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COMMITTEE HEARING ON COST AND 

CONFIDENTIALITY: UNFORSEEN CHALLENGES OF 

ELECTRONIC HEALTH RECORDS IN SMALL 

SPECIALITY PRACTICES 

COMMITTEE ON SMALL BUSINESS 

UNITED STATES HOUSE OF 

REPRESENTATIVES 

ONE HUNDRED TENTH CONGRESS 

SECOND SESSION 

JULY 31, 2008 

Serial Number 110-110 

Printed for the use of the Committee on Small Business 

( 

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

HOUSE COMMITTEE ON SMALL BUSINESS 

NYDIA M. VELA ́ ZQUEZ, New York, Chairwoman 

HEATH SHULER, North Carolina 

CHARLES GONZALEZ, Texas 

RICK LARSEN, Washington 

RAUL GRIJALVA, Arizona 

MICHAEL MICHAUD, Maine 

MELISSA BEAN, Illinois 

HENRY CUELLAR, Texas 

DAN LIPINSKI, Illinois 

GWEN MOORE, Wisconsin 

JASON ALTMIRE, Pennsylvania 

BRUCE BRALEY, Iowa 

YVETTE CLARKE, New York 

BRAD ELLSWORTH, Indiana 

HANK JOHNSON, Georgia 

JOE SESTAK, Pennsylvania 

BRIAN HIGGINS, New York 

MAZIE HIRONO, Hawaii 

STEVE CHABOT, Ohio, Ranking Member 

ROSCOE BARTLETT, Maryland 

SAM GRAVES, Missouri 

TODD AKIN, Missouri 

BILL SHUSTER, Pennsylvania 

MARILYN MUSGRAVE, Colorado 

STEVE KING, Iowa 

JEFF FORTENBERRY, Nebraska 

LYNN WESTMORELAND, Georgia 

LOUIE GOHMERT, Texas 

DAVID DAVIS, Tennessee 

MARY FALLIN, Oklahoma 

VERN BUCHANAN, Florida 

MICHAEL DAY, Majority Staff Director 

ADAM MINEHARDT, Deputy Staff Director 

TIM SLATTERY, Chief Counsel 

KEVIN FITZPATRICK, Minority Staff Director 

STANDING SUBCOMMITTEES 

Subcommittee on Finance and Tax 

MELISSA BEAN, Illinois, Chairwoman 

RAUL GRIJALVA, Arizona 

MICHAEL MICHAUD, Maine 

BRAD ELLSWORTH, Indiana 

HANK JOHNSON, Georgia 

JOE SESTAK, Pennsylvania 

VERN BUCHANAN, Florida, Ranking 

BILL SHUSTER, Pennsylvania 

STEVE KING, Iowa 

Subcommittee on Contracting and Technology 

BRUCE BRALEY, IOWA, Chairman 

HENRY CUELLAR, Texas 

GWEN MOORE, Wisconsin 

YVETTE CLARKE, New York 

JOE SESTAK, Pennsylvania 

DAVID DAVIS, Tennessee, Ranking 

ROSCOE BARTLETT, Maryland 

SAM GRAVES, Missouri 

TODD AKIN, Missouri 

MARY FALLIN, Oklahoma 

(II) 

Subcommittee on Regulations, Health Care and Trade 

CHARLES GONZALEZ, Texas, Chairman 

RICK LARSEN, Washington 

DAN LIPINSKI, Illinois 

MELISSA BEAN, Illinois 

GWEN MOORE, Wisconsin 

JASON ALTMIRE, Pennsylvania 

JOE SESTAK, Pennsylvania 

LYNN WESTMORELAND, Georgia, Ranking 

BILL SHUSTER, Pennsylvania 

STEVE KING, Iowa 

MARILYN MUSGRAVE, Colorado 

MARY FALLIN, Oklahoma 

VERN BUCHANAN, Florida 

Subcommittee on Rural and Urban Entrepreneurship 

HEATH SHULER, North Carolina, Chairman 

RICK LARSEN, Washington 

MICHAEL MICHAUD, Maine 

GWEN MOORE, Wisconsin 

YVETTE CLARKE, New York 

BRAD ELLSWORTH, Indiana 

HANK JOHNSON, Georgia 

JEFF FORTENBERRY, Nebraska, Ranking 

ROSCOE BARTLETT, Maryland 

MARILYN MUSGRAVE, Colorado 

DAVID DAVIS, Tennessee 

Subcommittee on Investigations and Oversight 

JASON ALTMIRE, PENNSYLVANIA, Chairman 

CHARLES GONZALEZ, Texas 

RAUL GRIJALVA, Arizona 

MARY FALLIN, Oklahoma, Ranking 

LYNN WESTMORELAND, Georgia 

(III) 

C O N T E N T S 

OPENING STATEMENTS 

Page 

Vela ́zquez, Hon. Nydia M. ....................................................................................... 1 

Chabot, Hon. Steve .................................................................................................. 2 

WITNESSES 

Tally, Dr. Philip W.,MD, Neuro-Spinal Associates, Bradenton, FL, on behalf 

of the American Association of Neurological Surgeons ..................................... 5 

Plovnick, Mr. Robert, Director of quality Improvement and Psychiatric Services, American Psychiatric Association .............................................................. 7 

Gotlieb, Dr. Edward, MD, FAAP, The Pediatric Center, Stone Mountain, 

GA, on behalf of the American Academy of Pediatrics ..................................... 10 

Hale, Dr. Ralph, MD, FACOG, Executive Vice President, American College 

of Obstetricians and Gynecologists ..................................................................... 12 

Bort, Dr. Thaddeus, MD, Family Medical Group, Cincinnati, OH ...................... 14 

APPENDIX 

PREPARED STATEMENTS: 

Vela ́zquez, Hon. Nydia M. ....................................................................................... 33 

Chabot, Hon. Steve .................................................................................................. 35 

Tally, Dr. Philip W.,MD, Neuro-Spinal Associates, Bradenton, FL, on behalf 

of the American Association of Neurological Surgeons ..................................... 36 

Plovnick, Mr. Robert, Director of quality Improvement and Psychiatric Services, American Psychiatric Association .............................................................. 41 

Gotlieb, Dr. Edward, MD, FAAP, The Pediatric Center, Stone Mountain, 

GA, on behalf of the American Academy of Pediatrics ..................................... 46 

Hale, Dr. Ralph, MD, FACOG, Executive Vice President, American College 

of Obstetricians and Gynecologists ..................................................................... 51 

Bort, Dr. Thaddeus, MD, Family Medical Group, Cincinnati, OH ...................... 55 

STATEMENTS FOR THE RECORD: 

American College of Physicians .............................................................................. 61 

(V) 

(1) 

COST AND CONFIDENTIALITY: UNFORESEEN 

CHALLENGES OF ELECTRONIC HEALTH 

RECORDS IN SMALL SPECIALTY PRACTICES 

Thursday, July 31, 2008 

U.S. HOUSE OF REPRESENTATIVES, 

COMMITTEE ON SMALL BUSINESS, 

Washington, DC. 

The Committee met, pursuant to call, at 10:00 a.m., in Room 

1539 Longworth House Office Building, Hon. Nydia Vela ́zquez 

[chairwoman of the Committee] presiding. 

Present: Representatives Vela ́zquez, Shuler, Gonzalez, Altmire, 

Clarke, Johnson, Chabot, and Buchanan. 

Chairwoman VELA ́ ZQUEZ. Good morning. I call this hearing of the 

House Small Business Committee to order. In the last few decades, 

information technology has revolutionized virtually every American 

industry. Today previously complex and time-consuming tasks can 

be easily accomplished with a click of the mouse. But, as with any 

large-scale shift or system overhaul, the adoption of new technology 

comes with certain growing pains. Nowhere is this more true than 

in our nation’s health care sector. 

By the year 2014, the national information technology coordinator expects the United States to have a nationwide network of 

electronic health records. Today several bipartisan proposals supporting this network are working their way through Congress. Both 

Democrats and Republicans recognize the value in HIT. After all, 

it promises to not only control costs but also to improve quality. 

That is an especially appealing prospect given the skyrocketing 

price and declining value of modern health care. 

In today’s hearing, we will discuss the value of HIT and also explore the various concerns surrounding its use. If properly implemented, HIT can streamline the flow of complex health care data. 

In doing so, the technology will improve communication between 

doctors and hospitals. And given the inherent complexities of medicine, a well-structured communication network is of the utmost importance. 

Despite growing support for health care technology, particularly 

in the form of electronic health records, small practices have been 

reluctant to take it up. Whereas, 57 percent of large care centers 

use EHR, only a handful of solo practitioners do. This is partially 

due to the high cost of implementation. 

When all is said and done, the price tag of EHR installation 

comes to over $32,000 for physician. Meanwhile, monthly maintenance fees run close to $1,200. 

2 

By the time heating costs have been factored in, final estimates 

can be $44,000 per doctor with upkeep fees of $8,500 a month for 

small health care providers with limited resources. These up-front 

costs are enough to break the bank. 

In addition to the weighty financial obligation, a series of legal 

and privacy concerns has deterred small health practices from 

adopting HIT. As a practical matter, electronic information can be 

transmitted and reviewed more easily than paper files. In light of 

this fact, some health professionals worry that HIT holds potential 

for health care fraud. 

At the same time, others are concerned that the technology 

might conflict with confidentiality issues outlined in the Health Insurance Portability and Accountability Act, or HIPAA. 

Finally, some specialty doctors, like neurosurgeons and pediatricians, are unable to find appropriate HIT systems. Oftentimes this 

technology caters only to mainstream medical practices, leaving the 

smaller, more specialized businesses behind. 

Health information technology has the potential to revolutionize 

American medicine. But, unfortunately, a series of concerns is 

blocking large-scale implementation. 

There is no silver bullet solution to America’s broken health care 

system. There are, however, a number of ways to address the issue. 

For one, financial incentives to HIT users will help spur uptake. So 

will strengthening privacy regulations for health records. 

As we move forward in the quest to improve health care coverage 

and cut costs, we can look to current technology and future innovation. And, yet, in doing so, we must be sure to act with caution. 

Otherwise we risk de-operatizing both small providers and the 

health and security of their patient. 

With that, I would like to take this opportunity to thank all the 

witnesses for coming here today to provide your insights regarding 

this issue. I look forward to their insight on the matter and yield 

to Ranking Member Chabot for his opening remarks. 

Mr. CHABOT. Thank you very much, Madam Chair. And thank 

you for holding this very important hearing on this very important 

topic here this morning. 

I would like to thank each one of our witnesses who have taken 

the time out of their busy schedules to provide this Committee the 

testimony that they will be giving us here this morning. 

And I would like to extend a special welcome to a fellow Cincinnatian, Dr. Thaddeus, or Ted, Bort, who also happens to be my 

personal physician. So I am particularly pleased to see him here 

today, and I will introduce him more formally later. 

Over the past 30 years, nearly every sector of the American economy has undertaken a sweeping transformation in the way information is collected, managed, and transmitted. As a result, productivity and efficiency have consistently increased. 

