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S. Hrg. 109–963

LESSONS LEARNED? ASSURING HEALTHY INITIATIVES IN HEALTH INFORMATION TECHNOLOGY

HEARING

BEFORE THE

FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT 

INFORMATION, AND INTERNATIONAL 

SECURITY SUBCOMMITTEE

OF THE

COMMITTEE ON 

HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE

ONE HUNDRED NINTH CONGRESS

SECOND SESSION

JUNE 22, 2006

Available via http://www.access.gpo.gov/congress/senate

Printed for the use of the Committee on Homeland Security 

and Governmental Affairs

(

(II)

COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS 

SUSAN M. COLLINS, Maine, Chairman 

TED STEVENS, Alaska 

GEORGE V. VOINOVICH, Ohio 

NORM COLEMAN, Minnesota 

TOM COBURN, Oklahoma 

LINCOLN D. CHAFEE, Rhode Island 

ROBERT F. BENNETT, Utah 

PETE V. DOMENICI, New Mexico 

JOHN W. WARNER, Virginia 

JOSEPH I. LIEBERMAN, Connecticut 

CARL LEVIN, Michigan 

DANIEL K. AKAKA, Hawaii 

THOMAS R. CARPER, Delaware 

MARK DAYTON, Minnesota 

FRANK LAUTENBERG, New Jersey 

MARK PRYOR, Arkansas

MICHAEL D. BOPP, Staff Director and Chief Counsel 

MICHAEL L. ALEXANDER, Minority Staff Director 

TRINA DRIESSNACK TYRER, Chief Clerk 

FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT INFORMATION, AND 

INTERNATIONAL SECURITY SUBCOMMITTEE 

TOM COBURN, Oklahoma, Chairman 

TED STEVENS, Alaska 

GEORGE V. VOINOVICH, Ohio 

LINCOLN D. CHAFEE, Rhode Island 

ROBERT F. BENNETT, Utah 

PETE V. DOMENICI, New Mexico 

JOHN W. WARNER, Virginia 

THOMAS CARPER, Delaware 

CARL LEVIN, Michigan 

DANIEL K. AKAKA, Hawaii 

MARK DAYTON, Minnesota 

FRANK LAUTENBERG, New Jersey 

MARK PRYOR, Arkansas

KATY FRENCH, Staff Director 

SHEILA MURPHY, Minority Staff Director 

JOHN KILVINGTON, Minority Deputy Staff Director 

LIZ SCRANTON, Chief Clerk 

(III)

C O N T E N T S 

Opening statements: Page 

Senator Coburn ................................................................................................. 1

Senator Carper ................................................................................................. 5

WITNESSES 

THURSDAY, JUNE 22, 2006

Jodi G. Daniel, J.D., M.P.H., Director, Policy and Research, Office of the 

National Coordinator for Health Information Technology, U.S. Department 

of Health and Human Services ........................................................................... 8

Linda D. Koontz, Director, Information Management Issues, U.S. Government 

Accountability Office ............................................................................................ 11

Carl E. Hendricks, Military Health System Chief Information Officer, U.S. 

Department of Defense ........................................................................................ 12

Michael Kussman, M.D., Deputy Under Secretary for Health, U.S. Department of Veterans’ Affairs accompanied by Robert Howard, Supervisor, Office of Information and Technology, U.S. Department of Veterans’ Affairs .... 15

Ross Fletcher, M.D., Chief of Staff, Veterans Medical Center ............................. 17

ALPHABETICAL LIST OF WITNESSES

Daniel, Jodi G., J.D., M.P.H.: 

Testimony .......................................................................................................... 8

Prepared statement .......................................................................................... 33

Fletcher, Ross, M.D.: 

Testimony .......................................................................................................... 17

Hendricks, Carl E.: 

Testimony .......................................................................................................... 12

Prepared statement .......................................................................................... 77

Koontz, Linda D.: 

Testimony .......................................................................................................... 11

Prepared statement .......................................................................................... 48

Kussman, Michael, M.D.: 

Testimony .......................................................................................................... 15

Prepared statement .......................................................................................... 89

APPENDIX 

Questions and responses for the Record from: 

Ms. Koontz ........................................................................................................ 100

Mr. Hendricks ................................................................................................... 108

Dr. Kussman ..................................................................................................... 137

(1)

LESSONS LEARNED? ASSURING HEALTHY 

INITIATIVES IN HEALTH INFORMATION 

TECHNOLOGY 

TUESDAY, JUNE 22, 2006

U.S. SENATE,

SUBCOMMITTEE ON FEDERAL FINANCIAL MANAGEMENT,

GOVERNMENT INFORMATION, AND INTERNATIONAL SECURITY, 

OF THE COMMITTEE ON HOMELAND SECURITY

AND GOVERNMENTAL AFFAIRS, 

Washington, DC. 

The Subcommittee met, pursuant to notice, at 2:27 p.m., in room 

SD–342, Dirksen Senate Office Building, Hon. Tom Coburn, Chairman of the Subcommittee, presiding. 

Present: Senators Coburn and Carper. 

OPENING STATEMENT OF SENATOR COBURN 

Senator COBURN. The hearing will come to order. Without objection, I would like my full statement to be included in the record. 

Senator CARPER. I reserve the right to object. Oh, I would not object. [Laughter.] 

Senator COBURN. I apologize. I have to make a speech on the 

floor, so I will not be able to stay for the entire hearing. 

I owned the first IBM System 3 for online inventories and used 

a toll-free telephone system to tell people what we could ship and 

when we could ship it. So I know the power, and I do not think 

anybody disputes the power to save lives, the power to save tremendous amounts of money, and the power to markedly improve 

what we know are best practices in health care standards in this 

country. 

I enjoyed my visit at the VA. I have been to approximately 25 

different organizations who are using electronic medical records. I 

am a proponent. I do not think anybody in the health care industry, even us older doctors, is going to be resistant to the things that 

we know will help us save money ourselves, improve our care, and 

give us time. 

I am concerned, and I want to be very frank with my concern. 

As I look at what is happening in interoperability, my concern is 

it is becoming a roadblock rather than something that is helping, 

and let me explain that. I formerly shared a practice with four 

other physicians. We have not gone to an electronic medical record, 

and the reason we have not gone to an electronic medical record 

is because we know our capital investments is going to double 

again as soon as you all decide on standards. So whatever we buy 

2

today is not going to work with whatever comes out, and then we 

are going to have to pay to have a system to make our system 

work. And we are not alone. The vast majority of physicians feel 

that way, and a lot of the hospitals who have not upgraded systems 

are not upgrading systems today because this has not come about. 

And so my real concern is: Have we gone about this the wrong 

way? Everybody who has testified before us is working to accomplish the same goal. We all want the same goal. But when we dangle money from the Federal Government to say, ‘‘Come help us do 

this,’’ and then we have the Federal Government saying, ‘‘Here is 

how we are going to do it,’’ rather than say, ‘‘Who sold the system 

to VA, who sold the system to the Department of Defense, what 

computer companies are out there, what insurance companies, 

where do they get their software/hardware systems,’’ rather than to 

ask those people, much like we did in the banking industry—there 

wasn’t a government agency that created the software security 

analysis for the banking industry. The very fact is that the profit 

motives created the security, the online advancement, and the economic benefit of everything that we see happening in the financial 

industry today. 

So my worry—and I hope to be convinced that we are not slowing 

down interoperable standards, because I have this trouble conceiving how it could take longer, if we took Microsoft and all these 

other people, and we took IBM, and we took the companies that 

have actually sold and written other software, and the insurance 

industry and some of the medical industry and the hospital industry, and say, ‘‘Go get in a room and come back in 9 months and 

tell us what we need to do,’’ would that have been a better situation? Would we end up with a better product at a more timely 

basis? And why is it important? Because if we had health IT today, 

true electronic medical records, we would be saving 50,000 to 

60,000 lives. And just the economic output of those 50,000 to 

60,000 lives would pay for everything we are doing. 

Now, we have spent a quarter of a billion dollars already on 

health IT interoperability. A quarter of a billion dollars. And nobody can tell me when we are going to have interoperability. Nobody will tell. And we are not going to get the movement to save 

those lives until those standards are set and people see some finite, 

fixed consistency to know that their investment is not going to 

have to be duplicated again before they do that. So that is my concern. 

I want to thank Senator Carper. We are having this hearing at 

his insistence. There are tons of hearings on IT across the Hill, and 

he has a significant insight and investment in this issue, which I 

appreciate, and my hope is that by having this hearing, we can answer some of those questions and kind of move it along and look 

at where it ought to be. 

I may differ somewhat from him. I do not think we have a topdown computer—or standard developed by the Federal Government. I think the standards that we get ought to be developed by 

the private industry because I think that the motivations will be 

better and the risk-taking will be better in terms of getting us a 

better product. But without that, we need a standard, and every 

day we do not have an interoperable standard in health care IT, 

3

thousands of people are going to die. And the other thing that we 

know from the Rand Corporation studies is anywhere from 5 to 20 

percent, somewhere around $300 billion of missed savings, we are 

passing up savings of about $300 billion a year every year we do 

not have IT in the health care industry. So it is important—lives, 

quality, and money, and time. And we need to get there, and we 

need to find out why we are not. 

Senator Carper, I will apologize to you now for not being here. 

I will try to come back. It will be my effort to come back. We will 

be asking questions, written questions of you, and if you would be 

so kind as to submit those answers within 2 weeks of the time you 

receive them, we would very much appreciate it. 

[The prepared statement of Senator Coburn follows:]

OPENING PREPARED STATEMENT OF SENATOR COBURN 

THE ISSUE—WE’RE NOT WHERE WE SHOULD BE IN HEALTH 

INFORMATION TECHNOLOGY 

Most industries are fully online and digitized. People bank electronically, shop 

electronically, pay their taxes electronically, plan vacations, weddings, hold 

videoconferences, you name it. But there’s one industry that is lagging woefully behind—healthcare—and it’s literally a matter of life and death that we get up to 

speed. June 5–8 was National Health IT Week. It’s time that every week was health 

IT week. 

The need is clear and the benefits of sharable—but secure—health IT products 

are many: All your doctors and other providers for one patient can communicate, 

see each other’s work, and work together to avoid duplication, medical errors, and 

drug interactions. Patients can put their whole health record on a ‘‘thumb’’ drive the 

size of, you guessed it, your thumb, and carry it with them on vacation, overseas 

travel, or when they switch insurers or primary care providers. 

Health IT isn’t just a neat idea that might have good benefits. In today’s world, 

health IT can produce greater efficiency and fewer medical errors, with the added 

benefit of fantastic cost savings for patients, providers, health plans and the taxpayers who partially or fully support the system. Moving healthcare to the digital 

universe is no longer an option, but a necessity. 

Right now, however, hardly anyone is benefiting from electronic health records because they are rarely used—even though studies estimate that a well-developed 

health IT system could save $81–$161 billion or more annually while greatly reducing sickness and death, medical errors and adverse drug events in patients. 

