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HEALTH INFORMATICS: WHAT IS THE PRESCRIPTION FOR SUCCESS IN INTERGOVERNMENTAL

INFORMATION SHARING AND EMERGENCY RESPONSE?

HEARING

BEFORE THE

SUBCOMMITTEE ON TECHNOLOGY, INFORMATION

POLICY, INTERGOVERNMENTAL RELATIONS AND

THE CENSUS

OF THE

COMMITTEE ON

GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED EIGHTH CONGRESS

SECOND SESSION

JULY 14, 2004

Serial No. 108–256

Printed for the use of the Committee on Government Reform

(

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

http://www.house.gov/reform

(II)

COMMITTEE ON GOVERNMENT REFORM

TOM DAVIS, Virginia, Chairman

DAN BURTON, Indiana

CHRISTOPHER SHAYS, Connecticut

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

MARK E. SOUDER, Indiana

STEVEN C. LATOURETTE, Ohio

DOUG OSE, California

RON LEWIS, Kentucky

JO ANN DAVIS, Virginia

TODD RUSSELL PLATTS, Pennsylvania

CHRIS CANNON, Utah

ADAM H. PUTNAM, Florida

EDWARD L. SCHROCK, Virginia

JOHN J. DUNCAN, JR., Tennessee

NATHAN DEAL, Georgia

CANDICE S. MILLER, Michigan

TIM MURPHY, Pennsylvania

MICHAEL R. TURNER, Ohio

JOHN R. CARTER, Texas

MARSHA BLACKBURN, Tennessee

PATRICK J. TIBERI, Ohio

KATHERINE HARRIS, Florida

HENRY A. WAXMAN, California

TOM LANTOS, California

MAJOR R. OWENS, New York

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

CAROLYN B. MALONEY, New York

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

CHRIS VAN HOLLEN, Maryland

LINDA T. SANCHEZ, California

C.A. ‘‘DUTCH’’ RUPPERSBERGER, Maryland

ELEANOR HOLMES NORTON, District of

Columbia

JIM COOPER, Tennessee

BETTY MCCOLLUM, Minnesota

———

BERNARD SANDERS, Vermont

(Independent)

MELISSA WOJCIAK, Staff Director

DAVID MARIN, Deputy Staff Director/Communications Director

ROB BORDEN, Parliamentarian

TERESA AUSTIN, Chief Clerk

PHIL BARNETT, Minority Chief of Staff/Chief Counsel

SUBCOMMITTEE ON TECHNOLOGY, INFORMATION POLICY, INTERGOVERNMENTAL

RELATIONS AND THE CENSUS

ADAM H. PUTNAM, Florida, Chairman

CANDICE S. MILLER, Michigan

DOUG OSE, California

TIM MURPHY, Pennsylvania

MICHAEL R. TURNER, Ohio

WM. LACY CLAY, Missouri

STEPHEN F. LYNCH, Massachusetts

——— ———

EX OFFICIO

TOM DAVIS, Virginia HENRY A. WAXMAN, California

BOB DIX, Staff Director

DAN DALY, Professional Staff Member and Deputy Counsel

JULIANA FRENCH, Clerk

ADAM BORDES, Minority Professional Staff Member

(III)

C O N T E N T S

Page

Hearing held on July 14, 2004 ............................................................................... 1

Statement of:

Foldy, Dr. Seth, M.D., former Chair, Information Technology Committee,

National Association of County and City Health Officials [NACCHO],

former health commissioner, city of Milwaukee, associate clinical professor, family and community medicine, Medical College of Wisconsin;

Richard S. Weisman, coordinator, Weapons of Mass Destruction Response Program, Jackson Memorial Medical Center, director, Florida

Poison Information Center/Miami, research associate professor, pediatrics, UM/Jackson Memorial Hospital; and Gordon Aoyagi, fire administrator, Montgomery County Fire and Rescue Service ................................ 115

Gingrich, Hon. Newt, former Speaker of the U.S. House of Representatives, the Gingrich Group; Karen S. Evans, Administrator of e-Government and Information Technology, Office of Management and Budget;

David A. Powner, Director, Information Technology Management

Issues, U.S. Government Accountability Office; and Dr. Claire V.

Broome, M.D., Senior Advisor to the Director for Integrated Health

Information Systems, Centers for Disease Control and Prevention, U.S.

Department of Health and Human Services .............................................. 13

Letters, statements, etc., submitted for the record by:

Aoyagi, Gordon, fire administrator, Montgomery County Fire and Rescue

Service, prepared statement of .................................................................... 133

Broome, Dr. Claire V., M.D., Senior Advisor to the Director for Integrated

Health Information Systems, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, prepared statement of ........................................................................................................... 86

Clay, Hon. Wm. Lacy, a Representative in Congress from the State of

Missouri, prepared statement of .................................................................. 8

Evans, Karen S., Administrator of e-Government and Information Technology, Office of Management and Budget:

Information concerning high level deliverables ............................................. 110

Prepared statement of ............................................................................... 62

Foldy, Dr. Seth, M.D., former Chair, Information Technology Committee,

National Association of County and City Health Officials [NACCHO],

former health commissioner, city of Milwaukee, associate clinical professor, family and community medicine, Medical College of Wisconsin,

prepared statement of ................................................................................... 118

Gingrich, Hon. Newt, former Speaker of the U.S. House of Representatives, the Gingrich Group, prepared statement of ..................................... 18

Murphy, Hon. Tim, a Representative in Congress from the State of Pennsylvania, prepared statement of .................................................................. 12

Powner, David A., Director, Information Technology Management Issues,

U.S. Government Accountability Office, prepared statement of ............... 70

Putnam, Hon. Adam H., a Representative in Congress from the State

of Florida, prepared statement of ................................................................ 4

Weisman, Richard S., coordinator, Weapons of Mass Destruction Response Program, Jackson Memorial Medical Center, director, Florida

Poison Information Center/Miami, research associate professor, pediatrics, UM/Jackson Memorial Hospital, prepared statement of ................... 127

(1)

HEALTH INFORMATICS: WHAT IS THE PRESCRIPTION FOR SUCCESS IN INTERGOVERNMENTAL INFORMATION SHARING AND

EMERGENCY RESPONSE?

WEDNESDAY, JULY 14, 2004

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON TECHNOLOGY, INFORMATION POLICY,

INTERGOVERNMENTAL RELATIONS AND THE CENSUS,

COMMITTEE ON GOVERNMENT REFORM,

Washington, DC.

The subcommittee met, pursuant to notice, at 2:35 p.m., in room

2154, Rayburn House Office Building, Hon. Adam Putnam (chairman of the subcommittee) presiding.

Present: Representatives Putnam, Murphy, Miller, and Clay.

Staff present: Bob Dix, staff director; John Hambel, senior counsel; Dan Daly and Shannon Weinberg, professional staff members

and deputy counsels; Juliana French, clerk; Felipe Colon, fellow;

Erik Glavich, legislative assistant; Adam Bordes, minority professional staff member; and Jean Gosa, minority assistant clerk.

Mr. PUTNAM. A quorum being present, this hearing of the Subcommittee on Technology, Information Policy, Intergovernmental

Relations and the Census will come to order.

Good afternoon and welcome to the subcommittee’s hearing entitled, ‘‘Health Informatics: What is the Prescription for Success in

Intergovernmental Information Sharing and Emergency Response?’’

The purpose of this oversight hearing is to examine the progress

and impediments to the development and implementation of an efficient, secure, and reliable health information sharing network related to public health issues and emergency response: at the clinical care delivery, public health and consumer health levels, as well

as among and between various government entities. At this hearing, the subcommittee will explore the role and status of technology

in contributing to the success of those efforts. The subcommittee

will also review the progress and results of the Federal Government’s efforts in Consolidated Health Informatics e-government initiative. Further, the subcommittee will explore efforts to develop

standards for the collection and use of health information to facilitate information sharing, as well as privacy protections that are related to the collection and use of such data.

Today’s hearing is an opportunity to examine the efforts underway in the advancement of information technology in the

healthcare industry. The industry also provides an opportunity to

examine the cross-agency coordination in the collection, consolidaVerDate 11-MAY-2000 12:12 Feb 11, 2005 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 D:\DOCS\98120.TXT HGOVREF1 PsN: HGOVREF1
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tion, maintenance, and sharing of healthcare data, as well as

across public and private sectors.

This hearing is the second in a series this week that focuses on

intergovernmental information sharing and the use of technology to

facilitate capabilities. Yesterday the subcommittee examined the

issue in the context of the linkage between law enforcement and

homeland security, and the need for timely, reliable, and secure information sharing between various Federal agencies, as well as

State and local government.

Our Nation benefits from great advances in information technology. Such technologies have introduced multimillion dollar diagnostic instruments, a vast facilities infrastructure, and highly

trained providers. However, our healthcare system has not leveraged information technology in healthcare record keeping. As Secretary Thompson remarked, ‘‘The most remarkable feature of this

21st century medicine is that we hold it together with 19th century

paperwork.’’

The resolution of this problem is a high priority for the President. Earlier this year, the President further accelerated this work,

calling for electronic health records to be available to most Americans within the next decade. His vision is to develop a nationwide

health information technology infrastructure that ensures appropriate information is available at the time and place of care, resulting in improved healthcare quality, fewer medical errors, and a reduction in healthcare costs. In April, the President signed an Executive order that laid out the first steps in pursuing this goal with

the establishment of a National Coordinator for Health Information

Technology within the Department of Health and Human Services.

The purpose behind the creation of this sub-cabinet level position

was to drive health information technology adoption in the health

system and to centralize leadership in the Federal Government in

pursuit of this objective.

To achieve the important goals of coordination across the sectors

of the U.S. healthcare system, the challenge of the development

and implementation of standards and interoperability must be addressed. In many cases, data is collected using a format and vocabulary that suits the individual data collector, without consideration

for the possibility of subsequent data sharing. The date is thus useless to others because the data was not collected in a standardized

format using standardized vocabulary, and is not interoperable

with data sets other healthcare providers may hold. This results in

wasteful redundancy and a reduced ability to perform critical

healthcare functions.

The consensus across the healthcare industry is that the time is

right to establish universal clinical vocabulary and messaging

standards to enable technology development which better supports

exchange in a secure environment. Leaders in the healthcare industry have communicated how important the Federal Government’s leadership role is in adoption of those standards. As the

Government is involved in providing and paying for healthcare—it

is the largest third-party purchaser of healthcare—the standards

used by Federal agencies significantly influence the decisions on

standards made by the rest of the healthcare marketplace.

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Through the administration CHI initiative, numerous agencies

and departments have endorsed 20 sets of standards thus far.

About 20 department and/or agencies, including Health and

Human Services, Veterans Administration, Department of Defense,

Social Security, GSA, and NIST, are active in the CHI governance

process. It is through this process that all Federal agencies will incorporate the adopted standards into their individual agency health

data enterprise architecture, which is used to build all new systems

or modify existing ones. CHI also conducts outreach to the private

sector through the National Committee on Vital and Health Statistics.

Beyond improving healthcare delivery and controlling rising

healthcare costs, improved information sharing will provide the

tools necessary to respond to a bioemergency event, whether terrorist-related or naturally occurring. It is through the development,

adoption, and implementation of standards in data collection and

transfer, as well as the installation of health IT systems in the clinical care and public health sectors, that the U.S. healthcare system

will be better equipped to share information with clinicians, public

health officials, and emergency response personnel in the event of

a public health emergency. With better information sharing comes

faster identification, containment, and response to any health-related emergency or disaster management situation such as bioterror,

a SARS-like epidemic, or floods, hurricanes, wildfires, or other natural disasters.

We are eager to hear about the current state of information technology and sharing in the healthcare industry, and what we can do

to move forward in creating a more efficient healthcare system not

only in terms of patient care, but in terms of improving our response and handling of any bioemergency that threatens the public

health at large. I eagerly look forward to the expert testimony of

our distinguished panel of leaders from throughout the Federal

Government and the private sector today.

[The prepared statement of Hon. Adam H. Putnam follows:]

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Mr. PUTNAM. And we do apologize for the delay in beginning the

hearing, as it is the rush to the August recess and votes have interrupted. But I believe that we do have a clean block of time for this

hearing. We do very much appreciate your patience and understanding, and at this time I will yield to the distinguished ranking

member from Missouri, Mr. Clay, for his opening remarks.

Mr. CLAY. Thank you, Mr. Chairman, and especially for calling

today’s hearing on ways we can improve the use of information

technology in our healthcare delivery system. Since our subcommittee has not spent much time addressing these topics, I hope our

witnesses will be thorough in their responses and in outlining their

positions on all topics.

Although our citizens are living longer and healthier lives, the

state of our Nation’s public health remains fragile, not only from

long-term public health crises such as HIV and AIDS, but the

emergency of new threats such as SARS or antibiotic resistant

strains of previously identified viruses. These problems are compounded by demographic disparities in access to quality healthcare,

an increasing population of uninsured citizens, and costs for services that continue to outpace the annual rate of inflation.

All of these problems, however, can be partially addressed

through the use of information technology in healthcare. Information technology has a positive impact on nearly all components of

a national public health infrastructure. More, its intangible measures, including: the improved response of an agency to a public

health crisis; significant reductions in the number of medical errors

among patients annually, thus reducing the cost and resources necessary for positive outcomes among patients and the improvement

of patient care through technology advances.

If we continue our pursuit of utilizing IT throughout our

healthcare delivery system, we are sure to experience shorter hospital stays, improved management of chronic disease, and a reduction in the number of needless tests and examinations administered over time. This cannot be accomplished, however, until geographic and economic boundaries are remedied to ensure that our

public health infrastructure has the necessary resources for implementing such a system and there remains a vibrant IT research

and development component throughout the public and private sector.

This concludes my remarks, Mr. Chairman, and I ask that they

be included in the record.

Mr. PUTNAM. Without objection, all Members’ opening statements

will be included in the record.

[The prepared statement of Hon. Wm. Lacy Clay follows:]

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Mr. PUTNAM. I would like to recognize the vice chair of the subcommittee, the gentlelady from Michigan, Ms. Miller.

Ms. MILLER. Thank you, Mr. Chairman. I will be very brief. We

all certainly want to hear the testimony from our distinguished

panelists here. And I appreciate your calling this hearing today,

and certainly all of the panelists for appearing here today, especially noting the presence of the distinguished former Speaker of

the House, Newt Gingrich, as well.