Yet, today health care, one of the most significant, one of the 

most important sectors of the American economy has not yet made 

this transformation, at least completely, although we are certainly 

beginning that at this time. This hearing is an important part of 

letting Congress know what is happening in that area at the 

present time. 

3 

Some of the most serious challenges facing health care today, 

medical errors, inconsistent quality, and rising costs can, at least 

partly, be addressed through the effective application of health information technology. Linking all elements of the health care system improves information available to physicians and boosts quality and enhances preventive care and reduces errors. 

On April 22nd, 2004, the President signed an executive order 

which established the position of the national health information 

technology coordinator within the Office of the Secretary of the Department of Health and Human Services and announced his commitment to the promotion of health information technology to lower 

costs, reduce medical errors, improve the quality of care, and provide better information for physicians, as well as for patients. 

In particular, the President called for widespread adoption of 

electronic health records and for health information to follow patients throughout their care in a seamless and secure manner. 

A September 2005 report by the RAND Corporation estimated that $77 billion annually could be saved if 90 percent of physicians 

adopted health information technology. The report also estimated 

another $4 billion in savings from reductions in prescription errors. 

A new report indicates that more than 35 million prescription 

transactions were sent electronically in 2007, which was a 170 percent increase over the year before. Despite documented advantages 

and federal support, physician adoption of health information technology has been slow. 

Research indicates that concerns about high cost, uncertainty of 

return on the investment, and worry over the usability and obsolescence of new technologies rank highest among reasons surveyed of 

physicians have not yet adopted health information technology. 

Doubts about the privacy and security of patient data, practice 

compliance with the Health Information Portability and Accountability Act of 1996, and the potential for inappropriate disclosure 

of patient information to third parties ranked just behind the financial concerns that I mentioned previously. 

Health information technology is a complex issue. The decision to 

implement health information technology in a small medical practice is considered an act of courage by many physicians. It will impact their work flow, staff, patients, and practice finances. 

Successful adoption of health information technology, including 

electronic medical records, will require evaluation, selection, planning, implementation, and effective use of the technology. 

Early adopters agree that there are multiple benefits but recognize a cultural change is required. Madam Chair, I look forward to 

working with you on this important issue. This would be another 

bipartisan issue that we could work on together, as we have done 

many times in the past. The rest of Congress may not do it, but 

you and I do. 

And, again, I want to thank you for your cooperation in this 

hearing today. And I want to thank the witnesses. We are looking 

forward to hearing their testimony. And I yield back the balance 

of my time. 

Chairwoman VELA ́ ZQUEZ. Thank you Mr. Chabot. And I recognize 

Mr. Shuler for an adoption statement. 

Mr. SHULER. Thank you, Madam Chair. 

4 

It is great to see that this meeting is being held. Before my days 

here in Washington, I actually ran a company called My Health 

Card, which was electronic medical records that people carry 

around in their pocket, a company that we found very difficult to 

get off the ground, very difficult to get the hospitals, their programs, whether it be GE Medical or whether it be Op Path or 

whether it be any of the major electronic medical record groups to 

get you to do an interface with their systems. But we did find a 

company that allowed us to do that. 

And in relationship with the University of Tennessee’s medical 

system, we actually worked with a geriatric population. We gave 

them all their cards for free. The hospital used it more as a marketing tool, but we realized in a very short time that it actually 

saved lives. So it wasn’t a chain pharmacy, but it was actually a 

pharmacy that allowed us to be able to put the database into their 

system. 

So a person would go to the primary care physician. That information was then downloaded onto the card, had a 119-digit 

encryption code, HIPAA-compliant. 

And then the person would go to the pharmacy. The pharmacy 

then would be able to only look at the information that the doctor 

put on the meds size. 

And we found out we saw drug interactions. They went from 

their primary care physician to a specialist. The specialist had no 

idea what the primary care physician had prescribed. And we saw 

numerous times of drug interaction that was caught by the physician. He then had the phone number because it was time-stamped 

and dated on the card. And they recognized very quickly that they 

had a problem. 

In the geriatric population, we saw a decrease in days in the hospital. Times in the emergency room significantly dropped. The hard 

part that we had was because of the interfaces with the big companies, if you will. They wanted to capture that data. 

We had other problems with pharmacies being able to allow the 

other pharmacies—they wanted to capture that data. They wanted 

their data for their own personal use. We didn’t look at it. We 

didn’t care about the data from the standpoint of what meds were 

being taken. We just wanted to make sure that the health and the 

care of the patient were taken care of first and foremost. 

And then we realized that the hospitals actually had no idea 

what was happening internally within their hospital. Now, when a 

person would come to the emergency room because they outsource 

their emergency room, that information technology system was different than the one that they have inside the hospital. Then they 

would go to an operating room. Well, the OR software is different 

than the outpatient surgery software. And so you had no way to 

communicate within the hospital. 

So we found ourselves having to implement interfaces with all of 

these systems. By the time we got one interface completed, we had 

to then start all over because it was time to complete the interface 

again. 

So we went through this, a complete circle of finishing the interface. And by the time we got it done in order to make the card 

5 

work completely throughout the hospital, we were forever doing an 

interface. 

And that cost money. So I commend you for being here today and 

talking on this very important subject. Actually, one of the most 

important things that we were able to do with the country—it 

seems like we do our philanthropy work more than anything—is 

kids with foster care. The child would go from place to place to 

place. The medical records were never with them. And so this card 

they can take with them. 

So, Madam Chair, I thank you for holding this very important 

hearing. It is a way to cut down costs of our overall medical crisis 

that we are in. And I think this is going to be a very important 

part of making a difference in health care. 

Thank you, Madam Chair. And I yield back. 

Chairwoman VELA ́ ZQUEZ. Thank you. 

And now it is my pleasure to welcome Dr. Philip W. Tally. Dr. 

Tally is a neurological surgeon in privacy practice and the Chief of 

Staff for Manatee Memorial Hospital in Bradenton, Florida. He 

currently serves as the Chairman of the Florida Medical Association’s Health Information Technology Committee and is a member 

of the American Medical Association’s HIT Advisory Panel. The 

American Association of Neurological Surgeons and The Congress 

of Neurological Surgeons represent more than 4,000 United States 

physicians trained and certified in the specialty of neurological surgery. 

Welcome. You have the timer. We will have five minutes when 

it is going to have the green light. And then red means that your 

time is expired. Welcome. 

Dr. TALLY. Thank you. 

STATEMENT OF PHILIP W. TALLY, M.D., NEUROSURGEON, 

NEURO-SPINAL ASSOCIATES, ON BEHALF OF THE AMERICAN 

ASSOCIATION OF NEUROLOGICAL SURGEONS AND THE CONGRESS OF NEUROLOGICAL SURGEONS 

Dr. TALLY. Good morning, Chairwoman Vela ́zquez, Ranking 

Member Chabot, and members of the Committee. Thank you for inviting me to appear today to discuss the challenges small physician 

specialty practices face in adopting electronic medical records. 

My name is Philip Tally. And I am one of three neurosurgeons 

in a small but full-service neurosurgical practice in Bradenton, 

Florida. I am here, as you stated, representing the neurosurgeons. 

I have been the Chairman, as you have stated, of the two committees. 

I would like to spend my time with you this morning telling you 

my story about how we integrated electronic medical records into 

our practice, some of the challenges we faced, the costs we incurred, and ultimately the benefits that we have reaped, both for 

our practice and our patients. 

In 1992, our practice was the fifth medical practice in the country and the first neurosurgical practice to go fully paperless. Implementing this new system was no easy feat. We could not simply 

plug in the machine and flip the switch. 

Because these systems are set up in a one-size-fits-all manner, 

it took over 1,000 hours to configure our system and create 

6 

neurosurgical templates since there were no existing specialty-specific programs. All told, implementing the first system required 

about a year of prep time to purchase, configure, and implement. 

In addition, it took about another year to refine it and for our practice to become proficient with it. 

The costs of setting up and maintaining this system were signifi- cant. We spent about $50,000 on the initial setup. The system also 

required regular maintenance and upgrades, which cost us at that 

time about $5,000 a month. 

During the early years, our vendor continued to create new systems and upgrades. Every improvement resulted in some unintended consequence, which required a software engineer’s time to 

repair. Implementing the system was particularly difficult on the 

staff. And not everyone was pleased to move to this new paradigm 

shift in our practice. 

These changes, coupled with the daily stress of working in a 

neurosurgical practice, simply proved too much. We suffered a 30 

percent staff turnover as they had difficulty in adapting to and 

learning entirely new procedures and methods. This produced problems with continuity of patient care and loss of productivity as we 

went the through process of hiring and training new staff. 

As our practice transitioned to EMR, we also had to keep the 

paper records for legal reasons. Interoperability was not even a 

concept at that point, and there was no talking between systems. 

Every paper document had to be scanned and transferred into the 

EMR. 

Notwithstanding these challenges, the physicians and our staff 

recognized the benefits of going paperless. The efficiency of the 

practice increased significantly. Staff no longer had to search for 

paper charts to answer patient phone calls, and they could quickly 

get information to the neurosurgeons. 

Our ability to quickly review and create new charts allowed us 

to spend more time with our patients. We improved our communications with other physicians since the completed patient record 

was never misplaced, always legible, and test results resided in a 

distinct folder within the EMR. 

In 1997, we converted to a Windows-based system. And we went 

through the same process again, incurring similar costs, down 

time, and lost productivity. This new system was an improvement 

and significantly expedited patient care. 

Maintaining this system for the last ten years has been a challenge. Hardware has failed. Servers have been hacked. Security requirements, particularly HIPAA, are onerous. And keeping a fulltime IT employee in a competitive job market has been difficult. 

This year we are once again in the process of converting to yet 

another new program and platform and incurring all the same 

costs as before. Even with our practice’s lengthy history and experience with EMR, this upgrade has been a costly and difficult process, with considerable loss of productivity. Furthermore and notwithstanding our experienced eyes, after we purchased this system, 

we have found flaws in the vendor’s product. 

Madam Chairman, as you can see, our practice has been ahead 

of the curve in using EMR. Unfortunately, most physicians have 

not shared this experience. Despite the fact that EMR has the poVerDate Aug 31 2005 19:20 Sep 03, 2008 Jkt 000000 PO 00000 Frm 00012 Fmt 6633 Sfmt 6633 G:\CLERK SB\HEARINGS\TRANSCRIPTS\42952.TXT RUSS
7 

tential to improve the delivery of health care, most physicians have 

been slow or reluctant to adopt these systems. 

A recent study found only four percent of physicians have a fully 

functional EMR system. So we have a very long way to go. And a 

three to four-year timetable for nationwide implementation is optimistic at best. 

Perhaps the new prescribing provisions included in the recently 

passed Medicare bill will help encourage physicians to implement 

this entry-level mode of EMR. However, over 70 percent of the 3 

billion prescriptions written every year are by primary care and 

emergency room physicians, currently the 2 groups with the lowest 

rates of EMR adoption. 