THE COST—THE FEDERAL INVESTMENT IN HIT HAS BEEN SIGNIFICANT—

BUT THE RESULTS ARE FEW 

However, I don’t think the lack of electronic health records is due to a lack of 

spending. In fact, the U.S. enormous investment in health care is staggering: In 

2006, total health spending is expected to approach $2.2 trillion and account for 

more than 16 percent of gross domestic product (GDP). We spend substantially more 

than other developed countries, both per capita and as a share of GDP. 

Of the billions of tax dollars spent on discretionary and mandatory health spending, information technology is not the poor step-child when it comes to Federal 

health investments—in fact, the government has spent an estimated $169 million 

this year alone on HIT initiatives. According to a March 2006 GAO report, the Office of the National Coordinator for Health IT has awarded $42 million in contracts 

intended to advance the use of health IT, while the Bush Administration has 

pledged $100 million for a national electronic Health Record system. On January 

27, 2006, President Bush asked for an additional $50 million for the Office of the 

National Coordinator for HealthIT, and his 2006 budget called for increasing funding for $125 million for demonstration projects. 

THE PLAYERS—DOD AND VA AS STANDARD BEARERS IN THE RACE TO 

WIDELY ACCESSIBLE ELECTRONIC HEALTH RECORDS? 

But HHS isn’t the only game in town. Many regard the Department of Veterans’ 

Affairs and the Department of Defense as standard bearers for health information 

technology due in part to their joint efforts to share medical records and, not least, 

4

the fact that they care for a combined 14.2 million active military and retired veterans. The services the VA and the DOD deliver to our armed forces are vital to 

our national security, and some have commended the VA for some of the agency’s 

cutting edge technologies and best practices development. 

The price for innovation and delivery of services at these two agencies is not 

cheap, however: The VA requested about $2.1 billion for its FY06 Information Technology programs, and has requested a new system and an additional $3.5 billion in 

funds to overhaul their current network over the next 10 years. DOD’s health care 

costs have doubled over the past 5 years to $38 billion in 2006, accounting for 8 

percent of DOD expenses. If current trends continue, the department would spend 

$64 billion in 2015, accounting for 12 percent of DOD’s costs. 

THE APPROPRIATE FEDERAL ROLE 

As usual, the private sector—where the bottom line drives performance—is the 

place where innovation must grow fastest and best. I don’t want to fetter the private 

providers, facilities, and health plans with too much government meddling in their 

efforts. There is an appropriate role for the Federal Government in providing leadership for data standard-setting and creating incentives for publicly funded healthcare 

to go digital. However, imposing a top-down model like the single-payer VA or 

TriCare systems, can’t work in the private sector where most people get their health 

care and want to keep getting their healthcare. The Office of Personnel Management (OPM) recently reported that the best way to encourage providers to adopt 

HIT is to promote the conditions for a free market. Some would like the Federal 

Government to try to replace that vibrant market with the roll-out of a one-sizefits-all interoperable government health IT system. Those waiting for such a system 

will be waiting a long time, given the slow progress we’ve seen so far. 

And that’s probably a good thing, because the private sector isn’t waiting around 

to get moving on HIT. Kaiser Permanente, which serves 3 million more people than 

the VA, has launched a 10-year, $3 billion computer overhaul. IBM testified at a 

recent House hearing that their use of employee electronic health records played a 

major part in lowering premiums and keeping employees health. IBM health care 

premiums are 6 percent lower for family coverage and 15 percent lower for single 

coverage than industry norms, and employee illness rates are consistently lower 

than industry levels. 

IN THE WAKE OF POOR MANAGEMENT, INNOVATION FLOUNDERS 

While it is clear to me that there is an enormous amount of effort and money 

being poured by the Federal Government into the health information technology 

field, I’m perplexed as to why we haven’t yet achieved more measurable results. 

Some have called the VA the model of IT perfection, but the history there of wasted 

funds and large cost and time overruns is less impressive than you might think. I 

hope we can get a clearer picture from some of our witnesses today. I don’t want 

to criticize the services that our veterans receive—and they truly deserve our 

thanks and care—but I think we can do a better job serving those veterans and the 

rest of America’s taxpayers by better managing our resources and investments. 

Both VA and DOD lack detailed management plans for health IT, which increases 

the risk of unaccountability. In fact, two recent GAO reports use the phrase ‘‘severely challenged’’ when describing VA and DOD long-term efforts to provide a virtual medical record in which data are in a format that can be acted upon in real 

time. Both VA and the DOD have been criticized for missed milestones and major 

expenses related to their two newest projects, Healthe Vet and ALHTA [‘‘ALTA’’]. 

HealtheVet in particular has received some particularly scathing reviews from independent review Carnegie Mellon suggesting that the ‘‘VA faces unparalleled challenges to manage change to deliver an operationally viable [HealtheVet] by 2010,’’ 

and that the plan to spend billions to modernize the health care system for that 

delivers services to 5 million veterans has unacceptably high risks. 

CONCLUSION 

It’s not fair to ask future generations—your grandchildren and mine—to pick up 

the tab tomorrow for systems and plans that don’t work well or on time today. I 

know that our witnesses have the very best wishes in their hearts for the well-being 

of our Nation’s honorable veterans and active-duty forces. To serve them with one 

fraction of the competence with which they’ve served us, we need to ask some tough 

questions today. Thank you for being here, for your time and preparation.

5

OPENING STATEMENT OF SENATOR CARPER 

Senator CARPER [presiding]. Thanks, Mr. Chairman, and the 

Subcommittee will stand in recess. We are going to watch Senator 

Coburn on a television monitor over here as he gives his speech. 

No, we are not going to do that. Go for it. 

I am delighted that we are having this hearing. I am delighted 

we are having it on this subject. I am an old Navy guy. I spent 

about 5 years on active duty, about 18 years in the Reserves, and 

I remember when I got out, I graduated from Ohio State, having 

been a Navy ROTC midshipman. And I headed out for Pensacola 

for my training, my first active-duty training. And when I left Ohio 

State, they gave me a brown manila folder that had my medical 

records from my 4 years at Ohio State, my physicals and that sort 

of thing. 

I went down to Pensacola. I turned them in, and they kept them 

there for—I do not know—the 6, 7, 8, 9 months that I was there. 

And then I left and went off to Naval Air Station, Corpus Christi, 

Texas, and they gave me back my brown manila folder, and I carried it with me in my Volkswagen Karmann Ghia to Corpus Christi 

Naval Air Station. I went to Corpus Christi, and I turned it in, and 

they kept it until I finished up. Then I went to North Iowa Naval 

Air Station, Coronado, and I carried it with me over there, and I 

turned it in. I left there and I went up to Moffett Field, California, 

near Mountain View, Palo Alto, Menlo Park, that area, a place 

where I revisited just 3 weeks ago and I got to stand in my old 

squadron. I do not know if you have ever heard of Moffett Field, 

but on Route 101, just south of San Francisco, is a big old naval 

air station. It is now a NASA base. It is called Ames. But they still 

have these three huge blimp hangars where we have our Navy P–

3 aircraft. I got to stand in my old hangar. 

And the one thing I did not have with me was my old brown folder with my then thickening naval medical records. I had to go overseas. We would go overseas. We would be home for about 8 months, 

overseas for 6, home for 8, overseas for 6. And the whole time I was 

in my squadron, they kept my brown manila folder. 

When I got out of the Navy in 1973, they gave it back to me. By 

this time it was pretty thick. And I carried it with me all the way 

across America in my Volkswagen Karmann Ghia. And I drove to 

Delaware, which I had found on a map, to go to business school. 

And a week after I started business school, I drove up to the VA 

hospital in Ellesmere, Delaware, and I gave them my brown manila 

folder. And it had all my medical records. I wanted to find out 

what I was eligible for, for benefits. 

And you know what? Today, when people get out of the Navy or 

the Army or the Air Force or the Marine Corps and they want to 

go to a VA facility and find out what they are eligible for, they do 

not carry brown manila folders anymore, do they? They do not, because everybody has an electronic health record. 

Down in Louisiana during the evacuation from Hurricane 

Katrina, we had a lot of people evacuated from nursing homes and 

hospitals, and civilians, when they tried to leave, a lot of their 

paper records were destroyed, as we all know. And people ended 

up in Houston, Baton Rouge, and even Delaware, all kinds of 

places, and they did not have their civilian health records anymore. 

6

But you know who had their medical records? The people in the 

VA hospitals, the people in the VA nursing homes, they had them, 

because they had electronic health records. And they were able to—

folks receiving them in the VA facilities, they knew what medicines 

these folks needed to take. They knew what their medical history 

was, their lab tests, their MRIs, all that stuff. Boy, that is a smart 

idea. 

And it is actually not an idea that the private sector brought us. 

At least I do not think so. It kind of grew out of the VA, and it 

sort of migrated to the Department of Defense. And there is a lot 

there for all of us to learn. 

I sort of come to this issue because I want to save lives. We are 

told that we may lose as many as 100,000 lives a year because of 

medical mistakes. It may be a little more, it might be a little less. 

But we lose a lot of lives. We spend a huge amount of money, as 

you know. We spend more money, I am told, than any other country in the world on health care, but we do not get the best results 

in the world. In fact, in some cases, if you look at things like longevity and life expectancy and all, you could argue we do not end 

up with the sort of system we are paying for. 

In any event, I do not know that there are any silver bullets in 

life. I do not think there are any in this regard. But I am convinced 

we can save lives and we can save money if we can figure out how 

to provide throughout the delivery of health care some of the stuff 

that we have been doing in the VA for a while and are trying to 

do in the DOD. 

The Chairman said that he thinks I am committed to a top-down 

solution here as opposed to a bottom-up, and I just want a solution. 

I am just interested in what works. And my hope is that today you 

will help provide us with what works. 

Meredith, is this something I should read? Thank you. It says, 

‘‘Hearing script.’’ I used to be in the House of Representatives, and 

I was a Chairman of my own Subcommittee, and here I get to be 

the Ranking Member with Senator Coburn, which is really a lot of 

fun. He and I are real interested in reducing budget deficits, and 

when you have run into budget deficits of $300, $400 billion a 

year—they basically continue as far as the eye can see—we have 

got to look for ways to save some money, and that is one of the reasons why I am real interested in this. So save some money, save 

some lives, improve health care delivery, and actually provide 

greater job satisfaction to the folks that are delivering the health 

care. 

Here we go, the hearing script. It says, ‘‘Bring the hearing to 

order.’’ The hearing will come to order. And we have given our 

opening statements. The Ranking Member—that is me—has been 

recognized for an opening statement. And if there were other Senators here, I would recognize them. Some of them are over on the 

floor, probably waiting for Senator Coburn to give his statement. 

And we have a bunch of other Committee hearings going on, but 

we will have some people who drift in and out and hear what you 

all have to say and maybe ask a couple of questions. 

I am going to ask our witnesses—and we thank you very much 

for coming, but I am going to ask you to limit your oral testimony 

to about 5 minutes, if you will. Just look for the red lights. Do you 

7

have a red light out there that you can see? What is it right now? 

