just talked about. 

Talk a little bit about how enabling patients to access and 

download their entire electronic record would improve the flow of 

information. 

Dr. PAYNE. Well, just as the Open Notes Project makes sense, we 

think that providing access to the entire record also makes sense, 

and it’s the right thing to do. The notes are very important, but 

elsewhere in the record are also pieces of information that are very 

important and that are still today very difficult for people to access. 

If we set the standard that the record that is truly the right of 

the person to see is available to them, they will have other benefits 

beyond just reading the notes. We think there will be innovation 

that will be based on having access to the entire record that we 

don’t see today. We think it is the logical next step, now that we 

have a good deal of the Nation’s health record in electronic form, 

that the person who owns it has a right to see it. 

Senator MURRAY. Well, in order to make sure that patients and 

clinicians have better access to electronic health information, we 

need to make sure that no one is deliberately blocking it. 

Mr. Patterson, I’m glad that in your written testimony you agree. 

We need to prohibit data blocking. HHS tells us that it can be difficult to distinguish between contract terms and pricing policies 

that are normal business practices and those that are designed to 

deliberately block information. 

In your view, can you share with us how vendors and providers 

deliberately block data? 

Mr. PATTERSON. The word, deliberate, is a bit caustic from the 

way I think it actually happens today. I think their historic practice is we’re not to share data. I think business strategies get in 

the way, and business models get in the way, saying, ‘‘I’m better 

off if I don’t share it.’’ 

In my written testimony, I frankly, if it’s you or your loved ones, 

and that information is vital, I consider it immoral for people to 

block that data and force us to carry it in bags. I think we’re just 

crossing over into a new era. I think, as I said earlier in my oral 

comments, your asking that question, is extraordinarily powerful, 

and I think you should continue to talk about it. 

We individuals, the citizens, the people who are served by the 

health system—those are our records, and I think you should pass 

a law that says we should have a copyright to that—we should 

have a legal standing in that information, because too many times, 

healthcare thinks it’s theirs. They should have a copy, too. They 

produced it. It’s a part of their—they have all kinds of reasons for 

that record. 

But when it’s digital, I can have my copy, too. I think it happens. 

It happens from a historical practice point of view. We need to 

change those practices or we’re never going to get rid of the bags. 

Senator MURRAY. Thank you very much. 

Thank you, Mr. Chairman. 

32 

The CHAIRMAN. I should repeat that one of our next hearings this 

summer is on precisely the subject of who controls my data and 

how do I get hold of it. Senator Collins is going to chair that hearing for the committee. 

Senator Burr. 

Senator BURR. Mr. Richardville, why is this so hard? 

Mr. RICHARDVILLE. Great question. There are actually multiple 

factors that makes interoperability difficult. First and foremost, it’s 

technically complex. You have a varied amount of different systems 

that have different rules of the road that they’re participating in, 

and we’re expected to try to connect that information that they’re 

producing together. 

Second, in terms of prioritization, when you look at the incentives, especially those that came out through Meaningful Use, a lot 

of the investments that healthcare providers had to make—it was 

not one of the top incentives. When you have limited resources, 

looking to try to achieve things that you need to have done—those 

are things that kind of fall a little bit more down to the bottom of 

the list. 

Senator BURR. What’s your definition of interoperability, and is 

your definition different than anybody else on this panel? 

Mr. RICHARDVILLE. I hope it’s not different. My definition of 

interoperability is the open, free exchange of secured data between 

providers and patients, utilizing health information technology systems as the road to provide that kind of activity. 

Senator BURR. Let me throw it out to any of you. Why would a 

provider not want to make a patient’s information available to a 

patient? 

Ms. BECHTEL. Well, I can tell you that when I asked for my 

health record electronically, I first had to convince them that I 

wasn’t trying to leave the practice. They have real endowed business reasons, because of the way we pay for healthcare in a feefor-service environment, to try to hold my data as a business asset 

so it’s not as easy for me to actually go get an office visit somewhere else. 

From a consumer perspective, it makes it much more challenging 

for me. Yet every piece of data says that if you give me my data, 

and you give me access to it, it actually increases my loyalty to the 

practice. Other folks may have comments. 

Mr. RICHARDVILLE. You know, at Carolinas HealthCare System, 

our motto is patient first always. For us to engage and involve the 

patient in everything that we do is part of how we are able to move 

forward and progress. 

The only thing that I would say in addition to what Ms. Bechtel 

has said is that sometimes some of the language and some of the 

data structures that are put in place may be difficult for a patient 

or a consumer to digest without some easier way to translate that 

into meaningful pieces that they can then absorb. 

Senator BURR. Dr. Payne. 

Dr. PAYNE. One friendly amendment to Craig’s definition—I 

would add that interoperability includes the ability to use the information when it is exchanged. There are many ways to exchange information, some of which leave it dormant. If we make the exVerDate Nov 24 2008 17:35 Jul 20, 2017 Jkt 000000 PO 00000 Frm 00036 Fmt 6633 Sfmt 6601 S:\DOCS\25971.TXT CAROL
33 

change occur in a way that it’s useful for its intended use, that’s 

an important element of interoperability. 

Senator BURR. Mr. Patterson. 

Mr. PATTERSON. To have true interoperability nationally or get 

close to the ATM card functionality, there’s really three things that 

have to be in place. One is there has to be an identification. When 

you’re going to send Neal Patterson’s record from physician to physician, provider to provider, there has to be an identifier of Neal. 

We do not have a national identification system in this country. It’s 

a subject that’s been discussed a lot, and it’s one that’s basically 

been tabled. 

In today’s world, we can solve that as an industry without you 

doing anything. But it has prohibited, because to curate who I am 

on the other receiving side is a lot of work. We lack a functionality 

around identification. 

We lack a functionality—there’s no place that knows where my 

records are, other than me, and, frankly, that’s—you know, Jeanne 

has been to 35 different places. I can figure it out, but it’s a—so 

we don’t have a system that says where my records are. 

And third, we really need a consent—everybody is very afraid— 

providers are very cautious of letting records out because HIPAA 

has some very stringent penalties in there around sharing information, patient information. We need a consent system. 

Senator BURR. It’s a shared feeling. We’re scared about opening 

up HIPAA to try to tweak it, because it may become more cumbersome and more onerous. 

Let me just say this to all of you. If you will think about, when 

you leave here, anything else that we might need to look at from 

a provider’s standpoint that’s a disincentive to sharing information, 

so that we know what we’re up against as we begin to look at legislation, as regulators begin to look at regulations, I think therein 

holds the key. 

If we’re just down to an economic decision, Ms. Bechtel, I think 

we can find a trigger for that. 

I’ve got to believe that there’s more than that, and I think it revolves around interoperability in some way, shape, or form. It may 

be what they chose to put their electronic medical records in and 

their inability to merge that into something else. 

I think that we’re going to find things that are out there that 

maybe, by themselves, you wouldn’t look at and say, ‘‘Here’s the 

problem,’’ but, collectively, they probably contribute greatly to this 

inability. 

I thank the chair. 

The CHAIRMAN. Thank you, Senator Burr. 

Senator Warren. 

STATEMENT OF SENATOR WARREN

Senator WARREN. Thank you, Mr. Chairman. So far, the Federal 

Government has invested $30 billion in electronic health records, 

in part because sharing health information between doctors can improve patient care. It’s still the case that the health record systems 

can’t always match a particular scan or test result to the right person, and mismatches can be very dangerous. As more patient information is stored electronically and as doctors exchange more health 

34 

records with other doctors, the risk of mismatching patient information goes up. 

We’ve got at least two studies that I know about on this. A 2008 

Rand Corporation study estimated that even with database management software and personnel that were dedicated to preventing 

such mistakes, hospitals mismatch patient information about 8 percent of the time. A 2012 study conducted by the Council of Health 

Information Management Executives found that one in five physicians encountered mismatched information that put a patient at 

risk during the previous years. 

I would like to start—Mr. Richardville, can you explain to us 

what tools Carolinas HealthCare used to solve this problem? 

Mr. RICHARDVILLE. Yes. CHS on many pieces are on the forefront 

of innovation. What we looked at several years ago and was the 

first, actually, to bring into the country was a biometric palm vein 

scanning system. It actually scans the veins in the palm. It’s not 

a palm print, but it’s the veins, like a snowflake, in the palm. We 

have that at all of our locations. We’ve had that for many years. 

Since then, when you quantify like the 8 percent, our medical 

record number duplicator error rate is .11, which is 80 times better 

than the average that you talked about. At least within our system, 

we’ve been able to mitigate that issue. 

As we try to match across the systems, I’m not saying that that 

is the answer for others. I think there’s probably other successes 

in the country, and we need to put those heads together and see 

if there is a way that we can expand that across. 

Senator WARREN. Let me ask the question about, then, among 

systems. Mr. Patterson, in your written testimony, you discussed 

CommonWell, an alliance of health IT companies that connects 

health records that are managed by different vendors. What has 

CommonWell done to avoid the mismatches? We’ve got between 

systems here. 

Mr. PATTERSON. Right. In broad terms, CommonWell allows you 

to create an account that is used for—and you, as an individual, 

create it. You say, ‘‘Here’s what consent I give to share my information, and here is my identification.’’ It’s like having your Google 

email account, and you are controlling that account as the person. 

Senator WARREN. This is done patient by patient. 

Mr. PATTERSON. Patient by patient at enrollment. Once you have 

that account—obviously, to start your first email account, there’s a 

process to it. Once you have your identification, then information 

can be sent and moved. CommonWell has solved the identification 

problem on a voluntary basis. 

Craig’s solution is much more precise and elegant, but I do not 

think we can implement that nationally. I’m not going to—you’ll 

have to have a hearing on that. That’s much more precise. 

Also CommonWell basically provides the software—we have near 

30 members of CommonWell. All of us as software companies agree 

to also—when we record the fact that there is information about 

a person under that ID in our records at these locations. We solve 

the record location issue. 

Senator WARREN. Carolinas HealthCare and CommonWell and 

others around the country are all working to prevent patient 

35 

matching errors within their own systems. There are obviously limitations on what you can do alone. 

Mr. Patterson, I’d like to ask you: What can Congress or the Office of the National Coordinator of Health IT do to help scale individual efforts to reduce matching errors and at the same time to 

protect patient privacy? 

Mr. PATTERSON. The ability to have an identifier that we all 

share would be an enormous help in reducing the risk and improving the value to patients. If it were possible for it to be simple to 

do and accurate, then it would happen more often, and I think patients would benefit enormously from that. 

In the absence of such an identifier, algorithms that help us do 

the next best thing, which is to use existing information to make 

sure that we know who the person is when the information is sent 

or received, would also be very helpful. Much work has already 

been conducted in this arena. 

It is a complex and very important question, and I’m glad that 

you are focusing on it. We also have people who come to us in our 

trauma center who are unconscious, unable to tell us who they are. 

It is a risk to them and requires enormous effort on the part of our 

staff to be sure we know who this is as we provide care to them 

in the safest way we can. 

Senator WARREN. Thank you. You know, accurately matching 

health information to the correct patient record is critical for the 

safety and the effectiveness of electronic health records. I look forward to seeing more research in this area. I hope that industry and 

government can work together to find a solution that keeps patients safe and that protects their private health information. 

Thank you very much. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Warren. 

Senator Cassidy, I’ve already noted that you’ll be chairing a 

hearing for the full committee. I think Senator Whitehouse may 

serve as the ranking member for that hearing on physician documentation. We appreciate your willingness to do that. 

STATEMENT OF SENATOR CASSIDY

Senator CASSIDY. Thank you. 

Mr. Patterson, you mentioned in your testimony semantic interoperability. Is that a challenge? Because it sounds like once you go 

through CommonWell, and you have this kind of ID that I volunteer and it goes to others, that there should be some sort of way 

to communicate. How much of an issue is that? 

Mr. PATTERSON. Dr. Payne would be probably the subject matter 

expert on it. I’m very impressed—so there is work on standards to 

create the next level of interoperability. In my testimony, I call 

that semantic interoperability. It’s one thing to move safely information about ourselves. For it to be consumed by the physician, if 

we can understand what’s in that record and it can be worked into 

the—— 

Senator CASSIDY. Simply, as Ms. Bechtel said, not necessarily as 

a pdf but rather structured so I can follow blood pressure over time 

with some chart relative to medicine. 

Mr. PATTERSON. Right. 

36 

Senator CASSIDY. That would somehow structure it between 

records. 

Mr. PATTERSON. Yes, you’ve got it near—you are perfect on that. 

Senator CASSIDY. Thank you. 

Mr. PATTERSON. And that’s a huge deal. 

Senator CASSIDY. Will you talk to my wife about that and extrapolate the other things? 

[Laughter.] 

CommonWell, you mentioned in your testimony that all major 

players except one are participating in CommonWell. Who is the 

major player not participating in CommonWell? 

Mr. PATTERSON. Epic is not participating in CommonWell. 

Senator CASSIDY. Senator Murray asked about business practices, or somehow that developed in the conversation—is it deliberate or is it business practices. The effect is the same, that data 

is not—I feel like Epic is the elephant in the room. 

It was implied in your testimony that a business practice which 

does not allow sharing somehow furthers their business model. If 

you want to share data with another Epic hospital, you have to 

have Epic, and they have such a market share that people will migrate. That’s my opinion, but is that a fair opinion? Is that defensible? 