The whole issue of healthcare, I think, and our ability to deliver

it cost-effectively, cost-efficiently, all these kinds of things, is certainly one of the more larger challenges that our Nation faces, and

I know every Member of Congress goes home to their districts and

hears about these challenges all the time, and I think we are all

very aware of many of the problems. I personally had the opportunity in a former life, it seems like, a former job that I had previously, serving as a trustee on the board of the second largest

healthcare system in my State of Michigan, the St. John’s

Healthcare System, and I think I certainly profited much from that

by just becoming more cognizant, aware of all of the problems that

everybody is facing.

You talk to the doctors and the doctors will tell you that they

were actually determining which profession they would pursue

based on medical malpractice, for instance. Perhaps they didn’t

want to be an OB-GYN anymore or a pediatrician or what have

you. The issue of critical nursing shortages, which is particularly

acute in Southeast Michigan, quite frankly. We have, I guess, the

fortunate experience of being able to cannibalize our neighbor to

the north of Canada. We have about 20 percent of any of the

nurses that are in any of our medical institutions are Canadian

nurses.

As well, you talk to the various hospitals, so many of them struggling with reimbursement rates, and their ability to collect, having

a huge amount of the percentage of their receivables in a float,

which a normal business would just not be able to withstand is

very commonplace today throughout the industry.

And, of course, we hear about the high accident rates in our hospital facilities or erroneously dispensing prescription drugs. In fact,

in Michigan we are, just about as we speak, our State house and

State senate is voting on a new piece of legislation that would require our doctors’ signatures to be legible about prescription drugs

because there have been all of these various incidents that had

happened there.

And, you know, I think sometimes you think, oh my gosh, there

are all these problems, it is just so overwhelming. Well, the reality

is that we are living longer, and we are living better, so how fantastic that we have an opportunity to have these problems, I suppose, and debate these different solutions to it. And I think it is

a positive trend line that will absolutely continue. There is nothing

more exciting than what is happening in the healthcare profession

today, particularly when you think about the information highway

and how we are utilizing technology. And I think it is for those of

us that are in any level of government, quite frankly, but particularly at the Federal level, to make sure that we do not over-tax or

11

over-regulate or over-something and stifle the creativity that is

happening in the medical field and in healthcare.

And I am very interested and desirous of working with the members of this panel and everybody in the healthcare industry to

make sure that our brain trust continue to be very creative and

flourish, and I thank you all for coming. I look forward to your testimony.

Mr. PUTNAM. The gentleman from Pennsylvania, Mr. Murphy.

Mr. MURPHY. Thank you, Mr. Speaker, and welcome to the panel.

Too often the matter of information sharing in the healthcare

field is overlooked or ignored because of the development of a

world-class system, and we face so many obstacles there. Private

health systems are reluctant to move forward with electronic

record systems because the costs, they say, are prohibitive. And

there is no common technology used or recognized by all health systems.

The use and transmission of electronic medical records poses innumerable privacy and security concerns which we have to deal

with; however, we have to acknowledge this is an issue that cannot

be ignored. Shockingly, of the over 3.7 billion prescriptions issued

last year, there were 8.8 million instances of serious illness resulting from drug errors. Medication-related errors or adverse drug

events are one of the most common types of medical errors and one

of the greatest threats to patient safety. I believe the CDC estimated about 7,000 U.S. deaths occur each year as a result of medication errors. On average, medication errors increase patient hospital stays by 2 to 5 days and increase medical bills by nearly

$6,000 a person.

Medication errors not only are harmful to patients, but are financially costly to healthcare providers. Resources that could be spent

on direct services are instead diverted to counteract adverse drug

events. Resources that could be used to improve healthcare end up

going to pay for higher insurance premiums because of the problems that come after this with lawsuits.

This issue goes beyond personal healthcare. How ready is our

health system infrastructure for a widespread health epidemic at

terrorists’ hands? Even if only one life is lost due to the inability

for community, State, and national health and emergency management systems to communicate in times of emergency, that is one

life too many.

The failure to use information technology in the healthcare field

is unacceptable and must be addressed not tomorrow, but today. It

is inexcusable and worrisome that this country is not leading the

world in the widespread use of health information technology, and

I fear that if this Congress does not do more to encourage a new

road for our healthcare systems, future generations will question

what we were waiting for.

For that reason, Mr. Chairman, I applaud you in calling this

hearing. It is extremely important, it is indeed one of making a difference in life or death. Thank you.

[The prepared statement of Hon. Tim Murphy follows:]

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Mr. PUTNAM. I thank all the Members for their opening statements. We will move to the administration of the oath. If the witnesses will please rise and raise your right hands.

[Witnesses sworn.]

Mr PUTNAM. Note for the record that the witnesses responded in

the affirmative.

We will move directly to testify, beginning with Dr. Gingrich. Dr.

Newt Gingrich served the Sixth District of Georgia in the U.S.

House of Representatives for more than 20 years and served as

Speaker of the House from 1995 to 1999. Since his time in Congress, Dr. Gingrich has become an outspoken advocate for a better

system of health for all Americans. His leadership in the arena

helped save Medicare from bankruptcy, prompted FDA reform to

help the seriously ill, and initiated a new focus on research prevention and wellness. His contributions have been so great that the

American Diabetes Association awarded him their highest nonmedical award and the March of Dimes named him their 1995

Georgia Citizen of the Year. Today he serves as a board member

on the Juvenile Diabetes Foundation.

In his book, Savings Lives and Saving Money, Dr. Gingrich

speaks directly on many of the issues at the heart of today’s hearing. He describes a vision of a 21st century system of health and

healthcare that is centered on the individual, prevention-focused,

knowledge-intense, and innovation-rich. To foster such a modern

health system that provides better outcomes at a lower cost, Dr.

Gingrich launched the Center for Health Transformation.

Dr. Gingrich is CEO of the Gingrich Group, a communications

and consulting firm that specializes in transformational change,

with offices in Atlanta and Washington. He serves as a senior fellow at the American Enterprise Institute here in Washington; a

distinguished visiting fellow at the Hoover Institution at Stanford

University in Palo Alto, CA; the honorary chairman of the Nano

Business Alliance; and is an advisory board member for the Museum of the Rockies. Dr. Gingrich is also a news and political analyst for the Fox News Channel. He received his bachelor’s from

Emory and a masters and doctorate in modern European history

from Tulane.

Welcome to the subcommittee. We are delighted to have you, and

you are recognized. Thank you.

STATEMENTS OF HON. NEWT GINGRICH, FORMER SPEAKER

OF THE U.S. HOUSE OF REPRESENTATIVES, THE GINGRICH

GROUP; KAREN S. EVANS, ADMINISTRATOR OF E-GOVERNMENT AND INFORMATION TECHNOLOGY, OFFICE OF MANAGEMENT AND BUDGET; DAVID A. POWNER, DIRECTOR, INFORMATION TECHNOLOGY MANAGEMENT ISSUES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE; AND DR. CLAIRE V.

BROOME, M.D., SENIOR ADVISOR TO THE DIRECTOR FOR INTEGRATED HEALTH INFORMATION SYSTEMS, CENTERS FOR

DISEASE CONTROL AND PREVENTION, U.S. DEPARTMENT OF

HEALTH AND HUMAN SERVICES

Mr. GINGRICH. Thank you, Mr. Chairman. I want to thank all the

members for allowing me to be here. I have submitted testimony

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for the record. I would like to summarize key things, particularly

in response to the statements that have already been made.

This is a very, very important topic, and it is a very bipartisan

topic because it goes literally to saving lives. I recently had the opportunity to keynote a conference at Brown University, chaired by

Congressman Patrick Kennedy, and I think we both found that

there was a great deal of common ground that people of all backgrounds could come together on.

It is particularly important because of the understated threat of

a biological weapon. In Savings Lives and Saving Money we had

an entire chapter that Commander Bill Sanders of the Navy helped

develop as a fellow at the American Enterprise Institute, and if we

get hit with a serious biological weapon, we could literally lose millions of people. And whatever you think of September 11, however

horrifying it was to lose 3,100 Americans, I think almost nobody

has come to grips yet with how dramatic and how serious this

problem could be.

I must say that President Bush has talked about it, Vice President Cheney has studied it, and Secretary Thompson has done a

remarkable job of organizing efforts at the Department of Health

and Human Services and has probably the finest command center

in the world today which would be responsive to a biological crisis,

but below that the rest of the system is still not prepared. I also

have to say that Dr. Gerberding at the Center for Disease Control

and Dr. Clancey at the Agency for Health Research and Quality

have also played a major role in trying to think this through.

Things like the Consolidated Health Informatics initiative are

the right start, but the Congress should encourage them to accelerate dramatically the development of standards. At the Center for

Health Transformation we recently held a workshop on initiatives

and incentives for better information technology, and a very substantial number of the people participating said that getting standards set—this is exactly like the railroad era, where you had to

change trains at every State border because they didn’t have a

common standard, and so the trains couldn’t run on the same rails.

I cannot overstate the importance of getting to a single standard,

making sure it is flexible and can grow, can evolve, but, nonetheless, that we have a starting point that is common. You see this

with automatic teller machines worldwide, you see it with cell

phones; all sorts of things people have solved this problem. We

need to do it with health information.

I also want to praise the President and Secretary Thompson for

appointing David Brailer to be the first real leader on a governmentwide basis, and I would urge the Congress to look very seriously, as a first key step, at creating a permanent national health

information technology coordinator and giving them some substantial ability to have budget review authority. Just creating the office

without power doesn’t get the job done. But the fact is the Government is the largest purchaser of healthcare in the world, and if it

were also the smartest purchaser of healthcare in the world, we

would have a transformation to an information system almost overnight, because every player would have to transform in order to

meet government purchasing. I will come back to that.

15

I think there are a couple of principles about the threat, and I

want to say this very directly. Paper kills. With all due respect to

those States which are trying to get doctors to print legibly, if they

spent the same amount of time as Congressman Murphy is trying

to get them to do, getting doctors to use e-prescribing, the savings

in lives would be staggering. Paper prescriptions kill. Paper records

kill. And if there is a real emergency, they are going to kill a lot

of people, probably in the millions if it is a biological threat. So

start with the idea anywhere you see paper you are seeing an obsolete system. And the question is how many lives are we willing to

lose before we change the system.

Now, in aviation—I used to serve in the Aviation Subcommittee—we have very high standards. In aviation, if a plane goes down

with 135 people, the National Transformation Safety Board reviews

it, the Federal Aviation Administration reviews it, the manufacturer reviews it, the airline pilots review it. It is a concerted effort

to say your life matters if you are in a plane. By contrast, the institute of medicine says we kill between 44,000 and 98,000 people a

year through medical error, we kill at least 9,000 people a year

through medication error, and we all shrug and go ‘‘isn’t that unfortunate.’’ But it is really not. It is the failure to impose systems

of competence and systems of responsibility.

I want to give you five specific principles for the solution. First,

do not create a series of silos. There has been a terrible tendency

in the last 3 years, after September 11, to want to get by on the

cheap by getting to an information system for a national emergency. When President Eisenhower, in 1955, proposed the National

Defense Highway Act specifically designed to enable us to get people out of cities if we were threatened with nuclear war, he did not

say let us build that as a separate highway and we won’t let anybody on it except in wartime. He said let us create that as an interstate highway system which, by the way, will also enable us to use

it everyday in peacetime. And that is why middle class Americans

can travel across this country with remarkable efficiency, because

of a bill that was a national defense bill.

Now, our goal should be a 21st century intelligent health system

in which every American is tied into the system electronically,

every American has an individual health record, and every American knows that the minute there is a real crisis we will all be

wired together and will respond to the biological threat in the

shortest possible time. And that is a national system, it is not simply a national defense system. But it ought to be built in the name

of national security.

Second, the Government, as the largest purchaser, should become the smartest purchaser. If the Federal Employee Health Benefit Plan, Medicare and Tricare decided that every individual was

going to have an individual health record, electronically, Webbased, encrypted, HIPPA-compliant, exactly the model the English

are launching this year, very rapidly every provider would be doing

it because the Federal Government is such a huge purchaser that

to meet the Federal Government standard they would have to do

it.

By the way, just for the record, we have had four firms indicate

they would bid $10 per record; that is, if you have 44 million people

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on Medicare for $440 million, every single person could have an

electronic record. You could sustain it for about $3 a year, or one

latte a year. Now, electronic medical records with huge bandwidth

are much harder, but a Web-based individual health record would

be very inexpensive and would overnight change the volume of information available in America, and should start, by the Government being the largest purchaser, saying why don’t our own citizens and our own staff have it.

Third, there should be a radical increase in the potential research data available to the National Institutes of Health, to CDC,

and to the Agency for Health Research and Quality, and that

should lead to the development of an evidence-based health system

of extraordinary capabilities. If you imagine how many million life

years of data are currently sitting in the Medicare financial data

base that are not being used, it makes the Framingham study,

which is the biggest longitudinal health study in history, trivial by

comparison. And yet we have no really large scale—I must say that

Dr. Zahouni has been trying very hard at NIH and that Dr.

Clancey has been trying hard at the Agency for Health Research

and Quality, but compared to the scale of the opportunity, we need

a much larger effort to develop the kind of data use and the kind

of data focus. Currently, that is what we do after we pay for everything we are already paying for that we have been doing forever,

and we have no notion of how big the opportunity is, I think, to

get dramatically larger data bases and to lead to dramatically better care.

Fourth, I think it is important in the Congress to pick up on the

President’s challenge and to insist that lives matter. President

Bush has given more speeches on health information technology

than all of the previous presidents combined. It doesn’t get page 1,

it is not the sort of thing the news media understands how to

cover, but he has given speech after speech on the importance of

health information technology; he has called for every American to

have a health record that is electronic and online. And I think it

is important to start with the premise that lives really matter, and

I would argue that it is important to challenge both the Office of

Management and Budget and the Congressional Budget Office to

use private sector experience in scoring.

The Agency for Health Research and Quality reported last June

that medication errors and other medical errors cost about $100

billion a year. Yet it is impossible to score getting to a better system as though it was going to save any money at all, a single

penny.

