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IS THERE A DOCTOR IN THE MOUSE? USING INFORMATION TECHNOLOGY TO IMPROVE

HEALTH CARE

HEARING

BEFORE THE

SUBCOMMITTEE ON THE FEDERAL WORKFORCE

AND AGENCY ORGANIZATION

OF THE

COMMITTEE ON

GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED NINTH CONGRESS

SECOND SESSION

JULY 27, 2005

Serial No. 109–127

Printed for the use of the Committee on Government Reform

(

Available via the World Wide Web: http://www.gpoaccess.gov/congress/index.html

http://www.house.gov/reform

(II)

COMMITTEE ON GOVERNMENT REFORM

TOM DAVIS, Virginia, Chairman

CHRISTOPHER SHAYS, Connecticut

DAN BURTON, Indiana

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

GIL GUTKNECHT, Minnesota

MARK E. SOUDER, Indiana

STEVEN C. LATOURETTE, Ohio

TODD RUSSELL PLATTS, Pennsylvania

CHRIS CANNON, Utah

JOHN J. DUNCAN, JR., Tennessee

CANDICE S. MILLER, Michigan

MICHAEL R. TURNER, Ohio

DARRELL E. ISSA, California

GINNY BROWN-WAITE, Florida

JON C. PORTER, Nevada

KENNY MARCHANT, Texas

LYNN A. WESTMORELAND, Georgia

PATRICK T. MCHENRY, North Carolina

CHARLES W. DENT, Pennsylvania

VIRGINIA FOXX, North Carolina

——— ———

HENRY A. WAXMAN, California

TOM LANTOS, California

MAJOR R. OWENS, New York

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

CAROLYN B. MALONEY, New York

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

DANNY K. DAVIS, Illinois

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

CHRIS VAN HOLLEN, Maryland

LINDA T. SANCHEZ, California

C.A. DUTCH RUPPERSBERGER, Maryland

BRIAN HIGGINS, New York

ELEANOR HOLMES NORTON, District of

Columbia

———

BERNARD SANDERS, Vermont

(Independent)

MELISSA WOJCIAK, Staff Director

DAVID MARIN, Deputy Staff Director/Communications Director

ROB BORDEN, Parliamentarian

TERESA AUSTIN, Chief Clerk

PHIL BARNETT, Minority Chief of Staff/Chief Counsel

SUBCOMMITTEE ON THE FEDERAL WORKFORCE AND AGENCY ORGANIZATION

JON C. PORTER, Nevada, Chairman

JOHN L. MICA, Florida

TOM DAVIS, Virginia

DARRELL E. ISSA, California

KENNY MARCHANT, Texas

PATRICK T. MCHENRY, North Carolina

JEAN SCHMIDT, Ohio

DANNY K. DAVIS, Illinois

MAJOR R. OWENS, New York

ELEANOR HOLMES NORTON, District of

Columbia

ELIJAH E. CUMMINGS, Maryland

CHRIS VAN HOLLEN, Maryland

EX OFFICIO

HENRY A. WAXMAN, CALIFORNIA

RON MARTINSON, Staff Director

CHAD BUNGARD, Deputy Staff Director

CHAD CHRISTOFFERSON, Clerk

TANIA SHAND, Minority Professional Staff Member

(III)

C O N T E N T S

Page

Hearing held on July 27, 2005 ............................................................................... 1

Statement of:

Brailer, David, M.D., Ph.D., National Health Information Technology Coordinator, Department of Health and Human Services; and Carolyn

M. Clancy, M.D., Director for the Agency for Health Care Research

and Quality, Department of Health and Human Services ........................ 30

Brailer, David ............................................................................................ 30

Clancy, Carolyn M. .................................................................................... 45

Fineburg, Harvey, M.D., Ph.D., president, Institute of Medicine; David

St. Clair, founder and CEO, MEDecision, Inc.; and Jan Walker, RN,

MBA, executive director, Center for Information Technology Leadership

[CITL] ............................................................................................................ 65

Fineburg, Harvey ...................................................................................... 65

St. Clair, David .......................................................................................... 75

Walker, Jan ................................................................................................ 81

Kennedy, Hon. Patrick, a Representative in Congress from the State

of Rhode Island ............................................................................................. 8

Springer, Linda M., Director, Office of Personnel Management .................. 23

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

Brailer, David, M.D., Ph.D., National Health Information Technology Coordinator, Department of Health and Human Services, prepared statement of ........................................................................................................... 33

Clancy, Carolyn M., M.D., Director for the Agency for Health Care Research and Quality, Department of Health and Human Services, prepared statement of ........................................................................................ 48

Cummings, Hon. Elijah E., a Representative in Congress from the State

of Maryland, prepared statement of ............................................................ 91

Davis, Hon. Danny K., a Representative in Congress from the State

of Illinois, prepared statement of ................................................................ 22

Fineburg, Harvey, M.D., Ph.D., president, Institute of Medicine, prepared

statement of ................................................................................................... 67