Is it green? Is it any color at all? Pretty soon it will be green. When 

you speak you will get a green light for 4 minutes, an amber for 

1, and then you will get a red light. Try to wrap it up about that 

point in time. Some of you have done this before, so this is old hat. 

But your complete written statements will be made part of our 

official record, and I am going to ask that we hold our questions 

until the entire panel has testified. 

Let me just say to our panelists today, thank you for coming. You 

all could have been someplace else. This is real important. I think 

this is important for our country, for the people who live in our 

country, and we are grateful that you would testify before us. 

The first person I want to recognize I think is from HHS. Is that 

right? Do you work for Governor Leavitt? 

Ms. DANIEL. Yes. 

Senator CARPER. Tell him an old governor sends his best. He is 

one of my favorite people. 

We are going to hear from Jodi Daniels, Director of the Office of 

Policy and Research, Office of the National Coordinator for Health 

Information Technology at HHS. Did David Brailer work with you? 

Ms. DANIEL. Yes, he was my former boss before he resigned from 

his position. 

Senator CARPER. I just talked to him a week or so ago. Good 

man. 

And I understand that Ms. Daniels is responsible for considering 

the policy implications of key health information technology activities and coordinating health information policy discussions and research within HHS. Welcome. Thank you for coming. 

Ms. DANIEL. Thank you. 

Senator CARPER. Second, Linda Koontz, welcome. How are you? 

The Director of Information Management Issues at GAO. You have 

testified before, haven’t you? Once or twice? 

Ms. KOONTZ. Maybe three times. 

Senator CARPER. More than that, I bet. 

But from GAO, we are delighted that you are here. We appreciate your willingness to testify on this subject, and I understand 

you are responsible for issues concerning the collection, the use, 

and the dissemination of government information in an era of rapidly changing technology. And Ms. Koontz has great responsibility 

at GAO for information technology management issues at various 

agencies, including the Department of Veterans’ Affairs, Department of Housing and Urban Development, and Social Security Administration. That is a lot. 

Our third witness is Carl Hendricks. I know a Carl Hendricks 

back home, but you are the real Carl Hendricks. We are glad that 

you are here. And I understand you are the Chief Information Officer for the Military Health System. Is that right? 

Mr. HENDRICKS. Yes, sir. 

Senator CARPER. Terrific. At the Department of Defense, and 

your past public service was as an Army Medical Service Corps Officer, and serving in a variety of positions spanning some 26 years 

of military service, with a concentration of experience in medical 

information technology and acquisition management. Is it Mr. Hendricks or Dr. Hendricks? 

8

1The prepared statement of Ms. Daniel appears in the Appendix on page 33. 

Mr. HENDRICKS. It is Mr. Hendricks. 

Senator CARPER. All right. Mr. Hendricks is the principal advisor 

to DOD medical leaders on all matters pertaining to health information management, information technology, information protection, enterprise architecture, IT capital investment, and IT strategic planning. That is quite a bit. 

Our fourth witness here today is—now, my notes here say Dr. 

Michael Kussman. And for some reason, we just skipped right over 

you, Mr. Howard, but we will come back. [Laughter.] 

Dr. Michael Kussman, Deputy Under Secretary for Health——

Mr. HOWARD. I am his shadow, sir. 

Senator CARPER. Is that right? Dr. Michael Kussman will be delivering testimony on behalf of the Department of Veterans’ Affairs. 

And he is joined at the table Mr. Robert Howard. Thank you, Mr. 

Howard, for being here—Senior Advisor to the Deputy Secretary 

with concentration on business operations for the Department, and 

Supervisor, Office of Information and Technology, also at Veterans 

Affairs. And when you testify, Dr. Kussman, I am going to look to 

see if Mr. Howard’s lips move at all. [Laughter.] 

We will see how he does. We are glad that you are both here and 

thank you for coming. 

And, finally, Dr. Ross Fletcher. who is the Chief of Staff at the 

Veterans Medical Center in Washington, and I understand you are 

going to be able to give us a demonstration as well. I have been 

looking forward to that. Meredith Pumphrey was telling me you 

were going to do that, and that would be great. 

That is a little bit about who you are—this is a wonderful panel. 

I don’t know who put this panel together, but whoever did, you did 

good work. 

Could I ask you to go ahead and make your presentations? And, 

Ms. Daniels, if you do not mind being our lead-off hitter, we will 

start with you, and then when we are finished, we will ask some 

questions. But thank you all for coming. 

Ms. Daniels. 

TESTIMONY OF JODI G. DANIEL, J.D., M.P.H.,1 DIRECTOR, POLICY AND RESEARCH, OFFICE OF THE NATIONAL COORDINATOR FOR HEALTH INFORMATION TECHNOLOGY, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Ms. DANIEL. Ranking Member Carper and Members of the Subcommittee, I am Jodi Daniel, and as you have mentioned, I am the 

Director of the Office of Policy and Research of the Office of the National Coordinator for Health Information Technology. Thank you 

very much for inviting me to testify today on some of our health 

information technology activities under way at the Department of 

Health and Human Services. 

In April 2004, the President signed an Executive Order creating 

the Office of the National Coordinator (ONC) for Health IT, within 

HHS and called for widespread adoption of electronic health 

records within 10 years so that health information will follow patients throughout their care in a seamless and secure manner. The 

9

goal is to improve the quality of care and provide better information for patients and physicians to improve efficiency. 

Reaching these ambitious goals requires cooperation among Federal agencies and cooperation with the private sector. ONC works 

closely with our Federal partners, including the Department of Defense and the Department of Veterans’ Affairs, to ensure synergy 

in our efforts and to avoid unnecessary duplication. 

Two critical challenges to realizing the President’s vision for 

health IT are now being addressed. The first is interoperability and 

electronic portability of health information, and the second is electronic health records adoption, and we are looking at both of these 

issues in tandem. 

These challenges are being met by key actions currently under 

way in ONC, both through infrastructure contracts that we have 

and through Secretary Leavitt’s Federal Advisory Committee, the 

American Health Information Community. Last year, Secretary 

Leavitt announced the formation of the American Health Information Community, otherwise known as ‘‘the Community.’’ It is a national public-private collaboration to facilitate the transition to 

interoperable electronic health systems in a market-led way. The 

Community formed work groups that were charged with making 

recommendations for specific achievable, near-term results in four 

areas: First is consumer empowerment; second, chronic care; third, 

electronic health records; and, fourth, biosurveillance. These work 

groups advanced and the community accepted recommendations on 

May 16, and key actions related to these and future recommendations are now under way. 

In addition to the formation of the Community, HHS through 

ONC has issued contracts to focus on some of the health IT infrastructure issues. There are four sets of contracts that I wanted to 

mention. 

The first, HHS awarded a contract to the American National 

Standards Institute to convene the Health Information Technology 

Standards Panel (HITSP). HITSP brings together U.S. standards 

development organizations and other stakeholders and is developing and implementing a harmonization process for achieving a 

widely acceptable and useful set of health IT standards to support 

interoperability among health care software applications, particularly electronic health records. 

A process was implemented whereby standards were identified 

and developed specific to real-world scenarios or use cases. HITSP 

is scheduled to have named standards and implementation specifications for three use cases this September. 

The second is compliance certification. HHS awarded a contract 

to the Certification Commission for Health Information Technology 

(CCHIT), to develop criteria and an evaluation process for certifying electronic health records and the infrastructure or network 

components through which they interoperate. The contract will address three areas of certification: Ambulatory electronic health 

records, inpatient electronic health records, and the infrastructure 

components. 

CCHIT has made significant progress toward the certification of 

commercial ambulatory electronic health records, and in July of 

this year, the first set of ambulatory electronic health record prodVerDate 0ct 09 2002 12:28 Aug 30, 2007 Jkt 029506 PO 00000 Frm 00013 Fmt 6633 Sfmt 6601 C:\DOCS\29506.TXT SAFFAIRS PsN: PAT
10

ucts will be certified. Certification will reduce risk by helping buyers of health IT determine whether products meet minimum requirements. 

Third, HHS has awarded contracts to four consortia of health 

care and health IT organizations to develop prototype architectures 

for a Nationwide Health Information Network. The goal is to develop real solutions for nationwide health information exchange by 

stimulating the market through a collaborative process and the development of network functions. In June 2006, this month, the contractors submitted proposed functional requirements for a NHIN to 

HHS, and there is going to be a public meeting next week to review 

those and to try to sort through those functional requirements from 

the four different contractors. 

Finally, HHS has awarded a contract to RTI International, which 

is working with the National Governors Association Center for Best 

Practices to form the Health Information Security and Privacy Collaboration. Through this contract, health care stakeholders, including consumers, within and across 34 States and territories will assess variations in organization-level business policies and State 

laws that affect health information exchange. These State subcontracts will work with stakeholders within their States to then 

identify and propose practical solutions to address this variation 

and develop detailed plans and implementation solutions. State solutions and implementation plans will be finalized in early 2007. 

Finally, there is an important initiative I wanted to mention 

given the Subcommittee’s interest. In order to promote adoption of 

interoperable health IT systems, last October the Centers for Medicare and Medicaid Services and the Office of Inspector General at 

HHS proposed exceptions to the physician self-referral law and safe 

harbors to the anti-kickback statute. These proposed rules would 

allow hospitals and certain other health care organizations to donate hardware, software, and related training services that meet 

certain interoperability criteria to physicians for both e-prescribing 

systems and electronic health records systems. 

The Department recognizes that interoperable health IT is critical in not only transforming how care may be delivered, but also 

in informing patients and other consumers about costs of care and 

some aspects of its quality. 

Thank you for the opportunity to update you on the progress we 

are making in the area of health IT. HHS, under Secretary 

Leavitt’s leadership, is giving the highest priority to fulfilling the 

President’s commitment to widespread adoption of interoperable 

electronic health records, and it is a privilege to be a part of this 

transformation. 

Thank you very much, and I would be happy to answer any questions. 

Senator CARPER. Great. Well, thanks for that testimony, and 

don’t go away. We will be back to ask some questions. And I am 

sure the Chairman will as well. 

Ms. Koontz, thank you. 

11

1The prepared statement of Ms. Koontz appears in the Appendix on page 48. 

TESTIMONY LINDA D. KOONTZ,1 DIRECTOR, INFORMATION 

MANAGEMENT ISSUES, U.S. GOVERNMENT ACCOUNTABILITY 

OFFICE 

Ms. KOONTZ. Ranking Member Carper, I am pleased to be here 

today to participate in the hearing on health information technology. As you know, VA and DOD are engaged in efforts to share 

electronic medical information, which is important in helping to ensure that active-duty military personnel and veterans receive highquality health care. Also important in the face of current military 

responses to national and foreign crises, is ensuring effective and 

efficient delivery of veterans’ benefits. This is the focus of VA’s development of the Veterans Service Network (VETSNET), a modernized system to support benefits payment processes. 