Mr. PATTERSON. That would be my experience, that they would 

use that as a marketing technique. 

Senator CASSIDY. Again, as Senator Murray—— 

Mr. PATTERSON. I might add that I believe—and I hope Epic will 

join CommonWell and that we work together as an industry. The 

only way this is going to get solved is that we work together. 

Senator CASSIDY. I accept that totally. On the other hand, sometimes we set this up—I say Congress—giving billions of dollars, 

and now a major player is not participating in a common effort to 

create the sort of structured data that Ms. Bechtel would find so 

useful and that you agree would be a nice way to do it. We need 

to have them come to say it. 

But that is a problem, and I say that as a physician who shakes 

my fist at the computer because I can’t get the data that I need 

as I am seeing a patient. Let me ask, and I’ll open this up. What 

can we legislate that would—if people don’t want to come forward 

voluntarily—we can say you’ve got to—it’s hard to say you have to 

participate in CommonWell, because CommonWell may become 

something different. 

Mr. PATTERSON. Right. 

Senator CASSIDY. Yet I have a sense that you prefer the private 

sector to be the setter of the standards as opposed to a Federal 

agency. Really, it may be that we have to have a Federal agency 

that says, ‘‘We shall solve these problems by this deadline or else 

we shall prescribe.’’ Do you have opinions on that? Is that what’s 

required? 

Dr. Payne? 

Dr. PAYNE. I think one move that we as a nation and Congress 

could take is to move toward reimbursement for value, for quality. 

If that movement accelerates, there will be a big drive for interoperability. 

37 

Senator CASSIDY. That just may be a big drive to continue business practices which say, 

‘‘Listen, if you want to play, you’ve got to play with me because I’m the big guy on the block, and so, therefore, I’m the 

only person that can give you everything.’’ 

Dr. PAYNE. I think it would also be a strong incentive for industry, but also provider organizations, to use standards that exist 

now for interoperability. We should do a better job with interoperability—— 

Senator CASSIDY. I’m not sure you’re answering my question. My 

question is: Do we have to be more coercive than we are now in 

order to crack it open? 

Mr. Richardville. 

Mr. RICHARDVILLE. I would say, Senator Cassidy, several things. 

One is I do think congressional action is needed so we can set up 

what I would call functional standards that we can all play by. I 

also think that the measures of the outcomes that was referred to 

needs to be part of it. Most importantly, is the enforcement. Make 

sure that compliance takes place as we start doing this. 

In addition to what Neal Patterson talked about and with 

CommonWell, I do think there are a handful of other integrative 

efforts that are going on in play. We at Carolinas HealthCare System actually—one of the unique systems that we actually have— 

Cerner, Epic, McKesson, Allscripts within our system, and we’ve 

built a core competency of interoperability with our health information exchange to actually change information within our system 

with different vendor partners that we work with. 

Senator CASSIDY. Does it cost you per transaction, or can you do 

that without charge? 

Mr. RICHARDVILLE. It is not per transaction. It’s per member. We 

pay based upon the number of people who actually participate in 

it. For us, as we have more physicians come into that, we actually 

pay based upon the people that consume and participate in our 

health information—— 

Senator CASSIDY. That’s interoperability with a charge. 

Mr. RICHARDVILLE. It’s interoperability with a charge based upon 

usage. 

Senator CASSIDY. OK. I yield back. Thank you. 

The CHAIRMAN. Thanks, Senator Cassidy. 

Senator Casey. 

STATEMENT OF SENATOR CASEY

Senator CASEY. Thank you, Mr. Chairman. 

I want to thank the panel for your testimony and for helping us 

to better understand and, we hope, figure out a complex problem. 

I wanted to start this morning with children. We have over many 

years developed programs that enhance children’s health insurance, whether it’s in the Children’s Health Insurance Program or 

Medicaid or otherwise. We often don’t ask, I think, an essential 

question, which is—just as we do in the context of protecting the 

environment, we say, ‘‘What’s the environmental impact of a particular policy?’’ or the environmental impact, more particularly, on 

a project. 

38 

We should ask the same question in the context of children: 

What will be the impact on a child or children if we take this step 

with regard to healthcare and, in this case, with regard to 

healthcare records? I wanted to start in a very particular way. 

Dr. Payne, you’ve heard child advocates say for a long time that 

children are not small adults. We need to make sure that we have 

strategies and approaches to children’s health insurance that may 

not be applicable or transferable from the strategies for adults. 

In particular, I wanted to highlight immunizations, so critical to 

pediatric healthcare and also providing a great public health benefit. Access to immunization records is necessary to ensure that 

children receive the recommended vaccinations at the appropriate 

time. 

What can you tell us in the context of this discussion with regard 

to the fundamental question, which is ways that having electronic 

health records that are interoperable—how can that improve access 

to immunizations? 

Dr. PAYNE. That’s a great question and a great example of the 

benefit of interoperability. In our report, we addressed just that 

issue, that there are a growing number of registries for children’s 

immunizations, because children, as do adults, move from city to 

city, and those registries contain the record of their immunizations. 

Most importantly, the record tells us what they have not received 

so that we can make sure that they do receive it. 

The challenge here is that the information in those registries is 

not flowing seamlessly into the electronic health records that the 

pediatrician or family doctor would use to look to see what’s needed 

next. That’s an example of where improved use of existing standards or refined standards would help children in a very direct way. 

This is an important preventative care measure, and we should 

make sure we use it every time it is appropriate for a child’s 

health. 

Senator CASEY. I want to open it up to the panel, if anyone else 

has any comments on this, and I’ll have a followup for Dr. Payne. 

Anyone on the panel? 

Ms. BECHTEL. Sure. I think this is a terrific use case for the kind 

of consumer demand for their health information that I was describing earlier. I think as moms and caregivers can begin to get 

and request an electronic copy of their health information from 

their doctor, they can begin to catalog those things, and, at least, 

until we fix the standards and fix the registries, I can build a comprehensive list of my immunizations. I can share that with my provider. I can manage that. I can set alerts when things are due. 

It really enables me as a caregiver to have a much more complete picture of my child’s health, including immunizations. Enabling that kind of consumer demand, that pulling on the rope right 

now, would be a really essential strategy to make very quick 

progress in the short term. 

Senator CASEY. I appreciate that. 

Mr. PATTERSON. I might add that immunizations is a very good 

example of something where IT creates a lot of value. Immunizations at birth—you know for the next 7 years when, approximately, 

immunizations need to be done. The systems should know what— 

not just help document what is happening. It should know what 

39 

isn’t happening, and it should be able to then report back to the 

pediatrician, report to the family that these events need to happen. 

There’s just too much reliance on well-intended—and the systems 

are increasingly getting smarter—would need to get smarter. 

That’s a great example of population health. 

Senator CASEY. I appreciate that. I’m almost out of time. Maybe 

for a fuller answer to this question, I’ll start with Dr. Payne—or 

I should say a fuller answer from everyone. It might be better just 

to put it in the record. 

I wanted to ask, in the context of transparency, what can we do 

more broadly now—not just with regard to children, but more 

broadly—to increase transparency as it relates to electronic health 

records? If you can give a short answer, and everyone else can put 

it in writing if that’s all right so I don’t get the chairman upset. 

Dr. PAYNE. I think you can highlight its importance and its value 

and encourage other regulatory bodies to embrace it. 

Senator CASEY. Thanks very much. 

The CHAIRMAN. Thanks, Senator Casey. 

Senator Franken. 

STATEMENT OF SENATOR FRANKEN

Senator FRANKEN. Thank you, Mr. Chairman. 

I’m co-chair of the bipartisan Senate Rural Health Caucus, and 

I’ve had a lot of roundtables around Minnesota—I think about 30 

between me and my staff having roundtables. At practically every 

roundtable, they bring up this issue of health records, electronic 

health records. In rural America, we have a lot of small providers, 

and one of the issues is the up front cost. 

I guess this is for Mr. Patterson, since you’re in this business. 

Even those who can afford the initial investment are often sort of— 

end up with the most basic out-of-box product because they don’t 

have the resources or the influence to demand a custom tailored solution from vendors. 

Are there ways that EHR vendors like Cerner can structure their 

sales models to help lower or eliminate the up front cost of implementing a new EHR system? 

Mr. PATTERSON. You’re talking to an old farm boy, and rural 

health is actually on my, if you will, professional bucket list to fundamentally make a difference in. We have been very aggressive in 

using kind of shared services and shared domains to create as low 

price points as we can to get out into critical access in smaller facilities. It’s been, frankly, fairly successful, both from the client side 

and from our side. Yes, they’re on very thin budgets, and I started 

that—they get advantages of very sophisticated technologies. 

My wife’s brother, who is still the farmer down there in Oklahoma, unnecessarily died from sepsis. I went to the local 

healthcare community and said that didn’t need to happen, and 

sepsis is a predictable condition. That community now has an intelligent set of algorithms looking over the entire community and 

identifying the people that look like they’re on a path to become 

septic, and it has fired over 60 times this year. It would have saved 

his life. 

They need, really, everything we talk about. You’ve got to create 

business models and get low price points. 

40 

Ms. BECHTEL. Senator, if I might, I think one of the things we 

haven’t really addressed—yet it plays a huge role in all of the challenges that clinicians and other providers are facing—is the fact 

that we don’t actually pay for and reward the kind of care that clinicians can deliver when they’re enabled by health IT and by an 

interoperable system. 

Senator FRANKEN. Sure. 

Ms. BECHTEL. The up front costs would be worth it, as they were 

for the banking industry, right? If we were able to start paying for 

coordinated care, paying for health outcomes, paying for better patient experiences, I think it would drive this discussion in a far different direction. The banks didn’t struggle with standards for 30 

and 40 years as we have in healthcare, right? We didn’t actually 

talk ever about bank IT. 

Senator FRANKEN. Well, this is supposed to lead to savings. This 

is supposed to lead to coordinated care. This is supposed to lead to 

value. I think the next questioner has some thoughts about that. 

Senator Whitehouse does. 

I want to talk about interoperability. Why, why, why can’t the 

VA and the Defense Department become interoperable? This is just 

a mystery to me. A lot of resources have been spent trying to do 

this. Does anybody have any thoughts on that? 

Mr. RICHARDVILLE. Senator, if I could just make a couple of comments, I do think that the lack of the standards, functional standards, in place that allows this transport of data back and forth between systems is difficult. It is expensive. You talked about the 

EHR with the rural facilities. We look at interoperability. It’s just 

as expensive and complex to try to connect them to other care providers when they do referrals back to other complex organizations. 

Until we actually have the government action in place to help us 

to have the functional standards, the measures, and the compliance 

to take place, we’re going to have this difficulty in this country. 

Senator FRANKEN. These are two government entities that are 

dealing with the same population. If they can’t get it together, I 

don’t understand how we’re supposed to be optimistic about us setting standards. I’m out of time. 

Thank you, Mr. Chairman. 

The CHAIRMAN. Thank you, Senator Franken. 

Senator Whitehouse. 

STATEMENT OF SENATOR WHITEHOUSE

Senator WHITEHOUSE. Thank you, Chairman. 

This is such an important issue, and Chairman Alexander and 

Ranking Member Murray have embarked on a committee-wide 

process to take a look at health information technology and information exchange. I would invite each of you, in terms of what a 

law student would call issue spotting, to feel free to send in to us 

the list of issues you think our process should be sure to be addressing, even if you haven’t had the chance to get to it in this 

hearing. I know that we would be interested in that. 

My particular concern comes from my Rhode Island experience. 

Many years ago when I was the attorney general in Rhode Island, 

I established an organization called the Rhode Island Quality Institute, and we embarked on, first, electronic prescribing and then 

41 

electronic health records, and now full-on health information exchange through a nonprofit organization called CurrentCare which 

has been very effective in terms of how broadly it has reached out 

and connected all the providers, connected with the Epic system in 

both of our major hospital chains. It’s been quite good. 

Here’s my concern. We’ve spent an enormous amount of money 

on Meaningful Use. Most of that has gone to end users, subsidizing 

the machinery on the doctors’ desks. We kind of take a bank shot 

off of that back into the information exchange piece by defining 

Meaningful Use in ways that require things to happen. 

For a lot of those providers, the healthcare providers, they don’t 

really have a big say in whether or not there’s a statewide health 

information exchange in their State. They just have to sort of live 

with the consequences of whatever their world is. 

Rhode Island has worked really hard to get the health information exchange up and going. I think they’ve done a terrific job. I 

believe that they’ve won every available grant every single time 

that there’s been one available. Even with all of that, they’ve had 

such a heavy load to carry. It’s like this little donkey trying so hard 

at the head of the pack with all these burdens of solutions that 

have to be achieved, and the Federal Government kind of over 

there in the next field throwing billions at Meaningful Use and not 

paying as much attention as it should to those States and those localities—it’s not always a full State—that are really trying to get 

the exchange piece right. 

If you’re going to have health information exchange, I think 

there has to be an exchange. Maybe it can happen in the cloud. I 

think it works a lot better if there’s actually an exchange, and I’d 

love to hear your thoughts on how, as we reconsider a Meaningful 

Use 2.0 or try to reboot this issue—how should we be focusing on 

exchange? 

The easy way to do it is to give money to big systems, and then 

they exchange data within the system, and a CEO gives a rule, and 

everybody complies. It gets harder when you’re doing it by State, 

and you’ve got a whole bunch of people together. I think that’s 

where we have to end up, is with cross-corporate exchange, and it 

seems to me that that is something that needs direct attention, not 

just the attention of conditions being put on Meaningful Use. 