Kennedy, Hon. Patrick, a Representative in Congress from the State

of Rhode Island, prepared statement of ...................................................... 9

Murphy, Hon. Tim, a Representative in Congress from the State of Pennsylvania, prepared statement of .................................................................. 13

Porter, Hon. Jon C., a Representative in Congress from the State of

Nevada, prepared statement of .................................................................... 5

Springer, Linda M., Director, Office of Personnel Management, prepared

statement of ................................................................................................... 26

St. Clair, David, founder and CEO, MEDecision, Inc., prepared statement

of ..................................................................................................................... 77

Walker, Jan, RN, MBA, executive director, Center for Information Technology Leadership [CITL], prepared statement of ..................................... 83

(1)

IS THERE A DOCTOR IN THE MOUSE? USING

INFORMATION TECHNOLOGY TO IMPROVE

HEALTH CARE

WEDNESDAY, JULY 27, 2005

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON FEDERAL WORKFORCE AND AGENCY

ORGANIZATION,

COMMITTEE ON GOVERNMENT REFORM,

Washington, DC.

The subcommittee met, pursuant to notice, at 2:02 p.m. in room

2154, Rayburn House Office Building, Hon. John C. Porter (chairman of the subcommittee) presiding.

Present: Representatives Porter, Davis of Illinois, and Norton.

Staff present: Chad Bungard, assistant staff director, chief counsel; Ronald Martinson, staff director; Chad Christofferson, clerk;

Patrick Jennings, detailee from OPM serving as senior counsel; and

Tania Shand, minority professional staff member.

Mr. PORTER. A quorum being present, the Subcommittee on the

Federal Workforce and Agency Organization will come to order.

Good afternoon. I would like to thank everyone for being here

today, especially our witnesses. The issue before us is an important

one and something to which we can all relate. Every single one of

us has gone to the doctor’s office or the hospital or knows someone

that has made such visits.

With both legislative jurisdiction over the Federal Employees

Health Benefits [FEHB], program and oversight jurisdiction over

health care policy, this subcommittee is poised to examine ways to

achieve President Bush’s goal for the majority of Americans to have

electronic health records within 10 years.

Notwithstanding the fact that the United States is a world leader

in health care science, its delivery and management of health care

is often outmoded and inefficient. Over 90 percent of the activities

that go into the delivery of health care are centered on information

and information exchange. If this component is flawed in any way,

the optimal delivery of care will not be achieved.

Health care costs are increasing at an alarming rate, rising 70

percent since 2000. The quality of care is riddled with preventable

medical and administrative errors and burdened with inefficiency.

Information technology can help cure these ills. With the deployment of health information technology in a global fashion, no

longer will patients have to be held captive to the brown padded

envelopes in the bottom of their chest of drawers full of incomplete

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medical records. No longer will patients have to track down personal health information from across the country.

No longer will a pharmacist misread a doctor’s handwriting and

prescribe the wrong medicine. No longer will medical errors occur

caused by the lack of or incomplete health information. And, as Dr.

David Brailer noted at a technology summit last year, ‘‘no longer

will we spend up to $300 billion a year on inappropriate treatment

or up to $150 billion on administrative waste.’’

The use of information technology has enormous potential to improve the quality of health care and is key to overall improved performance of the U.S. health system. Health care organizations are

only beginning to apply technological advances. Patient information

typically is dispersed in a collection of paper records, which often

are poorly organized, illegible, and not easy to retrieve, making it

nearly impossible to manage various chronic illnesses that require

frequent monitoring and ongoing patient support.

In a world where our cars, our pets, our checking accounts have

their own computerized record, is not it time for every American

to benefit from the same technology? And I must emphasize the

benefits are innumerable. The Institute of Medicine estimates that

medical errors account for approximately 45,000 to 98,000 deaths

each year in the United States, and 770,000 injuries due to adverse

drug events, many of which could have been prevented through the

use of health information technology.

In fact, more people die each year in the United States from

medical errors than from highway accidents, breast cancer, or even

AIDS. If death by medical errors were listed among the most deadly diseases, it would be among the top 10 leading causes of death

in the United States each year.

The use of technology will reduce medical errors by making

health information more accessible to both patients and providers,

no matter where the patient is receiving that care. For example,

the Boston Globe recently reported on the senseless, preventable

death of a 79 year old retired chemist who died after doctors at the

Massachusetts General Hospital treated him for a stroke when he

really was having an insulin reaction. Tragic. It is easy to see how

an electronic medical record could have assisted the physicians in

correctly diagnosing this patient.

In addition, the use of automated medication order entry systems

can reduce errors in prescribing drugs, and computerized reminders can help both patients and clinicians to identify needed services. The Journal of the American Medical Association reported in

a recent study that computerized prescriptions resulted in an 81

percent decrease in errors. The National Center for Vital and

Health Statistics reports that 20 percent of handwritten medical

documents are illegible, and 24 percent are incomplete. Prescription errors can result in real catastrophes that easily could be prevented.