For the last 8 years, VA and DOD have been working to share 

health information. The Department’s long-term goal is ambitious: 

Two-way, seamless sharing of virtual medical records. In a virtual 

medical record, data are not just displayed as in a paper record, 

but are computable—that is, they can trigger actions such as alerting clinicians of drug allergies. Virtual medical records are, thus, 

important for improving health care and patient safety, and they 

are the foundation of the modern health information systems that 

both Departments are currently developing. 

Besides working on long-term goals for future systems, VA and 

DOD are implementing two near-term demonstration projects that 

exchange limited data between their existing health information 

systems. One of these projects has achieved the two-way exchange 

of health information on patients who receive care from both Departments. The second has implemented an application that electronically transferred laboratory work orders and results between 

the Departments. According to VA and DOD, these projects have 

enabled lower-cost and improved service to patients by saving time 

and avoiding errors. 

In pursuing their longer-term objectives, the Departments have 

also made progress, but they still have much to do. In response to 

earlier GAO recommendations, VA and DOD have taken actions 

such as establishing a project management structure and designating a lead entity with final decisionmaking authority. Also, at 

the end of the month, they plan to begin a pilot to share computable data for the first time, specifically outpatient pharmacy and 

medication allergy information. This will support drug interaction 

checking and drug allergy alerts. 

However, the Departments have experienced delays in their efforts to begin this exchange, originally scheduled for September 

2005. According to officials, the delays occurred because implementing standards for pharmacy and drug allergy data were more 

complex than originally anticipated. In addition, the Departments 

have not yet implemented our recommendation that they develop 

a project management plan that clearly defines the technical and 

managerial processes needed to satisfy project requirements. The 

lack of such a plan increases project risk, including the risk of further delays. 

12

1The prepared statement of Mr. Hendricks appears in the Appendix on page 77. 

VA has also been working to modernize the delivery of benefits 

through its development of VETSNET, but the pace of progress has 

been discouraging. VETSNET was originally initiated in 1986 to 

modernize VA’s benefits delivery network, which the Department 

relies on to make benefits payments. In 1996, after numerous false starts and approximately $300 million in cost, VA revised its strategy and narrowed its focus to modernizing only the compensation and pension system. In earlier reviews, we made numerous recommendations to improve this program’s management, including a 2002 recommendation that VA develop an integrated project plan. 

In 2005, the VA’s CIO became concerned by continuing problems 

with VETSNET and arranged for an independent assessment of the 

Department’s options for the system, including whether it should 

be terminated. This assessment concluded that although VETSNET 

faced many risks, these from management, organizational, and program issues rather than technical barriers. According to the assessment, terminating the program would not solve the underlying 

problems, which would continue to hamper any new or revised effort. Accordingly, the recommendation was made that the program 

not be terminated since its goals were as important as ever, but instead that the Department take an aggressive approach to dealing 

with these management and organizational problems while continuing to work on the program at a reduced pace. In this way, VA 

could make gradual progress on VETSNET while it made necessary 

improvements to its capabilities in system and software engineering and in program management. 

In response to the independent evaluator as well as our recommendation, VA is now developing an integrated master plan for 

the compensation and pension system, which it plans to complete 

in August. This is a first step toward addressing the problems that 

have hampered the program. Until these are solved, it is uncertain 

when VA will be able to end its reliance on its aging benefits technology. 

This concludes my statement. I would be happy to answer questions at the appropriate time. 

Senator CARPER. Good. And there will be some. Thank you very 

much, Ms. Koontz. 

Mr. Hendricks, you are next. Thanks. 

TESTIMONY OF CARL E. HENDRICKS,1 MILITARY HEALTH SYSTEM CHIEF INFORMATION OFFICER, U.S. DEPARTMENT OF 

DEFENSE 

Mr. HENDRICKS. Ranking Member Carper, thank you for the opportunity to come in and discuss the significant achievements we 

have achieved within the Department of Defense as we leverage 

health information technology to enhance care for our beneficiaries, 

both in combat and back here in the States. I also appreciate the 

opportunity to come in and share with you the work that the DOD 

and the Department of Veterans’ Affairs are doing in exchanging 

electronic health information, and in an incredibly complex spectrum of care. 

13

In the DOD, we are driven to ensure that our soldiers, sailors, 

airmen, and marines receive the same quality health care in the 

combat zone that they receive in our brick-and-mortar hospitals 

here in the States. Evidence of our success was noted by the Army 

Surgeon General, General Kiley, in recent testimony in his comment, in which he stated, ‘‘We have recorded the highest casualty 

survival rate in modern history, with more than 90 percent of those 

wounded surviving, many returning fully fit for continued service.’’

One of the components of achieving this level of success is the 

incorporation of health information technology. As a mark of this 

success, since January 2005, we have captured electronically the 

encounters of more than 450,000 encounters in the combat zones, 

and those encounters have been transmitted back to the States for 

Clinical Data Repository and are being included in the electronic 

health records of the Service members. 

We are using the latest technologies in doing that. We are using 

handheld devices. Every medic in the combat zone carries a 

handheld device, and at the point of injury or illness, captures that 

encounter electronically. When they get back to the aid station, 

that is synched into the health system at the aid station and transmitted back to the States to become a part of that electronic health 

record. 

As a point of fact, just last month we captured electronically 

38,212 encounters from the combat zone, which are back in the 

Clinical Data Repository today. Other programs of success include 

the Joint Patient Tracking Application, which allow commanders 

and patient care providers to track the wounded Service members 

through the evacuation chain. More than 4,000 users of this application are using it today, and since 2003, we have tracked over 

120,000 injured soldiers, sailors, airmen, and marines through the 

evacuation chain. 

We are also using leading-edge technologies. In those cases in 

which soldiers, sailors, or airmen are evacuated before the synchronization of data can take place, research is ongoing for electronic 

dog tags to allow the information to be captured on the device, 

stored on the soldier’s body, and go back with them during the 

evacuation chain. To date, we have tested this on more than 9,000 

Stryker Brigade soldiers in the combat zone. Development continues on that device. 

One of the key cornerstones of our success in health IT is our 

electronic health record, AHLTA. It provides day-to-day functions 

of delivering and documenting health care for our 9.2 million beneficiaries. Today, we have deployed the Armed Forces Health Longitudinal Thechology Application (AHLTA) to over 115 of our 138 

sites and will have full deployment of AHLTA by the end of this 

calendar year. What it means is no matter which DOD hospital 

around the world a patient goes to, our providers will have access 

to their electronic health record. 

I mentioned earlier about ensuring continuity of care from one 

level of care to the next being critical, and especially true for our 

Service members that are transferring to the VA. Ms. Koontz mentioned the Federal Health Information Exchange, which is a oneway push of data from the DOD to the VA. As you spoke, you carried your records with you to the VA. We have pushed the elecVerDate 0ct 09 2002 12:28 Aug 30, 2007 Jkt 029506 PO 00000 Frm 00017 Fmt 6633 Sfmt 6601 C:\DOCS\29506.TXT SAFFAIRS PsN: PAT
14

tronic records of over 3.5 million Service members to the VA at 

time of their separation. Of those, 2.8 million have presented to the 

VA for care, treatment, or claims adjudication. 

We also have a Bidirectional Health Information Exchange, 

which enables real-time sharing of allergy, outpatient medication, 

demographics, lab, and radiology data. It is currently deployed to 

14 DOD sites, with more deployments going this year. 

The DOD Clinical Data Repository/VA Health Data Repository, 

referred to as ‘‘CHDR,’’ is established an interoperability of computable data between the two clinical data repositories—the Clinical 

Data Repository of the DOD and the Health Data Repository of the 

VA. That has been tested in the lab environment and will go live 

this month in El Paso, Texas, for on-site testing. 

Senator Carper, I would like to thank you again for the opportunity to discuss our progress. The DOD holds a strong commitment to leverage electronic health information in support of the 

Nation’s heroes and families. Much has been accomplished, and the 

groundwork has been laid for even greater progress in the future. 

This concludes my comments, and I stand subject to your questions. 

Senator CARPER. Thanks very much for your comments. 

Before I recognize Dr. Kussman, one of the incidents that occurred about a month and a half ago now in Iraq, actually in 

Fallujah, involved a marine who is a former member of my staff, 

my campaign staff and my Senate staff. He was shot in Fallujah 

by a sniper’s rifle, and it was buried right in his neck, right by his 

Adam’s apple. It missed it, severed his carotid artery completely, 

nipped his jugular vein, came out right by his spinal cord, missed 

it. And he ran to get behind some cover, and one of his colleagues, 

marine colleagues, radioed for help but got a Navy corpsman, found 

him not far away in a Humvee. And the Navy corpsman came, administered first aid, they got him to a Fallujah hospital within less 

than 15 minutes. A surgeon went to work on him and was able to 

put his artery back together to save his life, flew him to Germany, 

flew him to Bethesda, and about 2 weeks ago he walked out of Bethesda Hospital alive. And he has impairment of his shoulders, has 

nerve damage that does not allow him to move his right shoulder, 

but thank God he is alive. And last week, the Commandant of the 

Marine Corps in the building just next door, the Russell Building, 

gave him the Purple Heart. It was great, very special. But just 

from our own family here in the Senate, having almost lost one of 

our own, we are just deeply grateful for the extraordinary medical 

care and attention that he received on the spot, just like that, and 

it literally saved his life. I know he is just one of many, so thank 

you. 

Dr. Kussman. 

15

1The prepared statement of Dr. Kussman appears in the Appendix on page 89. 

TESTIMONY OF MICHAEL KUSSMAN, M.D.,1 DEPUTY UNDER 

SECRETARY FOR HEALTH, U.S. DEPARTMENT OF VETERANS’ 

AFFAIRS, ACCOMPANIED BY ROBERT HOWARD, SUPERVISOR, OFFICE OF INFORMATION AND TECHNOLOGY, U.S. 

DEPARTMENT OF VETERANS’ AFFAIRS 

Dr. KUSSMAN. Thank you, and good afternoon, Ranking Member 

Carper. On behalf of the Department of Veterans’ Affairs, I am 

pleased to take this opportunity to discuss the comprehensive electronic medical record used by VA to provide world-class medical 

care and to support our veterans. I am also pleased to discuss the 

significant progress we have made toward the development of secure, interoperable technologies to achieve sharing of health data 

within the Department of Defense. VA and DOD are working closely together to ensure the seamless transition of medical services for 

our men and women returning from Operation Iraqi Freedom and 

Operation Enduring Freedom. 

VistA, or the Veterans Health Information Systems and Technology Architecture, is recognized as the most comprehensive electronic health record in use anywhere. It allows VA to provide better, safer, and more consistent care to more than 5.3 million veterans in all VA hospitals, outpatient clinics, and nursing homes—

more than 1,400 points of care all across the Nation. Using VistA, 

doctors and other clinicians can easily pull up computerized patient 

data, including images. Clinicians can use the system to update a 

patient’s history, place orders, and review test results. They can 

quickly review information from previous visits, access clinical 

guidelines, and view medical publications to find the latest treatments in medication. All of this information is available wherever 

the patients are seen—in acute settings, clinics, exam rooms, nursing stations, and offices. Tools such as electronic health care 

prompts, computerized order entry, and barcode-assisted medication administration systems have largely eliminated transcription 

and medication errors while strengthening patient safety. 