My last point. As you are developing this, we need to really understand we are in the 21st century. We don’t need a massive investment in a 1935 public health service. What we need to invent

is a virtual public health service. There are 55,000 drug stores that

people are used to going to that they can find easily. All 55,000

should be wired together into a virtual public health service. There

are retired doctors and retired nurses and retired veterinarians we

will need dramatically if we have a really big health crisis. They

should all be wired into the system.

And, finally, and this may strike you as a bit odd, but it illustrates the scale of the problem. If we have a major nuclear event,

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we will literally need every long-term care facility within 100 miles

and every veterinarian’s facility within 100 miles, because you will

lose all the downtown hospitals. That is actually based on a University of Pennsylvania study. And that would suggest to me that

you want all of these systems wired together routinely every morning, just as automatic teller machines are wired together, just as

e-ticket systems are wired. These are not new things. All we are

trying to do is bring health into the 1980’s.

But I think with this subcommittee’s leadership and with the

President’s continued leadership and Secretary Thompson’s continued leadership, we might actually bring the system into the 21st

century, and then we would in fact be substantially safer.

Thank you, sir.

[The prepared statement of Hon. Newt Gingrich follows:]

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Mr. PUTNAM. Thank you.

Our next witness is Karen Evans. Karen Evans is the Administrator of the Office of Electronic Government and Information

Technology at the Office of Management and Budget. Ms. Evans is

a 20-year veteran of the Federal Government, and prior to joining

OMB she was Chief Information Officer at the Department of Energy and served as vice chairman of the CIO Council, the principal

forum for agency CIOs to develop recommendations. Previously,

she served at the Department of Justice as Assistant and Division

Director for Information System Management.

Welcome back to the subcommittee, Ms. Evans. You are recognized.

Ms. EVANS. Good afternoon, Mr. Chairman, Ranking Member

Clay, and members of the committee. Thank you for inviting me to

speak about health informatics and our intergovernmental information sharing efforts.

Until recently, the Federal health information enterprise was

neither operating at optimum economy and efficiency, nor able to

fully support critical national health and security needs. When

handling health data, we seldom spoke the same language. Our

ability to respond to national medical emergencies and bioterrorism

is hindered when we are not able to share and interpret information quickly and reliably.

To improve our ability to exchange health-related data nationally

within and across business functions, the President issued, on April

27, 2004, Executive Order 13335, ‘‘Incentives for the Use of Health

Information Technology and Establishing the Position of the National Health Information Technology Coordinator.’’ This Executive

order supports leadership for the development and the nationwide

implementation of an interoperable health information technology

infrastructure.

In addition, the administration has launched governmentwide efforts to improve the sharing of health-related data, including the

Consolidated Health Informatics e-government initiative and the

Federal Health Architecture [FHA], both led by HHS. Together,

these activities will improve the quality and the efficiency of

healthcare.

Through the CHI initiative, Federal agencies are adopting and

using health data standards to facilitate communications and to

achieve interoperability. The implementation of these standards

will take place as part of the FHA program.

CHI participants include the Departments of Health and Human

Services, Defense, and Veterans Affairs, as well as many supporting Federal agencies and interagency councils and committees. CHI

interacts with the private sector through the input of the National

Committee on Vital and Health Statistics. CHI working groups

have identified 24 clinical subject matter domains where data

standards should be considered. These domains encompass a significant amount of health-related data. Secretary Thompson announced the adoption of the first five standard domains in March

2003, and the additional 15 standard domains were adopted May

6, 2004.

As standards are being adopted by CHI, the FHA program is creating an architectural foundation by building out the health line of

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business within the Federal Enterprise Architecture. FHA has been

in existence for over a year and was more formally announced as

one of OMB’s lines of business task forces in March 2004. The FHA

will provide a framework for linking health business processes to

technology solutions and standards, and for demonstrating how

these solutions will achieve improved health performance outcomes. FHA and CHI have a governance structure well designed to

lead activities in a collaborative manner.

In order to achieve intergovernmental cooperation, they work to

leverage existing interagency efforts and have developed a clearly

defined organizational structure, communication strategy, effective

consensus process, and sequential proof of concept demonstrations

for individual health business processes. In May 2004, the new Office of the National Coordinator for Health Information Technology

was established within HHS. The new office will use the efforts of

FHA and CHI to foster agreements, support progress, select health

data standards, and ensure uniform and correct implementation of

those standards.

Emergency response is one area where Federal performance can

be improved by more integrated information exchange. FHA is developing a target architecture for public health surveillance systems to improve interoperability between surveillance systems

across multiple agencies and in the national health community.

The program is conducting an assessment of existing and planned

public health systems to begin the process of identifying opportunities for collaboration and possible cost savings. Because a realtime

surveillance capability depends upon the integration of information

across agencies, implementation at a national biosurveillance initiative will be coordinated with the Federal Health Architecture effort.

The FHA initiative includes the adoption of governmentwide

data standards through CHI and will create the master plan for developing a consistent Federal framework to facilitate communication and collaboration among entities across the healthcare spectrum. This will enable the quick and reliable sharing of information and will improve citizen access to health-related information

and services.

This concludes my statement, and I would be happy to take questions at the appropriate time.

[The prepared statement of Ms. Evans follows:]

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Mr. PUTNAM. Thank you very much.

Our next witness is David Powner. Mr. Powner is responsible for

a large segment of GAO’s information technology work, including

systems development and IT investment management reviews. He

has over 15 years of public and private information technology-related experience. In the private sector, Mr. Powner held several positions with Quest Communications, including Director of Internal

Audits, responsible for information technology and financial audits,

and Director of Information Technology, responsible for Quest digital subscriber lines software development efforts.

Mr. Powner has an undergraduate degree from the University of

Denver in business administration, and is a graduate of the Senior

Executive Fellows Program at Harvard’s Kennedy School of Government.

Welcome to the subcommittee. You are recognized for 5 minutes.

Mr. POWNER. Thank you, Mr. Chairman, Ranking Member Clay,

members of the subcommittee. We appreciate the opportunity to

testify on healthcare information technology. Significant opportunities exist to use IT to improve the delivery of care, reduce administrative costs, and improve our Nation’s ability to respond to public

health emergencies. This afternoon, I will briefly describe several

of the key technologies that, in addition to improving care and reducing costs, can improve our Nation’s ability to respond to public

health emergencies, including, as the former speaker mentioned,

acts of bioterrorism. I will also discuss the importance of implementing standards as new technologies are deployed and how a national strategy can greatly facilitate the implementation of these

technologies and associated standards.

Starting with technologies. The 2001 anthrax events confirmed

many beliefs that information sharing during a public health emergency has much room for improvement, as participants accumulated dissimilar data and principally exchanged it manually. Information technology can play a critical role in improving this information sharing. For example, surveillance systems can facilitate

collection, analysis, and interpretation of disease-related data; communications systems can facilitate the secure and timely delivery

of information to responders and decisionmakers; and also electronic medical records have the potential for creating a wealth of

data to feed surveillance systems.

Unfortunately, today’s public health infrastructure primarily

lacks realtime surveillance systems and has fragmented communication networks. Efforts are underway to remedy the situation.

For example, CDC is currently implementing its Public Health Information Network, which consists of a number of disease surveillance and communications systems, including the Health Alert Network.

Next, standards associated with new technologies. Last year,

when we reported on the identification and implementation of

healthcare data and communications standards, we noted that

standards development remained incomplete across the healthcare

sector. Since then, progress has been made in identifying standards. For example, OMB’s Consolidated Health Informatics e-gov

initiative has identified a number of standards that are to be applied to new development efforts to promote the interoperability of

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information across Federal agencies. However, implementing these

standards remains a work in progress. Until these standards are

effectively implemented, disparate systems that are incapable of

exchanging data will remain. In addition, legacy systems that

haven’t incorporated the new standards will also remain a problem.

Finally, turning to the importance of a national strategy. To address the challenges of coordinating the many IT initiatives and

implementing a consistent set of standards, we recommended last

year that HHS develop an IT strategy for public health preparedness and response to include setting priorities for IT initiatives and

establishing mechanisms to monitor the implementation of standards throughout the healthcare industry. Subsequently, the President recently issued an Executive order which calls for the establishment of the National IT Coordinator and an issuance of an even

broader plan to guide the nationwide implementation of interoperable healthcare systems.

Although it is encouraging that the coordinator plans to issue

this strategy next week, this huge undertaking will require continued leadership, clear direction, measurable goals, and mechanisms

to monitor progress. Additionally, this strategy will need to be

aligned with the Federal Health Architecture, provide incentives

for private sector participation, foster intergovernmental and private sector partnering, and stress the importance of robust security

measures that ensure patient confidentiality and resist attacks.

In summary, there are many opportunities associated with the

implementation of health IT for clinical care delivery and public

health. The Federal Government is taking a leadership role in establishing a strategy and identifying standards; however, much

work remains, including deploying realtime surveillance and communications systems, implementing the standards that have now

been defined, and carrying through on the strategy that is to be announced next week.

We look forward to working with you, Mr. Chairman, and your

continued oversight of this issue, which currently includes an ongoing review of Federal biosurveillance initiatives.

This concludes my statement. I would be pleased to respond to

any questions you or members of the committee have at this time.

[The prepared statement of Mr. Powner follows:]

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Mr. PUTNAM. Thank you.

And our final witness for the first panel is Dr. Claire Broome.

Dr. Broome serves as the Senior Advisor to the Director for Integrated Health Information Systems at the Centers for Disease Control and Prevention. Dr. Broome oversees the development and implementation of CDC’s National Electronic Disease Surveillance

Program. She is an Assistant Surgeon General in the Commissioned Corps of the U.S. Public Health Service. Dr. Broome graduated magna cum laude from Harvard and received her M.D. from

Harvard Medical School. She trained in internal medicine at the

University of California-San Francisco and in infectious diseases at

Massachusetts General Hospital.

Welcome to the subcommittee. You are recognized for 5 minutes.

Dr. BROOME. Mr. Chairman, members of the committee, thank

you for this opportunity to discuss information technology and

intergovernmental information sharing to support public health

preparedness and emergency response. The Centers for Disease

Control and Prevention [CDC] is working closely with Federal,

State and local partners to enhance and integrate information systems for public health preparedness. My testimony today will focus

on the capabilities that public health must have to support preparedness and our progress in developing the systems to support

these functions.

As you know, CDC’s mandate is to protect the country against

naturally occurring diseases, but also the deliberate use of all biological, chemical or radiologic agents. Obviously, the target in any

major health event is to minimize morbidity and mortality by rapid

intervention.

Achieving this target requires capabilities for early event detection. I think we all get that. But it also needs the capacity for investigation and effective response. Electronic laboratory result reporting is a new, I would say, 21st century tool which can really

help with this, and I will talk a little more about our progress in

this area. Finally, communication among key personnel involved in

the investigation and response, but also with the public, is an essential part of systems needed.

This is a complicated activity, as you can well imagine, partly because of the large numbers of partners involved. In my public

health career I have found myself working with air conditioning engineers, with tampon manufacturers. It is hard to predict what you

are going to be dealing with. But we know the core group of local

and State organizations, law enforcement, Federal agencies, are all

going to be involved.

Information technology presents the opportunity to contribute

critically by linking this vast array of partners, as well as by supporting the range of capabilities. CDC’s Public Health Information

Network, or PHIN, as we affectionately call it, advances national

preparedness by building critical interoperability tools. It also does

this by certifying that systems built with preparedness funding are

actually capable of fulfilling the functions that are needed, and also

that they work as part of an interconnected national public health

network, as several of the speakers have referred to.

Health data standards are a critical part of that, and we actually

have been implementing the Consolidated Health Informatics eVerDate 11-MAY-2000 12:12 Feb 11, 2005 Jkt 000000 PO 00000 Frm 00088 Fmt 6633 Sfmt 6633 D:\DOCS\98120.TXT HGOVREF1 PsN: HGOVREF1
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government standards that Ms. Evans alluded to. Implementing

standards are really where the rubber hits the road. We are learning a lot about what is involved in making these standards work

so that systems can actually work together.

We are also looking forward to working with the new office,

ONCHIT, I guess, or Dr. Brailer’s office, as we think the intersection with the clinical sector is critically important for public health

success.

All of the partners, of course, have information systems to meet

their own internal needs. The challenge is, first of all, to be sure

they have that functionality, but, second, to be sure that they can

work across the different organizations. We think it is critical that

those information exchanges are tested, developed, and regularly

used to assure that they will be reliably available during an emergency.

I will now briefly discuss the status of PHIN and hope that I

have some opportunity during questioning to go into more detail.

Although CDC received the first funding for PHIN in fiscal year

2004, PHIN integrates and leverages initiatives which have been

funded in previous years, so we do have substantial progress to report. In early event detection, the PHIN component is BioSense,

which pulls together virtually realtime information from sentinel

data sources. This is part of the Presidents 2005 biosurveillance

initiative, but right now we have Phase I up and running. This

captures sentinel data in 30 cities, covering 32 critical metropolitan

areas.

The second area capability that I mentioned was the investigation and response. Here we are working with the surveillance system, NEDSS, with the electronic lab reporting through the Laboratory Response Network and to support through the Outreach Management System, investigation and response capabilities. For example, in Nebraska we have tripled the number of cases that we

have heard about and we have taken the time from 26 days down

to 1 to 3 days.

Finally, in communications we have a national system, Epi-X,

which provides secure communications capacity for 3,500 users

across State and local health departments. We also have a Web site

with 10.5 million visitors a month where we have targeted information for the media and the public to get information out.

Finally, we have communications channels to distribute health

alerts, which have gone to millions of recipients, as well as distance

learning, for example, to get information on diagnosing anthrax out

to practicing clinicians.

This is just a sampling of the huge range of efforts that are being

supported in an attempt to enhance preparedness in this country.

I would be very happy to talk further about any of these areas in

detail, and appreciate the committee’s interest. Thank you.

[The prepared statement of Dr. Broome follows:]

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Mr. PUTNAM. Thank you very much.

Dr. Broome, I would like to talk to you about this past flu season

about the difficulty in determining which strain to develop a vaccine for to have stockpiled in time for that year’s strain, and that

we are overdue to have a super-strain, if you will, something akin

to the 1918 strain. How prepared are we for something like that

and how will advances in information technology mitigate an outbreak of that magnitude?