In addition, there are significant implementation issues, such as 

the pharmacy familiarity; proposed and fatally flawed new rigid 

DEA rules for Schedule II drugs, which will make compliance by 

most neurosurgical practices very difficult. 

Congress can help pave the way to widespread adoption of EMR 

by passing legislation that will standardize interoperability and 

provide financial incentives to physicians and practices. We cannot 

rush this process or force physicians to adopt EMR using a stick 

approach as this will only create more resentment among the physicians. It took over ten years for the stethoscope to become widely 

accepted as a medical tool. 

While it will take time, we are on the right path in promoting 

this. There is general agreement that HIT will improve patient 

safety, enhance quality of care, result in more efficient practice, 

and better health outcomes should follow. We should not deviate 

from this premise, nor should we rush launching a complex system 

to satisfy political or administrative goals. 

Thank you for the opportunity to share my experience, and I will 

be happy to answer questions at your discretion. 

[The prepared statement of Dr. Tally can be found in the appendix on page X.] 

Chairwoman VELA ́ ZQUEZ. Thank you, Dr. Tally. 

Our next witness is Robert Plovnick. Dr. Plovnick is the Director 

of the Department of Quality Improvement and Psychiatric Services at the American Psychiatric Association. He oversees preparation of APA’s psychiatric treatment guidelines, development and 

assessment of performance measures for psychiatric services. The 

American Psychiatric Association has more than 38,000 members. 

Welcome. 

Dr. PLOVNICK. Thank you. 

STATEMENT OF ROBERT PLOVNICK, M.D., M.S., DIRECTOR OF 

THE DEPARTMENT OF QUALITY IMPROVEMENT & PSYCHIATRIC SERVICES, AMERICAN PSYCHIATRIC ASSOCIATION 

Dr. PLOVNICK. Thank you, Madam Chairwoman. Members of the 

Small Business Committee, I am Dr. Rob Plovnick, Director of the 

Department of Quality Improvement and Psychiatric Services at 

the American Psychiatric Association. It is an honor for the APA 

to present this testimony to the committee regarding unforeseen 

challenges of EHRs to small specialty practices. 

8 

The APA represents more than 38,000 psychiatric physicians nationwide. Our members work within a variety of systems of care, 

including emergency departments, inpatient settings, and small 

private practices. 

The development of health information technology and corresponding federal and state laws and regulations are a matter of 

great interest and concern to the APA, our members, and their patients. The APA has one committee of members solely focused on 

various aspects of EHRs and a second committee solely focused on 

privacy and confidentiality concerns. 

Carefully structured, a national HIT infrastructure has great potential to improve the overall quality of care provided to patients, 

inform health professionals of the latest standards of care, and to 

improve communication of health care information across settings. 

However, there are two significant challenges to widespread 

adoption and implementation of EHR systems that the APA would 

like to highlight in our testimony today. First, the assurance of 

confidentiality is at the core of any effective patient-physician relationship. Electronic health information exchange could erode patient trust and impede clinical care if it facilitates dissemination of 

sensitive information without sufficient precautions to protect privacy and security. 

Second, a significant percentage of APA members operate in solo 

private practices in which the up-front costs of implementing an 

EHR system present a considerable barrier to adoption. 

Protecting and strengthening the confidentiality of the patientphysician relationship is critical to providing the highest quality 

medical care. This is particularly true with respect to psychiatric 

care because of ongoing inequity in insurance coverage, employment discrimination, and social stigma for people with mental illness. 

An unintended conscience of EHRs is that patients may be discouraged from seeking treatment or sharing information that is 

critical to their care due to concerns that it will be improperly disseminated. 

Treatment in behavioral health and other disciplines of medicine 

often require patients to share sensitive information, such as sexual history, drug use, pregnancy history, and HIV status. According 

to HHS, 2 million Americans, or 7 percent, of those with mental 

illness do not seek treatment specifically due to privacy concerns. 

A 2007 Harris interactive poll found that 17 percent of patients 

withheld information from health professionals because of worries 

the information might be disclosed. These rates are likely to be 

even greater if information exchange is electronically enabled and 

the confidentiality and security of health information cannot be assured. 

The trust required for a productive therapeutic relationship is 

undermined by accounts of health care workers who view electronic 

records of celebrity patients as well as by the loss or theft of 

laptops and CDs containing large quantities of health information. 

Apologizing and making improvements once data is lost is not a 

sufficient response. Privacy and security provisions must be keystones to the development of a nationally uniform HIT infrastructure. 

9 

There are many approaches that could help protect the patientphysician relationship and optimize the advantages of the EHR environment. Examples include ensuring the strictest security protections and auditing are employed, and giving patients and clinicians 

a degree of control as to who can access sensitive information. 

Despite the widespread recognition of the potential HIT holds to 

increase efficiency and quality health care delivery, system adoption rates remain low. A recent study in the New England Journal 

of Medicine found that only four percent of physicians had adopted 

fully functional EHRs and those that had tended to be in larger 

practices. Consistently, cost is cited as the largest barrier to wider 

adoption. 

Although estimates vary widely, studies report that the total costs for implementing office-based EHRs range from $25,000 to 

$45,000 per physician. And subsequent annual costs for maintaining the system range from $3,000 to $9,000 per physician per year. 

These expenditures are amplified for smaller practices, where there 

are fewer physicians to share the costs. 

Psychiatrists involved in solo practice, a significant percentage of 

APA members, often have little or no administrative support staff, 

further increasing the physician’s responsibilities with regards to 

selection, implementation, and maintenance of the system, and decreasing the time available for clinical care. 

The APA appreciates the efforts the Small Business Committee 

has made to address confidentiality concerns while developing an 

HIT infrastructure, which offers a great potential to raise the overall quality of care provided to patients. This goal can be met without breaching privacy protections and can assure patient trust if 

privacy is made a cornerstone of HIT development. 

The APA further recommends the use of financial incentives such 

as grants or other support to help practitioners in solo or small 

group practices cover the costs of hardware and software. 

Again, we thank you for the opportunity to testify today, and we 

hope the members of the Committee will consider the APA as a resource as this process continues. 

[The prepared statement of Dr. Plovnick can be found in the appendix on page X.] 

Chairwoman VELA ́ ZQUEZ. Thank you Dr. Plovnick. 

The Chair recognizes Mr. Johnson for the purpose of introducing 

our next witness. 

Mr. JOHNSON. Thank you, Madam Chair. 

I have today the pleasure of introducing Dr. Edward Gotlieb. Dr. 

Gotlieb is a pediatrician in private practice at the Pediatric Center 

in Stone Mountain, Georgia. He is a fellow both of the American 

Academy of Pediatrics and the Society of Adolescent Medicine. 

He has served as the Chair of the Policy Committee for the Academy’s Steering Committee on Clinical Information Technology, now 

the Council on Clinical Information Technology, on the Academy’s 

Committee on Adolescent Centers, the past Chair of the George 

AAP Chapters Committee on Adolescents. 

The American Academy of Pediatrics is a professional organization of pediatricians with more than 60,000 members trained to 

deal with the medical care of infants, children, and adolescents. 

10 

And we welcome you today to this Committee, sir. 

Chairwoman VELA ́ ZQUEZ. Welcome. 

Dr. GOTLIEB. Thank you very much, Madam Chairman 

Vela ́zquez, Ranking Member Mr. Chabot, and Members of the 

Committee. 

STATEMENT OF EDWARD GOTLIEB, M.D., FAAP, THE PEDIATRIC CENTER, ON BEHALF OF THE AMERICAN ACADEMY 

OF PEDIATRICS 

Dr. GOTLIEB. I am honored to represent the American Academy 

of Pediatrics before you. My name is Edward Gotlieb. I am a practicing physician, pediatrician, in Stone Mountain, Georgia. And you 

have heard my credentials. 

Let me tell you about pediatrics. Sixty percent of pediatricians 

practice in small businesses. Pediatricians are asked by industry to 

pay extra for electronic health capabilities to deal with the complexities of pediatric care that were reimbursed by the government 

less well to provide these services than our adult care colleagues. 

Let me explain. 

Pediatricians are different from other doctors because the major 

government program that pays for the health care of children is 

Medicaid, not Medicare. Medicaid has a major impact on children’s 

care, paying for 40 percent of births in the United States and I believe 60 percent in Georgia. 

Medicaid faces fiscal problems but not because of the more than 

30 million children that are covered by the program. These children 

account for more than 50 percent of Medicaid’s population but only 

25 percent of its cost. 

Pediatricians find it very costly to purchase health information 

systems. A real factor in our inability to afford these expensive 

technologies is the payment rates that pediatricians receive under 

Medicaid. Under Medicaid, payments for providing the same medical services average 69 percent of what Medicare pays. So the 

margins under which most pediatric practices operate are much 

more severe than those of our adult colleagues. 

Furthermore, if incentives for adopting health information technology is structured to flow through the Medicare program, as is 

now largely the case, more than 60,000 practicing pediatricians 

would be excluded from the opportunity to qualify for these incentives. The already inequitable system of funding programs for children will only be worsened. This is not a good investment in our 

future. 

Unfortunately, even if we do receive help to adopt health information systems in our practices, we face special constraints because of special needs of child care and the rules governing privacy 

for our patient population. Electronic medical records are frequently designed for adult care and do not take into account the 

specific needs of children. 

There are a number of special functions that a pediatric health 

record requires that must be implemented in an electronic medical 

record. In their absence, pediatricians are hampered in their ability 

to properly document care. 

Yet, the vendor community frequently asks us pediatricians to 

pay extra for these capabilities if they are willing to provide them 

11 

at all. Major areas in which these needs arise are in immunization 

documentation, immunization registry management, growth tracking, medication dosing, privacy for special pediatric populations, 

and in providing normative data by age, body mass index, or developmental stage. 

Of particular concern in today’s discussions of health information 

technology incentives are adolescent privacy concerns. The HIPAA 

privacy rule and its implementing regulations defer to the state 

and other applicable law on the issue of adolescent privacy. Laws 

about age of consent vary from state to state and according to the 

patient’s presenting problem. The electronic health records need to 

be able to reflect this. 

As an example, in many states, adolescents who present for the 

outpatient treatment of mental health disorders may consent to 

their treatment at an earlier age before they become 18 years old. 

Pediatric practices typically have policies with respect to what 

portion of an adolescent’s care should be handled with special privacy protections. EHR should be flexible enough to handle these 

practice-level policies. 

The recording of patient and parental consent, child assent, and 

the permission to treat are frequently less straightforward for children and adolescents than for the care of adults. Separation of the 

patient’s consent and the parent’s or guardian’s consent is particularly important in the areas of testing for drugs, screening for sexually transmitted illnesses, or in the case of abuse. Remember also 

that our privacy concerns are not limited to minors. 

We pediatricians continue to care for young people through age 

21 and in some cases beyond. My written testimony also focuses on 

other special cases: children in foster or custodial care, consent by 

proxy, adoption, guardianship, and emergency treatment. 