VA is proud of its leadership role in health information technology, and we are continuing to enhance VistA. We are now working to supplement the capabilities of VistA to capture the advances 

of new and emerging health care technology and improved care for 

veterans. The next generation of VistA will have the flexibility to 

better support integrated ambulatory care, home-based health care, 

tele-health, and improved response times. Next generation VistA 

will strengthen the existing privacy and security protections, and 

it will support a more robust sharing of patient data with our partners in the Department of Defense and other care providers. Like 

the current version, next generation VistA will remain in the public 

domain and available to other Federal agencies and providers in 

rural and underserved communities. 

VA and DOD efforts to achieve interoperable health technologies 

are guided by the VA/DOD Joint Electronic Health Records Interoperability Plan—known as JEHRI. Since we began implementation in 2002, we have steadily progressed toward the final goal of 

exchanging standardized computable health data between our Departments. The first phase of the plan, FHIE, as you heard, reVerDate 0ct 09 2002 12:28 Aug 30, 2007 Jkt 029506 PO 00000 Frm 00019 Fmt 6633 Sfmt 6601 C:\DOCS\29506.TXT SAFFAIRS PsN: PAT
16

sulted in the development of a one-way flow of electronic DOD 

health information to the VA, which allowed our clinicians to view 

all pertinent DOD historical electronic information. Later, we developed the capability to support the real-time bidirectional exchange of electronic medical records or data between DOD and VA 

hospitals and clinics. The bidirectional system delivers electronic 

outpatient pharmacy data, laboratory reports, radiology reports, 

and food and drug allergy information. 

The next phase of our plan includes the sharing of computable 

allergy and pharmacy data between our next generation systems. 

Both VA and DOD are in the process of working together to ensure 

that our next generation data repositories now under development 

are interoperable and capable of sharing standardized data. Thus 

far, we have demonstrated this capability in a laboratory test environment and are preparing to begin production testing of the software in July 2006. 

The Departments also are working together as VA modernizes its 

existing imagine solution and DOD explores acquisition of new imaging technology. The Departments are actively exploring a collaborative imaging solution that will use VA technology to support 

shared access to images such as radiologic studies in both DOD 

and VA facilities. The bidirectional exchange of electronic health 

data between different health information systems is a monumental accomplishment. The work is dependent upon the adoption 

and implementation of health data and communications standards. 

VA and DOD are breaking new ground in this area and remain at 

the forefront of health data collaboration and exchange activities 

within the Federal Government. 

I now wish to briefly discuss the existing protections that ensure 

that our DOD/VA health data exchange initiatives are secure and 

fully protect the personal health information of our veterans and 

military beneficiaries. 

Our sharing systems are in full compliance with the VA Office 

of Cyber Security policies and DOD Information Assurance policies. 

These projects also comply with the privacy regulations contained 

in the Privacy Act and the Health Insurance Portability and Accountability Act meant to protect the unauthorized use or transmission of personal health information. To ensure the highest level 

of protection for these clinical data, we employ a double-encryption 

method using a hardware-based Virtual Private Network (VPN). 

After having passed an initial and subsequent review of security 

protections, our systems framework received a VA-issued renewal 

of the Authority to Operate in December 2005. DOD information 

security officers concurred with and accepted this rigorous review. 

As sharing partners, VA and DOD take very seriously our duty to 

protect the sensitive health data entrusted to us in the course of 

caring for veterans and military beneficiaries. 

Health information technology is not about technology, but it is 

about improving the quality of care and health outcomes for patients. VA is fully committed to ongoing collaboration with VA to 

do just that. 

Sir, this completes my testimony, but my colleagues and I are 

happy to answer any questions that you or the Chairman, if he returns, or any other Member who comes have. 

17

Senator CARPER. OK, good. Dr. Kussman, thank you very much. 

Dr. Ross Fletcher, welcome, sir. Thank you. We are glad you are 

here. What are you going to show us today? 

TESTIMONY OF ROSS FLETCHER, M.D., CHIEF OF STAFF, 

VETERANS MEDICAL CENTER, WASHINGTON, DC 

Dr. FLETCHER. Thank you. What I plan to show is the electronic 

health record that we use at our hospital and across the system everywhere. 

Senator CARPER. Tell us a little bit about your hospital, if you 

would. 

Dr. FLETCHER. We can see you from our hospital. It is straight 

up North Capitol Street, and I am at the VA in Washington, DC, 

and we are tertiary care hospital that does cardiac surgery and a 

wide range of activities. 

We have been involved in the IT process for many years and 

have often instituted things first in our place, but we accept everything that has been done elsewhere in the system. So we now have 

a system that we feel very proud of and we enjoy a lot and tend 

to demonstrate to lots of people who come by. 

Senator CARPER. Good. Well, thanks. We are glad you are here 

and look forward to your presentation. 

Dr. FLETCHER. The lights can be dimmed. 

Senator CARPER. Can the lights be dimmed? 

Dr. FLETCHER. It would be nice. 

Senator CARPER. Apparently, if we dim the lights, then we are 

unable to record. 

Dr. FLETCHER. That is fine. I think that shows up relatively well. 

This is the way the record shows up when we open it up to a given 

patient. We have an active problem list, active medications. We 

have a list of their allergies and postings and their vital signs. 

We have tabs that are very user friendly. The nice thing about 

the system at the moment is the intern or resident can come, without knowing anything about the system, and be operating it very 

quickly, maybe 2 hours of training at the most, and be taking care 

of patients that day, that evening, and liking it better than the systems they have been on in the past. And that we have shown many 

times. 

If we go across the tabs, we see the problem list so that the problems can be changed at will. We have medications and all of the 

orders are done in the system. We are able to do inpatient, outpatient medication orders, imaging orders. If I simply click on ‘‘Imaging,’’ you can see that if I want general radiology, I can get it. 

Chest, PA, and lateral is now being ordered. If I say accept the 

order, it is in my Radiology Department. The patient goes down 

and gets his X-ray, just having told the clerk at the desk who he 

is. 

If I want to order medications, I simply order these. I have order 

sets as well, which are typical for our hospital, but we are using 

the standard software across the system. 

If I go into ‘‘Notes,’’ I can immediately see the notes that are 

available. I can see a list of all the notes that are here. And if I 

open up our imaging system by, in this instance, clicking down 

18

here, you can see that we have EKGs, X-rays on the patient, as 

well as any other pieces of data. 

If I move on to the discharge summaries, you can see that those 

are listed. If I go into ‘‘Labs,’’ we have the ability to look at each 

lab report that has come through, like you might see in a paper 

record. But, more importantly, I can take that information into a 

worksheet and ask for the data for all time for this particular patient. It is now in a spread sheet where I can easily see it in a 

graphic format, the sodiums being quite low when the patient first 

came in. 

If I want to see any of the other values, I can see that the hemoglobin was also quite low, and the white count was quite high. This 

patient had an elevated white count in the face of paralysis on the 

right leg first and then on the left leg second. He had been in another hospital for 2 months and was sent over to us. We did draw 

a Lyme disease titer, found out that he had deer tick disease, gave 

him the appropriate antibiotic, dropped his white count down, and 

he was able to walk in about 3 months. 

You can see that when he came in, his weight was quite low—

again, we go to ‘‘All Results‘‘—and came gradually up to normal 

weights, but started to have other kinds of problems out over to the 

right. 

I can expand that by simply clicking my zoom button, and he 

came in with a pleural effusion on his right side. I will move this 

over slightly. And when we saw the pleural effusion—this is a pleural effusion he had on the other side. As I go up and look at the 

X-rays, you can see that I can see fairly marked changes. Indeed, 

he had a pleural effusion on the other side, which I can simply put 

up next to that X-ray and compare. 

When he was on the left side, I simply asked him how he slept. 

He said, ‘‘I sleep on the left side.’’ That fits. We thought he had 

heart failure. Usually you have effusions on both sides. But I knew 

that he had one on the right side before, and I asked him if he always sleep on his left side. He said, ‘‘No. I used to sleep on my 

right side until I had a hip fracture,’’ which you can actually see 

by the X-ray in place here. And the fix for that was to put a hip 

nail in place. And you can see that comparison. 

The heart failure that he had was easily elucidated by an MRI. 

We saw when we did an MRI that his heart out laterally was moving quite well, but the heart on the septum was not, and that is 

because his electrocardiogram showed left bundle branch block. I 

will show you one more view. 

Senator CARPER. I am sorry. What did it show? 

Dr. FLETCHER. Left bundle branch block. Left bundle branch 

block is an electrocardiographic feature which is seen—I will move 

this over—right here, and it had gotten wider and wider and wider. 

And that prevented the septum from moving in the right direction. 

It moved towards the right heart instead of the left heart and 

caused the heart failure, which we can see easily on this other film. 

Notice that if I put the arrow on the septum, which should be moving to the right, in actual fact, if anything, it is moving over to the 

other side. 

So this man was brought in and treated. At any time, at any 

point of care, we could see all of these images and make our deciVerDate 0ct 09 2002 12:28 Aug 30, 2007 Jkt 029506 PO 00000 Frm 00022 Fmt 6633 Sfmt 6601 C:\DOCS\29506.TXT SAFFAIRS PsN: PAT
19

sions. We also could see any images that he might have had anywhere else in the VA system because we have remote image view. 

And, indeed, we had him followed in his home, and these particular 

very tight values that you see were taken on a scale in his home. 

They were digitally transmitted to the hospital and moved into his 

records. So I can see his weight when he was in the hospital and 

when we were taking off his effusions, but I also can see every 

weight at home, and notice that we did not bring him back into the 

hospital because once he got up close to this other weight, we 

would increase his lasix and bring the weight down. So we have 

home-based care for this particular patient. 

Many of our other patients, we are able to put them on a program we call My HealtheVet, and they have a cover sheet. Everything in the record on the thousand patients we have in the pilot 

site is being downloaded. Notice they have a problem list, they 

have progress notes that you can see as a list, and at home they 

can actually enter in their own weights and follow those along. 

They can also enter in their own blood pressures, which you can 

see that they follow graphically as well. 

They frequently are putting in comments, like they had too much 

salt, when the blood pressure gets up, so they are treating themselves very nicely and taking the role of the clinician between the 

visits. We might see them every 3 months, but they see themselves 

every day and are taking these values. When they get high, we are 

automatically triggered at our hospital to see them so that we have 

a very nice patient-centered record. Everything that happens to the 

patient goes in one record. Anytime the patient is seen, we see 

what’s happened at home, what’s happened in the outpatient clinics, what’s happened in the hospital, and can correlate those pieces 

of information for the best possible care for the veteran. 

Senator CARPER. Good. Thank you very much. That is impressive. 