Dr. BROOME. Thank you for the question. There are several aspects to that. We do think BioSense and analogous syndromic surveillance is highly likely to provide early warning of an increase in

febrile respiratory disease, which is the way that influenza would

present So we would get close to realtime warning, and it has been

shown with syndromic surveillance that this does go up faster than

the traditional flu surveillance mechanisms. So we think that can

help us identify that something is happening and also the geographic extent, how many cities is it happening in. However, without turning this hearing into a pandemic flu discussion, I would

point out that there are a number of other activities which are

critically necessary, such as being able to obtain the actual virus

and characterize it and rapidly develop vaccines, which will be necessary to mitigate the impact.

Mr. PUTNAM. Mr. Speaker, you referenced the 1918 strain in

your written testimony. Do you want to followup on that?

Mr. GINGRICH. Let me just comment, and Dr. Broome can correct

me if I get too much of this wrong. I think if you were to look, 1918

was an unusual event because you had the debilitation of the first

World War and you had a population that was probably more vulnerable than you would normally expect. We learned a couple of

years ago, with anthrax, that with healthy people, with rapid intervention, with all the things we can do nowadays, we had a lower

death rate than we would have expected, I think, theoretically.

But if you had avian flu crossover, for example, which is not impossible, but not likely, but not impossible, and you had the characteristics of the spread of flu, which we actually don’t understand;

it shows up in places, so you don’t have the smallpox quarantine

capability. With smallpox you can create circles of defense; with flu

we don’t understand how it spreads, so it is a lot more difficult

problem.

I think one of the things that is not part of this committee’s assignment, but one you should carry back, is we really need very

basic research in finding a way to manufacture vaccines that is a

total break from the current growing in an egg process, because the

current process presumes enough foresight that you can catch

something in Southeast Asia, and by the time it has circled the

planet you are ready for it. And in the age of the jet airplane, if

you had a sudden crossover of something, you want to be manufacturing new vaccines to meet the new challenges in days, not in

months. We have no technology today that can do that, and in

terms of basic research and development into national security,

that should be one of the highest values, that should be almost

comparable to where nuclear energy was in the late 1940’s.

Biologicals in the 21st century are what physics were in the 20th

century, and we have not yet, at the resource level caught up with

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big enough—it is not your topic for today, but I think it fits what

Dr. Broome is faced with and what the CDC is faced with with this

avian flu and with the patterns of the 1918 flu pandemic.

Mr. PUTNAM. Next week, HHS will unveil their new IT health

strategy. Mr. Speaker, recognizing the mechanics of our process in

policymaking, what should their initial focus be, given the magnitude of the challenge?

Mr. GINGRICH. I thank you for the question. I actually think

there are three parallel areas. The first is to set standards. The

work that is already being done, I think you are discovering, once

you work it through, it really makes a big difference. And we

found, in the Center for Health Transformation workshop about a

month ago, that almost everybody who came who was really sophisticated said, look, if you get the standards right, other pieces will

start to fall in place. But until, at a national level, you get standards, they are not going to migrate up from subgroups, because

subgroups all have their own vested interest, and they have all invented it here and they all want their version. So one is standards.

Second, I can’t overstate the importance of forcing CBO and

OMB, Congressional Budget Office and Office of Management and

Budget, to calculate what we are wasting. Let me give you an example that nobody can quantify today. If you were to try to ask in

Medicare or in Tricare or in FEHBP how much are you spending

to Xerox records and FedEx them, nobody knows. But because they

know what it costs to have an electronic system, they score the

electronic system as a cost and they absolutely refuse to score what

you would save by not Xeroxing and FedExing. Now, we had Anthony Nolan, who helped develop the English health record, and

Ralph Portman, who was on the advisory board to Prime Minister

Blair’s government, and they both said unequivocally, if you have

a Web-based individual health record system, as I said earlier, at

$10 a person, it is inconceivable it is not a net savings. And yet

I will guarantee you neither CBO nor OMB will score it.

So I would argue the second thing to look at is how do you get

governments in America to understand that the information age requires an entrepreneurial public management approach rather

than a bureaucratic public administration approach, and then how

do you get that kind of change.

The third place I want to come back to is investments. In the private sector, people estimate you should invest somewhere between

4 and 6 percent of your revenue into IT. The IT people tell you it

ought to be more like 8 or 10, but I think people would agree 4 to

6. Sutter Health, which is one of the leading hospital systems in

the United States, information technology has been putting in

about 4 percent a year for the last 7 or 8 years. The Federal Government should insist on a minimum of 1 percent of its own gross

spending, which would be, I am guessing—somebody here may

have a better number, but my guess is if you combine all Government health spending, you would be at $6 or $7 billion if 1 percent

of all health spending by the Federal Government went directly

into IT. If you did that, you would, within 3 or 4 years, have us

in a different world, and I think you could begin to back off.

I will say one last thing, and I apologize for adding one other

thing, but it was a commentary by one of the other panelists.

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One of the lessons that the English think they learned is you

have to have Web-based overlays and you have to have

middleware, because the cost of replacing all of the legacy systems

is so massive, and the amount of time and energy to implement it

is so huge that you cannot wait until you restructure the entire

country. It would be like arguing Henry Ford shouldn’t start selling

cars until we can replace every single horse and buggy in the country simultaneously. You have to have a method of overlaying Webbased systems and you have to have a method of overlaying

middleware systems that translate between legacy systems. And

when you do, you design a very different biosurveillance system,

because now you can get, at the Federal level, realtime data from

every single doctor, not coming up through the State public health

system in a 1935 model, but realtime data nationwide through expert systems, and it gives you a much different kind of scanning

capability.

Thank you for letting me go on.

Mr. PUTNAM. Does anyone wish to add? Dr. Broome.

Dr. BROOME. Well, just as a point of clarification The BioSense

system that I described is actually similar architecture to what Dr.

Gingrich was suggesting in that the information comes from existing electronic records directly to the BioSense platform and then is

made available at the same time at the Federal, local and State

level to authorized secure users. And we think there is real potential to work with existing data sources. Certainly there is a need

to assess and define which of those are truly valuable in providing

useful information. And there is also a need for public health to be

able to followup and investigate whether it is a true alarm or a

false alarm. But we agree there are many opportunities that need

exploring.

Mr. PUTNAM. Mr. Powner.

Mr. POWNER. If I can just elaborate on the point of implementing

the standards effectively. We are well aware and it is well documented that even now that these standards are identified, you

have local hospitals that cannot communicate with others even

though they are using the same standards. It is really in the implementation of these standards. When you look at Dr. Brailer’s strategy and what he needs to focus on, I think one of the key things,

if you have a big bang approach, it is going to be very difficult. You

probably need to look at regionalized or local success stories with

implementing standards, and then you could grow that into some

larger initiatives. That likely will be important if we can extend

that to a national level.

Mr. PUTNAM. When you say begin with a regional approach or a

smaller approach, would you start at the—for example, would your

first cut be at the Federal level, where you would do Medicare or

Federal employee benefits, VA, or would you let geography take its

course and let the State of Florida take the lead or the State of

Pennsylvania?

Mr. POWNER. I think either way. But I think if you focus on a

smaller scale basis, it is easier to realize some initial success stories, whether it is through some of the Federal programs or on a

regional basis associated with the State or a locality.

Mr. PUTNAM. Ms. Evans.

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Ms. EVANS. And I would like to, first of all, thank you for having

this panel, because I think it is an important topic. The strategy

that will be coming out from Dr. Brailer’s office will be coordinated

with all of these initiatives, taking into consideration several of the

things that have already been mentioned by the panel. You know,

I am speaking specifically as the IT executive here, and a lot of the

points that are being made are exactly what the CIO does as far

as recommending the strategy of going forward for the implementation. This is already covered in a lot of things going forward that

you do with a modular approach. The CHI initiative, as well as the

Federal Health Architecture initiative, are taking into consideration small proofs of concept in order to really drive at the points

that are being made by the distinguished panels here so that there

is a modular approach. As you do each portion of this implementation, you learn from it so that you can continuously roll those benefits into the implementation and move it forward, versus, as you

said, the big bang approach, and then you wait for everything all

at once, and if you have made a mistake, then you have a huge

mistake and then we haven’t moved forward.

So we are looking and we are working with his office on the

strategy to ensure that it does address standards, that we continue

the work of standards, but that we are looking at how this technology is going to roll out and how those standards will be implemented. As my distinguished colleague said, that is where the rubber hits the road.

Mr. PUTNAM. Mr. Speaker.

Mr. GINGRICH. I would like to agree if by big bang you mean trying to do everything at once. But I would disagree if it meant you

were going to create a series of local experiments without

connectivity. Let me make a couple quick points.

I have been involved in military transformation actively since

1979. I helped found the Military Reform Caucus; I was the third

witness at the initial Goldwater-Nichols testimony on jointness; I

am the longest serving teacher in the senior military; and I am on

the Defense Policy Board. So I have spent a long time on transformation. If you don’t have a clear national systems vision and

say, great, we will fund all sorts of local experiments that are

seeds, not silos, and the seeds have to have two characteristics that

are very different, I believe, from most of the thinking up until now

in the system. This is not a Government problem, this is how the

culture has evolved. The culture evolved locally and it evolved from

institutions. So almost all of the solutions tend to be local solutions

and institution solutions. They are both profoundly wrong for this

reason: health is essentially—should be centered on the individual.

What I care about is my health.

In England, when they started studying this, they discovered

that a person with cancer in the national health service could go

to 22 different specialists in five different institutions in a 2-year

period hand-carrying their records. So you start with the idea anything we do—and I think Dr. Brailer thoroughly understands and

agrees with this—anything we do should start with your individual

records and how we are going to match data up to you as a human

being, and it has an institutional effect and institutional overlay,

but it shouldn’t be institution-centric or provider-centric.

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Second, the reason it is ultimately going to be Web-based is simple: we travel. I mean, consider your own life. Consider the life of

a retiree. When the baby-boomers start to retire, they are not going

to sit in one place; they are going to be all over the place. So while

it is true that 90 or 95 percent of health is actually locally provided—and I just had somebody yesterday from Ford Motor Co.

whose father had a heart attack while visiting in Washington, and

they had to try to find his doctor in Southern Louisiana on a weekend, and it took Johns Hopkins 24 hours to be sure what they were

doing because they couldn’t find the patient records. Now, that is

all utterly absurd in terms of the technology available.

And so I would hope that, as we design a national architecture,

I couldn’t agree more, implementation building blocks should be

local, specific, measurable, but the core systems architecture should

be generally agreed upon, should be universal, and should ultimately have a very big Web-based part and should be individually

centered, not provider-centered or institution-centered.

Mr. PUTNAM. Mr. Clay.

Mr. CLAY. I thank the witnesses for their testimony today. I will

start with Dr. Broome.

Are we in a position today to quickly detect and respond to major

public health emergencies such as SARS and cases of bioterrorism,

given the challenges that remain in health IT?

Dr. BROOME. I think it is very important to remember that

human beings still matter. There really is no substitute for having

clinicians who are informed and aware and having people available

at their local or State health departments 24/7. That was certainly

the system that worked for the anthrax 2001, and I think it is

going to be an important part of activities; it is one of the areas

we have been focusing on. At the same time, we think IT is a critical complement to complementing and enhancing that system.

We think that BioSense is a very good first step in providing an

automatic scan of sentinel electronic data bases. The President’s

2005 initiative for biosurveillance proposes very substantial resources to increase the coverage of that system so that it would be

much more encompassing of the private healthcare delivery setting.

Mr. CLAY. Thank you for that answer.

Mr. Powner, since the Federal Government administers the

Medicare and Medicaid programs, what lessons can be learned by

the entire healthcare industry in terms of improving the quality

and efficiency of care provided to the general population? And are

we becoming more effective in implementing programs that demonstrate positive results in both public and private healthcare settings?

Mr. POWNER. I think some of the key lessons that can be learned

are from Veterans Affairs and DOD, with electronic medical

records. They clearly both have initiatives underway to put those

in place. Clearly, they are further ahead than other entities, and

there is a lot of work going on where they are attempting to have

a two-way exchange of those electronic medical records. There are

some challenges there, clearly, but there are some lessons learned,

too, from those organizations, since they are a bit ahead of others.

Mr. CLAY. Thank you.

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Ms. Evans, please give us some examples on how the Consolidated Health Informatics initiative is aiding agencies in their sharing of health-related information. Are the standards recommended

being taken to heart by the private sector as well as Government

agencies?

Ms. EVANS. Based on going forward with the CHI initiative, as

I mentioned in my statement, they have worked very closely together. We do have a consolidated business case which, from an

OMB perspective, shows that the agencies are taking this very seriously. There are over 23 partner agencies that are working on this

initiative together to define what those domains are, to define what

the standards are.

And as I pointed out in my testimony, they have mutually agreed

to adopt 20 out of the 24 standard domains going forward. They

have also agreed together, without OMB saying this is how it will

be, to adopt several of the standards that are available for the

healthcare industry, and they continuously work together because

they recognize the importance of this initiative.

We, from an OMB perspective, believe that we have now enhanced this and we are trying to help further this initiative so that

it can get implemented even faster through the Federal Health Architecture effort, again, through another consolidated business case

where they have come together and agreed that this is something

that they need to do and work together. The agencies that are listed in there are like EPA—I mean outside of the regular ones that

you would think—HHS, DOD, VA. And we watch them very closely

and ensure that they are hitting their milestones through the

President’s management agenda.

So there are several mechanisms that we are using, but the

agencies themselves agree that this is truly important and are

working together.

Mr. CLAY. Thank you for that response.

Mr. Gingrich, first let me say that it is a pleasure to see you

working with both sides of the isle, with friends like Patrick Kennedy, on issues that are so important to the health and economy

of our Nation. In the July 13th Washington Post article by C.C.

Connolly, you speak of your vision to transform the American

healthcare system as a more efficient and technologically adept

arena. Could you expand on whether our challenge is more in

terms of public resistance to changing the current system they

know and live with, or are the challenges more in terms of technology and its limits?

Mr. GINGRICH. Let me say, Congressman Clay, first of all, I am

delighted to be here with you, and I would look forward to working

with you on a bipartisan basis on these things. And you might notice that in your hometown, the Mercy health system has a remarkable track record in the last 2 years of applying information

technology and incentives, and has actually substantially brought

down costs in one of their clients by getting people deeply involved

in compliance and taking care of their own diabetes and taking

care of their own heart disease in ways that has really changed the

cost trajectory in St. Louis.