If you could take that right down the line, starting with Dr. 

Payne, I’d appreciate it. 

Dr. PAYNE. I agree with your premise that we’re really after 

health information for its being used, and exchange makes that 

happen. I think one element that would really help with exchange 

would be to include the patient in that so that they get the entire 

record, because we will not be able to anticipate all the uses they 

might have for that. 

I think also that for critically ill patients who need exchange of 

information, such exchanges as you described in your region would 

be incredibly helpful. There are other solutions, also. I’ll be brief. 

We have much more information we can provide because we agree 

with you that that is really how we’re going to get the best use out 

of these systems that we’ve invested so much in. 

Senator WHITEHOUSE. Mr. Richardville. 

42 

Mr. RICHARDVILLE. Yes, thank you. I would make two points. 

One is we talked earlier about the patient match or the patient ID. 

We have to solve that problem. It’s a foundational component of exchanging information back and forth in between providers. 

And second is how we do it. We have to do it in a very cost-effective way. Today, it’s onerous and it’s very expensive, and many 

cannot afford to do what some other systems have been able to do. 

For me, it would be kind of moving toward the open API, a more 

innovative type of technology, to allow you to freely share information back and forth. 

Also, it allows innovation from other companies who actually 

have access to that as well, and they can start generating apps and 

other things for patients and others, but it can also consume the 

data from the different EMRs that we’ve all installed and put together. Those would be the two components. 

Senator WHITEHOUSE. Ms. Bechtel. 

Ms. BECHTEL. I couldn’t agree more. Far as I understand it, ONC 

has invested about $570 million in State health information exchanges, so that pales in comparison to the Meaningful Use price 

tag. No question about it. They have tested a couple of different 

models, one, of course, that looks a lot like—suspiciously like 

Rhode Island’s. 

Also is consumer-mediated exchanges I testified to earlier. This 

is certainly an area where I think Congress could help invest in developing the infrastructure further. 

Senator WHITEHOUSE. Mr. Patterson. 

Mr. PATTERSON. Finally, I might be a bit contraire in here, but 

I think you all pioneered some real meaningful work in Rhode Island. You implied, though, in your statements there’s not a fundamental business model for the exchange. It has to either be financed through grants and/or through the healthcare providers 

that are exchanging information. 

The people that are actually benefiting from the information 

aren’t actually funding that. It did not solve all of the fundamental—so you still are curating an identification—identification is 

still an issue, and it’s part of the cost of you running it. 

What we’re saying is through standards—and then get the software manufacturers—people who make software and sell into these 

marketplaces—and if CommonWell is not the answer, show it—I 

think we need a national system, because you’ve got boundaries. 

You’ve got water on one side but you’ve got boundaries on the other 

side, and people are transient. We need a national approach to this 

and one that is sustainable. 

Senator WHITEHOUSE. Chairman, thank you for the hearing. I 

think this is very helpful and constructive, and we clearly—I think 

one thing that the witnesses will all agree on is that we have work 

to do. 

The CHAIRMAN. Well, thank you, Senator Whitehouse. I mentioned earlier that I thank Senator Cassidy, who I’ve asked—and 

you, who Senator Murray has asked, who will chair a hearing on 

physician documentation later, and that will be an important part 

of what we do. 

Senator Murray, do you have any final comments? 

43 

Senator MURRAY. I don’t have any additional questions. I just 

want to thank all of our witnesses for being here today. I think this 

is really a critically important conversation. I think we all know 

that effective health information technology is really essential to 

improving quality and the cost of care. 

We’ve got to find a way, and the best way, for providers and patients to share information securely and efficiently in order to get 

people the best care possible. I’m really glad that we’re making this 

a bipartisan priority on this committee and doing the work that I 

think is so important to get us to a better place. Thank you. 

The CHAIRMAN. Thank you, Senator Murray. This has been very 

helpful. I think you can see that we’re pretty committed to this, 

given the amount of time we’re spending on it, and that we’re 

working in a bipartisan way, not just among ourselves, but with 

the Administration. 

Of course, the best way to solve whatever problems exist are, 

first, for the community to do it itself, for the industry to do it 

itself; second, for the Administration to be able to do it; and, third, 

we might have to pass a law. In my view, those are the steps of 

preference. 

Just so I can get it clear, Mr. Patterson, you held up an ATM 

card. Would you say this is the goal, that a patient-centered electronic medical system—that the goal is that I would have the ability to have all my medical information on a card? If we started 

from there and worked back to where we are today, would that be 

the way to think about this? Or am I simplifying it too much? 

Mr. PATTERSON. I think it is the goal, but it’s the fact that the 

real information about what my bank account is isn’t on that card. 

We have to have a way of identifying ourselves in accessing highly 

critical information at almost any point, any time. 

The way the ATM system works—that card does not have your 

bank balance on it. That bank balance is somewhere—I don’t want 

to say in the cloud, but it is on a database. If you’re in France, 

you’re not going to get—— 

The CHAIRMAN. If the card works, the bank needs to know my 

bank balance. 

Mr. PATTERSON. That’s what I’m saying. I’m just saying your 

bank balance isn’t on the card. 

The CHAIRMAN. What I’m really trying to get at is there are different ways to approach this. One way to approach it is from the 

point of view of what you do, or the point of view of what each of 

you do. The other way to think about the whole thing, it seems to 

me, would be to start with this and work back to all the other 

issues that there are. 

Mr. PATTERSON. I don’t disagree with that. At least, it should 

work as simple as that. 

The CHAIRMAN. As I’m hearing you, what you’re saying—and I 

think Senator Cassidy’s comment was an important one, and I 

haven’t made my mind up about this yet. Do we need to do something to cause to happen here what needs to happen, for example, 

standards for all the people who do what Mr. Patterson does, to 

work together? 

My very strong bias is that the less we have to do, the more efficient it will work. The ATM card probably doesn’t work because of 

44 

a law that Congress passed. The terrific airplane reservation system that we enjoy every day probably doesn’t work because of anything we did, and if we had done it, it probably wouldn’t work as 

well. 

What we need to know from you is what are the things that we 

have to do to get you to do it? That is the question, and we don’t 

have to know that today. It sounds like standards is one of those. 

My bias is that we are better as enablers rather than mandaters— 

the government is, and that the more we have to mandate, the less 

successful we’re likely to be. 

Senator WHITEHOUSE. Mr. Chairman. 

The CHAIRMAN. Yes, Senator Whitehouse. 

Senator WHITEHOUSE. Can I address your point just for one moment? 

The CHAIRMAN. Sure. 

Senator WHITEHOUSE. I think that having the card and having 

a mechanism by which the individual patient has access to their 

data is one of the important goals that we need to achieve. I think 

we also need to achieve the goal for the patient who is unconscious, 

who is very elderly and perhaps at the end of their life, who is perhaps not at their full mental capacity, to have the data system 

work, even when the patient is not a participant. 

I think we’ve all had the experience, either ourselves or with 

loved ones, of being in a hospital and having to be there at the bedside to help manage what’s going on just in that hospital, just for 

that patient. I think there are two goals. One is the ownership and 

command of information by the patient themselves, and the other 

is a system whose information support will take care of that patient even when they are alone and incapable and eliminates a lot 

of the confusion and misinformation that bedevils modern complex 

practice. 

The CHAIRMAN. Dr. Payne mentioned that example, and I see 

what—Ms. Bechtel, I wonder if you are thinking something. 

Ms. BECHTEL. I am, always. How did you know? I think that, 

conceptually, you’re right. The challenge is I have two ATM cards 

and three credit cards in my purse. My bank card isn’t linked 

across the data systems. What is, though, is Mint, right, Mint.com, 

where I can connect it to all of my accounts. We still do need the 

electronic—the systems to connect to each other. 

I think you’re fundamentally right, which is this is my electronic 

health record right now, and I can add to it in this particular 

version. It’s not particularly secure. You saw Neal grabbing it earlier, and I hope I don’t lose it today. The concept that I described 

around how consumers can ask for, aggregate, and hold their 

health information, at least in the near term, would start to unlock 

that data and enable me to share it with the providers who do need 

it and who can rightly have access to it. 

Mr. RICHARDVILLE. Senator, if I could add to the comment, I do 

think that where we’re moving toward, or where we’d like to move 

toward, is truly changing the culture of how health and care is 

looked at by the patients and by other consumers, and really move 

that to be part of your daily life. One aspect of doing that, like 

we’ve all done with our smart phones and with apps, for those that 

have those—and it keeps growing and growing—is that open API 

45 

infrastructure that allows people like Mint.com and others to grab 

that information and present it back to the patient or back to the 

provider. 

The action that we need is to help support us to move this so this 

becomes part of the rhythm of life. You wake up every day. You 

check your email. You check your texts. You check your Facebook. 

You need to check your health status, and this is part of what we 

want to try to incorporate as we continue to move toward the 

value-based system of prevention. 

The CHAIRMAN. Dr. Payne, everyone else has had a last word. 

Would you like to? 

Dr. PAYNE. I would just add that innovation can help in coming 

up with ways to solve this problem. I agree with your approach 

that we want to have something we can work toward that’s practical, and the way to come up with that is probably to leverage the 

ideas of people who are not at this table and maybe not even a 

health IT at the moment, but are clever people who can help us 

solve that problem. Our report encourages the development of innovation to help solve some of these problems. 

The CHAIRMAN. Senator Murray, anything else? 

Senator MURRAY. No. 

The CHAIRMAN. Thanks to all of you. It seems to me a couple of 

unresolved questions that I’ll be looking for answers to are, No. 1, 

to followup on Senator Cassidy’s point, to what extent do we need 

to use coercion to cause things to happen so that you can do what 

needs to be done? And, No. 2, I take the point about delay of the 

Meaningful Use 3 regulations. There’s probably some downside to 

that. 

For something that seems to have as much resistance right now 

and as much need to improve, human nature tells me that it may 

be better to step back a little bit on at least some parts of the rules 

and work with physicians and vendors and hospitals and take some 

advice about how to improve things, and then once they’re better, 

to accept and go forward. We want to do this as rapidly as we can. 

We don’t want to lose the impulse to cause people to do this. 

At the same time, the more important thing, I would think, is 

to make sure that we get it done in a way that causes patients, 

doctors and hospitals to look forward to the experience of this system rather than to dread it. If you have, after you leave, specific 

suggestions about these parts of the regulations that absolutely not 

be delayed, these parts might be delayed while we continue to work 

together to try to improve them, that would be very helpful. 

The hearing record will remain open for 10 days. Members may 

submit additional information if they would like. 

The next hearing will be Achieving the Promise of Health Information Technology: What Can Providers and the U.S. Department 

of Health and Human Services Do To Improve the Electronic 

Health Record User Experience? That’s the one which the shorthand name would be physician documentation, and Senator 

Cassidy and Senator Whitehouse will chair that. Senator 

Whitehouse will be the ranking member on that hearing. 

Thank you for being here today. The committee will stand adjourned. 

[Additional Material follows.] 

46 

11ONC Health IT Certification Program, ‘‘About the ONC Health IT Certification Program,’’ 

http://bit.ly/1FLG7ip accessed June 11, 2015. 

ADDITIONAL MATERIAL 

JULY 14, 2015. 

To: Alicia Hennie, Health Policy Advisor, Sen. Alexander (R–Tenn.); Colin Goldfinch, Health Policy Advisor, Sen. Murray (D–Wash.) 

From: Jeffery Smith, Vice President Public Policy, AMIA 

Re: Strategies to improve interoperability of health IT through changes to certification and adoption incentives 

This memo outlines ways to amend and enhance Federal health IT policy to further widespread interoperability. Recommendations focus on ONC’s Health IT Certification Program and potential changes to CMS’s incentive structure for meaningful use and other value-based reimbursement programs. 

ONC HEALTH IT CERTIFICATION PROGRAM

As part of the HITECH Act, the Office of the National Coordinator (ONC) for 

Health IT established a health IT certification program to help ‘‘ensure that health 

IT conforms to the standards and certification criteria adopted by the Secretary of 

Health and Human Services.’’ 11 The Federal health IT certification program is 

meant to provide assurances to users that the technology meets certain capability, 

functionality and security requirements adopted by HHS, and provides assurance 

that the products are interoperable (the systems can exchange information and use 

that information for a specific purpose once it’s received). As the Federal Government’s only policy lever to impact the technical development of information technology in healthcare, ONC’s Certification Program should be seen as vital pathway 

to improve interoperability, usability and patient safety. 

Recommendations 

• Improve interoperability through more robust testing. 

• Require interoperability testing on both the sending and receiving of data. 

• Incorporate exception handling into EHR certification. 

• Develop C–CDA guidance and tests to support exchange. 

• Contract for—or otherwise solicit—testing methods from developers and other 

stakeholders. 

• This is a current policy option, but ONC has had limited success engaging 

with others to help develop testing methods. 

• Without more ‘‘skin in the game’’ vendors may continue to ‘‘develop to the 

tests’’ that government policymakers design. 

• Force transparency into obfuscated market. 

• Require additional information to be submitted for, or captured during, certification testing, and make these publicly available. This includes: 

• Establish greater transparency and uniformity on UCD testing and process results. 

• Screen shots and/or video of workflow configurations. 