Thank you for the opportunity to testify before you today. 

[The prepared statement of Dr. Gotlieb can be found in the appendix on page X.] 

Chairwoman VELA ́ ZQUEZ. Thank you, Dr. Gotlieb. 

Our next witness is Ralph Hale. Dr. Hale is the Executive Vice 

President for the American College of Obstetricians and Gynecologists. He is a past President of the Association of Professors of 

Gynecology and Obstetrics and a past President of the Pacific 

Coast Fertility Society. 

ACOG is a professional association of medical doctors specializing in obstetrics and gynecology in the United States. It has a 

membership of over 49,000 and represents 90 percent of U.S. 

Board-certified obstetrician/gynecologists. 

Welcome. 

Dr. HALE. Thank you, Madam Chairperson/woman. We actually 

like women. Actually, it is interesting that I am following Dr. 

Gotlieb— 

[Laughter.] 

Dr. HALE. —since Dr. Gotlieb usually follows me in the delivery 

room. 

[Laughter.] 

12 

STATEMENT OF RALPH HALE, M.D., FACOG, EXECUTIVE VICE 

PRESIDENT, AMERICAN COLLEGE OF OBSTETRICIANS AND 

GYNECOLOGISTS 

Dr. HALE. We appreciate very much the opportunity— 

Chairwoman VELA ́ ZQUEZ. President Bush does, too. 

Dr. HALE. Yes. That is true. I have been the ACOG Executive 

Vice President since 1993, when I left the University of Hawaii to 

come here to Washington, D.C. 

I can tell you that our organization is strongly supportive of 

health information technology. As a matter of fact, our last Executive Board meeting, which was just recently held in July, we had 

an expert come in and talk to us for over an hour. And the main 

thrust is, how can we get all ob/gyns in the United States into 

health information technology? 

As part of that, our organization has made our antepartum 

record, and our women’s health record free to any electronic vendor 

that would like to use them. We will prepare them. We will make 

them available to them at no cost because we feel this is important. 

The problem with HIT is that it has not matured to the level 

where most of our Fellows who are in small practices can use these 

systems. They are costly. They are not interoperable. They cannot 

take their health record into a hospital that has a different platform base and use them. This is a problem we see: the lack of ability for us to move across the various platforms. 

And while HIT will save the insurers a lot of money, it has yet 

to save our members money. The costs involved are still excessive, 

as you have heard from our previous testimony, and we run into 

problems with confidentiality. Confidentiality is very important because these are sensitive records. And in our specialty, as with Dr. 

Gotlieb, we deal with a lot of extremely sensitive issues. We need 

to make certain that these records, even though they may be transferred between providers, are flexible enough to accommodate state 

privacy laws and the HIPAA. 

HIPAA, of course, is extremely important. And we are very supportive of HIPAA because many of our women have many issues 

that they would not like to have on the latest tabloid in the supermarket. 

Forty percent, as you have already heard, of deliveries in this 

country are paid by Medicaid. And, yet, there is nothing in Medicaid that helps support an electronic medical record. And we fear 

that within the next couple of years, Fellows who do not use Medicaid electronic medical records will be punished. 

While there is an increased need for HIT, physicians have less 

ability to afford these systems. This is a compelling reason for physician assistance in paying for HIT. 

We all know that the clinical benefit of the electronic medical 

record is great. In one of our groups at the Massachusetts General 

Hospital they have an outstanding medical record which they have 

put together, which allows patients to be seen in any office related 

to their physicians. 

And we need to bring that record into the hospital so if the patient has a problem in pregnancy, this record is there. The physician who sees the patient in the emergency room or sees the patient in the hospital can immediately pull up this record and can 

13 

take care of the patient for her care and for the care of her infant. 

Unfortunately, this is not true throughout the medical system and 

among all the electronic medical record vendors. 

Representative Shuler has identified the problem. And all I can 

say is amen to what you ran into because that is what our Fellows 

see. The records are not adaptable across many, many areas. This 

is a problem. 

I would like to say that H.R. 2377 is a good start to guide us forward in this as we develop incentives for physicians to purchase 

HIT and to seek consensus on important privacy issues. This is a 

massive undertaking that requires physicians to trust their investment in HIT and for the patients to trust that their sensitive 

health information is protected. 

Thank you very much for the opportunity to testify. And ACOG 

is more than willing to assist you in any way that we can. 

[The prepared statement of Dr. Hale can be found in the appendix on page X.] 

Chairwoman VELA ́ ZQUEZ. Thank you, Dr. Hale. 

And now the Chair recognizes Mr. Chabot for the purpose of introducing our next witness. 

Mr. CHABOT. Thank you very much, Chairwoman. 

Dr. Bort is a fellow Cincinnatian, as I mentioned before. He is 

also a Board-certified family physician and a fellow of the American Academy of Family Physicians. 

He is Chairman of the Board of Directors of The Family Medical 

Group of Cincinnati. And after completing his residency at the University of Cincinnati in the Department of Family Medicine, he 

commenced private practice in 1986 with a physician partner. 

Since then, the Family Medical Group, which is a partner-owned 

practice, has grown to 12 physicians, 5 other health care professionals, and 86 employees overall, with over 28,000 patients, including me and my family, in 3 different Cincinnati locations. 

One of Dr. Bort’s major areas of interest is headache diagnosis 

and treatment as well as diabetes and other areas as well, but 

those are two of his special areas of interest. 

Two years ago, the group implemented a fully integrated technology platform. Today every person in the group utilizes a computer. 

Dr. Bort is a volunteer Assistant Professor of Family Medicine at 

the University of Cincinnati. He also serves on the Advisory Board 

of Crossroads Health Center in Cincinnati, which treats substance 

abuse. 

Cincinnati Magazine included Dr. Bort in their summer edition 

this year, in 2008, as best doctors in Cincinnati edition. We welcome him here today and look forward to his testimony. 

And all the other doctors have set a very high standard here, Dr. 

Bort. So we know you won’t let us down. 

[Laughter.] 

Dr. BORT. Thank you very much. 

STATEMENT OF THADDEUS BORT, M.D., CHAIR, BOARD OF 

DIRECTORS, FAMILY MEDICAL GROUP 

Dr. BORT. Chairwoman Vela ́zquez and members of the Committee, I am honored to be here today on behalf of family physiVerDate Aug 31 2005 19:20 Sep 03, 2008 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6633 G:\CLERK SB\HEARINGS\TRANSCRIPTS\42952.TXT RUSS
14 

cians; my partners at The Family Medical Group of Cincinnati; 

Ohio; and, most importantly, our patients. 

I am a Board-certified family physician and member of the American Academy of Family Physicians. I commenced practice, private 

practice, in 1986 with my partner, Dr. Timothy McCarren. Since 

then, as Congressman Chabot was kind enough to say, we have 

grown to 12 partners and 5 mid-level providers, and 86 employees. 

We have over 28,000 patients. 

After waiting for years for the perfect EMR system, we decided 

in 2006 that it was time to invest in one. After investigating a 

number of systems, we purchased the Misys EMR system but 

found that converting our practice from paper to electronic records 

was an arduous process. Only our integrity and our desire to help 

our patients kept us on task. The report from the Institute of Medicine on the unacceptable number of avoidable medical errors stimulated our resolve. 

During the first year of installing the EMR, we actually had to 

decrease our patient load by 20 percent until we became more comfortable with the system. Now, with two years experience, we realize that we deliver health care on a technology platform. Every employee uses a computer. And every patient encounter involves entering data into our EMR system. The experience has provided us 

some perspective on the cost, benefits, as well as the challenges associated with the use of EMRs. 

Costs. When we decided to convert to EMR, we didn’t anticipate 

the ongoing cost of developing and maintaining a system. We purchased our system at an initial total cost of over $228,000, which 

did not include the transfer of existing paper files to an electronic 

format, nor did not include the time and effort required for the entire staff to become proficient and lost revenue while in training. 

However, we found that there is not only the up-front cost, as in the past year we paid over $258,000 to the EMR vendor. This is 

an annual expense that is not based on volume but the reality of 

maintaining a system. 

One of the largest expenses was converting 25,000-plus paper 

charts to a format the EMR could use. This required scanning of 

important documents of each chart. We tried to do this on our own 

but then resorted to shipping the remaining charts to North Carolina to be scanned professionally, at a total cost of $80,000. 

Benefits. Convenience, accuracy, efficiency, and completeness are 

among the benefits of the system. For example, our patients can 

schedule appointments or request a prescription refill, which is 

then sent directly to their pharmacy. When I am with my patient 

in an exam room, I am able to access lab results or check past history all with a click of a mouse. This fosters better patient care because of our ability to track measures, benchmarks, and standards. 

We find privacy and confidentiality are enhanced with EMRs. 

With paper charts that were all over our office, there was no way 

to know who looked at the chart. Thus, it was near impossible to 

monitor HIPAA compliance. Now it is necessary to log on using 

password protection, and an audit trail is recorded down to the second. 

Finally, one of the most important roles that effective HIT, like 

an EMR, can play is to implement what is called a ‘‘patient-cenVerDate Aug 31 2005 19:20 Sep 03, 2008 Jkt 000000 PO 00000 Frm 00020 Fmt 6633 Sfmt 6633 G:\CLERK SB\HEARINGS\TRANSCRIPTS\42952.TXT RUSS
15 

tered medical home.’’ This is a team-based health care model that 

emphasizes coordination of care that is particularly important for 

patients with chronic conditions, such as diabetes. The EMR is central to the operation of a primary care practice that serves as a patient-centered medical home. 

Challenges. Our EMR uses an encrypted system to transmit information. While this acts to insure patient security, it also poses 

a great challenge. When our doctors visit patients at some of the 

hospitals, we are unable to access the patient’s information in our 

office because the hospital system and our office system are not 

compatible. 

Moreover, as family physicians, we interact with a variety of providers, such as my colleagues at this table: laboratories, radiology, 

consultants, hospitals, nursing homes, et cetera. Each of these providers has their own computer system, but because they are not 

interoperable, communication from these various providers still requires paper. 

While I would like to say that we have achieved a paperless office, we continue to be inundated with paper. All day long our fax 

streams hundreds of prescription refill requests to us since there 

is no direct electronic communication between our system and the 

pharmacy or other providers. 

The hospitals as well fax us reams of paper reports since thus 

far there is no standard for hospitals to electronically communicate 

with EMR. This amounts to several hundred sheets of paper, which 

we must scan into the EMR, then pay to shred. 

Based on our EMR experience, I would like to offer two recommendations. Number one, due to the potential benefits but in 

recognition of the substantial cost associated with the EMRs, the 

investment and the utilization of HIT should receive some form of 

tax incentive or system of reward. 

Number two, Congress should foster an environment that provides incentives for the private sector to hasten the interoperability 

of EMR systems, work flow, and clinical data to promote low-cost 

solutions to enable quality measurement and improvement. 