Let me start off with a question of our friends from the VA. Just 

if you will kind of go back in time and give us some idea of the 

genesis of the VA’s revolutionary work with respect to IT, harnessing IT in the delivery of health care. How did it start? 

Dr. KUSSMAN. Thank you for the question. 

Senator CARPER. What sustained it to the point that we have just 

seen today with Dr. Fletcher’s presentation? 

Dr. KUSSMAN. Yes, sir. One of the exciting things about the historical development of the VA’s electronic health record is it started 

with the people who are in the foxhole providing the care. One of 

the things that we have seen and one of the resistances for the deployment of an electronic health record around the country—and I 

concur wholeheartedly with the Chairman’s comments that he 

made—a lot of times physicians resist things happening to them, 

especially if it is pushed on them from someplace else. 

Senator CARPER. It is not just physicians, too. It is nurses, it is 

others. 

Dr. KUSSMAN. Well, society in general, perhaps. But, in truth, a 

lot of the case histories where the implementation of electronic 

health record in the civilian community have failed when the providers themselves, the doctors and nurses, particularly the doctors, 

have not been brought into the system right from the beginning 

20

and felt confident that this was value-added to them and their patients. 

One of the strengths for us has been that we were able to develop that from the users, and over a period of time this evolved 

to the point where everybody learned from everybody else. There 

were developments made and ultimately cascaded into what we believe is the premier electronic health record in the country. 

I might ask Dr. Kolodner, who works in Information Management for us, to make a comment on that if you don’t mind, sir. And 

tell us again your affiliation. 

Mr. KOLODNER. I am the Chief Health Informatics Officer in the 

Veterans Health Administration, Department of Veterans’ Affairs. 

Senator CARPER. All right. Well, welcome. 

Mr. KOLODNER. Thank you. Yes, the opportunity to work together hand in hand with our IT colleagues has been really the 

characteristic that allows us to have succeeded as well as we have 

with both the delivery of the software but, even more importantly, 

the acceptance of it and the growth of it over time. So we started 

this 20 years ago. Ten years ago, we upgraded our system to have 

the application that you saw here today, which we call CPRS, and 

that point-and-click system was one that just was very easy for our 

clinicians to use and to accept. 

As we put it out, the doctors and nurses and psychologists and 

social workers around the country would work with us and provide 

back suggestions for how to improve it. We are currently on version 

26 of this software, and it has been something that we find is extremely widespread so that, for example, 81 percent of our encounters, our patient encounters, have an electronic note within 24 

hours. 

Senator CARPER. Say that percentage again? 

Mr. KOLODNER. Eighty-one percent within 24 hours, and we have 

57 million encounters per year. So this is something that is used 

in all of our hospitals, clinics, and long-term care facilities, the 

same software. And our providers are the ones who use it and also 

provide suggestions on how to improve it and really have a sense 

of ownership as we roll it out. 

Senator CARPER. In terms of lessons learned from what the VA 

has gone through over the last—it sounded like 20 years. I thought 

it was more like 10 years, but it sounds like it is longer than that. 

But in terms of the lessons learned within the VA for the rest of 

us, for the rest of us within government, I think especially about 

Medicare and Medicaid where costs are exploding, and we cannot 

pay for those already; we cannot afford those already. And the 

costs are getting larger. The boomers are heading toward retirement territory. So the pressure is going to be even greater financially on us. 

But what are some of the lessons learned as we attempt to harness IT, health IT, and bring it to other parts of our Federal Government? 

Mr. KOLODNER. There are a few things that certainly we are able 

to bring forth, as well as our colleagues at the Department of Defense, where they also have an extensive use of their system as 

well. One of the things is that it must be something where there 

is a partnership by the end users with the people who are proVerDate 0ct 09 2002 12:28 Aug 30, 2007 Jkt 029506 PO 00000 Frm 00024 Fmt 6633 Sfmt 6601 C:\DOCS\29506.TXT SAFFAIRS PsN: PAT
21

viding the system or requiring the system. It also is something 

where the alignment of payer-provider incentives is very important. 

We are able to gain the benefit of the system—of having the IT system in place because we give better quality care to our veterans; 

we are able to see that as providers. That is very reinforcing. And 

we also have a savings by not having unnecessary tests or unnecessary hospitalizations. 

If a provider is asked to have a system and there is no sharing 

of that overall savings within the system, then it does create a barrier, as the Chairman pointed out. And so we need to look at how 

to make sure that those incentives are there in place. 

Senator CARPER. How might we do that? 

Mr. KOLODNER. I think that is one of the challenges that we are 

wrestling with as a Nation, and certainly Secretary Leavitt and the 

AHIC are looking at how to provide the business case, how to provide those right incentives, and how to make sure that the barrier 

for entry is low enough that we, in fact, can bring the Nation along, 

either by a pull from the providers or by also educating the consumers so that they can provide a push and indicate to their clinicians how important it is for their clinicians to have the electronic 

health record since most of us don’t receive all of our care from one 

particular provider. Even in VA, we estimate that 40 percent of the 

veterans we treat each year get care outside of VA. So the interoperability, whether it be with the Department of Defense where 

we have several hundred thousand veterans who get care each 

year, both at VA and DOD, or whether it is in the private sector, 

where we have additional hundreds—actually, millions of veterans 

who get care outside of VA. The interoperability is critical for us. 

Dr. KUSSMAN. Sir, I might add to that that the Chairman’s comment about the economic reality of—even in his group he was talking about that everybody is waiting because you want to know the 

standards or you do not want to invest in something that you will 

have to reinvest in. I am the VA’s representative to the House of 

Delegates at the American Medical Association, and just talking to 

people in the private sector, a lot of that is discussed because they 

want to know what the value-added for them is, and they certainly 

do not want to make a significant economic commitment, and then 

find out that they have to do it again a year or two or three from 

now. 

So one of the incentives I think would be—and this is just talking personally—trying to figure out what those standards are as 

soon as we can get them out and assure people that their investment will be worth it and have some sustaining value for at least 

a finite period of time. 

Senator CARPER. Has there been an effort to take the work that 

you do in the VA and to be able to share it with other providers 

outside of the VA? I believe the answer is yes, but talk about that 

effort. How has it succeeded? Where has it gone well and maybe 

where has it not gone well? 

Mr. KOLODNER. There are two types of efforts. Because our system is public domain, we actually have our code posted on the Web, 

and it has been downloaded and used by other entities. 

Senator CARPER. By a lot of other entities? 

22

Mr. KOLODNER. A few other entities. The issue there is support, 

and one other aspect of success is that this is not like installing a 

word processor or a spread sheet. It is a complex system. It has 

various standards. It needs support of a vendor or an organization 

to make sure that this is successful. And until recently, that was 

not an infrastructure that was available to support the VistA system. That is not within our mission or our funding. So, recently, 

there are other companies that have come forth and are supporting 

VistA in non-VA settings. 

In addition, one other effort that is going on in the Federal Government is one that HHS has undertaken through the Centers for 

Medicare and Medicaid Services, CMS, and that is a project called 

VistA Office EHR, and they are responsible for that, so I would 

need to turn to HHS. I don’t know whether Jodi is in a position 

to comment on it or whether she would want to defer. 

Senator CARPER. Ms. Daniel, would you care to comment on that? 

Ms. DANIEL. Sure. I cannot talk in too much detail about it. It 

is a CMS project, but basically the——

Senator CARPER. How would you explain what you are talking 

about in laymen’s terms so that anybody who might be listening or 

watching would understand it. 

Ms. DANIEL. Sure. There has been some interest in using the 

VistA system for physicians’ offices, but there are very different 

types of needs in a physician’s office compared to an inpatient setting. So CMS has been working toward modifying the VA system 

in order to make it useful for a physician’s office. 

They are currently doing a demonstration right now. It is in beta 

testing. They are trying to see if this is something that is workable, 

if it is something that is useful in a physician’s office, and they are 

still in the testing phase right now. We are planning to work with 

CMS to see what kind of results they find through that process. 

One of the significant issues that we see, though, is that there 

is an expense of the technology, but there is also needs to have 

training and ongoing support for use of an electronic health record 

system, which also can be a challenge in a small physician’s office. 

So while this may be one possible approach that can help with 

adoption, there are many other possible approaches, and there are 

some challenges that still lie ahead. 

Senator CARPER. All right. Thank you. 

I think I would like to go to our friends from the Department of 

Defense, and talk to us, if you will, about the effort to sort of better 

interface between DOD active duty and the VA and how those efforts have gone. If you could just talk about that a bit, I would appreciate it. 

Mr. HENDRICKS. Yes, sir. We have worked a number of years 

with the VA and sharing data between the two Departments. The 

approach that was taken was to basically break down the type of 

data that the providers are going to need. One of the critical decisions that was made early was to separate it into what is necessary 

from a viewable standpoint, what data do you simply need to see, 

versus what data needs to be computable. 

The Bidirectional Health Information Exchange (BHIE) is a huge 

breakthrough for both Departments, which allows a provider, when 

a retiree who is disabled and is getting care from the VA goes to 

23

either the DOD or the VA site where they have BHIE, that provider can pull up the records from the other Department and actually view it. When the patient leaves, the data goes away, so, therefore, you do not have the security challenges with that. So making 

viewable data has been worked, allowing us to expand many types 

of data sets. 

But there is also computable data that is necessary. Computable 

data and sharing that is significantly more difficult in that you 

have to map the data elements from both systems such that the 

computer can understand the terms and the data elements that are 

coming across. And that is the work that we are doing in El Paso, 

Texas, as we speak. 

What this allows is for medications and for allergies, so instead 

of having the provider understand that I may be allergic to Tylenol 

and if they are giving me codeine, to understand that that particular codeine has Tylenol as a carrier with it, the computer automatically knows because the data is computable and can give the 

alert to the provider. 

The computer also know that there are secondary allergies, and 

during the computable data match, it mirrors both systems. 

So, again, I think the biggest success we have achieved is by 

looking at the types of data that we are looking to exchange and 

what is necessary as a part of that exchange. 

Senator CARPER. Thank you. 

Some of us in the Senate are contemplating introducing legislation this summer that would require insurance companies that 

cover Federal employees or families or dependents or Federal retirees to require within a period of a year or so for those health insurance companies to provide electronic health records for Federal employees or Federal retirees and our family members. 

Would any of you care to comment on the wisdom of that? Good 

idea? Bad idea? Well-intended but maybe flawed? Or if you have 

some advice as to how we might go about and how we might craft 

the legislation, I would appreciate that. Anybody at all. 

Dr. KUSSMAN. I guess no one else is volunteering, so, sir, I think 

that from the VA’s perspective, we are looking at aggressively, as 

we buy health care in the community, and looking at our contracts 

and looking at how we do that, to try to be sure, as much as possible, and try to write this into the potential future contracts, that 

whoever we buy the care from would have the ability to accept and 

transfer electronic information. 

The challenge, the obvious one, is that does not exist in many 

places around the country. So when you are trying to get care, how 

do you do that? And so I think it is a challenge that really goes 

back to the original thing. How do we encourage the health care 

community around the country to want to become part of an electronic record to better the care for our patients as well as the interoperability and transfer of information. 