• Screen shots and/or video of exception handling with data provided by 

testing body, not the developer. • Participation in on-going interoperability testing with an ONC–ACB or 

other entity, as designated by the HHS Secretary. 

• Require ONC–ACBs to conduct post-market surveillance through in situ testing. 

• This will require resources and agreement on how to test, which will require stakeholder buy-in. 

• This is in keeping with anti-information blocking efforts. 

• Promote pathways and protocols for users of certified technology to report information blocking. 

• Provide regulatory clarity and certainty to an emerging market. 

• Support ONC efforts around the Standards Advisory and regular updates to 

Certified Health IT Editions. 

• This supports policies already underway at ONC, but will require ongoing leadership when the inevitable pushback comes. 

47 

1Sittig DF, Wright A, J Am Med Inform Assoc 2015;0:1–3. doi:10.1093/jamia/ocv060. 

• Make ONC develop a multiyear—3- or even 5-year—Edition development 

plan. 

• This would be similar to a vendor’s product development plan and it 

would help vendors know what to expect long before its officially proposed 

as part of a regulation. 

• An example might be a certification for LTPAC or behavior health, improvements to quality measure report generation, etc. 

• Limit the scope of ONC certification to areas with a ‘‘demonstrated need’’. 

• This will help assuage fears that ONC will start certifying everything in 

health IT and it would create an opportunity to define some kind of rationale identifying circumstances when certification would be more harmful than helpful. 

CMS INCENTIVES: MEANINGFUL USE AND OTHER VALUE-BASED PAYMENTS

Should ONC make substantive improvements to its certification program, it will 

not have the intended impact unless there are continued incentives (positive and 

negative) to drive further adoption of health IT and to compel continued upgrades 

of certified health IT technology. While we acknowledge that financial incentives are 

not the domain of Senate HELP, we felt it was important to complete the logic 

model of how to improve interoperability from a policy and program perspective. 

Recommendations 

• Provide relief to a highly regulated sector of the economy. 

• Prohibit CMS from issuing a final Stage 3 rule until at least 60 percent of 

EHs and EPs are successfully demonstrating Stage 2 (as defined in an upcoming rule—expected August 2015). 

• Provide incentives rather than deadlines. 

• Sunset MU penalties and make CMS incorporate MU ‘‘status’’ as part of reimbursement updates ala MACRA/MIPS. 

• This provides long-term sustainability in incentive to participate in the 

program; without which all other policy levers are substantially weakened. 

• Hospitals are not impacted by MACRA and so their market basket update would be a good candidate to make this happen. 

RESPONSE BY THOMAS H. PAYNE, M.D., FACP, FACMI, TO QUESTIONS OF

SENATOR ALEXANDER AND SENATOR MURRAY

SENATOR ALEXANDER

Question 1a. Many stakeholders have suggested that the health information technology industry could come up with many solutions to the problem of interoperability on its own. However, so far, we are stuck with a system that does not work 

even though the government has spent over $30 billion. 

What areas would be best determined by private industry? What areas should the 

government decide, if any? 

Answer 1a. Overview: Americans benefit when their health information is available when and where needed. To get there, the private sector should be responsible 

for developing technical standards to support interoperability that have consensus 

across stakeholders. The government should help convene stakeholders, support pilots and enforce adherence to standards—their use in certified products, their implementation in provider settings and their application toward the widespread use of 

‘‘open’’ EHRs.1 The government should also continue to create and integrate incentives for use of health IT as part of evolving alternative payment models. Further, 

the government should conduct a full review of Federal and State privacy laws, harmonizing legal inconsistencies, correcting misinterpretations and prosecuting bad 

actors who inhibit exchange or improperly disclose information. 

Detail: The current state of interoperability cannot be addressed solely by the 

health information technology (health IT) industry. As you and your committee have 

heard, the lack of interoperability—the ability of two or more systems to exchange 

data and use that data to care for patients once exchanged—is a multifaceted problem. Numerous technical, business and cultural barriers have converged to inhibit 

48 

2 Centers for Medicare & Medicaid Services, ‘‘May 2015 CMS HITPC Report,’’ http:// 

go.cms.gov/1MhJ924 (accessed July 9, 2015). 3 Ibid. 

4 Centers for Medicare & Medicaid Services, Notice of Proposed Rulemaking (CMS 3311P) 

http://go.cms.gov/1HqJNqV. 

the free flow of information in healthcare and nothing short of on-going public-private collaboration will change this current State of challenges. 

Policymakers should focus their efforts on refining the mechanisms and policy levers already at their disposal and consider augmenting those levers with new ones. 

Specifically, the Federal Government’s primary policy lever when it comes to interoperability is the Federal Health IT Certification Program and health IT adoption 

incentives. Certification has the potential to produce harmonized technology that 

conforms to foundational standards upon which developers can innovate and augment technology for their customer’s needs. This has always been the goal of the 

Federal certification program, but only recently has it been possible. 

Prior to 2012, there was no national conversation, nor agreement, on standards 

prerequisite for interoperability: namely, content standards, vocabulary standards 

and transport standards. Prior to 2014, and perhaps even true to this date, the technology bundle containing these standards—the 2014 Edition of Certified EHR Technology (CEHRT)—had not been widely adopted, as required for Stage 2 of meaningful use (MU). Also, prior to 2014, no hospital or physician had met the objectives 

for Stage 2, which included process requirements to exchange health information 

across care delivery settings and technology platforms. According to the most recent 

data available from the Centers for Medicare & Medicaid Services (CMS) only 36 

percent of hospitals and 10 percent of eligible professionals have met the requirements of Stage 2, using the 2014 Edition of CEHRT.2 Moreover, 91 percent of hospitals and 82 percent of professionals chose to defer the requirement to send a summary of care record at transitions of care, which is the process requirement in MU 

Stage 1, preceding the most straightforward ‘‘interoperability requirement’’ in Stage 

2 to electronically send a summary of care record at transitions of care.3 In other 

words, the ecosystem of technology and processes which would demonstrate interoperability to a degree worthy of $30 billion in taxpayer investment is highly underdeveloped and the vast majority of providers do not even practice the processes laid 

out in regulation that would move data from place to place. This is true even without considering the business and policy barriers that inhibit interoperability. 

I will not go into detail here, but as it pertains to your question, Congress should 

continue efforts to change Medicare & Medicaid fee-for-service reimbursement by 

helping CMS develop, evaluate and scale alternative payment models. Changing 

how we pay for care can lead to great advances in interoperability. Congress should 

also reassess Federal & State privacy laws—with broad input from patients, providers, researchers and the informaticians who support them. 

In my testimony, I mentioned the need to, 

‘‘streamline the Federal health IT certification program so that the process is 

more flexible, more transparent, focuses on clinically relevant functionality, and 

tests for true interoperability.’’ 

The practical application of this phrase is provided in a memo developed by AMIA 

staff, and included as an enclosure to this response, but I would reinforce the notion 

that to improve interoperability, Congress should focus on improving ONC’s certification program, especially as it relates to testing for interoperability, and reconsider 

ways to incentivize further adoption and continued upgrade of certified health IT 

technology. 

Finally, Congress should embrace the notion of ‘‘slowing down regulation to accelerate progress on EHR usability, interoperability and innovation.’’ Federal regulators should not rush to get to the next stage of meaningful use, but should instead 

work to help the private sector accelerate optimization of the tools and regulations 

that are already in place. Again, the enclosed memo goes into more detail, but I reiterate my previous statement that Stage 3 rules not be finalized in haste. I believe 

it is imperative that Congress keep MU requirements, with penalties for noncompliance, in place over the near and mid-term. The forthcoming ‘‘meaningful use modifications’’ rule has proposed a number of changes to help streamline and simplify 

participation.4 These changes would apply to the current program year through to 

2018 and they will give providers a stationary set of requirements while technology 

optimization and workflow enhancements occur. 

Question 1b. Does the government need to set deadlines or otherwise encourage 

industry to make decisions? 

49 

5http://www.commonwellalliance.org/. 6http://sequoiaproject.org/. 

Answer 1b. Overview: Deadlines are not as impactful as providing strong incentives. 

Detail: Both positive and negative government incentive programs have been successful in converting health information from paper to electronic form. This was necessary for interoperability, but not sufficient. There have also been encouraging efforts for greater interoperability in the private sector, such as CommonWell Health 

Alliance,5 the Sequoia Project6 and others. However, the vast majority of work—and 

all of the regulatory consequences—of exchanging and using healthcare data falls 

to hospitals, physicians, clinics, and other providers. And few are happy with the 

result we’ve achieved to-date. Today, the best way to ensure data can be used at 

the point of care across settings is to have a single EHR vendor across all settings. 

This single-system approach is counter to prevailing trends in technology, which 

allow for substitutability and modularity. The most successful utilizers of information technology know that diversity is far preferable than expecting one system to 

do all functions well. But adherence to common standards is prerequisite for a diverse ecosystem to work. 

As an example of the current state, there are enormous national meetings for customers of EHR vendors. There is no comparable meeting devoted to interoperability 

across EHR vendor products, or in caring for patients whose health records are dispersed. The unspoken message is that the simplest route to interoperability is to 

use one vendor, but this does not fit how Americans live and receive health care. 

And this is where government can help. 

Incentives should be changed so all government-certified EHR vendors whose 

products are used to care for Medicare/Medicaid beneficiaries work together to have 

the same rapid advance in interoperability that we have seen in EHR adoption. This 

doesn’t mean government creates interoperability. It means government moves the 

market toward rapid rise in interoperability. 

New incentives are not needed, nor are heavy-handed penalties. The recently 

passed MACRA may provide a template for incentives that can be long-lasting and 

impactful. For physicians participating in the Merit-based Incentive Program System (MIPS) meaningful use penalties will sunset in 2018, and participation in MU 

will constitute 1⁄4 of a composite score that will determine a physician’s reimbursement rate. This dynamic provides a pay increase for successful participation in MU, 

which is significant because there are very few—if any—incentive dollars left from 

the HITECH Act in 2018. For physicians participating in MIPS who fail to meet 

meaningful use requirements, they forego the possibility of obtaining a full increase 

in payment, but it does not necessarily translate to a penalty, or a negative payment 

adjustment. 

Congress should look at this model and determine if a similar approach can be 

used with hospitals and clinicians not participating in MIPS. Increases to hospitals’ 

market basket update, or additional funds for ACOs, bundled payments, et cetera, 

could be leveraged to encourage participation. Nonparticipation will not be penalized, yet money will be ‘‘left on the table,’’ so to speak. Key to this recommendation 

is adjusting the meaningful use ‘‘all or nothing’’ paradigm where providers must 

meet all requirements or receive no incentives/full penalties. Such flexibility will be 

needed to keep providers engaged in the only Federal Government program that dictates use of modern information and communication technology in healthcare. 

Likewise, Congress needs to examine ways to incentivize—or compel—interoperability between and among competing EHR developers as a business imperative, 

rather than just pressuring providers and care delivery system. 

Question 2a. If you could change all or parts of the rules for Stage 2 and 3 of 

Meaningful Use and the 2015 certification rule, what would you change? 

Are there particular parts that should be delayed and others that should go forward? What changes would you make to them? 

Answer 2a. On the macropolicy level, the ‘‘Stage 2 modifications’’ rule, issued by 

CMS April 10, 2015, should be finalized as soon as possible and it should be finalized largely as proposed. The certification rule, likewise should be finalized on 

schedule and according to general consensus received through the open commenting 

process. Stage 3 meaningful use rules should not be finalized until 2018—at the earliest—or until 60 percent of EHs and EPs are demonstrating Stage 2 as modified. 

This dynamic keeps provider requirements set for a time where technology and 

workflows can be optimized to deliver on the promise of modern communication and 

information technology. It also allows for ONC to move forward with updates to cerVerDate Nov 24 2008 17:35 Jul 20, 2017 Jkt 000000 PO 00000 Frm 00053 Fmt 6633 Sfmt 6621 S:\DOCS\25971.TXT CAROL
50 

tified technology to incorporate fixes to known ‘‘bugs’’ or to accommodate emerging 

national standards. 

On the program design-level, participation in meaningful use cannot continue 

365-days per year ad infinitum. Much-needed downtime for upgrades, bug fixes and 

workflow re-design is necessary during any, and most likely every, year. For this 

reason, and for related reasons of patient safety, CMS should not require 365-day 

EHR reporting periods, but something closer to 180-days or 270-days. Likewise, 

more flexibility needs to be built into the program by removing the ‘‘all or nothing’’ 

construct. Especially as the program is integrated into MIPS, there are rational policy changes that could allow for this to happen because meaningful use becomes 

part of a composite score dictating reimbursement. A rudimental example could be 

that if a physician meets 80 percent of MU objectives, they receive 80 percent of 

the available meaningful use points that are part of the composite score. 

On the program content-level, it will be difficult for various stakeholders to agree 

on all the necessary program components. Meaningful use was developed with broad 

input from various stakeholders and because of this, it has requirements important 

to many groups of health professionals and patient advocates. The problematic areas 

of the program are well-documented—patient action requirements, such as patient 

portals and secure messaging and summary of care requirements for transitions of 

care are among the most often cited. Despite the challenges associated with these 

objectives, they have strong support from different segments of the stakeholder community, and they have illuminated technical, cultural and business barriers that are 

signals of progress. We would not be as cognizant of our ‘‘interoperability problem’’ 

without the requirement that data be exchanged and used after transitions of care— 

or at least we would not know the extent of the challenge. 