In closing, both despite and because of our experience, I believe 

the benefits of EMR over paper charting are numerous and profound. But because of the substantial costs and time barriers, it is 

quite difficult for a small practice to convert to EMR. Yet, we recognize how EMRs can improve the quality and efficiency of our care. 

We all share the goal of better outcomes at lower costs. Widespread use of health care information technology and electronic 

medical records is central to achieving that goal. 

Thank you for inviting me to testify. And I look forward to your 

questions. 

[The prepared statement of Dr. Bort can be found in the appendix on page X.] 

Chairwoman VELA ́ ZQUEZ. Thank you, Dr. Bort. 

Believe me, this has been quite a learning experience. And if 

there is something that I can say, it is that there is no easy answer. We all want to produce savings when it comes to the health 

care system and to produce and integrated system and the benefits 

16 

of health IT. Everybody talks about it. But how do we get there? 

That is the real challenge. 

We hear about the costs of adopting EHR systems and the lack 

of benefit, of direct benefit, especially true for small practitioners. 

Dr. Plovnick, I would like to ask you, in your estimation, what 

barriers to EHR implementation do psychiatrists face? And what 

are the unique challenges to the mental health profession? 

Dr. PLOVNICK. A few barriers that come to mind offhand, there 

is not wide breadth of software options to choose from that are specific to mental health care in psychiatric treatment settings. So selecting a system that will work for the solo practice psychiatrist is 

a challenge. 

As I mentioned, psychiatrists often have very small offices and 

little administrative support. So all of the work involved in selecting a system, putting it together, and then maintaining it falls disproportionately on the physicians themselves, which takes away 

from the time for clinical care. 

The cost, as has been discussed by most people at the table 

today, has a particular impact on psychiatry, the solo practice in 

terms of the overall revenue. And the number of patients that psychiatrists see tends to be fewer than some other clinicians, which 

provides less opportunity to make up the cost savings for the expense of the system. 

Chairwoman VELA ́ ZQUEZ. Do you have any specific recommendation in terms of your profession in terms of what we can do here 

in Congress that will alleviate? 

Dr. PLOVNICK. It is a hefty question. I think that the issue of 

standards that has been raised is true with psychiatry, as with any 

other profession. 

Right now every system works on its own. And there is little opportunity for connecting between clinicians or within the inpatient 

setting. So assistance in providing interconnecting systems would 

be quite advantageous. 

Chairwoman VELA ́ ZQUEZ. Thank you. 

Dr. Tally, I heard you loud and clear. The cost, the preliminary 

cost, $15,000, the $5,000 monthly maintenance fee, the 30 percent 

turnover, how we comprise continuity of care, the loss of productivity, not having systems interact with, communicate with each 

other. So the question of obsolescence is of particular concern to 

small practice specialists, who rely on fairly sophisticated systems. 

Have vendors responded to this concern? And what steps in the 

health IT industry would help to alleviate this problem of investing 

in a system that may not be useable in five years? 

Dr. TALLY. Madam Chair there is obsolescence and we are no different than any other industry because there are continual upgrades. We have to keep up with the technology. 

We are not using a CT scanner that was developed in 1988. Now 

what used to take 30 minutes can take 12 seconds. EMR and all 

electronics must continue to evolve, which dictates that parts of it 

will become obsolescent. This includes the Internet, and that is the 

reason we actually chose to go on an entirely new platform. 

It is a matter of how to adapt to this at an affordable cost. Our 

situation, in particular, is hampered by the fact that there is no 

company that would be willing to invest the amount of time to deVerDate Aug 31 2005 19:20 Sep 03, 2008 Jkt 000000 PO 00000 Frm 00022 Fmt 6633 Sfmt 6633 G:\CLERK SB\HEARINGS\TRANSCRIPTS\42952.TXT RUSS
17 

velop a specific neurosurgical program. There are not enough practitioners to make it financially viable and we have complex templates that one would have to construct. 

The Congress can act as a convener to orchestrate those involved 

to adapt certain standards. We are doing this currently with MRIs 

so that all MRI information has basic platforms that all of us can 

read. Currently that is not the case. 

If we had a basic platform that we could all read, such as what 

we would now call interoperable, then, as progress develops and 

technology improves, then industry could simply tack on an additional feature. But the basic system would still be there. 

And that is where I think that your role would be very helpful. 

Chairwoman VELA ́ ZQUEZ. Okay. Thank you. 

Dr. Gotlieb, you point out that the average pediatrician’s Medicaid payment is about two-thirds of what is received by adult care 

doctors for the same service. And this would seem to place pediatricians at a distinct disadvantage when it comes to health IT adoption. 

What is needed from us, Congress, to encourage greater adoption 

of health IT by pediatricians? 

Dr. GOTLIEB. Well, I think, first of all, if there were incentives, 

they need to pass through something other than Medicare because 

we have no access to those funds. The only funds that I have seen 

come through Congress recently is with the S-CHIP program, 

which could get us as much as $200 million over 10 years. And you 

guys have passed that. That has been vetoed twice. And it is sitting 

somewhere. So finding some way for us to get funds to do it would 

be a real help. 

Another thing that is not an Academy position but an idea that 

I would like to suggest is you have done it with drugs, where you 

have given benefits to drug companies, to include pediatric research for medications. Maybe you could do the same thing with 

health information technology people and say, ‘‘If you have the 

functionality that pediatricians require, there is some benefit to 

you.’’ 

Chairwoman VELA ́ ZQUEZ. Okay. Dr. Hale? No. Dr. Bort, let go 

with you first. Health IT security poses a significant challenge to 

physicians trying to access their patients’ information outside of 

their office. You suggest standardizing electronic health record systems as a possible solution. 

What steps at the federal or state level could create this standardization and ensure the security of records? 

Dr. BORT. I guess the way I would approach this is that looking 

at the cell phone industry as an analogy, what is so frustrating to 

us, Madame Chairman, is that we have, all of us in the room have, 

a cell phone. And there is a multiple number of carriers. But if 

they did not communicate, it would be so frustrating because we 

couldn’t talk to one another, even though we had the cell phones, 

et cetera. 

And that is what we are living with, I believe, in HIT at this 

point because the security is not—I believe they are all encrypted 

in ways that I don’t entirely understand. So it is not a safety as 

much as a communication problem that we are encountering that 

18 

leads us back to resorting to endless faxes and defaulting to paper, 

which is the lowest common denominator. 

I believe this was mentioned earlier that HIT has lagged far behind the rest, for example, the business sector, where everybody 

lives on a Blackberry. We are not using that technology at this 

time in health care. 

I have a couple of thoughts, that, first of all. It is a paradigm 

shift because we have all been on paper. And we have our work 

flow issues. So it is easy to do different paper patterns in that regard. But now we are bringing a paradigm shift with the computers. And that is a big step. 

Now, if we would give computers, electronic prescribing, for example, to medical students, they would never have a paper pad or 

understand that. Since they have all been weaned on Game Boys, 

et cetera, that is no big step for them. They actually expect it. 

So we are dealing with problems of what to do with those of us 

who have been used to paper for years and then the new generation, which I think is where the answer lies: the medical students. 

For example, we see students and residents from the University of 

Cincinnati. And when they come to us, we have asked for them to 

have a computer so they could access our medical record. That has 

not been possible. 

As to your original point on the privacy and confidentiality, I 

have great confidence that the software managers know how to 

program that stuff aide make it safe. And, as I mentioned in my 

testimony, we have audit trails in our office. 

Chairwoman VELA ́ ZQUEZ. Okay. Now I recognize the ranking 

member. Thank you. 

Mr. CHABOT. Thank you very much. 

Chairwoman VELA ́ ZQUEZ. Yes. 

Mr. CHABOT. Dr. Tally, if I could just ask you a quick question? 

What year did you initially start your— 

Dr. TALLY. We started the process in 1992. 

Mr. CHABOT. ’92. And the cost was $50,000 I think at that time? 

Dr. TALLY. Back then. 

Mr. CHABOT. That is what I was thinking because I know Dr. Bort said it was $228,000 in his practice. So we are basically talking ’92 versus 2006. 

And I think both of you mentioned that one of the initial things 

that you either hadn’t anticipated or didn’t appreciate was the 

maintenance of this system, monthly payments and upgrading it, 

and that sort of thing. Would you both like to just touch on that 

briefly maybe, Dr. Tally and Dr. Bort? 

Dr. TALLY. Well, upgrading it is no different than the similarity 

which many people are familiar with, like opening up a Word document, Word 2003 versus Word ’97. We all know that a Word 2003 

will not decode a ’97, which is why the Library of Congress is having so much trouble. 

So innovation is great, but you have to keep up with it. And as 

you keep up with that, again, there has been no standardization. 

As I was talking about with the Chairwoman, if you have a basic 

function, then you can add features on such as the cell phone analogy. You may have all of these features in the cell phone, but you 

still use a number. Even it has a voice recognition, it is a number 

19 

that transmits. So you have that basic function. You can add on 

any other ‘‘gee whiz’’ features that you choose. 

But we should have all the vendors come to a common agreement 

that there is a platform with which we will persist. And then that 

will be the interoperable platform. 

Mr. CHABOT. Dr. Bort, did you want to touch on that? 

Dr. BORT. Well, it was a shocker to us because of the sticker 

shock of the initial outlay. But then the ongoing upkeep and enhancements as we got further into the system and dependent, to 

be honest, where we depend upon it. So we are obligated to upgrade it and make sure that we have the latest version because, 

for example, there are drug interactions. 

Well, there are no drugs coming out monthly. So we have to 

make sure that our software when we are prescribing, eventually 

when we hope to do that via voice, that will help us to know that 

we are catching all of the possible reactions for patient safety. 

Mr. CHABOT. And, Doctor, let me follow up, if I can. You had 

mentioned about what you believe Congress should do, how we can 

be helpful. And you had mentioned—and this goes along with the 

cost—perhaps some tax incentive that would help those that are 

doing it now and maybe those that are anticipating it in the future, 

maybe make it more likely for them to modernize. 

I would assume that at this point in time the equipment that you 

purchase, you know, depending on how many years it is going to 

be good for, you can deduct that from the tax of the partnership 

or if you are a Sub. S or whatever you are individually, whatever. 

What you would prefer to have, something that would be more 

of an incentive, a tax credit or something. Have you thought about 

that? 

Dr. BORT. Well, I can’t speak specifically as to tax credits, but 

I will say this, that, for example, what you all in Congress have 

done with the Medicare D incentives for encouraging us to go for 

E prescribing, I believe that is a step in the right direction. I think 

it is a small step, but that is, for example, an incentive that will 

help us with the costs that we are incurring. 

As to the tax incentives, we are just struggling with the overhead. We are drowning in overhead. And this was one that we 

didn’t foresee. It is one thing to deal with the overhead with our 

staff and salaries, benefits, et cetera. But now with the upkeep 

costs—and once we are down the road with this EMR system and 

committed to it, when they say that, you know, ‘‘This version is 

going to be necessary if we want to get results’’ down the road from 

the hospital, then we are obligated to take that step. 

Mr. CHABOT. Thank you, Doctor. 