The core of what I think has to happen is to first of all—and this

goes right back to the lessons that I learned working with the DeVerDate 11-MAY-2000 12:12 Feb 11, 2005 Jkt 000000 PO 00000 Frm 00106 Fmt 6633 Sfmt 6633 D:\DOCS\98120.TXT HGOVREF1 PsN: HGOVREF1
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fense Department in the 1980’s and 1990’s—you first have to get

a clear vision of where we are going, and then you have to start

building solutions to fit the vision. We are beginning to see that.

Again, Congressman Murphy, as an example of this, on electronic

prescribing. It is very clear by any standard that there should not

be any paper prescriptions, except in the strangest of circumstance.

Routinely, they ought to be electronic; routinely, they ought to be

monitored by an expert system to make sure that you don’t have

a drug problem that we already have something else wrong with

you and that drug is not one you should take; to make sure that

it is an accurate data so, for example, if the doctor, by accident,

puts in the wrong number, an expert system should come back and

say that would kill them, as happened to a young girl here in

Washington last year, because they misread the prescription.

So I start with the idea that on almost every front—what happened in Britain is interesting. They discovered that you were

three times as likely to die of breast cancer in Britain as in France.

And that was politically so unacceptable that they had to confront

reforming the national health service. And the national service

didn’t review itself, but the Exchequer, which is their treasury department, brought in a retired banker, not somebody from health,

and said look at the system and tell us what is going on; and the

banker came back and said if I had the information systems in

banking that you have in health, we would go broke in 3 days. And

that was the base of their entire effort to create a national system.

So I start with the idea you—and what we talk about the Center

for Health Transformation is very straightforward: how do you

incentivize people to take care of themselves? And this applies to

Medicaid, it applies to Medicare, it applies to private sector plans.

If you can incentivize people so they are winning when they are

winning, they change their behavior. Second, how do you inform

them and give them a chance to inform themselves so they know

how to take care of themselves? And, third, how do you take all

that data and get it into research capability so whether it is a

realtime information going to the Center for Disease Control that

says, gee, 39 people this morning got the kind of drug you would

give somebody if they had SARS; I wonder if we better check it.

And I couldn’t agree more with what Dr. Broome said. I would

recommend this subcommittee or the full committee go down the

street one building, visit HHS and see what Secretary Thompson

has done with his command post, which is literally, I think, the

best command post today and the most modern in the world. But

then recognize that if you don’t have a competent trained professional at the other end of all that technology, it is literally worthless. And so it has to be a total systems approach, not just a single

magic bullet approach, and that is harder, it is somewhat more expensive, but in the long-run I think it is going to be dramatically

better.

I would also say one other thing where both, I believe, Tricare

and Veterans have missed the boat, although I think Veterans are

starting back to catch up on it. An individual health record is very

different from an electronic medical record. An individual health

record is Web-based, relatively simple, can be downloaded over a

rural doctor’s office on a telephone line. An electronic medical

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record is massive, it has every MRI, every lab report, everything

ever done to you, and it takes huge bandwidth.

We could have for the entire country an individual electronic

health record online for something on the order of $3 billion, and

we could sustain it annually for about $1 billion a year. Totally different proposition. An electronic medical record for every American

would be, I think, well over $100 billion.

Mr. CLAY. Thank you.

Mr. PUTNAM. Ms. Miller.

Ms. MILLER. Thank you, Mr. Chairman. I appreciate all of the

testimony here today, particularly the sweeping vision of what we

ought to do with our healthcare system, and certainly what Congress needs to move more expediently toward some of the settings.

But unlike my colleague Dr. Murphy here, I am struggling myself

with some of these different terms and understanding all of this.

I had an incident in one of my local hospitals just during the

break during the 4th where I went to—this is sort of a rural hospital; not completely rural, but very small town. And this was a

hospital where the doctors had previously just run around with

clipboards, right? They are going into each individual place with

their patient with their clipboard. Now they have an electronic

notepad. It is sort of in the front of each patient’s room; it is on

the wall. They can write on it whatever they are doing; they can

take it from there and move it into the individual patient’s room.

So I think one of the biggest problems they are having, though, is

getting the doctors to really use these things, because there is a big

push back, they don’t want to change, if they think it is a nurse’s

job to use all this technology. And I know that is not a huge thing

on the global scheme of things, but it is having a huge impact in

this one particular rural hospital, and they were very, very proud

of themselves.

And I just wonder if you have some comments about, for instance, in a rural hospital, where they wouldn’t have the availability in a big city hospital facility of duplicating all those kinds of

things, or having the doctors on staff for all the different kinds of

challenges that they might meet. Do you have any comment on

what some of these smaller hospitals might be able to do to access

information electronically from a larger facility or spread that out

where you might have a command post of some type in a rural hospital, where they could take care of half a dozen beds, monitor

what is going on there, something along those lines?

I just throw that out there.

Ms. EVANS. I will start from a purely IT perspective, because

what you are talking about is a challenge that we face regardless

of whether it is at the Federal level or local level. My husband, I

will share with you, happens to be a dentist, a healthcare provider.

And so trying to automate his office is exactly what you are talking

about; it is a change management issue. And so as we are working

through these and as we continue to work through these types of

projects, that is a very clear issue that needs to be addressed

through small modular types of approaches, to be able to try out

different types of approaches for implementation to deal with that,

and what would be the best way to handle that.

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We can’t give you necessarily a blanket ‘‘this is the way it is

going to work,’’ but we would apply what we learn as we continuously roll that out. And you are right, it is going to be different in

a rural area than it would be in a large metropolitan area, and

that is one thing that we are cognizant of at a Federal level when

we are trying to put things together about what that impact would

be at a local jurisdiction.

I don’t know if my colleague from the CDC has something to say.

Dr. BROOME. I think, as Ms. Evans has indicated, and I think

has come up previously, you need to think on several different levels in terms of what kind of solutions you are proposing, and they

do need to fit with the technologic capacity as long as you have the

big picture vision of where you are trying to get to. In the public

health sphere we actually recognize that some of our local health

departments didn’t even have broadband Internet connections, so

one of the preceding initiatives to PHIN was Health Alert Network,

which really focused on getting broadband 24/7 Internet

connectivity to about 1,000 core local health departments so that

they could play. And that is one of the reasons why this is so complex, that you are trying to build infrastructure capacity at the

same time that you want to make sure there are applications, there

are useful things for people to do with that broadband connectivity;

it is not just a point of hooking them up to the Web, it is saying,

OK, now we will give you a simple Web screen where you can actually report something that is happening and you can also get

alerts, you can find out e.g., that there is an increase of gastrointestinal disease.

So it is a highly complex undertaking, but we recognize the need

to think about folks who are in the more rural areas or who don’t

have the kind of resources.

Mr. GINGRICH. You raise a really good point at a couple of levels.

First of all, at a broader level we need to look at the right incentives. If we were prepared to quantify what an electronic record

will save in terms of Xeroxing and FedExing, and share half of that

savings with the doctor, every doctor in your rural hospital would

learn how to change their behavior. I mean, health is one of those

places it is a little bit like education; we keep trying to get behavioral change without paying for it, and then we are shocked that

people don’t change. But why should a doctor go out and have to

learn a brand new workflow, a whole new way of doing things, etc.,

for no compensation? And I think that is a significant part of the

problem.

Second, you need to look at large systems that are really working. Visi-Q is a Johns Hopkins spinoff, it is an electronic intensive

care unit. Every small hospital in the country should be tied into,

whether it is done State-by-State or in some manner, but they

should have that kind of quality that is bringing world-class information into local hospitals. The University of Texas medical system, which actually runs the Texas prisons’ medical systems, is

proof of the concept that you can deliver extraordinary quality of

information, you can run emergency rooms on a 24/7 basis with

centralized information flow. It is a system worth your looking at.

I just had somebody come by the other day from the American

Medical Group Association with a wristwatch that the current genVerDate 11-MAY-2000 12:12 Feb 11, 2005 Jkt 000000 PO 00000 Frm 00109 Fmt 6633 Sfmt 6633 D:\DOCS\98120.TXT HGOVREF1 PsN: HGOVREF1
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eration is a 250 megabit computer and the next generation is a 2

gigabyte computer, where the doctor could literally walk into a

room, plug in the watch, use the keys and the screen—and you are

totally HIPPA compliant because it is never going over the Internet. It is half gimmick but half fascination about where the world

is going.

Last example of complexity. I think we should be bar coding. We

should be bar coding single-dose medication; we should be bar coding medical technology; we should be bar coding hospital supplies.

If you are a small hospital and you could get pre-bar coded all that

material, you would save a lot of money. One of the interesting

problems is that the Federal child safety laws make it impossible

to have single dose medication that is too easy to get to for certain

things, and so certain things aren’t produced in a single dose medication model, because it wouldn’t find the tamper-proof system.

Very interesting complexities that are in there.

But one of the things you should be looking at from a rural hospital standpoint and a small hospital standpoint is how do we

maximize the ease of migrating into the information age so that

they are getting the benefit of the cost savings as the system modernizes, rather than having to pay intermediate costs. Today, if you

bar code, you have to pay an intermediary to re-bar code most of

the medicines into a single-dose packaging for you. That is an extra

cost, and small hospitals just won’t do it.

Ms. MILLER. That is interesting. Perhaps we need to take the

lead on really trying to encourage and incentivize, as you say, in

some ways, through HHS or what have you, for the different doctors and that.

I guess my other question would be, we just went through this

Medicare reform with the prescription drug benefit now for, I don’t

know, by anybody’s interpolation, how many millions of seniors will

advantage themselves of this, hopefully. But is the Federal Government, as we are capturing all of this information, whatever information we are capturing from these seniors, are we doing anything

with that electronically? Is there some best practice that we might

be able to point to or some idea? I don’t know if any of you are familiar with what is happening with that particular bit of information, but you have all of this new information that we are going to

be capturing here.

Dr. BROOME. There is a provision in the law which encourages

that, and we actually had a discussion at the Health and Human

Services Data Council inviting all of the different operating divisions to work with CMS to consider how this could be most advantageously used to provide valuable information for improving

healthcare quality and safety. And I am sure they will also engage

private sector, probably through the National Committee on Health

and Vital Statistics, to participate in that planning.

Ms. MILLER. I see.

Ms. EVANS. Also what is happening in that particular area is

that the Social Security Administration is working directly with

HHS to deal specifically with what you are talking about, the collection of the information, what is the best way to do that, and to

ensure that we do it efficiently and effectively.

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It is also probably critical to mention that this, of course, will put

a paramount concern on the security of the information and the

privacy.

Ms. MILLER. Thank you, Mr. Chairman.

Mr. PUTNAM. Thank you.

Mr. Murphy.

Mr. MURPHY. Thank you, Mr. Chairman.

Since you have seen fit to mention my bill a couple times, I

would just like to use this to talk a little bit about it and how this

would work. It is H.R. 4805 of the Ensuring Medication Safety for

Seniors Act, and it would establish a demonstration program under

the Secretary of Health and Human Services and offer grants to

Medicare providers to offset the costs of establishing electronic prescribing systems, and set this up in a region where the hospitals,

pharmacists, and physicians are connected in realtime so that it increases patient safety by eliminating confusion and errors from

handwritten prescriptions, provide realtime access to consultants,

allow doctors to view information on alternate medications, dosage

levels, drug interactions, generic availability, and improve the quality of care by providing doctors with the information that really is

not available in a paper and pen system, and, most importantly, reduce patient risk. We have to keep reminding ourselves that the

current death rate is about 20 people a day, I think. It is huge; 19

or so.

Having worked in hospitals for 25 years myself, in hospitals and

clinics, I recognize that oftentimes when I would see a patient, that

I would be on volume 3 of a chart and each volume would be about

two inches thick, and I would be dealing with a baby that was perhaps 2 months old. It was absolutely impossible, impossible to go

through there and have any sense of all the detail that was in

there; and it was ripe with potential for errors. Now, luckily there

were so many people involved in every case, many doctors, nurses,

etc., double-checking and triple-checking things, that we minimized

the chance for those risks. But the point is when somebody else

comes on shift, they should have that information immediately. In

today’s world, too, if we are looking for another way of cutting

costs, and you recognize to sit and try and review these charts in

what you may be allowed in your schedule, 5 or 10 minutes to see

a consult, where it requires hours of perusing a chart, it contributes massively to the cost of healthcare, and I add that to your savings.

But I would like to mention this, Mr. Speaker. One of the things

that has come up is that there is a lack of uniform standards that

really prevent us from knowing the full benefits of healthcare IT

initiatives. And I know from exploring my bill, that is one of the

things that has happened. They talk about somewhere between 6

months and several years before we get to know all these standards. I think the current deadline is several months away.

I wonder if you and other members of the panel can talk about

why it is taking so long to develop these minimum standards and

what can we do to speed these things up, because that is a huge

hurdle we have to face.

Mr. GINGRICH. Let me start with that and then talk about the

system you just described for a second.

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My conclusion, doing both national security and health, is that

it is this hard in part because health is about 30 times more complicated than national security, and it is actually much harder to

do. It is much more decentralized; there are many more kinds of

professions involved; the rhythm of each of those subcultures is

very different. Having done a lot of work on how you transform the

Defense Department, that is easy. This is much, much denser and

more complicated. So some of it is legitimate.

The second difference is a lot of us who were very big on computers very early—and I started looking at them at Georgia Tech in

1965—we were right about where they would eventually get to, but

they weren’t there. And I would argue in some ways it is only in

the last decade that we are beginning to get to usable realtime capabilities. And a lot of people who were early pioneers burned out

and said I don’t want to go back and do that again, or they watched

their friends do it and they said I don’t want to be involved in that

mess. So I think you have to understand at one level the experience of some of it.

But let me go through your points for a second. The Mayo Clinic

in Jacksonville has been paperless since 1996. One of the advantages is doctors can access the patient record from home or on vacation. So if they want to think about something, they can actually

get the data in realtime, at 10 at night, and think about it, which

is your point. It is not just staring at the chart now, but you think

over the weekend about a particular problem, you would like to

have access. That is why online will always beat having a smart

card. Ultimately, you want a Web-based system, not a smart card

system.