Question 2b. Do you think that the proposed rules will make health information 

technology better? If so, which parts? 

Answer 2b. The degree to which MU and the Federal health IT certification program have advanced the ecosystem for health IT cannot be overstated. The regulations have served as an important catalyst and the work to develop and implement 

them has enabled the entire sector to evolve at an incredibly fast rate. We can’t exchange health information electronically if it is on paper. The proposals in question 

will undoubtedly have a positive impact on the health IT landscape, but they will 

also engender more disdain unless they are implemented properly—at a pace the 

industry can handle and with flexibility to accommodate a dynamic system. 

Specifically, the Stage 2 modifications rule will make several changes to remove 

topped-out measures and provide a single definition for all providers beginning 

2015. Keeping the requirements steady for a period of 3 to 5 years will give providers time to optimize the technology they have and developers the time to innovate on the versions already deployed. Lowering the patient action thresholds, while 

controversial, is the right step absent a more nuanced conversation over how to encourage—and measure—patient engagement. 

ONC’s 2015 Edition Certification rule contains many proposals that should improve the State of health IT, including: 

• A proposal to expand the ONC Health IT Certification Program to additional 

types of care and practice settings; • An expansion of existing surveillance efforts of health IT under the ONC Health 

IT Certification Program, where ONC–ACBs (authorized certification bodies) would 

conduct annual randomized in-the-field surveillance; • A significant expansion of health IT developer transparency and disclosure requirements for certified health IT; • Expansion on the 2014 Edition transitions of care criterion by using updated 

C–CDA standard and requiring capabilities to detect valid and invalid C–CDA documents; • Enhanced requirements for data portability to facilitate the accessibility and exchange of data; and • A new requirement that health IT would have to demonstrate that an API responds to data requests for any one, and for all, of the data referenced in the Common Clinical Data Set (CCDS). This criterion would rigorously assess a product’s 

C–CDA creation performance (for both C–CDA version 1.1 and 2.0) when presented 

for certification for exchange capabilities. 

The net-effect of these changes should be more usable, safer and more interoperable health IT. However, passing a regulation with these changes does not ensure 

these outcomes. Developers must build technology that performs these functions in 

a way that corresponds with how care is delivered; providers must adopt, implement, test, train and use the technology as its intended and a large share of providers must do this before the impacts will be noticeable. 

51 

Question 2c. Are there any parts of the proposed rules that you think would make 

health information technology worse? If so, which parts? 

It may be premature to know which parts of the proposed rules will make HIT 

worse, but there are a number of proposals that necessitate close watch; that will 

be very difficult to operationalize and scale; or that will create stress on an alreadystressed system. For example, the Stage 3 proposed requirements to incorporate patient-generated health data and requirements related to ‘‘clinical information reconciliation’’ fall across several of the aforementioned categories. There are well-documented use cases where PGHD or reconciliation have added value and safety to 

care, but these are domains with little experience and immature standards. 

SENATOR MURRAY

In your testimony, you suggest that in order to, 

‘‘see the same success that we’ve seen in the internet, we need a stable base 

of standard building blocks that allows us to create new technology to benefit 

patients.’’ 

You also note that these ‘‘building blocks’’ will support the development of new 

electronically specified clinical quality measures to help streamline and improve 

Medicare’s quality incentive programs. 

Question 1. How would these building blocks allow for the development of better 

measures and streamlined processes for reporting electronically specified measures? 

Could they help align reporting requirements across quality reporting programs and 

accelerate interoperability between electronic health records and registries? 

Overview: Congress is well-positioned to help advance quality measurement in 

healthcare by moving toward outcomes-based clinical quality measures (CQMs) and 

by supporting technical improvements to CQMs produced in the digital age. Given 

Federal plans to accelerate toward reimbursement based on value and outcomes, 

rather than volume, now is the right time to think systematically about quality 

measurement. This means simplifying the process, streamlining the number, and 

harmonizing the types of CQMs required for public reporting. Alignment of CQMs 

across programs is largely a policy issue; whereas the need to generate accurate and 

complete CQMs, and accelerate interoperability between EHRs and registries is a 

technical one. 

In order to accelerate development of quality measures to improve Medicare’s 

quality incentive programs, and to improve interoperability between EHRs and registries, policymakers must take three important steps: (1) review and adopt a national format standard for common data elements (CDEs) used to generate CQMs; 

(2) simplify quality measures by rethinking exclusion criteria for CQMs and (3) improve the quality of data in CQMs by encouraging broader adoption of up-to-date 

EHRs. 

Detail: Similar to the internet, there are foundational ‘‘building blocks’’ that support flexible, standards-based interoperability. For health IT there are five building 

blocks that we need to facilitate standards-based exchange of information and 

streamlined interoperability: 

1. Standardized Meaning 

2. Standardized Format (or structure) 

3. Standardized Transport 

4. Standardized Security 

5. Standardized APIs or services 

Standardized meaning 

Standardized vocabularies and terminologies like SNOMED and ICD–10 allow a 

computer to understand that ‘‘heart attack’’ and ‘‘myocardial infarction’’ are the 

same concept, because they have the same standardized code. MU provides for four 

major vocabularies—LOINC for lab tests, RxNorm for medications, SNOMED for 

problem and symptom descriptions and ICD–10 for billing diagnoses. These should 

be used for all quality measures and registries so that the vocabularies are the same 

as those used in EHRs. 

Standardized Format 

MU has adopted a number of document-centric ways to standardize information 

that include a patient care summary or a transitions of care document. However, 

two additional standardized formats are needed: (1) A standardized format for 

granular data that can be used to build quality measures and new kinds of documents; and (2) a standardized format for unstructured data so that patients can 

share their entire medical record in an electronic format. Both of these play an important role in improving quality reporting. 

52 

Standardized Transport and Security 

These standards are typically drawn from fundamental building blocks that support the internet and the WWW. In healthcare, we should leverage these mechanisms like email and Web page interactions, or secure ways to encrypt data or authenticate users, but not develop specific transport or security standards . 

Standardized Services, such as Application Programming Interfaces (APIs) 

APIs provide very specific channels or connections between two systems. These 

are useful to connect systems, but cannot substitute for a full export of a medical 

record for a patient to access their information. 

By focusing development on format standards that are more data-centric and less 

document-centric, different pieces of medical data can be used in modular ways. Perhaps no better example of this is quality measurement. Development of granular 

data standards would most certainly yield positive benefits for quality measurement 

reporting, measure specification alignment and facilitate interoperability of EHRs 

and registries. 

Quality measures are made up of three kinds of information: (1) Meta-data; (2) 

a data value; and (3) a formula. The meta-data describes what the quality measure 

is, when it was developed, who developed it, and other provenance data. Data value, 

includes the actual values for things like lab test result, medication, or problem list, 

for example. Finally a formula is needed to calculate the quality measure; for example a formula to identify all patients with diabetes who have an elevated HbA1C. 

If one had a granular data element that defined diabetes (all patients with a problem list that had a SNOMED code for diabetes) and defined what an ‘‘elevated 

HbA1C level’’ is, one could identify those patients who need more help caring for 

their diabetes. In the diagram below, each of the boxes represents a granular data 

building block that are reusable. 

This approach is generalizable. If there was a national common data element 

structure that used standardized vocabularies, the same structure could be used to 

describe the data values in a quality measure, the data values in a registry, and 

the data values in the electronic health records. This common format would accelerate interoperability for granular data elements, and provide a fundamental building block for other initiatives such as precision medicine and decision support. 

Candidate standards for common data elements (CDE) currently exist. For example, a CDE standard was developed through the standards and interoperability 

framework at ONC (http://hl7.org/fhir/2015May/sdc.html), and has been balloted 

through HL7 as a FHIR resource; however the standards has yet to be adopted by 

Federal agencies. Such a format standard, if adopted nationally, would be an important step toward accelerating quality reporting programs, registry and EHR interoperability. 

Once there was a common format standard for granular data elements, additional 

work to agree on the standardized meaning would be greatly accelerated. Domain 

experts in medicine and quality assessment can focus on reaching agreement on the 

definitions of data elements, knowing that once an agreement is reached on the definitions, the technical format will allow for rapid adoption and use for quality measures, registries, and EHRs. 

Last, I would urge Congress to use the upcoming development of the MIPS as an 

opportunity to focus more work toward simplifying quality measures in healthcare. 

Many measures have tens of hundreds of data elements that are of dubious quality 

and that complicate the user interface and documentation requirements for clinicians. Each additional data element creates additional cost and complexity while 

adding only marginal value. One source for this problem is a proliferation of exclusion criteria, which are highly variable across programs and CQM specifications. We 

would do better to have quality measures with simple, but high-quality data. 


95101-1.eps
53 

7 National Quality Forum, Measure Applications Partnership, http://bit.ly/1dW7VJq 

(accessed July 10). 8 Amster A., Jentzsch J., Pasupuleti H., Subramanian K ‘‘Completeness, accuracy, and computability of National Quality Forum-specified eMeasures,’’ J Am Med Inform Assoc, http:// 

dx.doi.org/10.1136/amiajnl-2014-002865 409–16, October 2014. 9Garrido T., Kumar S., Lekas J., et al, ‘‘e-Measures: insight into the challenges and opportunities of automating publicly reported quality measures’’ J Am Med Inform Assoc, http:// 

dx.doi.org/10.1136/amiajnl-2013-001789 181–84 Jan. 2014. 10Parsons A., McCullough C., Wang J., Shih S., ‘‘Validity of electronic health record-derived 

quality measurement for performance monitoring,’’ J Am Med Inform Assoc, July 2012 http:// 

bit.ly/1HqDUtK. 

Question 2. How would you recommend that clinicians and HHS identify these 

building blocks, and what process should be used to translate them into quality 

measures? 

Answer 2. The Federal Government has a process to develop and maintain quality 

measures, and this process has gone through several evolutions since EHRs were 

used to generate quality measures. The unfortunate truth is that the current process is still new and still evolving, and I fear that it will need further modification 

and improvement before it will yield the intended results. This means dedicated resources are needed and the process must include individuals with deep clinical and 

technical expertise. 

Generally speaking, the National Quality Forum (NQF) and CMS have worked to 

‘‘regularize’’ a process to identify areas of quality measurement and update those 

quality measures over time. Through the Measure Applications Partnership (MAP) 

HHS has convened multiple stakeholders to guide ‘‘the selection of performance 

measures for Federal health programs,’’ to provide ‘‘a coordinated look across Federal programs at performance measures being considered.’’ 7 This effort has been developing recommendations since 2011 and has played an important role in helping 

define core measures for Medicaid populations, including adults, children and dual 

eligible beneficiaries. However, work related to eMeasures or eCQMs (measures generated by EHRs) is still on-going with little demonstrable success, due to a lack of 

aforementioned building blocks. The original notion was to ‘‘retool’’ paper-based 

measures as electronically generated measures. This approach has been largely 

abandoned and now most eCQMs are de novo, or newly constructed. The 

foundational problem is that some data needed to complete eCQM specifications are 

not currently captured by EHRs, or not captured in a way that can be used to generate quality measure reports.8 9

As is often the case in the regulator-regulated relationship, requirements developed by the regulators are often incomplete because regulators have little direct exposure to the regulations they develop. In this instance, measure developers, technology developers and government regulators are not required to gather/input data 

necessary to generate eCQMs—clinicians gather these data at the point of care, 

often in ways unreflective or disjointed from clinical workflows. This has contributed 

to poor usability in EHRs and incomplete quality measures.10

One potential approach would provide dedicated resources to quality measure experts, inside and outside government, developers and clinicians to develop measures 

consistent with realistic clinical workflows. Bringing together clinical and technical 

expertise could then help inform the process already developed by CMS and the 

NQF MAP. Stated simply, measure developers and EHR developers must incorporate the views of practicing clinicians and their workflows. However, without a 

granular data standard, as outlined above, we will continue to have little success 

measuring quality as a ‘‘byproduct’’ of care delivery. 

CAROLINAS HEALTHCARE SYSTEM, 

July 13, 2015. 

Hon. LAMAR ALEXANDER, Chairman, 

Health, Education, Labor, & Pensions Committee, 

U.S. Senate, 

Washington DC, 20510. 

Hon. PATTY MURRAY, Ranking Member, 

Health, Education, Labor, & Pensions Committee, 

U.S. Senate, 

Washington DC, 20510. 

DEAR CHAIRMAN ALEXANDER AND RANKING MEMBER MURRAY: Thank you for the 

opportunity to testify on behalf of Carolinas HealthCare System and the Premier 

54 

healthcare alliance at the ‘‘Health Information Exchange: A Path Toward Improving 

the Quality and Value of Health Care for Patients’’ hearing on June 10, 2015. Attached are my responses to the Questions for the Record posed by the Chairman 

and the Ranking Member. 

Sincerely, 

CRAIG RICHARDVILLE, 

Senior Vice President & Chief Information Officer, 

Carolinas HealthCare System, 

Chair, Premier Healthcare Alliance, 

Member, Technology Improvement Committee. 

RESPONSE BY CRAIG D. RICHARDVILLE, MBA, FACHE, TO QUESTIONS OF

SENATOR ALEXANDER AND SENATOR MURRAY

SENATOR ALEXANDER

Question 1. Many stakeholders have suggested that the health information technology industry could come up with many solutions to the problem of interoperability on its own. However, so far, we are stuck with a system that does not work 

even though the government has spent over $30 billion. 