Let me go to Dr. Plovnick and Dr. Hale next, if I could. I guess 

in the fields that you are in, both psychiatry and obstetrics and 

gynecology, you emphasize the privacy issues and the sensitivities 

that might be there if personal information gets out. And that 

would seem obvious. 

I know up here, just as a member of Congress, I can tell you I 

was one member whose computer system got hacked into by the 

Chinese. And there were other committee chairs who got hacked in. 

We think the Chinese probably chose us because I am one of the 

Co-chairs of the Congressional Taiwan Caucus. And we have also 

20 

been pretty outspoken on human rights abuses in China. So we 

were one of the ones that got hacked in. 

We had the incidence of an IRS agent recently who was snooping 

into the IRS returns of celebrities and things. So there is always 

a concern out there about information. 

Are there any suggestions that the two of you might make to us 

or anything that we can do to improve the concerns that might be 

out there about privacy issues relative to the electronic records in 

the medical fields and your fields? 

One or both. 

Dr. PLOVNICK. Offhand there are two types of situations, where 

information could be disseminated. One is a security-related issue 

with hacking, as you mentioned, where an outsider gets into the 

system and accesses information. And there are a variety of technological solutions to prevent that in terms of encryption and password protection and protecting the information as it goes online. 

Any system with sensitive health information needs to have that 

level of protection. 

Another situation where information can be accessed is actually 

be somebody who may have legitimate access within a system. 

That is in the situation of celebrity records being accessed. Those 

are often by people who do have access to the system, hospital staff 

or IRS staff, in the situation you mentioned. 

So in that situation, having as strict a control over information 

as possible, having more than just all or none access to records but 

really limiting access to those who are authorized to use it and 

standards built in from the start that allow that level of protection 

really help protect sensitive information. 

Mr. CHABOT. Thank you. 

Dr. Hale? 

Dr. HALE. Yes. Thank you, Representative Chabot. 

Obviously externally you can have firewalls. You can have coded 

entry protection. One of the problems our fellows see is that, with 

no ability to transfer records from one platform to another platform 

the greatest breach of security happens when a contractor goes into 

the record to move it to another platform. You can’t always say 

that that individual, who is transferring records from one platform 

to another will retain the information’s privacy. 

Just as you said, there are people out there who, even though 

they talk about how secure their record is, when they get to another platform, somebody has had to breach that security. 

That is one of the problems we face with this lack of ability to 

move medical records. I hadn’t originally thought about it, but I 

think the cell phone analogy is very true. Let me just give you an 

example that we have found. 

As I indicated earlier, we have made our record available free of 

charge. We have an outstanding antepartum record for pregnant 

women. It is used by hundreds of thousands of pregnancies every 

year. We have said we will make it available to any electronic vendor that wants to use that record. 

Yet we have a few vendors who are actually using it. We have 

others that are using part of it and want to use it. And why will 

they not use it? They don’t want to make certain that anybody else 

could use it or that it is compatible with other groups because it 

21 

ultimately compromises their ability to retain business and threatens their profit margin. That is where we see the greatest difficultly. 

If we had a consistent platform, our records could go to Dr. Bort’s 

physicians. Obviously with Dr. Gotlieb, our records need to be compatible. And, yet, they are not. So every time you have to share 

that record with some other system, you run the great risk of loss 

of security. That is where one of our biggest problems is today. 

Mr. CHABOT. Thank you. 

Dr. Gotlieb, did you want to respond? Then maybe I will ask a 

question. 

Dr. GOTLIEB. Could I, please? 

Mr. CHABOT. Yes. Okay. 

Dr. GOTLIEB. For pediatrics, there are state jurisdiction issues on 

privacy. So if I have to send a record to Alabama, which has privacy protections for the adolescents in my practice, the things are 

different in Alabama. So my computer would not only have to be 

interoperable, but it would have to take in specific legislation in a 

different jurisdiction. And once you start doing that, you get into 

great trouble. 

Our trouble for a lot of folks is not trying to worry about whether 

the Chinese are going to break in but whether the parents are 

going to break in. You know, if I have a patient who comes to me 

with abdominal pain because her boyfriend is yelling at her a lot 

and I find out that she actually has appendicitis, I have to deal 

with the reality with an electronic health record, within a note, of 

protecting the psychiatric information in that visit with the physical information in that visit. I have to deal with the interface between the parents’ right to know and the adolescent’s right to privacy. 

Mr. CHABOT. Thank you very much, Doctor. 

I yield back, Madam Chair. 

Chairwoman VELA ́ ZQUEZ. Mr. Gonzalez? 

Mr. GONZALEZ. Thank you very much, Madam Chair. 

I am going to make some observations so that there is kind of 

a frame of reference. The medical profession I think needs to understand where this is legislatively and where it is all going so that 

you can become part of it so that your voices are heard, so that 

your considerations and your observations and your input are part 

of the final product. 

I will put it this way. I believe that health information technology, electronic medical records, whatever you want to call it, 

that the train has left the station. And let me explain why. 

One, I think the government has determined that it is an effective way of saving money. And for government, budgets are big 

things. And because the government has such a state financially in 

providing health care services, it will be heard. 

Number two, I think the private sector is already on it. I think 

you all have your own experiences in dealing with private insurance companies of what they may insist in the way that you may 

submit for your billing and so on and what information. It is happening. You have got Google out there now that is providing some 

sort of a service regarding an individual who may want to create 

some sort of an electronic medical record file. 

22 

All these things are moving forward. It is just a question of 

whether we are going to take your real life experiences and factor 

them in. And I think that is totally essential or it is not going 

work. So you are needed. That is one thing that I want you to understand. 

In my discussions with members of the medical profession and 

teachers and such, I don’t know if it is generational. It is in a lot 

of other professions. I came from the legal one. And when we went 

from hard copy and my big law books and my CD-ROM, I went 

nuts. My mind wasn’t even—I couldn’t even digest the information. 

I was so used to the way that it was already. I mean, you all probably would shake your heads in agreement. It is the same thing. 

I know that in medical schools and such, these recent graduates 

are pretty savvy when it comes to what is going on out there in 

the electronic world. They are fully embracing it. It is just a matter 

of whether you have the systems for these entering doctors to utilize. 

The other observation, let us not confuse privacy with security. 

That is so important because, as members of Congress, we have a 

problem with that when we discuss legislation. We will always 

have concerns about privacy. Medical records privacy in the hierarchy of privacy concerns is at the very top because of the nature 

of it. I mean, we understand that. 

But let us not go—security is another thing. That is the other 

component. We understand privacy and the precautions we are 

going to take and the policies. And we will have federal standards 

for that. 

I also believe that in due course—and it is going to happen much 

sooner, and the medical profession has to be more nimble than 

other professions. I think electronic records are actually going to be 

part of a standard of care. 

I think, Dr. Tally, you said it took ten years for doctors to finally 

say, ‘‘We are going to have stethoscopes.’’ Maybe the stethoscope of 

the Twenty-First Century or something is electronic medical 

records, but it is going to be part. It is going to be a factor and a 

component as to say whether you are truly practicing state-of-theart medicine in today’s society because the question will always be 

posed, ‘‘Well, if you had had electronic medical records and you had 

had access to this because every other doctor does but you don’t,’’ 

I think there is a very, very serious question that we are going to 

have there. 

I will agree with each and every one of you about interoperability, about federal standards. We are working on that. We are 

not just going to go in there and mandate or reward or punish 

someone for the lack of utilizing electronic medical records. 

Without understanding the cost of it—and I am going to get into 

the cost in a minute. Yes, we will have standards. And then, of 

course, you can fine-tune it regarding what is the specialty. But I 

think also there is tremendous education that is lacking as to what 

you really need basically to probably comply with what the federal 

government is going to require. 

Now, there are two ways of doing this: you know, positive or negative incentives. And we have been talking about it. There are all 

23 

sorts of these bills out there. One of them is mine with Dr. 

Gingrey. We have got tax incentive. We have got grants. We have 

got loans. We understand that. And we need to be providing that. 

The other is obviously enhancing how we reimburse physicians 

when it is a federal dollar being paid for the health care that is 

being delivered. I believe in positive incentives, but you need to understand that there are those in government that believe that the 

negative incentive works just as well. 

And we can go over if the Chairwoman would just give me some 

additional time to come back visit this, about how we are going to 

do that, the negative incentives are basically being punished for 

not complying with some sort of a standard in having electronic 

records. 

And we have people in very high positions that believe that is 

the way to go. I disagree, but we really need for you to be part of 

this debate and removing all obstacles because it is coming, it is 

happening. Believe me, it would just be part of your practice. There 

is nothing you can do to delay it much because it is going to be implemented. 

I know that I have gone over time, and I haven’t asked the one 

question I want. So I will just yield back and see if the Chairwoman will give me— 

Chairwoman VELA ́ ZQUEZ. We will have a second round. 

Mr. GONZALEZ. We will have a second round? 

Chairwoman VELA ́ ZQUEZ. Sure. 

Mr. GONZALEZ. Thank you. 

Chairwoman VELA ́ ZQUEZ. Mr. Buchanan? 

Mr. BUCHANAN. Thank you, Madam Chair. 

I got in late, had another meeting, but I want to recognize Dr. 

Tally is from our congressional area. And I appreciate your effort, 

energy coming up here because I know all of the doctors are busy. 

Again, I don’t want to be redundant. Maybe it was said. But 

what is did you find your return on investment in terms of energy 

and time and the investment? I am sure you probably talked about 

it, but I hear so much about these electronic records. And it is 

going to save us a lot of money. 

I am sure I agree with the congressman. That is the future. I 

was just curious as it relates to your practice. What have you found 

the efficiencies? Have you been able to have less employees or what 

has happened, in essence, as a result of putting your system in? 

Dr. TALLY. Sure. Thank you. 

I was just discussing this with my administrator, who has been 

through this process with me, this tripled process over the last 12 

years. ROI, and even when I give some of the seminars on teaching 

it, is very difficult to link to a financial number because it is an 

ongoing cost of doing business. We just made the commitment 

years ago that this was going to be a better way to deliver health 

care. 

ROI is more physician satisfaction. Are there cost savings? Clearly when we first did this system, our transcription costs dropped 

90 percent. But, as someone pointed out, it is a paperless system, 

not a paper-free system. So you still have a lot of the world who 

sends you paper, even if you are electronic. 

24 

Now with voice recognition—and we are in the up front with 

doing voice recognition. This is going to give us some cost savings, 

even off the last ten percent. Technology has gone forward. 

Am I going to get an ROI on that when you then calculate in the 

upgrade cost and cost of doing business, such as was mentioned 

when it was sort of a shock figure? It is going to be very difficult 

for me to tell any physician ‘‘Oh, this is how much it is going to 

save you’’ because, as costs of staff and everything else goes on, it 

may just keep you from going under faster in today’s current market. 

Mr. BUCHANAN. Yes. I think it is inevitable. I think the other 

thing that has been brought up just since I have been here is the 

whole generational thing. I know a lot of doctors in their 50s. And 

they are just hoping to get their retirement. They don’t have to get 

involved. They know it is coming. But I am just interested to see 

how that is going to play out over time. 