Senator CARPER. Let me hear from some others. Mr. Hendricks. 

Mr. HENDRICKS. Yes, sir. In writing contracts for electronic 

health records, I think one of the challenges we are going to run 

into will be how do you write the contract. Do you write the contract such that you keep them current with each standard? Which 

is the released number of standards could be difficult to have the 

24

audit trail to ensure that they are in compliance with that? The 

work of the Office of the National Coordinator and the American 

Health Information Community, I think, is taking this a long way 

down a path that could make that a little easier. They have established a certification process for electronic health records by requiring those contracts to state that you must be compliant with the 

certification process. I think it would make it far easier for us to 

then audit the contracts in place. 

So, I would simply suggest as long as the language doesn’t focus 

on standards per se and focuses on certification, it would make it 

a lot easier for implementation. 

Senator CARPER. Thank you. Ms. Daniel. 

Ms. DANIEL. Yes, there are two points I wanted to make with regard to this. 

First, we recently had, as I had mentioned, recommendations 

made by the American Health Information Community, and one of 

those recommendations was to try to consider ways to incorporate 

standards and certification into our contracts, as some other folks 

had mentioned. So we are thinking now about how we can include 

those kinds of processes and standards in the contracts that we 

currently have, and we have a Health IT Policy Council that has 

represented us from DOD, VA, and OPM, as well as other Federal 

agencies, that are sitting around the table together to try to figure 

out how to address that type of issue as well as other issues related 

to health IT. 

The one point that I would like to note and that I would want 

to caution is that using health plans may not be the best approach 

because claims data may not be complete and is often delayed. It 

is not real-time data like clinical data would be. 

So there are some concerns about claims data as opposed to clinical care data that are important to consider, and also focusing on 

the health plans rather than the clinicians has some consequences 

to it. 

So I just wanted to raise that point as you are thinking about 

that legislation 

Senator CARPER. OK, good. If we are interested in some further 

guidance, could we come back to you? 

Ms. DANIEL. Absolutely. 

Senator CARPER. All right. Good. You are a Federal employee, 

aren’t you? 

Ms. DANIEL. Yes. 

Senator CARPER. Any input and guidance you could give us, we 

would be grateful. 

Ms. Koontz, could I direct the next question to you? I may have 

mentioned in my opening statement, I believe, that the health care 

providers outside of the VA and the DOD can learn some valuable 

lessons from these two Departments about how to best implement 

and use health information technology. Do you also believe that 

there are some lessons that can be learned from these Departments? And if so, do you want to share those with us? 

Ms. KOONTZ. I do. In fact, GAO has previously reported on a 

number of lessons that were learned from the VA/DOD interoperability experience that we thought might be applicable to the larger 

effort to develop national health information records. And among 

25

the lessons learned that we mentioned are many of the ones that 

Dr. Kolodner already previously went over, and I would be happy 

to submit the whole list for the record. 

Some of the ones, though, that we specifically talked about was 

the interaction with stakeholders and the need to bring those together in order to develop the initiative. 

Senator CARPER. Is that something that needs to be done early 

on? 

Ms. KOONTZ. Absolutely. As early as day one. And, also, I think 

we also emphasize the importance of——

Senator CARPER. Whenever I am trying to get somebody to go 

along with me if I have an idea, I try to first convince them it was 

their idea. [Laughter.] 

And that they are convincing me to go along with their idea. 

Ms. KOONTZ. I do not know if our lessons learned went that far. 

Senator CARPER. I understand. 

Ms. KOONTZ. I think the other thing that we mentioned, too, as 

well as many others, was the importance of adopting common 

standards, terminology, and performance measures, in developing 

the health IT records. 

Senator CARPER. Talk to us just as a follow-up to that about the 

development of the standards. Legislation has actually been introduced in the Senate, I think last year, offered by Senator Frist, 

Senator Enzi, Senator Clinton, maybe all of the above, and that 

legislation has passed the Senate, I think unanimously and is over 

in the House. I do not know that the House has focused much on 

it. 

Ms. Daniel, is that something you are familiar with? I see you 

nodding your head. 

Ms. DANIEL. Yes, I am. 

Senator CARPER. Could you talk to us a little bit about what the 

Senate has done and what the House might be contemplating? 

Ms. DANIEL. As you had mentioned, the Senate has passed a 

health IT bill last fall. I believe that the House has a bill that has 

passed out of committee, out of both Ways and Means and Energy 

and Commerce. 

Senator CARPER. How do the two approaches compare and contrast? Can you help me with that? And if somebody else who might 

be sitting in the row behind any of you would like to share their 

insight, you are welcome to step to the table, and we will hear from 

you as well. Anybody who has special insights? 

Back to you, Ms. Daniel. If you are able to compare and contrast 

the legislation, the two approaches, that would be fine. 

Ms. DANIEL. I am not really prepared to do that today. I apologize. 

Senator CARPER. If you could just do that for the record, that 

would be fine. That is all right. I do not expect you to know everything. 

One of the things that has been mentioned is training. I was in 

a health care setting the other day—actually, last week, and the 

folks that were taking me through said—it was actually a nursing 

home, one that had some people in reasonably good health and 

some people in very bad health. And they said about half the peoVerDate 0ct 09 2002 12:28 Aug 30, 2007 Jkt 029506 PO 00000 Frm 00029 Fmt 6633 Sfmt 6601 C:\DOCS\29506.TXT SAFFAIRS PsN: PAT
26

ple who come there to live go home and about half who come there 

to live, live there for the rest of their lives. 

They indicated to me that it was difficult to get their staff to accept and to literally be trained on using the systems that had been 

introduced, and they actually talked about the reluctance of, in this 

case, some of the nursing staff not wanting to type information into 

the system. 

I suggested to them to maybe consider asking Delaware Technical Community College to consider offering training programs for 

folks in all kinds of health settings to use systems of this nature 

if the in-house training was not good enough. 

When I was governor, we tried to harness the technology and put 

it in our schools, a lot of computers in our classrooms. We sought 

to get our teachers to use them and try to relate our academic 

standards to the technology and to use the Internet and so forth 

to bring the learning into the classroom. We found that there is a 

lot of reluctance. We had a better ratio of computers to students 

than any State in America. We had a reluctance on the part of the 

teachers to use the stuff, except for the new teachers, the ones recently out of college who were familiar with the technology, comfortable with the technology. 

Eventually what happened was we contracted with the Delaware 

Technical Community College, and they started training some of 

the veteran teachers, and we had the younger teachers who came 

out of colleges and began teaching, and they sort of trained the veterans. And between the two, we finally got to the point where we 

are doing a much better job of harnessing technology to promote 

learning in the classrooms. 

But just in terms of training doctors and nurses—not just registered nurses but LPNs and others—to use these systems, what 

seems to be working and maybe what does not work? 

Mr. KOLODNER. What we have found over the years is that you 

really had to have a tremendous amount of help, what we call 

‘‘help at the elbow,’’ help right there early on. Simply putting in the 

technology, doing a quick class, and then walking away does not 

help people to change that practice and to get comfortable with the 

system. 

So what we end up doing is having people deployed throughout 

the facility, whether that is inpatient or outpatient settings, to be 

there, especially early on when the system first goes up, to answer 

any questions, to go around and check with the users to see what 

are those little things that they have not gotten comfortable with 

yet or that they have not figured out how to work with very 

smoothly, and for what we call our clinical application coordinators 

to be there and help them through that. 

We also use a process of having clinical champions. Dr. Fletcher 

was one when this first came out and he was Chief of Cardiology. 

And they are the advocates. It is not pushed in from the outside. 

It is actually drawn in from the inside, and you find those early 

adopters, have them make sure that the system really does work, 

work out whatever little barriers there might be, get those 

smoothed out, and then——

Senator CARPER. Sort of a kind of bottoms-up approach that the 

Chairman was talking about? 

27

Mr. KOLODNER. Absolutely. And once it reaches a certain level, 

like 40 or 50 percent of the users, at that point the top-down management saying this is the target that can drive it to completion. 

But doing that too early actually gets resistance, and doing it too 

late wastes the opportunity to have it used widely. 

Senator CARPER. Good. Thank you. Dr. Kussman. 

Dr. KUSSMAN. Sir, on top of that, you had mentioned there are 

cultural and age differences. The new group of interns and residents that Dr. Fletcher mentioned, they take to this very easily. 

They have grown up with computers. They feel comfortable with it. 

Some of us are little dinosaurs, and when we went through the 

process, it took a little longer to adapt to it because early on—for 

me anyway, I do not type too well or too fast, I use two fingers. 

When I was going to write a prescription for somebody, it took me 

a minute or two to go through the steps of writing it. I could write 

a prescription in 15 seconds. And so I had to learn, but the valueadded, as I got better with it and became inculturized with it is 

really learning and feeling comfortable with it. And that is the 

process that Dr. Kolodner was mentioning. 

But most people, when they get comfortable, realize that it is a 

quantum leap improvement in the delivery of care. 

Senator CARPER. I would think if I were a provider, maybe a doctor or maybe a nurse or an LPN or someone who is even less senior 

than that, but if this was a skill that I learned—in some of these 

settings, especially nursing homes—there is huge turnover. But my 

sense was that if I was someone working in one of those places, if 

I could learn these skills, learn these systems, I just think it would 

make me more marketable, more employable, and hopefully to earn 

more money. Is that the case? 

Mr. KOLODNER. It is, but even more importantly, what we find 

is that the people who have that skill then either choose to stay 

at that facility because it has the capabilities and they know that 

they are able to give better care. 

Or they look for facilities that have that, so that it becomes a 

driver in the system as well. The first time that we have a nurse 

who does not give a medicine because the barcode medication administration system stopped him or her from giving medicine, they 

become a believer in the system. 

Senator CARPER. Yes. I have been to hospitals, VA hospitals, 

where they are actually using that barcode, and it is pretty impressive to see how that works. 

Ms. Daniel, I have a question for you and then maybe a couple 

more, and then we will perhaps wrap it up. I understand that the 

Office of the National Coordinator has experienced some pretty big 

changes this year, not just with the departure of Dr. Brailer, but 

with the addition of four new intra-offices. I do not know much 

about this, but can you just give us some further details on the reasoning behind the expansion in the roles of these new offices? 

Ms. DANIEL. Sure, I would be happy to. 

Senator CARPER. What are they? 

Ms. DANIEL. There are four new offices and an immediate Office 

of the National Coordinator. The four offices are the Office of 

Health Information Technology Adoption, the Office of Interoperability and Standards—so those are sort of the two goals that I had 

28

mentioned that we are working towards—and then the Office of 

Policy and Research, which is the office that I had up; and the Office of Programs and Coordination. 

The reason that these new offices were formed is that originally 

it was sort of just a very small group of folks when the office was 

first founded that were trying to pull all this together. And just 

last summer, there was a formalization of the office. The Secretary’s office had played a role in figuring out what the best approach was for formalizing the office and setting up the different 

structures so that we can be responsive in a variety of different 

areas and different approaches. 