What areas would be best determined by private industry? What areas should the 

government decide, if any? 

Does the government need to set deadlines or otherwise encourage industry to 

make decisions? 

Answer 1. Despite its potential, the current HIT ecosystem continues to be challenging for healthcare providers because of a lack of interoperability between systems. Cost-effective, efficient, and easy to use and integrate health information is 

foundational to advancing and providing excellent care in this country. 

As this committee heard earlier this year, the current market incentives are 

not aligned with open exchange of necessary healthcare data in cost-effective ways. The sharing of data that sits in software systems across the care continuum is not only technically complex, it is also expensive and time-consuming to 

integrate. Data resides in many systems, not just electronic medical records. Registration, billing, lab, pathology systems, medical devices, sensors and monitors, to 

name just a few, all have vital data that can and should be integrated and accessible across the care spectrum, no matter what the underlying software system is. 

The difficulty in achieving this has an impact not only in care quality but also in 

cost. 

Despite the challenges, significant strides have been made with digitizing health 

information in the last 6 years. More than 80 percent of eligible providers and more 

than 90 percent of hospitals have begun the work to digitize their patient health 

data. Still, achieving necessary data integration to move forward has not been easy 

or inexpensive. Today, in order to build the bridges that connect disparate data sets 

necessary to provide comprehensive and informed decisions or care, providers must 

either pay their original system vendors thousands and sometimes millions of dollars to custom code linkages so they can ‘‘talk’’ to other systems, or they often find 

paper-based workarounds that are fraught with potential for both errors and wasted 

resources and expense. 

In order to achieve the goal of having data that is secure, accessible and actionable by providers and patients, one of the key prerequisites is creation of patient 

matching systems. It is imperative that for the patient data to be interoperable we 

have a rational and effective method to match the right data to the right patient. 

A patient matching system is also foundational to interoperability. This goal of a 

secure HIT ecosystem that enables an easy exchange of health information in timely 

and cost-effective ways could be achieved with foundational work in patient matching. 

To accomplish these goals, we ask for a combination of congressional and 

administrative actions that promote policy principles that further open 

health IT infrastructures. In creating those structures, we need clear rules 

of the road for providers and vendors alike through establishment of functional data and transport standards, and methods to measure and test 

functionalities, with enhanced enforcement tools for regulatory bodies to 

drive compliance in the marketplace. These include: 

• Establishing governance: A private-public partnership on HIT interoperability governance should be established to provide clear rules of the road on interoperability. This should be done in consultation and coordination with Federal agencies, such as HHS and ONC, and the private sector. Providers, vendors, patients 

55 

and payers should be consulted. The government entities should provide regular reports to Congress and the Administration on current standards development status 

as well as ready to market timelines and assessments for their applications. • Identifying functional data and transport standards that promote interoperability and innovation: The governance mechanisms should focus on identifying and setting the development of functional data and transport standards in key 

areas including: patient matching, terminologies, clinical data query language, security, open application program interfaces (APIs), and clinical decisions that support 

algorithms as well as business practices and policies. • Focusing on public interoperability, cost and quality: Transparent and 

public measures of interoperability should be developed in collaboration with the 

Federal Government, including HHS and ONC, and standard-setting bodies in consultation with the private sector and be required as part of ONC’s certified technology program. 

• These measures should be validated and tested in terms of functional standards, processes, and their maturity for application in the marketplace in a 

timely way, and within specific use case scenarios. • Measures should include business and implementation approaches that deliver functional interoperability outcomes and include operational processes 

and implementation practices. • Measures should also include assessment of clinical quality and cost efficiency 

metrics achieved through incorporating innovative technologies, such as existing APIs, which are open source codes that enable third-party applications to 

exchange data. 

• Encouraging transparency: Data should flow freely and easily. Determinants 

of transparency should include: 

• Availability of ‘‘free’’ (no cost) export of publishable EHR domains. 

• Prohibition of specific fees for access to necessary data through API or other 

functional standard callable methods. 

• Publication of technical instructions on how to interact with APIs, interface 

standards or other callable methods. These should be published either publicly or broadly to any authorized third party. 

• Requiring technology and devices that generate health information to publish 

clinical data to any other authorized consuming applications, including EHR/ 

EMRs, to create interoperability. Consuming applications’ ability to develop 

methods to ingest information from other HIT assets, including devices, 

should adhere to current and future medical device interoperability standards. 

• Enforcing functional data and transport standards and measures of 

HIT: The Federal Government should be enabled to enhance its enforcement tools 

to ensure functional data and transport standards and to measure compliance of 

vendors through its certified technology program. Enforcement also can be encouraged through measurement and adherence to Meaningful Use standards. 

Question 2. If you could change all or parts of the proposed rules for Stage 2 and 

3 of Meaningful Use and the 2015 certification rule, what would you change? 

Are there particular parts that should be delayed and others that should go forward? What changes would you make to them? 

Do you think that the proposed rules will make health information technology better? If so, which parts? 

Are there any parts of the proposed rules that you think would make health information technology worse? If so, which parts? 

Answer 2. Given the complexity of the objectives proposed under Stage 3, 

we believe meaningful use of EHRs can only be achieved if and when data 

captured in various EHRs and other data systems are interoperable. Being 

able to fully leverage the robust clinical and health data in various disparate systems is essential not only to deliver efficient, high-quality, and patient-centered care 

but also to provide patient access and engagement. The data is digitized. Now it 

needs to be shared freely and easily. The HIT assets within the current ecosystem 

continue to be challenging for healthcare providers; however, due to the lack of 

interoperable HIT infrastructure as market incentives are not aligned with the open 

exchange of necessary healthcare data in cost-effective ways. As a result, data is 

locked in proprietary software systems. 

As we have commented to CMS on the proposed rules for Stage 3, without 

an interoperable HIT infrastructure in place first, the increased thresholds 

for the various objectives proposed under Stage 3 will be challenging for 

providers. While we applaud the optional measures utilizing APIs to meet 

56 

some of the objectives proposed, we have requested that CMS minimize and 

keep consistent the baseline compliance thresholds when it comes to most 

of the objectives and patient access and engagement provisions in particular. More specifically: 

• Calendar Year Reporting Period for 2015 CEHRT. Under the CMS proposed rule, the EHR reporting period for all providers, including eligible professionals (EPs), eligible hospitals and critical access hospitals (CAHs), would be a full 

calendar year, beginning with calendar year (CY) 2017. In particular, for the first 

year in which the 2015 edition of certified EHR technology (CEHRT) must be used 

and Stage 3 meaningful use requirements met, providers would have a full CY 2018 

EHR reporting period. 

We strongly oppose requiring a full calendar year reporting requirement for the 

first year of Stage 3, whether that first year occurs in 2017 (by a provider’s choice) 

or in 2018 (as required under the proposed rule). It is unrealistic to expect all providers to adopt a new edition of CEHRT and initially meet the full array of Stage 

3 meaningful use requirements for an entire year, whether or not they have previously been able to satisfy Stage 1 or Stage 2 EHR meaningful use requirements. 

We, therefore, urge CMS to allow for a 90-day reporting period for the first year. 

We argued for similar treatment for 2015 and CMS has recently, and somewhat belatedly, proposed to provide this recommendation. We believe it would be a serious 

mistake to fail to give providers the flexibility to use a 90-day reporting period for 

the first year in which they adopt the 2015 Edition of CEHRT to meet Stage 3 requirements. • Objective 4: Computerized Order Entry. Objective 4 focuses on computerized 

provider order entry (CPOE) for medication orders, laboratory orders, and diagnostic 

imaging orders. The proposed objective calls for such orders to be directly entered 

by any licensed healthcare professional, credentialed medical assistant, or a medical 

staff member credentialed to and performing the equivalent duties of a credentialed 

medical assistant who can enter orders into the medical record per State, local, and 

professional guidelines. CMS emphasizes that a layperson is not qualified to perform functions associated with order entry, and that medical staff whose organizational or job title, or the title of their credential, is other than medical assistant may 

enter orders if these staff are credentialed to perform the equivalent duties of a 

credentialed medical assistant by a credentialing body other than their employer. 

Providers’ primary concern with this proposed objective is the demand that medical staff member credentialing be conducted by an entity other than the staff person’s employer. In the case of providers, that would mean that a hospital would be 

unable to credential such individuals, even though hospitals are in the regular business of credentialing members of their medical staff. We see no additive value 

to imposing such external credentialing costs and burdens on the Nation’s 

hospitals and we strongly oppose this aspect of the CMS’ proposal. • Objective 5: Patient Electronic Access to Health Information. Objective 5 

focuses on providing access for patients to view online, download and transmit their 

health information (e.g., through a portal), or retrieve their health information 

through an API, within 24 hours of its availability. 

Provider’s primary concern with this proposed objective is the unrealistic timeframe for making the information accessible, moving from the current Stage 2 requirements of 4 business days for EPs and 36 hours post discharge for hospitals to 

24 hours for all providers. We believe this is unrealistic from a workflow perspective 

and also risks forcing information to become accessible before its content can be adequately assessed for accuracy and before actions can be taken by the provider to 

educate or prepare the patient, if this is necessary. Since the thresholds for the objective are being increased and since CMS is interested in having near-identical 

requirements for both EPs and hospitals, we urge adoption of the same 

four business day timeframe for all providers. 

In contrast to our concerns regarding timeframe, we heartily endorse CMS’ 

proposal to offer providers the option to use an API-based mechanism to provide 

patient access to their health information, in addition to the existing option of viewing online, downloading and transmitting such information. To enable this option, 

however, it will be essential for CEHRT vendors be required to provide open and 

functional standard APIs that will enable secure applications to facilitate the exchange of information. We encourage CMS to look beyond data in EHRs and also 

consider the growing usage by patients and consumers of tools where they store, 

track and can share their own health data with providers. 

• Objective 6: Coordination of Care through Patient Engagement. Objective 

6 focuses on provider use of the communication functions of CEHRT to engage with 

patients and their authorized representatives about the patient’s care. For this objective, providers would be expected to attest to the numerator and denominator of 

57 

all three proposed measures and successfully meet the threshold for two of these 

three measures. Proposed measure 1 would, for example, require that more than 25 

percent of all unique patients discharged from the hospital inpatient or emergency 

department during the EHR reporting period view, download or transmit to a third 

party their health information or access their health information through the use 

of an ONC-certified API that can be used by third-party applications or devices. 

Similarly, proposed measure 2 would require hospitals to send a secure message 

using the electronic messaging function of CEHRT to more than 35 percent of such 

unique patients. Proposed measure 3 would also require hospitals to incorporate 

into the CEHRT patient-generated health data or data from ‘‘a non-clinical setting’’ 

for more than 15 percent of such unique patients. 

We have concerns with Objective 6, especially its proposed increase in percentage 

thresholds. First, in the case of measure 1, we believe it would be unfair to providers to hold them accountable for patients’ ability and willingness to electronically 

access their health information, especially given the proposed 25 percent threshold. 

CMS itself notes that median hospital performance for Stage 2 (for a related measure) is only 11 percent. Additionally, CMS has recently proposed to change the 

Stage 2 threshold for this measure so that providers would be able to meet the 

measure if at least one patient views, downloads or transmits his or her health information to a third party. 

Given all the other changes being contemplated for Stage 3, and given CMS’ proposed change for Stage 2, we urged CMS to adopt a 5 percent threshold for 

Stage 3, which is the threshold previously finalized under Stage 2 for the 

comparable measure. This would more realistically recognize that the patient 

populations served by providers vary widely in terms of their medical literacy, their 

access to computers and other technologies, their desire to access their health information under various scenarios, and even their interest in doing something they 

have never done before: electronically access their health information (that is, be 

early adopters of a new option). We would also note that the current broadband 

availability exclusion is inadequate, especially as measure thresholds increase; some 

providers have indicated that the current exclusion does not apply to their locale 

even though a significant proportion of their patient population do not have ready 

access to computers and/or the Internet. In addition, CMS also needs to recognize 

that some patients with multiple chronic conditions who are receiving care from 

multiple providers during an EHR reporting period may have no interest or need 

to access information from all of these providers. For all of these reasons, a 25 percent threshold for measure 1 would be unrealistic. Providers need more experience with electronic patient access to health information to better understand which patients take advantage of and value such accessibility before being able to provide advice regarding a threshold greater than 5 percent. 

We also consider proposed measures 2 and 3 for this objective to be extremely 

problematic. We do not believe these measures should apply to hospital inpatients 

or to individuals presenting themselves to hospital emergency departments. We do 

not understand CMS’ objective in requiring emails to be sent to patients after their 

discharge from the hospital or emergency departments. The issue with hospitalbased providers being held accountable for sending secure messages is that it does 

not acknowledge how that care differs from an ambulatory setting and how care is 

delivered through hospitals. Patients often are cared for by hospitalists and then 

when the patient is discharged, care is returned to the patient’s primary care provider. Oversight and coordination of care happens with the primary provider. 

Further, a 35 percent threshold for measure 2, which is a new measure, is unrealistic. Similarly, we do not believe that hospitals should be expected to incorporate 

patient-generated data or information from ‘‘non-clinical’’ settings for patients’ postdischarge from the hospital inpatient setting or emergency department. Thus, for 

hospitals, we believe that only measure 1 should apply and only if a 5 percent threshold is adopted. Even for EPs, we believe that measure 3 would be 

challenging, as this is a brand new concept and fails to recognize the diversity of 

patient health literacy and willingness or need to furnish patient-generated data. 