You know, it is one thing to have electronic records. It is more 

efficient. Then it is another thing to force people or encourage people, however you are going to do that, to change the way they have 

been doing things for 25-30 years. And we have a lot of physicians 

you know in our area that are in their 50s thinking about retirement in 10 years, 5 years. And I know it has been touched on a 

bunch here today. 

What are your thoughts? Any additional thoughts on that? 

Dr. TALLY. Our current thinking is if you are not thinking about 

practicing more than five years, don’t bother because the transition 

of the costs and then trying to make it proficient enough for you 

in a small practice is probably not worth that with one exception. 

And that would only be that if you intend to sell your practice 

someday. Whoever buys your practice is going to want an electronic 

format, absolutely. 

The unusual thing about who is willing to adopt and who is not 

is typical even among the neurosurgeons across the country. It has 

been somewhat of a dichotomy. I find just as many of those who 

are in their 45 or 50-year age group who want to embrace electronics and their junior partners do not want them to invest. 

And, as someone said, we have all of these residents coming out 

who are used to the electronic format. They may well be because 

they were trained on one system, and they are used to that. But 

as soon as they get out into a regular practice, they are going to 

suddenly find a plethora of systems that won’t cross-talk. And they 

will be experiencing the same frustrations that you have heard 

here today. 

It is going to be just a gradual paradigm shift. And, unfortunately, it is going to take a lot longer than the vast majority of any 

of us would prefer. 

Mr. BUCHANAN. Yes. I have been in business myself 30 years. We 

have implemented a lot of systems. It usually takes longer, costs 

more, but eventually it works its way in and becomes part of the 

culture of the business. So I think it is inevitable. 

Thanks for coming. I don’t want to take any more time of the 

Committee. Thank you, Madam Chair. I yield back. 

Chairwoman VELA ́ ZQUEZ. Thank you. 

25 

Dr. Hale, the Director of the Congressional Budget Office recently testified that withholding Medicare payments or creating 

some other financial levy are efficient ways to encourage EHR 

adoption. He went on to say that if you want to get to near universal health IT in the next five years, it has got to be the stick. 

Do you agree that tying Medicare payments to EHR adoption is 

the best approach? 

Dr. HALE. Interesting question. I read what the Congressional 

Budget Office said. And I think if you look at it from the bigger 

perspective, yes, the only way sometimes that you are going to get 

the carrot is when you have the stick. 

The small practitioner is going to look at it just the opposite. 

They are going to say, ‘‘It is a cost factor which I cannot afford. 

And my only recourse to that is I will see no more Medicare patients.’’ And I don’t think we want that. 

One of the issues, though, that we have not talked about with 

the electronic medical record—we have talked about the cost, we 

have talked about the efficiency—is patient safety. We have seen 

in our own specialty that those people who have adopted an electronic medical record, patient safety becomes a very critical issue 

and is very important because written notes, things like that that 

are not easily seem—we all know that it is easy to misstate what 

a prescription is. Patient safety is a big issue. 

That is what we have tried to push in our own emphasis. We 

haven’t tried to push penalties because doctors don’t respond well 

to penalties and to forcefulness. We have tried to push patient safety in the office, patient safety in the hospital. The management of 

the patient, that is what is going to benefit you. And yes, it is going 

to cost more at first. 

Wwhen I read what the CBO said and at least the Washington 

Post adaptation of what the CBO said, I think that many doctors 

would get their hackles up immediately and say, ‘‘Wait a minute. 

You are going to punish me for not having a record when I would 

like to adapt to something that is reasonable and cost efficiency’’ 

because I understand the young people like the record. But let me 

give you an example outside of patient care. 

In our organization with our Executive Board, most of the physicians are at my age, maybe a little younger. But we have instituted 

totally paperless meetings. Everything is done by the computer. We 

thought people would object to it. 

We recently decided to hold a meeting outside of Washington, 

D.C. And we were going to have to go to paper. And what was the 

biggest complaint we got? ‘‘It is not electronic. We want to go back 

to the electronic. We don’t want all of those papers. We don’t have 

to carry a folder.’’ 

So I think physicians are willing to adapt. As Mr. Buchanan 

said, I think physicians will adapt to it. I think they are willing 

to put it in. I think it is the factor of costs given the already reduced Medicare payment. Fortunately, the 10.6 percent didn’t go 

into place. 

So I think they are willing to do it, but they want to be able to 

show that it does work, that they can continue to see their patients, and that they have a compatible record. They don’t want to 

pay for have a record today, spend the $40,000 to $50,000, and next 

26 

year be told ‘‘That record is obsolete. You have got to put another 

40 to 50 thousand.’’ 

That is not only difficult for the physician. It is difficult for the 

patient. And it is extremely difficult for the staff. 

Chairwoman VELA ́ ZQUEZ. And, Dr. Hale, for this Committee, that 

is basically the most important issue. How can we help solo and 

small practitioners to adopt IT? And we will be looking into legislation that will provide ways to be able to provide affordable financing for the adoption of IT for small practitioners and solo practitioners. And we are going to be working to see if we could craft legislation that will provide the mechanism where we can use the 

Small Business Administration loan programs to help achieve that 

goal. 

With that, I would like to ask Dr. Gotlieb, under the Medicare 

physician fee fix bill that passed here in Congress, are those physicians offered incentives to purchase if prescribing systems. Like 

most health IT funding if prescribing incentives are structured to 

flow through the Medicare program. This funding structure does 

not apply to Medicaid payments. 

As a result, do you see pediatricians moving more slowly towards 

e-prescribing? 

Dr. GOTLIEB. I don’t think pediatricians are moving slowly toward it. It is an Academy policy that we approve of and urge our 

members to go to e-prescribing. Most of the things pediatricians do 

don’t have a whole lot to do with money or we wouldn’t be in pediatrics. We do it because it is the right thing to do. And e-prescribing would really be a help for us and others. 

So we would certainly like to find some way to enhance the income to the practices. And e-prescribing would be a method to get 

it to us. 

You know, if you went to the adult community and tried to drop 

Medicare by ten percent, you would have an insurrection. If you 

tried to give us 90 percent of Medicare, we would be dancing in the 

aisles. 

[Laughter.] 

Chairwoman VELA ́ ZQUEZ. Okay. Thank you. 

Dr. Bort? Dr. Bort, despite the challenges your practice has encountered implementing its system, you remain a strong supporter 

of health IT adoption. How did your previous experience as a 

health IT vendor make adoption simpler for your practice? 

Dr. BORT. I believe you are referencing my experience with 

Pocketscript— 

Chairwoman VELA ́ ZQUEZ. Correct. 

Dr. BORT. —that Steve Burns and I started, actually out of our 

pain. One day I was realizing that most of my day, a great part 

of my day was spent scribbling prescriptions on pieces of paper 

that flew out of the office. I wasn’t sure how legible they were and 

how they were interpreted, drug interactions and so forth and so 

on. 

So I have a passion for e-prescribing because the second largest 

paper transaction in our economy happens to be prescriptions, upwards of 4 billion. I know the number 3 billion was mentioned earlier, but I have seen data up to 4 billion pieces of paper with scribVerDate Aug 31 2005 19:20 Sep 03, 2008 Jkt 000000 PO 00000 Frm 00032 Fmt 6633 Sfmt 6633 G:\CLERK SB\HEARINGS\TRANSCRIPTS\42952.TXT RUSS
27 

bles floating around sometimes. Hopefully they make it to the 

pharmacy and they are filled properly. 

Well, I think that, unfortunately, perhaps we are ahead of our 

time, as we were told. We were unable to sustain that back in 

2000. But going from that step back into full-time practice, I was 

convinced that we had to draw a line in the sand sometime, we 

would never have the perfect EHR system out there that we had 

to start. 

And amongst our group, there are 12 of us. And it has been 

somewhat of a bell-shaped curve. There are some early adopters, 

as was mentioned earlier by Congressman Chabot. A few of the 

partners surprisingly—and this was referenced earlier—some older, 

some younger, were really gung-ho for it. And that really drove the 

passion in our office to follow through with it. Others were less 

likely and less comfortable. We sort of had to drag them along. 

But we looked at different options, such as voice recognition software, that one of my partners, middle-aged, two middle-aged and 

one younger doc, who preferred dictating and have voice recognition. So that has helped the adoption. I think once you make the 

commitment, there is no turning back. 

One of the problems we have faced is what happens when the 

power goes down. What we have found has happened a few months 

ago, that we were helpless, that everything depended from the 

phone systems in our office to the front office, back office. And that 

was a big impairment. For a day or two, we had to resort to paper. 

And it was so archaic to fall back to that. And we realized that 

there is absolutely no turning back. 

Chairwoman VELA ́ ZQUEZ. Thank you. 

Now I recognize Mr. Chabot. 

Mr. CHABOT. Thank you, Madam Chair. 

I, first of all, want to once again commend you for holding this 

hearing. This is really very important. It has been very enlightening to me and I am sure the staff that is here and the other 

members. 

It is such an important issue. And most of the doctors that we 

are talking about really do fall right in the small business category, 

which is the jurisdiction of this Committee. And so it is a perfect 

thing for us to be talking about. 

I also wanted to mention I can certainly relate to what Mr. Gonzalez said before relative to when practicing law, the challenge that 

there was when we went from paper and books and Westlaw and 

all of that to the computer. And then it was just sort of mind-boggling. 

I had to sort of laugh when somebody hit McCain recently because he was sort of mystified by the Internet and technologies. 

And it might be to some degree an age thing, but you can sort of 

relate to it. 

Rather than us moving forward with this, I think we would probably be wise to get input from our fellow colleagues who happen 

to have been medical doctors and practicing medical doctors before 

they got here, both the House and the Senate, both Republicans 

and Democrats, because we have quite a few. And I think we ought 

to also rely upon some of the things they have experienced and 

their instincts in this area. 

28 

Finally, rather than ask a specific question, I would just ask anyone who would like to comment, is there anything ‘‘I wish I would 

have made this point when I was testifying’’ or, you know, ‘‘I wish 

they would have asked me this. One thing we really didn’t touch 

on, you know, that we probably should have in afterthought’’? If 

there is any one thing that you just want to suggest that perhaps 

we look into if you want to comment? If we have covered everything, that is fine, too, because this has been a pretty comprehensive hearing. 

And I will just go down the line. So, Dr. Tally, if there is anything you want to sum up with or bring up that we didn’t talk 

about, for that matter? 

Dr. TALLY. Thank you. 

I think there are two issues. One, you just addressed, which is, 

unfortunately, right now a lot of comments are being made by 

those who neither build systems or actually have to operate them. 

I liken this to the fact that I may enjoy the benefits of air travel, 

but Boeing is not asking me how to build a plane, and I am not 

telling the pilot how to fly or asking every pilot to be in a 747. 