Second, Gold Standard Multimedia is an overlay in Florida on

top of a e-prescribing system. The State of Florida got them involved with Medicaid. They are currently, according to the State of

Florida, saving $6,000 per Medicaid doctor by three things:

realtime reporting of less expensive medicines that are available,

stopping medication errors, and detecting fraud; people who went

to five doctors the same week to get the same drugs to sell them.

Six thousand dollars net per doctor per year is what Florida is now

getting out Gold Standard Multimedia.

Evra-Care is a United Health product that takes care of senior

citizens. The minute they create an electronic data base about the

senior citizens in nursing homes, most of them over 80, many, onethird with Alzheimer’s, they almost always reduce the number of

drugs they are getting, because once they see the total record, they

realize three different doctors have been prescribing, not talking to

each other, and, in fact, the person is over-medicated; dramatic reduction in hospital admission.

Last example, though, what I mean about the scoring problem.

In Rhode Island in the early 1990’s, the estimate was made that

every fourth emergency room visit by senior citizens was a medication error. Well, if you went in and said, great, if we could eliminate half of those, how much would we save on emergency room

visits? Could we count that against the cost of e-prescribing? The

answer would be no. It is always every improvement in health is

a plus even if it saves money and saves lives; you never get the

advantage of the change. And I would just suggest that is intellecVerDate 11-MAY-2000 12:12 Feb 11, 2005 Jkt 000000 PO 00000 Frm 00112 Fmt 6633 Sfmt 6633 D:\DOCS\98120.TXT HGOVREF1 PsN: HGOVREF1
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tually wrong, and it is a major inhibition to adopting new, better

systems.

Mr. MURPHY. I would just like to move to pass my bill tonight,

if we could do that.

Mr. PUTNAM. I think you would find widespread support in the

subcommittee, but I am not sure we have enough juice.

Ms. Evans, there are several different paths being pursued, the

working groups in food safety, health services and electronic health

records, interoperability, and public health surveillance, all under

the FHA. They will develop target technical standards and a business architecture for the health line of business. Could you give us

a status report on each of these, please?

Ms. EVANS. We are currently working forward on that, and we

have consolidated it into what we are now calling the line of business. So they have specific targets that they are working on. I do

not have the specific deliverable dates under each of those, I would

be glad to go back and look at that. They are working on the plans

for what they are going to be requesting for their path forward in

fiscal year 2006. We are working on that consolidated business case

right now for all the agencies.

We do continue to work on the CHI initiative as well, and there

is going to be a second phase of that to address the additional domains that have not been agreed upon yet. Both of these will roll

up together and will be reflected in the strategy that is coming forward from HHS dealing with this overall. So there will be a general timeline in that as well, when that strategy is released.

Mr. PUTNAM. If you could get those dates for us. I think that is

an important piece of what we are after.

Ms. EVANS. Sure.

[The information referred to follows:]

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Mr. PUTNAM. Mr. Powner, you cited the VA as being one of the

leading innovators using information technology to bring greater

efficiency to healthcare. Have you done any of the work on the Bay

Pines computer pilot project fiasco?

Mr. POWNER. I have not, Mr. Chairman.

Mr. PUTNAM. OK. Then I won’t ask you any questions about it.

And, Mr. Speaker, we have referred a great deal to the U.K.

model of healthcare delivery, but your comments, your references

to it were new to me, so I would like you to take an opportunity,

please, to describe where they were, where they are going, and how

they made their transformation, understanding that they face the

same friction that we would face here, on perhaps a smaller scale,

but, nevertheless, the same issues.

Mr. GINGRICH. Well, it is a national health service, and they

have certain advantages because they actually employ most of the

doctors. They, for a very long time, have had a fair amount of information electronically available inside any particular facility, but

not available nationally. And I think they are going to have a lot

of teething pains; it goes back a little bit to why the big bang can

be more exciting than you want it to be.

But what they designed was five regional systems networked together by what they call a national spine. The national spine would

really contain the individual health record; the regional systems

would contain the medical records. And the health record is built

up by simply copying automatically out of the electronic medical

records. So you would end up with everybody in England—it is in

England, not Scotland, Whales, and Northern Ireland. But in England you have about 55 million individual health records. They are

beginning to launch them this summer. They are having teething

pains, but the theoretical model that they are working off of is of

three very different things. First, this is an excuse to replace the

legacy systems and they are going to spend a fair amount of

money, about 6 billion pounds plus, over the next 5 years, which

would translate roughly into about $10 billion. And this population

is slightly larger than California, to give you a sense of scale for

an American model. And there they are going to try to actually replace the legacy systems. We have talked, for example, with IDX,

which is very deeply involved—and IBM are very deeply involved

with the biggest hospital system in London, trying to replace their

entire legacy system.

Second, they have the regional centers that are being set up and

run by a variety of companies. There were five different bids. And

companies like Excenture of Hujitsu won those bids, BT, formerly

British Telecom. And then BT, or British Telecom, as they used to

be, won the national spine, which is putting together this data so

that wherever you go in England you will have access to this. And

it will be on the Web, so literally wherever you went in the world,

if you get access back into the system, you can get it. That piece

is, I think, the most revolutionary because it is individually centered, Web-based, it is secure, and it allows the information to follow you everywhere.

I suspect sometime this summer we will start to see it actually

happening. But I would think of it as three different projects with

three different cost centers. The least expensive, ironically, is the

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individual health record for the whole country. The most expensive

is replacing the legacy systems, which is going to be very expensive. And as several people have alluded to, once you get involved

in the workflow problems and all the different things that happen

at that level, it is a big challenge.

Mr. PUTNAM. Thank you very much.

Ms. Miller, do you have any additional questions for the panel?

Ms. MILLER. I don’t, Mr. Chairman. Thank you.

Mr. PUTNAM. Well, in that case, I want to give each of you the

opportunity to rebut or add to anything that any of your fellow

panelists have said, answer the question that you wish you had

been asked, or give any parting comments, beginning with Dr.

Broome.

Dr. BROOME. This has been a wonderful opportunity, I think, to

talk about some issues that are really critically important for the

country. I think it is helpful to get down to the fairly practical

areas of what are going to be the payoffs for this, and so we are

really trying to implement the Public Health Information Network

in a way which lets us document payoffs for the health system.

And the one area that I would like to just say a few more words

about is the area of electronic laboratory reporting, because I think

that demonstrates the kind of payoffs that we are already seeing.

It also shows standards in practice. This employs the CHI standards for messaging specifications and for what we call controlled

vocabulary, SNOMED and LOINC, and it lets a clinical laboratory

trigger an automatic notification to public health that a condition

of public health importance has occurred. So that is helpful to us.

As I think I mentioned, we actually tripled the number of cases we

heard about from one single laboratory. Using this kind of automatic notification doesn’t require the lab to think, oh, I have to notify public health.

More to the point, the same standards could be used to notify the

FDA about an adverse event related to a vaccine or drug. They

could be used to notify the FDA, USDA, CDC about food safety laboratory results. They could be used to notify the EPA about safe

water results. So I think you can sort of see the options; you can

either go the route of sort of chaos and putting a burden on laboratories to communicate, or you really can expedite and solve a lot

of problems by doing this right.

Mr. PUTNAM. Mr. Powner.

Mr. POWNER. Two points, Mr. Chairman. One, a lot of the initiatives associated with PHIN that Dr. Broome mentioned are steps

in the right direction, but clearly where we need to go with that

is nationwide implementation and full functionality. We talk about

different phases and when additional phases are going to come on

board. It is very important that these things get deployed with full

functionality and on a nationwide basis. We have a good start, but

I think we need to keep the momentum and we need to continue

to drive that progress with solid milestones and accountability over

those systems. Realtime surveillance and communication will be

extremely important as we respond to public health emergencies

down the road.

Second point is implementation of standards. There is a good discussion going on here about what we need to do with implementing

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standards. That is very difficult. And the scale that we are discussing right here is just a huge, huge challenge; and hopefully Dr.

Brailer’s strategy will lay out some milestones and steps that we

can take in moving that in the right direction.

Mr. PUTNAM. Ms. Evans.

Ms. EVANS. As always, sir, I would like to thank you again for

highlighting the e-government initiative in this area that is so important to this administration, but also giving the opportunity to

talk about other initiatives and showing how they all come together

here, for example, the President’s initiative on broadband, which

would address the rural issues that we were talking about being

able to establish that connectivity; the Executive order on health,

as well as our initiative going forward on biosurveillance. But I

think all of these really show the President’s commitment to a citizen-centered government using e-government as his tool, using information technology to be able to bring those services to the citizen.

So I thank you, and I thank you for the opportunity to appear

with my esteemed colleagues today.

Mr. PUTNAM. Thank you.

Mr. GINGRICH. Thank you very, very much for having this panel

and for asking these questions, and for allowing particularly my

colleagues on the panel who have worked for the U.S. Government

and done so much to try to bring their professional capabilities and

their integrity to this.

As a historian politician, if I could close this out, I would say if

you go back to your colleagues and tell them that the biggest problem is that we don’t have a threat of urgency. If I had a single slogan, it would be ‘‘we have been warned.’’ People, right after September 11, said why weren’t we ready. From 1347 to 1349 the

Black Death killed a third of the people of England. In 1918, more

people died from the flu than died in the entire first World War

in 4 years. And we recently watched SARS briefly emerge and

then, fortunately for us, disappear. The Center for Disease Control

watches the avian flu every day and is desperately hoping that it

doesn’t cross over and become a human susceptible system.

I think there are three simple questions that the Congress has

to ask itself: What is the value of life? If it is a car wreck, we will

get a helicopter to take you to the emergency room. If it is a heart

attack, we will get the ambulance to show up. So what is the

value? Because we could be in a situation where we could lose a

million people, and we are not making the kind of investing saving

a million lives would be worth.

Second: How real is the risk? You could bring in a panel of Nobel

winning biologists and ask them that question, and if it is a closed

hearing, what they will tell you would be really, really sobering, because it probably won’t happen; but if it did happen tomorrow, we

really couldn’t stop it. We can stop smallpox. Smallpox is not the

problem. It is painful, it is difficult, it is dangerous, but in the end

you can quarantine smallpox. That is how we beat it last time. But

you get something like the flu that spreads the way the flu does,

we are in big trouble.

Last: How vital is health information technology to the safety of

our Nation? I think it is absolutely central. I regard a biological

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threat as a greater threat than a nuclear threat. And I think that

what these folks are doing and what the agencies they represent

are doing is as central to our survival as the strategic air command

was in the cold war.

And I really thank you very much for taking the time to hold this

hearing, and I hope that you will share with your colleagues how

really serious this is. Thank you very much.

Mr. PUTNAM. Thank you, Mr. Speaker. And thank all of you very

much for your outstanding contributions to this hearing, and for

this sobering and somber assessment of where we are, but certainly

giving us a path toward progress.

With that, the subcommittee will stand in recess while we reshuffle the cards for the second panel.

Thank you again for your assistance.

[Recess.]

Mr. PUTNAM. The subcommittee will reconvene. I want to thank

our second panel for their patience. I know we are running a little

bit behind. And I want to thank the diehards in the audience for

sticking around, even though the rock stars have gone.

At this point I would like to swear in the second panel. Please

rise and raise your right hands.

[Witnesses sworn.]

Mr. PUTNAM. Note for the record that all the witnesses responded in the affirmative. We will move immediately into testimony.

Our first witness is Dr. Seth Foldy. Is that correct?

Dr. FOLDY. That is right.

Mr. PUTNAM. Dr. Foldy recently ended a 6-year term as commissioner of health in Milwaukee, WI, where his innovations in disease surveillance, electronic communications, and multi-jurisdictional and public/private collaborations earned him the American

Public Health Association’s Roemer Prize for creative local public

health work and other awards. Dr. Foldy also chaired the Information Technology Committee for the National Association of County

and City Health Officials, and served on the Foundation for eHealth Initiative Board, the CDC’s Information Council, and other

groups devoted to public health information infrastructure. A board

certified family physician, Dr. Foldy is associate clinical professor

of family and community medicine and health policy at the Medical

College of Wisconsin, and offers consultation on population health

strategy, health informatics, and health policy.

Welcome to the subcommittee. You are recognized for 5 minutes.

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STATEMENTS OF DR. SETH FOLDY, M.D., FORMER CHAIR, INFORMATION TECHNOLOGY COMMITTEE, NATIONAL ASSOCIATION OF COUNTY AND CITY HEALTH OFFICIALS

[NACCHO], FORMER HEALTH COMMISSIONER, CITY OF MILWAUKEE, ASSOCIATE CLINICAL PROFESSOR, FAMILY AND

COMMUNITY MEDICINE, MEDICAL COLLEGE OF WISCONSIN;

RICHARD S. WEISMAN, COORDINATOR, WEAPONS OF MASS

DESTRUCTION RESPONSE PROGRAM, JACKSON MEMORIAL

MEDICAL CENTER, DIRECTOR, FLORIDA POISON INFORMATION CENTER/MIAMI, RESEARCH ASSOCIATE PROFESSOR,

PEDIATRICS, UM/JACKSON MEMORIAL HOSPITAL; AND GORDON AOYAGI, FIRE ADMINISTRATOR, MONTGOMERY COUNTY FIRE AND RESCUE SERVICE

Dr. FOLDY. Thank you very much. Thank you, Chairman Putnam, members of the committee, and all of my colleagues here for

seeking the input of the Nation’s 3,000 local health departments

who play a critical role in the Nation’s health protection. To my

qualifications I would add I was also a family physician who was

among those who, about 20 percent of the patients I saw, I did not

have medical records on to make decisions. Many of the admissions

that I made were due to lack of information.

Although we are talking about very complex issues today, it boils

down to the most critical issue, which is making sure that the clinician or the public health official have the information in front of

them that they need when they need it to make a critical decision.

My rather unlikely involvement with health informatics came

from moving to Milwaukee in the aftermath of two serious events

there, the first in 1993, where a waterborne outbreak sickened

more than 400,000 people at the same time with a severe diarrheal

illness that killed more than 100. This was an illness that went unnoticed by the public health system for as many as 7 to 8 days

after the increase in illness had begun, and an even longer period

after environmental cues could have triggered public health awareness and response. The year before I arrived, the severe heat wave

in 1995 was brought to public health attention not by hospitals, not

by clients, but by the morgue and by the coroner’s office.