• Objective 7: Health Information Exchange. Objective 7 focuses on the provision of a summary of care record when providers transition or refer their patients 

to another setting of care, retrieval of a summary of care record by providers receiving a transitioning or referred patient (or upon the first encounter with a new patient), and incorporation into the EHR of summary of care information from other 

providers using the functions of CEHRT. For this objective, providers would be expected to meet two of the three proposed measures. Measure 1 focuses on the creation and electronic exchange of summary of care records by the providers initiating 

a transfer or referral. Measure 2 focuses on the incorporation of electronic summary 

58 

of care documents by the receiving providers (or those seeing a new patient for the 

first time). And measure 3 would, for example, require hospitals to perform clinical 

information reconciliation for more than 80 percent of transitions or referrals received and for new patient encounters. This reconciliation could, for example, address the reconciliation of medication, medication allergy or patient problem lists. 

We have significant concerns with Objective 7. For measure 1, our primary concern is the lack of adequate infrastructure for electronically exchanging summary of care documents with many providers likely to be on 

the receiving end of transitions of care or referrals, such as post-acute care 

providers. We do not believe it would be reasonable to hold hospitals accountable for other providers’ inability to electronically accept a document. Thus, at minimum, the 50 percent threshold for measure 1 is unrealistically high. 

In the case of measures 2 and 3, we oppose the application of these measures to 

patients who are not the subject of a transition of care or referral. We believe it 

is unrealistic, for example, to apply this requirement to first patient encounters in 

hospital emergency departments. In many cases, there will be no referring physician 

or even a physician of record, and no clinical information available to reconcile. Further, we believe that any such requirements would be extremely disruptive to emergency department workflows. These measures also presume the existence of an infrastructure that is capable of efficiently exchanging available information and such 

infrastructure does not currently exist in many or most cases. 

In sum, for Objective 7, we believe that only measure 1 should apply to 

hospitals for Stage 3 purposes and only if a much more reasonable measure 

threshold is adopted. As infrastructure interoperability capabilities improve, we believe it would then be reasonable to reconsider the appropriateness of applying measures 2 and/or 3 in the hospital context for specified patient populations. 

• Objective 8: Public Health and Clinical Data Registry Reporting. Objective 8 focuses on active provider engagement with a wide range of public health 

agencies (PHAs) and/or clinical data registries (CDRs). As proposed, this objective 

would require EPs to meet three of five possible measures (with two of these measures able to count more than once if more than one PHA or CDR were involved), 

while hospitals would be required to meet four of six possible measures (with measure 6 focusing on electronic reportable laboratory result reporting). 

With respect to Objective 8 and its many associated measures, we believe that the 

number of measures that need to be met by providers should be uniformly set at 

two, rather than the proposed three for EPs and the proposed four for hospitals. We 

recognize that the proposed rule includes a number of exclusions that would have 

the effect of reducing the number of measures that a given EP or hospital would 

need to meet, in some cases below the required three or four, but we believe that 

the proposed thresholds of three and four are too high given the current state of 

readiness and the lack of provider experience. While we understand that CMS views 

Stage 3 as the final stage, CMS also acknowledges that future changes to the objectives and measures are likely to be warranted for a variety of reasons. Therefore, 

we believe that additional experience with provider reporting to PHAs and 

CDRs should precede any decision about the reasonableness of requiring 

provider reporting to three or more PHAs or CDRs. 

SENATOR MURRAY

Question 1. The private sector is beginning to make progress toward standards, 

including the development of Fast Healthcare Interoperability Resources (FHIR) 

that will promote the interoperability of health information technology. In your testimony, you note that, ‘‘the Federal Government should be enabled to enhance its 

enforcement tools to ensure functional data and transport standards.’’ What enforcement mechanisms should be enhanced? 

Answer 1. As this committee heard during the hearing, the current market incentives are not aligned with open exchange of necessary healthcare data 

in cost-effective ways. The sharing of data that sits in software systems across 

the care continuum is not only technically complex, it is also expensive. 

The costs of sharing this critical data among other health systems is not just in 

dollars. It also results in inefficiently using some of our most valuable resources—our people. Having care providers faxing or mailing information to other 

providers is not the best use of these highly skilled clinical people. 

Thus, the reform goals should be to design and implement a secure HIT ecosystem 

that enables an easy exchange of health information in timely and cost-effective 

ways. The system should promote collaboration among all stakeholders, from paVerDate Nov 24 2008 17:35 Jul 20, 2017 Jkt 000000 PO 00000 Frm 00062 Fmt 6633 Sfmt 6621 S:\DOCS\25971.TXT CAROL
59 

tients to providers to vendor partners and payers. We need a system of standards 

that focuses on improving healthcare quality, efficiency, safety, affordability and access through government and market incentives, while encouraging innovation and 

competition. 

To accomplish these goals, we ask for a combination of congressional and Administrative actions that promote policy principles that further open health IT infrastructures. In creating those structures, we need a combination of clear rules of the 

road for providers and vendors alike through establishment of functional data and 

transport standards, and methods to measure and test functionalities, with enhanced enforcement tools for regulatory bodies to drive compliance in the marketplace. More specifically: 

• On standards, we need functional data and transport standards with a focus 

on key areas including: patient matching, terminologies, clinical data query language, security, open application program interfaces (APIs), and clinical decision 

support algorithms as well as business practices and policies. Although FHIR is 

promising, we need government leadership to prioritize the need for functional data 

and transport standards that are necessary within a care context to enable adoption 

as they become market-ready. 

• On the enhancement of enforcement tools, enforcement should focus on 

compliance by technology vendors and entities who choose to do business in the 

CEHRT marketplace. Through the ONC certified technology program, they should 

be required to demonstrate through testing results that they meet functional data 

and transport standards to validate that they meet the metrics for interoperability. 

The Federal Government should be enabled to use its existing enforcement tools 

as well as be provided with additional tools to ensure compliance through the ONC 

certified technology program with impactful consequences for noncompliance. The 

provider consumers who suffer the consequences and disruption due to technology 

vendors or entities who fail to comply with the standards and metrics of interoperability should be provided with hardship exemptions from meaningful use penalties. 

RESPONSE BY CHRISTINE BECHTEL TO QUESTIONS OF SENATOR MURRAY

Question 1. How would you recommend that the Department of Health and 

Human Services (HHS) leverage rulemaking to enhance patient engagement in 

health information technology products? 

Answer 1. Thank you for the opportunity to expand on this essential issue. There 

are several ways in which rulemaking can advance patient and family engagement 

in health IT, as well as in their own care. 

We recently launched the GetMyHealthData campaign, spearheaded by the National Partnership for Women & Families, in collaboration with Amida Technology 

Solutions; Code for America; Genetic Alliance; Health Data Consortium; and NATE. 

What we have learned so far, unequivocally, is that most patients and most providers don’t know about patients’ right to an electronic copy of their records under 

HIPAA—an important provision of the HITECH law. What’s more, many providers 

often don’t refer patients to their own portal, which should be capable of permitting 

downloads of records if the provider participates in Meaningful Use. These problems 

are not caused by ill-intentioned or bad actors; these providers and their staff are 

simply unaware of the law and do not have a workflow designed to produce e-Copies. 

To remedy this, and facilitate broader patient engagement, rulemaking can help: 

• Guidance from the Office of Civil Rights regarding the HIPAA right of 

access. OCR should strengthen its guidance around this right, and conduct significant outreach and education efforts to providers and consumers.

• The Meaningful Use program has been and continues to be a powerful 

lever for patient and family engagement. Its power lies in the requirement to 

genuinely engage patients in using online access to their health data, as well as in 

new proposed requirements that facilitate care coordination. Specifically: 

• Stage 3 would also increase the percentage of patients, or authorized family 

caregivers, that use online access and secure messaging. Nationally representative data demonstrate beyond any doubt that electronic access to 

health information is a significant catalyst for engaging patients and families 

in their care: Almost 9 in 10 patients who have such access use it, and it has 

60 

1 National Partnership for Women & Families. (2014, December). Engaging Patients and Families: How Consumers Value and Use Health IT, from http://www.nationalpartnership.org/research-library/health-care/HIT/engaging-patients-and-families.pdf. 

a significantly positive impact on better care, better communication with providers and improved outcomes.1

• However, many patients today do not know that they have online access and 

can download their records, because they are not told by their providers. The 

requirement implemented in Stage 2 and continued in Stage 3 for providers 

to actively engage a percentage of patients to use their data is mission-critical 

in addressing these challenges and making consumers’ use of their own data 

a reality. 

• Stage 3 would also introduce Application Programming Interfaces (APIs) into 

Meaningful Use for the first time. These, and the health applications they 

make possible, could be a significant benefit to many patients and providers. 

APIs could give patients the ability to more easily download the data they 

need, in ways they find more useful, and incorporate the data into their comprehensive record, to be shared and used by primary care providers and others involved in the patient’s care on an ongoing basis. 

• A new requirement would also enable providers to not only send patients’ 

health data electronically, but also to incorporate patients’ health data sent 

by other providers. 

• New abilities would also enable patients and caregivers to contribute information to their medical record that is specific and material to their care, including correcting errors in doctors’ records. 

Therefore, measures of patient electronic access and health information exchange 

must be left intact for Stage 3, and these aspects of Stage 3 cannot be delayed. Further, CMS’s proposal for Stage 2 to reduce the required threshold for patients accessing their health data to just a single patient should not be finalized. 

• The EHR Certification rule also offers an important opportunity to create 

the necessary technical ability to deliver on the policy promises outlined above. 

Through the Certification rule, the ability to download and transmit patients’ own 

data, as well as the additional Stage 3 proposed requirements described above, will 

become feasible for providers using certified systems. 

• Alternative Payment Model (APM) rules also offer an important opportunity to advance patient and family engagement via health IT. APMs should require the use of certified EHRs, as well as include at least Stage 2 of Meaningful 

Use as a basic requirement of qualification for participation in APMs. 

Question 2. What would you identify as key short- and long-term objectives for 

patient engagement in the Health Information Technology for Economic and Clinical 

Health (HITECH) Act. 

Answer 2. Short-term patient engagement objectives: 

• Accelerating health data access for consumers. HITECH established in 

law the policies, technology standards and education outreach that permit and encourage patient electronic access to and use of health data. HITECH not only created the Meaningful Use program, but also created a new right of access to an electronic copy of one’s health record. Also included in the Act was an education campaign focusing on health IT, privacy and this new right of access. 

• Reducing health disparities. HITECH included a provision to advance standardized ways of collecting data on race, ethnicity, language and gender so these data 

may be used to reduce health disparities in the short term, and advance health equity in the long term. 

• Giving consumers a voice. HITECH also established important Federal advisory committees with specifically designated consumer seats, in recognition of the 

essential role consumers and their advocates should play in Federal policymaking. 

Meaningful Use may not have had a priority focus on patient engagement without 

these consumer voices, and more consumer voices are needed as current policymakers consider the future of health IT policy, including interoperability and Meaningful Use. 

Long-term patient engagement objectives: Based on the short-term objectives laid 

out in the HITECH law, it is clear that long-term objectives for patient engagement 

include: 

• Making consumer access to data ubiquitous, seamless and easy to use. 

• Advancing health equity, including equal access to health information for all 

individuals, in languages of their choice, as well as measures of quality that are 

61 

stratified by disparity variables (specifically race, ethnicity, language, gender, 

sexual orientation and gender identity). 

• Achieving patient- and family-centered care, including care that is coordinated, affordable, planned, effective and efficient. 

Thank you again for the opportunity to provide input. Please don’t hesitate to contact me with any questions. 

CERNER, 

KANSAS CITY, MO 64117, 

July 13, 2015. 

Hon. LAMAR ALEXANDER, Chairman, 

Senate HELP Committee, 

428 Dirksen Senate Office Building, 

Washington, DC 20510. 

Hon. PATTY MURRAY, Ranking Member, 

Senate HELP Committee, 

428 Dirksen Senate Office Building, 

Washington, DC 20510. 

Hon. ORRIN HATCH, 

Senate HELP Committee, 

428 Dirksen Senate Office Building, 

Washington, DC 20510. 

Hon. TAMMY BALDWIN, 

Senate HELP Committee, 

428 Dirksen Senate Office Building, 

Washington, DC 20510. 

DEAR CHAIRMAN ALEXANDER, RANKING MEMBER MURRAY, SENATOR HATCH AND

SENATOR BALDWIN: Thank you for the opportunity to testify at the June 10, 2015, 

HELP Committee Hearing entitled, ‘‘Health Information Exchange: A Path Toward 

Improving the Quality and Value of Health Care for Patients.’’ 

Please find attached my responses to your Questions for the Record. 

I welcome any opportunity to discuss these questions or any others as you continue your very important work. 

Respectfully yours, 

NEAL L. PATTERSON, 

Chairman and CEO. 

RESPONSE OF NEAL L. PATTERSON TO QUESTIONS OF SENATOR ALEXANDER, 

SENATOR HATCH AND SENATOR BALDWIN

SENATOR ALEXANDER

Question 1. You have mentioned that there are four specific things that physicians 

complain about the most relating to the burden of documentation. You’ve also said 

that three of those four things could be shifted to other members of the care team 

to free up more physician time. 