The second issue—and so asking those of us, the people who are 

going to build the systems and the people who have to use them, 

how to get—as you have said, that is critical to making sure we 

have some type of accepted usage throughout the nation. 

The second thing is what has just become available, which is still 

going to be a huge stumbling block. And that is e-prescribing. It 

looks very good from the top down. The pharmacies and some of 

the big companies have done a great job establishing the freeway, 

but getting everybody a car on it right now is going to be the real 

challenge. 

And right now one of the things that has held us back, as is 

many specialties, is because we do have to do a lot of prescribing 

of narcotics. What we do involves that a lot, the Schedule II drugs. 

And the DEA finally because of your efforts, you all managed to get 

the DEA to say, ‘‘Okay. We will allow you electronic prescribing.’’ 

They just established some rules, which are in my estimation 

right now a poison pill. There is in my estimation no way that 

under the current proposed rules that the vast majority of doctors 

will undergo the details and rigid rules that the DEA has proposed 

in order to do what they are already doing for other non-Schedule 

II drugs. We do this every day. And to get us to allow that rule 

or those types of encryption and onerous procedures when most of 

us would spend ten seconds writing a prescription, it will force 

many people to get off of it entirely. 

So I know that this is a proposed rulemaking, but I would just 

ask you to look very closely at that process. 

Mr. CHABOT. Thank you, Doctor. 

Dr. Plovnick, anything? 

Dr. PLOVNICK. Thanks for the opportunity. 

Just to emphasize that a lot of concerns about protection of sensitive information have been raised at the table today. And the earlier the infrastructure is built in to protect that information, the 

easier it will be to incorporate it in a system. 

If you have a wider degree of adoption than we currently have 

trying to plug in privacy protection of sensitive information at a 

29 

later stage, it will make the matter a lot more difficult. So now is 

an excellent opportunity to address those issues. 

Mr. CHABOT. Thank you. 

Dr. Gotlieb? 

Dr. GOTLIEB. Since you asked, care of children in this country 

shouldn’t be a partisan issue. In the last fiscal budget, when you 

remove military kinds of fundings and stuff and you look at what 

has happened, one percent of the budget went to children’s issues 

of new spending. And I can get you the reference. 

If we are really serious about taking care of the next generation, 

we need to start finding some ways to take better care of kids. 

Mr. CHABOT. Thank you, Doctor. 

Dr. Hale? 

Dr. HALE. Thank you very much. 

I would just like to reemphasize again the Gingrey-Gonzalez bill, 

H.R. 2377, that I think that is a very good first step because it increases the IRS tax deduction for HIT purchase. And it also doubles the depreciation in the first year. That will be a big help. 

I would also like to say that my own personal health care is 

given to me by the Medical Faculty Associates at George Washington University, which is here. They have a very strong integrated HIT program. And if you need to see a program where doctors can write a prescription and you can walk down to the hospital 

pharmacy and pick it up or to the physician’s office and pick it up 

and when you go in for your routine colonoscopy, which I did not 

too long ago, and have all of your record just routinely transferred 

over, they have a very good system, which is I think the type of 

thing we would like to see all of medicine have. 

Mr. CHABOT. Thank you very much, Doctor. 

And last, but not least, Dr. Bort? 

Dr. BORT. Thank you. 

First and foremost, I am a small business. And I live small business. I love small business. I think that is what drives our country. 

So bless you all for doing this important work. 

One thing that was not mentioned earlier, it was told to me that 

we would be able to decrease the number of employees in our office 

when we went electronic. The good news is we got rid of 28,000- 

plus charts. We have some more space. But we have not been able 

to decrease full-time equivalents, which, again, is affecting our 

overhead. 

I do believe voice-activated software programs are—that is the 

easiest thing that we are all used to. And there are a number of 

platforms out there that are being developed. And I believe that 

will be the most user-friendly personally. And I had mentioned earlier about putting this software and these devices in the hands of 

medical students and residents because that is the future for the 

children that we are hearing about and so forth in going forward, 

I believe. They are used to that technology, as was just mentioned 

by Dr. Hale. 

Another example where this is being done well, I believe, is the 

VA system. Now when I get records from the VA on a patient, they 

are very concise and legible and very well done. 

Thank you. 

Mr. CHABOT. Thank you very much, Doctor. 

30 

I yield back, Madam Chair. 

Chairwoman VELA ́ ZQUEZ. Sure. Mr. Gonzalez? 

Mr. GONZALEZ. Thank you very much, Madam Chair. And you 

don’t know how much we welcome your input on this because I say 

if it is going to be successful, can’t do it without the person on the 

ground that deals every day with the patient in how to best meet 

those needs. 

I will give you a real quick example of something. And I don’t 

know how we get past this other than we are going to set some 

minimum standards and such so that when you do make that investment, you are getting something that basically is understood 

by everybody, interoperability,—that is a given—and so on, but I 

have a small application software vendor in San Antonio. She is 

absolutely brilliant. She is wonderful and made quite an investment. So I go, and I get briefed by what she has to offer the medical profession in San Antonio. 

I go to my cardiologist. And I am sitting there. And his wife is 

the office manager. So I just said, ‘‘Where did you purchase your 

electronic medical records?’’ And they tell me about this big, giant 

national firm. 

So I said, ‘‘Well, do you know about’’ so and so ‘‘who is here locally?’’ And she is a local leader and everything else. 

So ‘‘Yes.’’ And they had made their presentation, and they considered it. 

So I asked the officer manager, who is the real boss, the wife. 

And I asked her, ‘‘Why didn’t you all buy that system?’’ 

She said, ‘‘Well, because my husband,’’ the cardiologist, ‘‘wanted 

something with all the bells and whistles.’’ 

I said, ‘‘But did the local vendor, what they offered, meet the 

needs?’’ 

And she said, ‘‘Yes. We don’t really use all the bells and whistles 

that my husband wanted, but that is the way he is about cars, too.’’ 

[Laughter.] 

Mr. GONZALEZ. So I am just saying that I think there are some 

basic systems out there. And I know they need special tweaking because of cardiologists, just like a neurologist. It is going to be different from the family practitioner and so on. But I think that it 

is out there. 

The question that I have is, how are you making your voices 

heard? Each of you who is in a specialty obviously has an organization, an association. Are they coming together and identifying the 

special needs of your specialty in making sure that that is being 

reflected? 

I don’t know. Look, the American Medical Association is engaged. 

Don’t get me wrong. And that is the big umbrella. But I am just 

talking about something that Dr. Tally has made reference to a 

couple of times. And that is, again, tailoring things to make sure 

that they meet your needs. 

So just quickly if you will tell me what efforts are being made 

within your own specialty, with your own group, within your own 

association to be able to communicate your special needs? 

Dr. TALLY. Well, as you said, every specialty is different. It is 

somewhat based on size. The American Association of Family Practice has done a fabulous job. They have a very intense IT departVerDate Aug 31 2005 19:20 Sep 03, 2008 Jkt 000000 PO 00000 Frm 00036 Fmt 6633 Sfmt 6633 G:\CLERK SB\HEARINGS\TRANSCRIPTS\42952.TXT RUSS
31 

ment that has done a great job of promoting them. I am strongly 

in favor of that because that is where you, the congressmen and 

the government, need to work. And it is primary care. 

People like me, we are one percent of the physicians. Getting us 

up and running is a challenge for our association. And we have our 

own internal committees. And, as you have seen, I am also working 

with the AMA for this. The bulk if you can get anything to do 90 

percent of the work, our challenge is to get 90 percent of the people 

who give 90 percent of the care. And that involves family practice, 

ob, pediatrics. The rest of us will come along in time. 

So the time and the effort to be spent by Congress, vendors, associations is where the vast majority of health care is being given, 

just like for the areas where we spend most of our money in Medicare: CHF, MI, diabetes, pneumonia. That is where the bulk of the 

savings has to come. And that is where HIT will deal its greatest 

benefit. 

Mr. GONZALEZ. Good point. 

Dr. PLOVNICK. At the American Psychiatric Association, we have 

a committee of members specifically focused on electronic health 

records. They are early adopters who picked this up now. And a 

part of what they do is articulate some of the needs that they have 

for software in their various psychiatric practices. And this information is made available to members on the Web site and in other 

forums. 

And we actually have members who have adopted software. They 

have an opportunity to share their experiences with software on 

their Web site so that members can learn from other psychiatrists 

who have already adopted the systems. That is some of the activity 

of the APA. 

Dr. GOTLIEB. The American Academy of Pediatrics has many policy statement, position papers on what we need. We are not talking 

about pie in the sky stuff. We have specific issues that can be dealt 

with with such a small part of what the vendors considered to be 

their market, that they have a real interest in not listening to us 

sometimes. 

We are required in the State of Georgia to report immunizations 

to the immunization registry. I was on a committee with the State 

American Academy of Pediatrics going to the vendors one by one 

and them telling us ‘‘Yes, we will do this. Give us yet another 

$100,000 per practice just to integrate your EHR or your practice 

management system into that. And we will be glad to think about 

it in the next iteration of the software.’’ 

We have things that we can offer. It is out there. I would be glad 

to present it. 

Mr. GONZALEZ. Thank you. 

Dr. HALE. I am fortunate at the American College of Obstetricians and Gynecologists, I am the one that makes the decision as 

to where we are going. And our Executive Board has directed that 

one of our top priorities is to have all of our Fellows using an electronic health record. 

At our annual clinical meeting, we now bring in as many as 24 

different vendors and make them available so our Fellows have the 

opportunity to meet them. 

32 

We are pushing it very hard. We would like to see by the year 

2015 that every ob/gyn in the country is using electronic health 

records. I don’t think we will succeed, but that is our goal. Unless 

you have a goal to reach for, you will never get there. 

Dr. BORT. As a family doc in the trenches of primary care,—as 

I like to say, that is where I live and work,—I know how important 

it is to our small business. 

When I think back, I can’t recall any edition of the American 

Academy of Family Physicians that hasn’t had some article, either 

encouraging us, instructing us, or putting together guidelines to 

help us implement EHR into make us realize that it is imperative 

that we embrace these standards. 

The most important concept that is developed is that of the medical home. And for the medical home concept to work where you see 

your family physician for your health care needs, the EMR is actually mission-critical to having that come to fruition. 

Mr. GONZALEZ. Thank you very much, Madam Chair. 

Chairwoman VELA ́ ZQUEZ. Okay. Well, again let me take this opportunity to thank all of you for taking time to come before this 

Committee. 

And let me say that we know that there are different legislative 

proposals moving through different committees. Just Wednesday 

the Energy and Commerce Committee reported out the H.R. 6357. 

And the Ways and Means also is considering legislation as it pertained to IT. And I just want to make sure that this Committee 

plays a role in making sure that the perspective and the challenges 

faced by small practitioners are heard. And we will do everything 

that we can. 

So, with that, let me just say I ask unanimous consent that 

members will have five days to submit a statement and supporting 

materials for the record. Without objection, so ordered. 

This hearing is now adjourned. 

[Whereupon, at 11:50 a.m., the foregoing matter was concluded.] 

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