So my goal as health commissioner in the city of Milwaukee was

to greatly shorten by any means necessary the period between an

event and the earliest possible opportunity to engage in public

health action, which obviously was sub-optimal at that time. We

have gone a long ways. My staff has finally developed their diarrhea meter that can show me simultaneously the number of EMS

runs, hospital visits, nursing home illness, laboratory requests that

all relate to diarrheal disease. We have similar monitors for respiratory disease.

Last year was a banner year for us in many years. First, looking

at the top-down model, when CDC asked the healthcare community

to start surveilling for SARS, within 72 hours we had all the emergency rooms in the community using a standardized screening form

that alerted them to possible SARS in the community. They were

also able to electronically report to us once a day, the volumes of

SARS-like symptoms that they saw. Because of the Internet and

interlocking health applications that were in use in more than two

dozen cities across the country, three other cities adopted the same

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system, this was a local-to-local cooperative effort, and were able

to initiate SARS surveillance near realtime in our communities.

On the other hand, from the bottom-up perspective, when we

found one individual who had kind of a strange illness and had

been in contact with a sick prairie dog, this was the second case,

this was the case that tipped the balance, that caused us to begin

investigating what ended up being the hemisphere’s first outbreak

of monkeypox, a virus that, if I studied it in medical school, I surely forgot about. We had one opportunity to make sure that this

virus did not become established in the domestic and wild animals

of our community, so our cats were not bringing it in into our

homes on a regular basis. Local public health and the city of Milwaukee had to manage 30 patients on an urgent basis, 90 contacts,

hundreds of animals in a data nightmare. Our goal, of course, was

to isolate, to quarantine, to act, to contain. It was done successfully. This outbreak ended up involving 11 States and overseas, but

it certainly gave rise to our understanding that we really need to

share health information rather than just push it around.

This raises two important points: one, NACCHO fully endorses

the President’s vision of a rapid ascension to electronic medical

records and national health informatics infrastructure. We strongly

support the efforts at HHS of Dr. Brailer; two, you cannot underestimate the importance of this project to local public health, and

I need to warn you that local public health is not in a great position to fully avail themselves of the benefit of this new opportunity.

Dr. Gingrich raised the example of ‘‘what if CDC, through its

automated data gathering systems, learned about 39 SARS-like patients?’’ Then it becomes incumbent on the local health officer,

wherever that outbreak may be occurring, to identify those patients, not just to know that they are there, but to interview them,

to quarantine them, to identify their contacts, to send laboratory

tests, to bill for those laboratory tests, to quarantine contacts; a

very huge labor-intensive process of work. What you need to understand is that the local health departments of this country are the

eyes and ears and hands and feet of public health, not the Centers

for Disease Control. CDC is critical, very important, but the actual

success of our outcome will not be because CDC knows something

is going on, but because the local public health foot soldier on the

ground has the capacity to respond immediately, confidently, with

excellent health information.

That leads me to our recommendations. I will make one point.

The point was made by Dr. Broome that Federal funding had gone

far to bring what had once been fewer than half of the Nation’s

local health officials online with rapid Internet access and email.

That was because Congress mandated that bioterrorism funds go

to that purpose, that 85 percent of a particular fund line go to local

public health infrastructure to make sure that they can participate

in the electronic revolution in health. We think that kind of effort

needs to continue. Unfortunately, the 2005 request of the President, has actually taken money from local and State preparedness

to spend on the BioSense initiative. The BioSense initiative is a

great experiment in syndromic surveillance, but we can’t be robbing the local Peter to pay the national Paul, because when it

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comes to actually doing the work of fighting an outbreak, in the

end we will lose.

My written testimony includes seven very specific recommendations: To make sure that we have real access to real health information. The first and perhaps most important of these, is the

measure we use to know if this system is really going to make a

difference. That measure needs to be that the local partners on the

ground demonstrate that they can exchange information electronically. If that measure is not established at the national level,

tracked at the national level, then we could be building castles in

the sky and leaving the local partners out of the loop; and I suggest

strongly that the Federal policy not make that mistake.

Thank you.

[The prepared statement of Dr. Foldy follows:]

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Mr. PUTNAM. Thank you.

Our next witness is Dr. Richard Weisman. Dr. Weisman is an associate professor of pediatrics at the University of Miami School of

Medicine at Jackson Memorial Hospital and the director of the

Florida Poison Information Center in Miami. Dr. Weisman received

his undergraduate training in pharmacy at Temple University and

his doctorate in clinical pharmacy from Duquesne University. He

is board certified in toxicology and a fellow of the American Academy of Clinical Toxicology. Dr. Weisman serves as the Medical Information Office for south Florida’s Metropolitan Medical Response

System, a member of the Terrorism Advisory Task Force, and as

a toxicologist/pharmacologist with the Department of Homeland Security, FEMA, Disaster Medical Assistance Team, and the International Medical Surgical Emergency Response Team.

Welcome to the subcommittee. You are recognized for 5 minutes.

Mr. WEISMAN. Thank you very much, Mr. Chairman, members of

the subcommittee. My name is Dr. Richard Weisman. I am director

of both the Hospital Terrorism Response and the Florida Poison Information Center in Miami.

Jackson Memorial Hospital is the largest public hospital and a

safety net in Florida. With over 1,500 beds, Jackson Memorial provides the highest level of care to an inner city culturally diverse

population. The Florida Poison Information Center in Miami provides service to a population of 5 million people and has 63 hospitals within its region. Jackson Memorial Hospital is the largest

hospital within the Poison Center’s region.

I would like to describe the experience we had at the epicenter

of the anthrax attack in Florida and to highlight the problems that

could be prevented with enhanced information technologies at our

Nation’s hospitals and poison control centers.

On the morning of Thursday, October 4, 2001, Steven Wiersma

the Florida State Epidemiologist, released to the public that the

State laboratory had confirmed that a patient, Robert Stevens, at

JFK Hospital in Palm Beach County, had inhalation anthrax. This

was followed by a press conference in which the Florida commissioner of health and State epidemiologist announced that the public

should not be concerned, that anthrax was a naturally occurring

disease, and that this could not possibly be a terrorism event.

It is important to set the stage of the public’s mind-set on this

date. Most notably it was occurring in the shadow of September 11,

where virtually every television and radio station was still on a 24-

hour post-September 11 frenzy. What may not have been evident

to the rest of the country is that the infectious disease physician

at JFK made the diagnosis because that week the local news had

reported that two of the September 11 hijackers had attempted to

rent a crop-duster at nearby Lantana Airport. When the inhalation

anthrax story went front page, the media immediately connected

the dots and concluded that it was terrorism and supported their

hypothesis with the CDC data that there were only 18 inhalation

cases in the past 100 years, the last occurring in 1978.

It was too coincidental in the wake of the Lantana Airport story.

The commissioner of health kept insisting that this was an isolated

occurrence and a rare disease, until 4 days later, when a second

patient was identified in south Florida. The public became very

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confused, very angry, and lost confidence in our government’s response to the crisis.

I first learned about the anthrax case in the emergency department at Jackson Memorial Hospital, when a patient who had been

watching the press conference on television in the waiting room

came in and asked me what I thought of anthrax. I thought he was

talking about the 1990’s rock group. In the emergency department,

we are very disconnected from the world and need a new way of

being kept up to date while actively seeing patients. Most emergency departments in the United States have telephones, fax machines, and receive electrocardiograms from the field from paramedics. We truly are well into the 1970’s. We have a computer terminal that links us to the hospital’s data base that allows us to

look up some lab data, if it had been entered, but it really doesn’t

allow us to receive e-mails or to access the Web, because that

would be a violation of security, and certainly someone is sitting

there waiting to hack into our data system.

On Friday, October 5th, the Poison Center received about calls

related to anthrax. Approximately 50 were from coworkers at the

American Media International, or AMI, building who had direct

contact with Mr. Stevens, half were from the emergency department physicians in search of recommendations for patients requesting prescriptions for cipro, and the remainder were from the media

in search of additional information about anthrax. Thirty-six hours

after the initial press conference, the Poison Center finally received

a fax sheet from the CDC discussing anthrax and providing much

needed guidelines to treat only patients that had been in the AMI

building for at least 1 hour within the last 3 months. Not knowing

if this valuable fax sheet was going to get to our emergency department physicians, we faxed the document to every emergency department in our catchment area. We subsequently learned that

only half of the hospitals ever received it from CDC, and only 10

percent got it at the total end from the Poison Control Center.

On Monday, October 7th, all hell broke loose. The emergency department at Jackson Memorial saw an additional 65 patients.

Many hospitals in the area also had a dramatically increased census. The Poison Center went from receiving about 300 calls a day

to over 300 calls per hour. The actual number of calls that the Poison Control Center received we will probably never know because

the automatic call tracking system kind of stopped at about 4,000

calls, and that was reached sometime by about 2 in the afternoon.

By afternoon, the Poison Center abandoned trying to record the

cases because the phones were ringing so quickly, and people that

had real poisonings could not get through on the standard number.

An additional four poison information specialists were brought in,

and all of the rotating medical students, pharmacy students, and

medical residents were asked to help with the telephone.

When an additional staff person arrived with a newspaper, we

learned for the first time what had happened. The headline stated

that the anthrax spores had been found by the CDC in the AMI

building. Later that day information were released that spores had

also been found in the nasal swab of another AMI worker. Rumor

also began to circulate that a second patient, also from AMI, was

being investigated as a second victim in a Miami hospital. By day’s

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end, his identity was known, Mr. Ernesto Blanco. He was at Cedars Medical Center, immediately across the street from where we

were located, and he was Mr. Stevens’ boss in the mailroom at

AMI. They had received a threatening letter containing a white

powder. The media was now announcing that this was another terrorism attack and that anthrax had been sent through the mail.

Before it was over, hazardous materials response teams had to respond to 15,000 false calls for white powders. Nationwide, it exceeded over 65,000.

The call volume at the Poison Center and the patient volume in

the emergency department continued to be out of control for about

7 days, finally returning to some level of normality about October

14th. The contacts were primarily occurring between the hours of

8 a.m. and 9 p.m., and on October 13th the Florida Department of

Health began to refer all of their calls into the Poison Control Center. The normality was very short-lived. On about October 16th letters arrived at CBS, ABC, the New York Post in New York, and

the Hart Office Senate Office Building here in Washington. The

high profile exposure stood in stark contrast to the death and illness of the less well-known postal workers. Anthrax was killing the

common man. The barrage of calls would continue through October

to just before Thanksgiving. The calls now began to be mixed with

inquiries about adverse reactions that were occurring with a high

frequency of people and the over 5,000 that were not having to take

cipro.

We have a remarkable opportunity to improve patient care

through improved communication strategies and e-technology. An

investment at the healthcare delivery will allow us to be better prepared for an array of adverse events such as a SARS outbreak or

any newly emerging infectious disease or chemical or nuclear

event.

I have four recommendations. There needs to be a secure means

of communicating the most accurate, up-to-date information.

Mr. PUTNAM. If I may, let me make that one of my first questions

to you. I am worried about us getting caught by a vote, and I want

everyone to have an opportunity to go. So if you would, just hold

that thought and I will come back to that.

Mr. WEISMAN. OK.

[The prepared statement of Mr. Weisman follows:]

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Mr. PUTNAM. Our third witness for this panel is Gordon Aoyagi.

Mr. AOYAGI. Correct.

Mr. PUTNAM. Did I say that right?

Mr. AOYAGI. Yes, very well.

Mr. PUTNAM. Mr. Aoyagi is the fire administrator for Montgomery County, MD. He directs the efforts of approximately 950 career

employees and 800 volunteers. Mr. Aoyagi also coordinates the fire

and rescue services which are provided through 19 local volunteer

departments. He serves as a disaster manager of the Emergency

Management Group, responsible for emergency preparedness in response for Montgomery County. He is also Chair of the local Emergency Planning Council and commissioner on Maryland State Fire

Prevention Commission. Mr. Aoyagi has over 30 years of public administration and public policy experience. He is a graduate of Colorado College, with a master’s degree in public administration from

the University of Colorado.

Welcome to the subcommittee. You are recognized for 5 minutes.

Mr. AOYAGI. Thank you very much, Chairman Putnam. I appreciate the opportunity to provide the perspectives of a local government emergency manager on this topic.

Slide 2 shows that Montgomery County is a growing suburb of

the region, plays an important role, and is well practiced in responding to emergencies. Montgomery County has made significant

investments in our public safety communication networks and our

wireless data systems. Effective health informatics and other emergency response systems will depend upon robust, redundant, and

reliable wireless data systems. We encourage continued congressional support for this technology. Push this technology down to

local government; it is the battle front of our local communities

where first responders confront the emerging terrorist threats, as

well fulfill their daily mission of keeping our communities safe and

saving lives.

Technology infrastructure is a necessary element for health

informatics, but is it sufficient? Ingredients for success include:

planning, collaboration, and communications. And I would like to

use Montgomery County as an example.

Montgomery County has a disease surveillance system called ESSENCE II. Through the leadership of our Maryland congressional

delegation, we received a 2002 Federal Byrne Grant, which was

used to develop a test bed for a sophisticated disease surveillance

system. ESSENCE II, described in slide 3, is the first system to integrate both the military and civilian indicators for disease surveillance. It uses traditional and non-traditional health indicators in

syndromic groups, coupled with advanced analytical techniques.

The Applied Physics Lab of Johns Hopkins University developed

ESSENCE II in collaboration with the Department of Defense

Global Emergent Infection Systems and other State and local partners.

ESSENCE IV, which is our new generation, will in fact be installed throughout the region and Northern Virginia and the State

of Maryland.

Slide 4 shows the various sources used by ESSENCE II for biosurveillance. Among these sources are hospital laboratories, 911

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calls, over-the-counter drug purchases, etc. Other variables are also

considered.

Slide 5 shows the syndromic grouping used for analysis. Baseline

data is projected and any unusual spikes are investigated. Any significant event allows us to detect, respond, and contain locally, regionally, and statewide.

Slide 6 shows the application of ESSENCE II in predicting the

recent influenza and the tracking of its incidents through that

same disease surveillance system.