What do you think providers should continue to document and what do you think 

could be shifted to other members of the care team? 

Answer 1. Capturing the patient’s health history, present illness, and course of 

treatment through observations, evidence of medical decisionmaking, treatment 

plans and outcomes is critical for facilitating treatment and continuity of care, driving accurate coding to maximize revenue, and calculating a facility’s quality of care 

indicators. These needs are not new—they existed in the paper world and are deeply 

embedded in the Fee-For-Service model. 

Further confounding the automation of the clinical workflow through electronic 

health records is the effect of narrowly interpreting prescriptive regulatory requirements, resulting in workflows that have driven physicians to become highly trained, 

highly specialized data entry experts. 

State licensure, State boards governing specific professions, Medicare conditions 

of participation, and hospital or practice policies dictate patient care activities dependent on physician involvement, as well as permitted activities for non-physicians, such as physician assistants and advanced practice nurses. Specific to Meaningful Use requirements, according to CMS FAQ10071, computerized physician 

62 

order entry (CPOE) is the only Meaningful Use objective that has limitations on 

who can perform the activities necessary for that particular objective to meet the 

measure—it must be performed by a licensed or certified provider with clinical 

knowledge. 

What we have seen implemented at hospitals and physician practices, however, 

are complicated physician workflows that go beyond traditional approaches and attempt to address multiple objectives: e-prescribing (eRx), medication reconciliation, 

clinical summary, patient education, transition of care summaries (for which the 

physician must verify that the summary contains a problem list, medication list and 

medication allergy list), and patient portal. 

I believe that government needs to ‘‘round the corners and smooth the edges’’ of 

regulations and provide guidance so that critical data can still be captured as part 

of the patient’s record, yet care team members—including nurses and physician assistants—are able to proxy for physicians, particularly in the areas of medication 

reconciliation, orders, clinical documentation and discharge planning, where exclusive physician responsibility for these activities is not required. The shift away from the Fee-For-Service payment model is a major step in the 

right direction. CMS could speed this process by relaxing the complex evaluation 

and management (E/M) documentation guidelines or by expressly allowing non-physicians to complete the aspects of that work that do not require physician judgment, 

but with physician final review. Further, Meaningful Use must not impose any additional requirements—either actual or perceived—that hospitals and physician offices 

should presume physicians must perform when State licensure and State medical 

and health professional board regulations allow non-physician roles to do so. 

Question 2. Many stakeholders have suggested that the health information technology industry could come up with many solutions to the problem of interoperability on its own. However, so far, we are stuck with a system that does not work 

even though the government has spent over $30 billion. 

What areas would be best determined by private industry? What areas should the 

government decide, if any? 

Does the government need to set deadlines or otherwise encourage industry to 

make decisions? 

Answer 2. EHRs should be built to be interoperable—to exchange critical information with providers and organizations across the patient’s entire continuum of care. 

Clinical data should always flow unimpeded to wherever it is needed for direct clinical care of the patient. It is true the industry has not yet ‘‘solved interoperability’’ for seamless exchange, 

yet we have made significant strides and learned valuable lessons. 

• Standards alone will not create interoperability. Standards must be developed 

and tested by the private industry based on real-word use cases. Deployment and 

use of the standards must be to achieve a business purpose. Government should continue to facilitate emergence of appropriate business drivers through changes in provider payment that reward managing care over a continuum, and perhaps other regulatory pressures if market forces prove to be inadequate. Government could also play 

a role in funding pilots and demonstrations of up-and-coming standards. Government should facilitate transparency around the degree of actual data sharing so that 

‘‘data blockers’’ will be exposed to market scrutiny. • Nationwide interoperability requires an open network that has a reliable method of patient identity management, record location tracking and patient-driven consent. 

• The network must manage contractual and legal arrangements necessary to 

share health data, as well as deploy a governance mechanism to ensure the 

arrangements are followed. Government could play a role in ‘‘blessing’’ material elements of such arrangements to reduce the amount of time needed to negotiate new relationships and to ensure that participants are comfortable that 

such an arrangement complies with appropriate regulations. The government 

could encourage and/or require public transparency of business practices, and 

provide enforcement mechanisms when a business entity falls short of its obligations. • These networks require the active engagement and collaboration of their participating entities. They cannot be simply created by a legislative vehicle. 

• CommonWell Health Alliance is such a network. 

The government should define the ‘‘what’’ and ‘‘when’’—the U.S. health care 

stakeholders should define and achieve the ‘‘how.’’ 

Question 3. If you could change all or parts of the proposed rules for Stage 2 and 

3 of Meaningful Use and the 2015 certification rule, what would you change? 

63 

* Due to the high cost of printing, the attachment referred to have been retained in committee 

files. 

Are there particular parts that should be delayed and others that should go forward? What changes would you make to them? 

Do you think that the proposed rules will make health information technology better? If so, which parts? 

Are there any parts of the proposed rules that you think would make health information technology worse? If so, which parts? 

Answer 3. For more detailed responses to your questions, I have attached Cerner’s 

responses to each respective proposed rule: Modification of Stage 2, Stage 3 and 

2015 CEHRT.* 

Two key points: 

1. A wholesale delay of the Stage 3 timeline could create a major disruption in 

momentum of health IT adoption that could interfere with payment reform and advanced initiatives such as precision medicine. January 1, 2018, should remain as the 

start date for Stage 3; however, the final rules should proceed with a purposeful 

focus on requirements that advance interoperability and increase patient engagement. 

2. ONC should propose certification criteria beyond what is necessary for Meaningful Use only at the point in time they are required by other Federal program 

requirements, and not presume a market role absent a Federal policy interest. 

SENATOR HATCH

An HIT vendor change brings with it new challenges, including data collection 

and reporting, which are both part of Meaningful Use requirements, as well as patient safety issues. One hospital system in my State estimated that it could take 

as long as 19 months to safely transition EHRs. 

Question 1. From your experience, can you tell us how long installing an EHR 

takes and give us a sense of all of the steps required? Please describe the timing 

and the complexity of the problem for a physician office, for a hospital, and for a 

multi-hospital system. 

Answer 1. The answer varies based on organization size and profile. For example, 

we can have a stand-alone physician office live in 3 months. A single hospital system typically requires 14 months, as is our standard recommendation for a community-based health system; however, a larger, multi-facility health system could reasonably expect 18–24 months. 

Most EHRs are highly configurable so they can meet the needs of a variety of different kinds of provider organizations. At a high level, steps accomplished in the implementation timeframe include: 

• Planning: Project governance, organizational change management, resource allocation, current State assessment, definition of measurable project outcome. 

• Execution: Executing the plan, defining future State (people, process, technology), building the configurable parts of the EHR, testing and training. 

• Conversion/System Adoption: Includes post conversion assessment, adoption 

confirmation, outcomes measurements. 

Question 2. In what ways would transitioning to a new HIT vendor interfere with 

a provider’s ability to comply with Meaningful Use requirements? What considerations would ease the burden on providers looking to transition from one vendor to 

another? What are the merits of a hardship exemption from Meaningful Use penalties for such circumstances, and what other options would you suggest? What 

would be an appropriate amount of time for a hardship exception from Meaningful 

Use penalties for providers who transition vendors? 

Answer 2. Even with a fairly seamless transition to a new system, the provider 

or hospital must be live on this new system for some time to reach productive use 

in the same (or improved) mode and manner experienced before. Expecting immediate par level results with a new conversion may not be realistic for at least a period of months. 

The challenge of transitioning to a new technology is much greater than simple 

data migration—the provider/hospital must essentially re-implement and roll out all 

features. This likely requires process and workflow changes, database customization, education, and so on. Post implementation, a client may experience a re-adoption curve where performance levels may dip, or a dual system period with multiple 

reporting approaches. 

Some measures allow for consideration of activity that occurs before, during or 

after the reporting period. That data may not be available to the new system, as 

64 

the old system’s mechanism may not be ‘‘translatable’’ for how the new system recognizes numerator credit, the data that was the basis of proof in the old may not 

be able to be converted, or it simply may be a process not available to the new. To 

that extent, any such functional measures need time to build that history for the 

activity data, which may require more than simple data conversation but actual new 

rounds of seeing existing patients to establish or re-establish that history. 

In Cerner’s experience dealing with technology transitions, one of our clients’ biggest issues is related to the patient reminders objective for Stage 2 Eligible Providers (EPs). Fortunately, this issue would be addressed under the proposed Stage 

2 Modification Rule. As way of example, however, on that measure, there is a requirement that the provider send patient reminders to 10 percent of patients that 

have had two or more encounters in the 24 months prior to the reporting period. 

If the provider switched vendors, pulling relevant data could be a potentially expensive and time-consuming process for that one measure. 

Public health reporting may create another issue. If a provider/hospital is submitting on an ongoing basis for public health and then switches technologies, the rule 

is not clear as to whether there will be a new time to enter into ‘‘active engagement’’ 

again. 

To help facilitate a technology transition, we suggest, at a minimum, a hardship 

exemption that avoids penalties. To support ongoing incentives, and/or in lieu of a 

hardship exemption, allowing the provider/hospital the ability to attest in good 

faith—without being judged strictly on measurement achievement—may also be a 

helpful option. So would allowing a temporary break in reporting, focusing on attestation when the provider is fully operational on the new system, but not necessarily 

the entire year. In general, regulatory measures that focus on ‘‘process’’ rather than 

‘‘outcome’’ will be harder to transition to a new system. This is one reason why we 

favor focus on the ‘‘what’’ rather than the ‘‘how.’’ If a new system has a better approach to certain processes, then those process changes should not adversely effect 

achievement of incentives. 

SENATOR BALDWIN

Question 1. I am encouraged by progress made on vendor-developed exchanged 

networks, such as Epic’s Carequality and Cerner’s CommonWell. How many patients have opted in to CommonWell as of the date of this hearing? What percentage 

of hospitals and clinics using Cerner’s EHR software are currently connected to 

CommonWell? 

Answer 1. CommonWell Health Alliance, an open, industry-driven, vendor-led Alliance consisting of 29 health IT organizations including Cerner, concluded its yearlong pilot testing and began nationwide rollout of services in January 2015. Seventy-three facilities were connected and live on CommonWell services as of June 10 

(the date of my testimony), with 5,000 facilities anticipated to be enrolled by years’ 

end. 

While CommonWell is in early deployment across the country, we are reporting 

promising patient adoption. As of June 10th, over 30,000 patients were actively enrolled in CommonWell, and active data exchange was occurring nationwide. We fully 

anticipate that growth in these numbers will accelerate as the national rollout expands, as new members extend services, and as provider utilization increases. 

Specific to Cerner, 336 acute facilities using Cerner’s EHR are currently enrolled 

in CommonWell services. This represents approximately 10 percent of Cerner’s 

acute client base. 

Of course, even as CommonWell adoption grows, we continue to support a number 

of interoperability activities, including connections to more than 130 HIEs and numerous point-to-point connections, many facilitated by Cerner’s open, standardsbased exchange network. All told, last month (June), we generated more than 7.7 

million CCD records across our client base. Most were for consumption by nonCerner systems. 

If you have additional questions specific to CommonWell, I encourage you to contact: Jitin Asnaani, Executive Director, CommonWell Health Alliance. 617.396.4009; 

jitin@commonwellalliance.org, commonwellalliance.org. 

Question 2. It is important that we support putting into place a national structure 

to enhance and connect existing networks so they can seamlessly and securely share 

patient records with each other. Therefore, it is critical to identify any barriers to 

participation in networks, as well as barriers that may inhibit connecting of networks. Do you see potential drawbacks in charging for the licensing or use of interoperability software? Does this create any barriers for participation? 

Answer 2. The pricing of interoperability services is a great concern, particularly 

as we try to encourage a State of true nationwide interoperability. Point-to-point 

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interfacing has traditionally been very labor intensive and costly, and that is one 

of the reasons we saw a need for CommonWell. Interoperability should be free for 

patients, and priced like a public utility (like water or electricity) for provider organizations. As the beneficiary of all the public investment in health IT, it doesn’t 

bother me if the industry/vendors have to pay a little more to make this happen. 

It is Cerner’s goal to provide interoperability services at a low cost to health care 

providers, and to engage in fair practices that do not financially penalize connections that flow outside of our own network to other vendors or other networks. We 

endeavor to embrace the notion of FRAND (fair, reasonable and non-discriminatory) 

pricing. A good example of FRAND pricing at work: when a Cerner client signs up 

for CommonWell, they pay a low, one-time setup fee, and that covers all their standards-based connections, whether those connections are to the CommonWell network 

or to organizations using non-CommonWell vendors such as Epic. Right now we 

don’t have direct bridging between CommonWell and the entire Care Everywhere 

network, but we support unlimited connections to points inside that network. We 

believe that direct bridging of networks will follow. When that happens, our work 

will be easier, not harder. 

Countless dollars have been spent as a nation on health information exchange 

networks, yet they rarely scale to all the venues where any given patient actually 

receives care. I believe the greatest barriers to participation in networks are associated to the creation of the networks themselves, not a result of connecting them. 

These are the exact frustrations—governance and data sharing agreements, patient 

identification, record location and consent management—that sparked the need for 

CommonWell to provide more services than simply bridging limited network infrastructures. In other words, problems within the networks themselves must be addressed—not just the efforts—and costs—necessary to connect them. 

[Whereupon, at 11:45 a.m., the hearing was adjourned.] 

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