So we have the National Coordinator, a Deputy, Directors of 

those four offices that I mentioned, and then staff below all of those 

four Directors. 

As you mentioned, we have recently, sadly, lost Dr. Brailer. He 

resigned last month. I believe that from what I hear, the Department is currently looking for a new candidate to fill his role, and 

I do not have any information about where that stands at this 

point. 

Senator CARPER. All right. Good. 

A question, if I could, maybe for Mr. Hendricks, please. Mr. Hendricks, in Delaware, we raise a lot of chickens. In fact, in Delaware, 

there are 300 chickens for every person who lives in our State. So 

for anybody in the audience who is eating chicken these days, God 

bless you. Keep it up. 

We have a concern in Delaware about avian flu because what 

happens when there are scares of avian influenza, an avian flu 

pandemic around the country or around the world, people stop eating chicken and it hits the bottom line, hits us in the pocketbook 

on the Delmarva Peninsula. So it is something that gets our attention. 

There is concern about avian influenza on the Delmarva Peninsula and throughout this country, and I think around the world. 

And it is not just avian flu but other potential outbreaks of this nature, but we are just focused on this kind of pandemic, future potential pandemic right now. But being able to identify outbreaks 

early seems to be the key to properly responding and helping to 

control their spreads. 

I was just wondering, what does AHLTA stand for? 

Mr. HENDRICKS. AHLTA is the Armed Forces Health Longitudinal Technology Application. 

Senator CARPER. Of course. Thank you. 

Any way that AHLTA can help our Nation deal with these kinds 

of potential risks? 

Mr. HENDRICKS. Yes, sir. If you look at the structure of AHLTA, 

you are going to find that it is somewhat different than that structure of the VA’s system and that AHLTA is built far more utilizing 

structured date. And we utilize that simply because of the mission 

of the Department of Defense. We have some other challenges that 

we have to be cautious of, and that is chemical and biological 

agents that we want to be aware of. And to do that, we use structured data for signs and symptoms of patient encounters. And 

many systems today across the Nation will go off with a diagnosis, 

and then you will do surveillance based off those diagnoses. 

29

Well, to get to a diagnosis, it may take a week to 2 weeks to get 

to the diagnosis. By looking at signs and symptoms, you perhaps 

in avian influenza could catch that by simply looking at flu-like 

symptoms and following the temperature. And Dr. Kussman will 

probably have to help me out here. I suspect the avian influenza 

is more noted by a rapid increase in temperature of the patients. 

So by looking at the signs and symptoms of the AHLTA database, which happens to be in 70 hospitals and will be in over 400 

medical clinics around the world, if you look at the signs and symptoms and trends of a geographical nature, perhaps you can see outbreaks that would warrant further investigation to see if perhaps 

the Nation is seeing something that could be an avian influenza. 

Senator CARPER. Thank you. Dr. Kussman, do you want to add 

to that? 

Dr. KUSSMAN. Yes, sir. As we speak, actually, with DOD we are, 

as I mentioned in my prepared remarks, in 1,400 sites around the 

country. We are partnering with CDC and other organizations to 

be the sort of canary in the mine. We are constantly monitoring reporting already, clusters of symptoms that automatically are reported to the CDC so they can monitor that if it was in Delaware 

or Texas, or wherever it was, if there was an outbreak of something 

we can then react early. It does not necessarily mean that we need 

to know the diagnosis, as Mr. Hendricks mentioned, but, rather, 

that there is an outbreak of something. And then the epidemiologists and the other clinicians can make the diagnosis. 

So this is very important to us, not only with avian flu, but all 

kinds of other potential outbreaks of things, whether it is biological, chemical, or whatever it would be. 

Senator CARPER. All right. Thanks. 

A vote has begun, and I have asked Meredith Pumphrey, who is 

sitting right behind me, to let me know when there is 5 minutes 

remaining. We usually have 15 minutes to get there to vote, and 

when the clock ticks down to 5 minutes, we are going to probably 

adjourn. 

Before we do that, Mr. Howard, could I ask a question of you? 

Mr. HOWARD. Yes, sir. 

Senator CARPER. As you know, it is estimated that over 40 percent of our veterans seek health care services—I think that was 

mentioned earlier—outside of VA medical facilities. Do you know, 

does the VA have any plans to exchange electronic health records 

with health care providers outside of the VA network? Have you 

heard any talk of that? 

Mr. HOWARD. Well, Dr. Kussman knows more about that than I 

do, sir, but I believe we already do. We have research going on 

where some of that takes place, and we also have private sector 

support involved in some of the diagnoses and what have you. But 

I will let Dr. Kussman answer that. 

Senator CARPER. Thank you. 

Dr. KUSSMAN. Yes, sir, as we and Dr. Kolodner mentioned, particularly with DOD, for instance, not all veterans are retirees, but 

all retirees are veterans, and so we have a sub-segment of our population that can go back and forth from DOD to the VA. And so 

now we are able to make sure that data works because someone 

like those of us who are retired here in Washington can go to WalVerDate 0ct 09 2002 12:28 Aug 30, 2007 Jkt 029506 PO 00000 Frm 00033 Fmt 6633 Sfmt 6601 C:\DOCS\29506.TXT SAFFAIRS PsN: PAT
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ter Reed or Bethesda and the Washington VA, and it is very important for that information to be easily accessible. 

As we mentioned, we are trying to work with the civilian community and HHS to maximize our capability, but as you alluded to 

and the Chairman alluded to, the use of the electronic health 

record in the civilian community has been less than we would like 

to see. And as that expands, more and more capability would be 

able to be achieved. 

Senator CARPER. I want to ask one last question of each of you. 

As I said earlier in my comments, we are spending a ton of money 

in this country for health care, much more, I am told, on a per capita basis than anybody else in the world. The results are not necessarily the best in the world, at least by a number of measures. 

No silver bullets, but one of the ways—it seems we work in the VA 

and DOD and other civilian installations where we have begun to 

harness health IT. We are starting to see some results in terms of 

holding down costs, saving lives, providing better care, and also 

seemingly to provide greater job satisfaction for some of the folks 

who are using the technology. 

We serve here in the Senate—a couple of us are doctors, most of 

us are not, but we all care about trying to save lives and care about 

improving our health care for the rest of us and care about saving 

money because we do not have it in great abundance these days. 

But as we, as legislators, attempt to find the appropriate role for 

us and help get our country on the right track, what closing words 

of advice would each of you have for us in the Senate, and particularly on this Subcommittee? Ms. Daniel. 

Ms. DANIEL. Thank you, Senator. From our standpoint, we have 

been working under our existing authorities that we have in order 

to do all of the work that we are doing, the collaborative processes 

that we have in place to work towards standards, developing certification, getting public-private collaboration through our American Health Information Community, looking at the Stark and 

kickback regulations or other areas where we can make changes in 

order to help encourage adoption and encourage interoperability. 

So we are working under our existing authorities, and we believe 

we have the authorities that we need in order to pursue the work 

that we are doing. We have been working very close, as I said, with 

our Federal partners, and I think those collaborative efforts are 

really working and I think are going to show some really strong results in the near future. 

So the one piece of advice I would say, if you are considering legislation, is to assure that legislation does not impede the current 

good work that we are doing and does not cause us to take steps 

backward in the work that we are doing but lets us continue to 

progress. 

Senator CARPER. Good. Well, we just need to have a good dialogue with you, and we look forward to that. 

Ms. Koontz, please. 

Ms. KOONTZ. I will just comment that I think what DOD and VA 

are doing in terms of trying to achieve a virtual medical record is 

a very important initiative, and GAO has made a number of recommendations, I think, which have improved what they are doing. 

31

Senator CARPER. And I understand they have been accepting of 

those recommendations. 

Ms. KOONTZ. Generally so. We have some still outstanding, and 

we are working with them on that. And I would just only encourage the Congress to continue their oversight over these issues. 

Senator CARPER. All right. Thank you. Mr. Hendricks. 

Mr. HENDRICKS. Yes, sir, just a short comment, just a suggestion. 

It is very easy to jump to the return on investment and expect immediate savings on implementation of any electronic health system. And I would just caution that I think that for the Nation, electronic health records savings will come more in the long term. The 

electronic health record will allow us to do such things as disease 

management, to give better control on the diabetes and the asthma, and these are things that we will not see an immediate return. 

Those will be years out. 

Senator CARPER. That is a good point. Thank you. Mr. Howard. 

Mr. HOWARD. Sir, I only have one suggestion, and for obvious 

reasons, due to our most recent incident regarding data security. 

And it is very easy to exchange information, in the digital age, lots 

of it. So I would say, in whatever legislation is proposed, we get 

into the exchange of data among DOD, VA, other government agencies, and I really think that needs to be continually highlighted. I 

think the VA has pretty good controls over all that in the health 

area, but we have seen how easy it is to fall into the trap of passing information around without proper security. 

Senator CARPER. OK. Thank you, sir. Timely and well spoken. 

Dr. Kussman. 

Dr. KUSSMAN. Sir, I think we would like, as mentioned, to work 

with you as you develop the legislation to potentially add whatever 

experience we have to that. I think it is a mix of a carrot and a 

stick to get people to do things that they may not feel comfortable 

with. And I think that as Mr. Hendricks mentioned, a lot of it is 

concern about sunk costs with the benefit later on, and I think that 

has to be addressed. If it is not, there will be continued resistance 

to spending money without an obvious payback for that. 

Senator CARPER. All right. Thank you. The last word. 

Mr. KOLODNER. I think it is important to recognize that where 

we are today is very different than 5 years ago. There really is 

progress, there really is momentum. It is important to reinforce 

that and not have a force that comes in, as Jodi Daniel mentioned, 

that is in conflict or competition. 

I think in that sense, what Congress can do is to look to make 

sure that the environment and the parameters are right for this to 

move forward. And you might think in terms of the Internet. Nobody mandated the Internet as a solution. In fact, if they had come 

in with solutions, they would have gotten in the way. But to create 

the right environment, the right reinforcements, and the right incentives, and to then do that in alignment with the other activities. 

Senator CARPER. Good. Well, this has been a terrific hearing. I 

am delighted I was here. And I am delighted that you were here. 

I want to express my thanks to Meredith Pumphrey, who is sitting 

right behind me, to the Chairman for his willingness to have a 

hearing on this subject, and to the members of his staff for helping 

to plan it and to get all of you to come. 

32

We would ask that you be willing to respond to some further 

questions in writing, and we look forward to collaborating with you 

as we go forward. 

On behalf of all of us on this Subcommittee and our full Committee, and, frankly, I think probably on behalf of all of us in the 

Senate, thank you for the good work that you are doing, especially 

for those of you that are serving our veterans and our military personnel and those who are trying to help us take those lessons and 

extend them to the rest of our civilian population. You are doing 

the Lord’s work. It is important work, and we are grateful. 

Thank you, and with that, the Subcommittee stands adjourned. 

[Whereupon, at 4 p.m., the Subcommittee was adjourned.] 

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