Planning is also important. The Emergency Management Group

established a bioterrorism task force to plan, discuss respective

roles, and develop a unified command system for bioterrorism incidents. This framework served us well in the anthrax response in

2001. In planning for future events, we are provided pre-distribution biomedical packs to our first responders, and we continue to

plan for SARS and other events.

Collaboration is essential. We recognize that hospitals are key

elements of our emergency response system and engage them in extensive collaboration efforts. Our five hospitals are on our 800

megahertz radio system. Administrators or doctors may talk to

other hospitals, public health representatives, our emergency communication center, as well as the incident commander. We also

share decontamination protocols. The county recently executed a

Memorandum of Understanding with our five hospitals, National

Institutes of Health, Navy Medical, and Kaiser Permanente to rapidly provide supplies, equipment, and credentialed medical personnel to maximize medical services during emergencies in the county

and in the region.

Lateral and horizontal communications are also required. Our

public health division uses email and hot faxes to provide public

health alerts to physicians and clinics. The RICCS system in this

region provides notification to our regional policy leaders,

healthcare providers, and Federal officials.

In the State of Maryland we have what we call FRED, the Facilities Resource Emergency Data base, which provides state-wide hospital capabilities, as well as a secure method of notification to hospitals throughout the State.

In closing, I believe the prescriptions for success involve ongoing

support for local governments to respond to emergencies; enabling

the transfer of effective technologies to local governments; funding

of robust, reliable, and redundant wireless technology to support

healthcare and emergency medical providers; and, last, coordinated, collaborative, and integrated planning and response systems

at the local, regional, State, and Federal levels.

Thank you.

[The prepared statement of Mr. Aoyagi follows:]

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Mr. PUTNAM. Thank you very much.

Dr. Weisman, why don’t you wrap up the four recommendations

that you had for us, now that we know we have time?

Mr. WEISMAN. There needs to be a secure means of communicating the most accurate and up-to-date information to all of our hospitals, emergency departments, poison centers, pre-hospital care

providers, private physicians’ office, and health departments. Too

often we are depending upon CNN and Fox News to be able to get

‘‘accurate’’ information. The word ‘‘accurate’’ is certainly in

quotation marks.

At present, there is no effective means of getting lifesaving technical information to our Nation’s front-line healthcare providers.

That needs to change.

Hospitals, poison centers, emergency medical services, and

health departments in areas of the United States considered to be

at risk for terrorism must be provided the resources to be able to

manage a surge of affected patients. Information technologies will

allow us to provide optimal care and to utilize our scarce resources

most effectively; however, if our large inner city hospitals are at

105 percent occupancy and there are patients waiting in the emergency department, it is going to be very difficult for us to be able

to accept a surge of patients, and our response to the catastrophe

will be less than optimal.

The Federal Government must make immediately available to

the media, knowledgeable and informed experts. We witnessed experts’ opinions on anthrax from retired microbiologists who were

honored to give their very uninformed opinion and to add to the

confusion and hysteria. A media campaign needs to occur in advance of the next crisis to educate the people about the investigation of a disease outbreak or terrorism event. They need to understand that events take time to investigate and that in the very beginning or very early hours the amount of information may be very

limited, and that it will grow exponentially as the powers are

brought to work on the particular crisis. But what they are doing

right now is they announce the crisis and then try to fill the next

24 hours with media, and it basically whips the public into a mystical frenzy.

This is something that we found to be absolutely contra to the

grain of what we are trying to do and resulted in numerous patients coming into the emergency department that just didn’t need

to be there, and often them got there by ambulance, tying up very

critical resources.

Thank you very much for this opportunity.

Mr. PUTNAM. Thank you.

Considering the benefits—we have heard an awful lot about all

the benefits of using better information technology for health

informatics—why haven’t we seen greater adoption of these benefits by providers and payors? Dr. Foldy.

Dr. FOLDY. I think many of the factors were alluded to in the last

session. Whereas the cost of the information systems is in itself a

barrier, I think the two larger barriers are uncertainty and the

workflow and the recruitment of the work force into doing work in

a different way. Certainly it was true in my department, as it is

in the healthcare setting. The uncertainty relates to the fear everyVerDate 11-MAY-2000 12:12 Feb 11, 2005 Jkt 000000 PO 00000 Frm 00146 Fmt 6633 Sfmt 6633 D:\DOCS\98120.TXT HGOVREF1 PsN: HGOVREF1
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body has in making an investment in the next great system that

ends up not meeting the soon-to-be or later-to-be announced standards. Standardization is a requirement, giving both the informatics

industry, the healthcare industry, and even the little public health

department the confidence to go ahead and invest.

I have to tell you that many of the steps that we took that involved information management are still manual, because the

standards were not quite yet ready, and I could not really move forward knowing that what is going to be for us a fairly long legacy

of hardware and software. Because of the small amount of dollars

available in local public health, I need to make sure it is going to

work and integrate right the first time.

Finally, revolutionizing the flow of information from paper to

electronic interface devices is going to require changes in the work

of a large number of healthcare professionals, and that will be a

difficult task. Very worthwhile, however.

Mr. PUTNAM. Anyone else wish to take a crack at that? Yes, sir.

Mr. AOYAGI. I certainly can’t speak from the patient perspective,

because my perspective is really one of a local emergency manager.

And I can say that as I talk to colleagues across the country, as

Dr. Gingrich referred to, there are a number of silos out there, and

emergency management has a silo, health and human services has

a silo, public health has a silo. I think what is emerging at your

local government level are very strong efforts to break those silos

down and to work in a more collaborative way; but it isn’t easy.

There are a number of turf issues, and it really comes down to focusing on delivery of service to the citizens, making sure they are

safe, and leveraging of resources in the most effective way.

I think Federal leadership is important. It was important, when

the Pentagon occurred, for the general to stand before all his troops

and say the first responder is the incident commander. And I think

as a result of that statement all the local resources that were available at that time were seamlessly inserted to that response. If we

were to encounter a major bioterrorism event, and say the impact

is local, if we suddenly had a Federal official announce that they

were in charge, you would find mass confusion at the local level

trying to determine do we wait or do we move. And I would just

encourage that we all embrace the national incident management

system and acknowledge the role of local government in responding

first to the incident and then receiving the support of the State and

Federal Government upon declarations of emergencies.

Mr. PUTNAM. Does the current homeland security structure reinforce what you just said?

Mr. AOYAGI. Yes, it does, both that and the announcement of the

President with regard to the national incident management system

reinforces a structured incident command system that acknowledges and recognizes the role of unified command at the local level.

Mr. PUTNAM. Dr. Weisman, did you want to add anything on why

more people haven’t adopted these standards practices?

Mr. WEISMAN. I think that the particular area that we are interested in looking at is a relatively easy one, and I am not sure why

it hasn’t been adopted. The CDC has an excellent communication

system called Epi-x that allows the CDC to very rapidly communicate information out to 3,500 health departments, State health

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departments, local health departments. This type of same system

needs to be brought down to probably populations of 3 or 4 million

and allow that same technology to be transferred in so that we can

link all of the hospital physicians that will be caring for patients,

all the infectious disease physicians, all the hospital emergency departments, so that instantly, when a problem is identified, they can

begin to know that they have to change the way that they are practicing. Very similar to the way Epi-x works, I envision them being

referred to a Web site, which they would then be able to log into

with their secure certificate and be able to identify the information

that they need to provide care to the patients. And this would be

standardized because it would be coming from the highest authority, the most knowledgeable people.

The second thing is that I envision on the same Web site the possibility of being able to log in and to record patient information for

patients that have similar symptoms that would have been detected under syndromic surveillance that are now being seen in

that area, and that this data would then immediately become available to the local, State, and eventually the CDC to manage.

These are all very simple things that only require pushing out

this Epi-x package that has been so well developed by CDC to a

more local area, because currently the CDC system is limited with

the fact that you can’t send out a page, a telephone call, a call to

home and a call to work to a billion different physicians across the

country with all of those means of communication. What you need

to do is to bring it down to one or two or three of these units existing for every 10 or 15 million population, and you would be able

to effectively communicate the most accurate information down to

the clinician, and we can turn Fox News off.

Mr. PUTNAM. There are some concerns that biosurveillance initiative data bypass State and local officials, and that it will have the

effect of making the response more difficult. Traditionally, as you

know, public health data has flowed up, but with the BI, some

data, especially commercial data, may go straight to the feds. Do

you think that there are safeguards in place to rapidly communicate the findings back to you, when that is essentially the reverse

direction?

Dr. FOLDY. If information is going to travel at the speed of electrons, it doesn’t necessary matter where it goes first, so long as all

the good rich information reaches the local actor extremely promptly. It would not do me a great deal of good to be told that there

is a hypothetical problem, there is a problem of unknown significance occurring in my area, but, unfortunately, we can’t provide

you with the names of the individuals affected, where they were

seen, or where they live. I would be left with an alarm without

clear action.

I see no reason, in the long-run, why information from such national data bases cannot travel through the CDC to the local health

officer including these important personal identifier information

types to which local health officers are authorized to have access

in fighting infections. But until that part of the link is built,

BioSense by itself comes nowhere close to a meaningful surveillance system that will actually generate action.

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What this means, practically speaking, is although Web-type

interfaces can do a lot of work for us, the real name of the game

here is the ability to exchange electronic messages that give each

of our agencies the information they need. Those messages obviously need to be kept secure and confidential, they need to reach

only the type of official authorized to get them. But ultimately,

ideally, patient information flows in a secure fashion from the point

at which healthcare is being produced to the point at which it

needs to be acted on by the local public health authority.

I just say the backward corollary is also the same There is no

way I am going to recruit all of the physicians of the world to come

to my great public health Web site; they are too busy doing work.

What would be an ideal is that the physician, in their practice is

busy doing work and receove an alert from me, the local health officer, saying be aware there are two cases of whooping cough in our

community. If you see somebody coughing, you should think about

it. That image literally can pop up on the screen as they are doing

work in their own healthcare application, because my application

has messaged their application. This, rather than wishing that everyone was going to check my Web site every 8 hours.

So, as you can see, we are all likely to continue using the applications to which our systems are wedded, just like we continue to

live on the residential streets in which we have always lived. What

we need is the freeway system whereby we can get from a residential system in Milwaukee to a residential street in Washington in

short order, and that is what I think Dr. Gingrich was talking

about, the ability to send information out to our existing legacy systems.

Mr. PUTNAM. Dr. Weisman, have the poison control centers been

asked to submit information through the BI?

Mr. WEISMAN. We are one of the data sources that are currently

being considered for BioSense and a couple of the other programs.

The poison centers nationally have a realtime data surveillance.

We standardized all the definitions about 12 years ago, and all of

the data is collected and analyzed and mined by the American Association of Poison Centers and CDC at 10-minute intervals, and

they are looking for some of the early markers that would indicate

either biological, chemical, or nuclear events; and that is available

in all 50 States, so it is a good system at the present time.

Mr. PUTNAM. You received the HANs?

Mr. WEISMAN. Excuse me?

Mr. PUTNAM. The health alerts?

Mr. WEISMAN. That gets as far as the health department and the

county health department. That, I do not get. I was able to get Epix as a poison center director. I was very surprised. I share the information that I get with our hospital epidemiologist, who then also

applied and was actually turned down to get on it. You see a person like that who is at a major point, and it is unfortunate because

it is limited by the size of the system and how many users can be

hooked into it. So that certainly that type of thing ought to change

as we try to improve the flow of information.

Mr. PUTNAM. Well, those were the vote bills going off, so we are

going to need to bring this in for a landing. Very quickly, any final

comments? Mr. Aoyagi.

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Mr. AOYAGI. Well, I just want to re-emphasize and thank the

committee chair for holding this hearing and to underscore the role

of local governments in responding to major emergencies, and that

we are a partner to both State and Federal agencies. We need the

information at our level. We shouldn’t be preempted from using

that information in order to respond, and we hope that the promise

of health informatics makes the services that we deliver more effective and more efficient.

Mr. PUTNAM. Thank you.

Dr. Weisman.

Mr. WEISMAN. Final comment is that if I had to summarize into

one sentence, we need desperately to get a very effective bi-directional flow of information in and out of hospitals. To date, it only

is going to the level of the county health department, and then the

communication seems to break down. So that I think that the next

major step is to get it out to the level of the person actually taking

care of the patient.

Thank you.

Mr. PUTNAM. Dr. Foldy.

Dr. FOLDY. In a way echoing the remarks of the other two speakers, information travels when there is trust, and then when there

is a system. In Milwaukee we use systems that other people had

already built for their own use, such as the EM system secure

Internet. So we could take the information from CDC and push it

out to emergency rooms. We weren’t able to do that for doctors in

their clinics because no such system or no such relationship existed. But I think that the national health infrastructure vision is

likely to grow because local communities and all of the players in

those communities get together and agree to share information the

way Mr. Aoyagi says is what is happening in Montgomery County.

Regional health information infrastructures will be built that have

to learn all the hard lessons about how and when to communicate

what types of materials, and to overcome the medical, legal, and

other barriers.

At the same time, the Federal Government needs to play a critical role by really pushing standardization, using its purchasing

power to encourage standardization, focusing resources on the efforts of these regional collaborations, and as lessons are learned at

the regional level, to make them available to all of those nationwide who want to build the same kind of infrastructure.

Thank you.

Mr. PUTNAM. Thank you. Thank you all very much. We appreciate all of the input and testimony that all of our witnesses have

provided. This was the subcommittee’s first opportunity to explore

the consolidated health informatics e-government initiative and the

current state of IT and information sharing in the healthcare industry. As we have seen, all the players in the game agree it is

time to bring healthcare forward into the information technology

era, and we have also seen that the crux of the task is the development and widespread use of standards and the collection and

transmission of data. Without these standards, all the diligence in

the world in collecting the data and all the newest technology for

storing and transmitting that data will be worthless unless the information that is collected is interoperable. If we can achieve this,

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we will not only make great strides in improving the delivery of

healthcare, but also in improving the coordination among private

healthcare providers, public health officials, and emergency responders in the event of a biological emergency, be it terror-related

or a natural disaster. In either case, improved communication and

coordination are vital to lead to quicker identification, containment,

and response, and in these cases time saves lives.

I want to thank everyone for their participation and staff for

their hard work inputting this together. And, with that, the subcommittee stands adjourned.

[Whereupon, at 5 p.m., the subcommittee was adjourned, to reconvene at the call of the Chair.]

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