Recently, a 42-year-old male patient died 2 weeks after taking

the wrong prescription drug. In that case the doctor who wrote the

prescription wrote it for the wrong amount. It was actually eight

times higher than what he should have been receiving.

The Department of Health and Human Services also reports that

health information technology can significantly reduce cost by savVerDate 11-MAY-2000 12:41 May 01, 2006 Jkt 000000 PO 00000 Frm 00006 Fmt 6633 Sfmt 6633 D:\DOCS\26656.TXT HGOVREF1 PsN: HGOVREF1
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ing time, reducing duplication and waste, and improving efficiency.

The Center for Information Technology Leadership estimates that

a national health information technology system will result in annual savings of $132 billion. With national health care spending at

a 15.6 percent share of the GDP, this is welcome news.

The benefits of computerizing health records are substantial.

Health information technology will improve the quality of care, reduce the redundancy of testing and paperwork, virtually eliminating prescription errors, prevent adverse effects from conflicting

courses of treatment, and significantly reduce medical errors and

administrative costs.

In announcing his 10 year goal, the President admonished the

Federal Government to take the lead. The FEHB program is no exception and should leverage its buying power of about 81⁄2 million

participants to support President Bush’s goal and lead by example.

As the Institute of Medicine’s president, Dr. Harvey Fineburg,

stressed in testimony before this subcommittee this past March,

the FEHB program could promote data standards and appropriate

deployment of information technology providers. And since that

hearing I am pleased to see that the Office of Personnel Management emphasized the importance of increase of health information

technology for the first time in its April 2005, program carrier letter, offering guidance to insurance carriers for negotiating with the

OPM.

The FEHB program can enhance its service to Federal employees

and serve as a model for improving the performance of U.S. health

care systems as a whole.

Progress is also being made on the national front. In June of this

year HHS Secretary Mike Leavitt announced new efforts to help

speed the President’s 10-year proposal, stating that the HHS will

establish a national health information infrastructure that will effectively be taken over by the public and private health sectors,

eventually eliminating the need for extensive Federal involvement.

No one can claim that moving information technology into the

health care industry is going to be easy. There are many challenges

of implementing information technology, including financial, technical, cultural, turf. These are but a few of the challenges that we

have.

As chairman of this subcommittee, I am committed to supporting

the President’s goal and guiding the implementation of health information technology in both the FEHB program and throughout

the Nation. This subcommittee will hold additional hearings over

the next several months to face the challenges head on and achieve

meaningful improvement in America’s health care system.

The individuals before the subcommittee today are vital players

and leaders in achieving our goal and the President’s goal, and I

look forward to discussion from all the witnesses this afternoon.

I have had the opportunity to spend time in Nevada hospitals.

I have had a chance to see first-hand. And yes, I have been sick

in the hospitals before, but I have been very specific in spending

time in the emergency rooms to see what I could do as a Member

of Congress. University Medical Center, a major facility in southern Nevada, I have spent a couple of days just working hand in

hand with the doctors—of course, staying out of the way—trying to

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see what we could do. I am amazed at how well our delivery system does work, even in spite of some of the technological challenges. But I saw first-hand how technology could be such a lifesaver in many respects around the country, not only in Nevada but

in every community across this great country.

Having said that, I would like to now recognize our ranking minority member of the subcommittee, Mr. Danny Davis. Mr. Davis.

[The prepared statement of Hon. Jon C. Porter follows:]

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Mr. DAVIS OF ILLINOIS. Mr. Chairman, I do not know what Representative Kennedy’s time piece is, but if he would have a problem

returning after the votes then I would defer to him and let him

give his testimony. If not, then I will go ahead.

Mr. KENNEDY. No problem. That would be appreciated. If you are

having another hearing down the road, I would be willing to testify

at that, as well. If you want me to make brief comments now, I

would be happy to come back at the next hearing.

Mr. PORTER. Without objection.

Mr. DAVIS OF ILLINOIS. I am prepared to yield to the Representative.

Mr. PORTER. Thank you. Without objection, please. Welcome.

STATEMENT OF HON. PATRICK KENNEDY, A REPRESENTATIVE

IN CONGRESS FROM THE STATE OF RHODE ISLAND

Mr. KENNEDY. Thank you. Thanks, Mr. Chairman, Representative Davis.

Mr. Chairman, you just outlined essentially the problem and possibly the direction for us to go in terms of the solution. But I think

what is important here is that this is not a hearing about technology. This is a hearing about saving lives.

You hit it on the head at the outset, Mr. Chairman, when you

said that roughly 48,000 to 100,000 people in this country die of

medical errors. It is the equivalent of a jumbo jet crashing every

3 days in this country. If the American people really understood

the degree to which they are in jeopardy of being a victim of a medical error when they go to the hospital, Mr. Chairman, I know this

Capitol would be awash with people from all over the country demanding that we would do something.

Mr. Chairman, I think people are learning about this and they

are expecting us to begin to reform this system. Technology can be

a big part of that. Mr. Chairman, Representative Murphy and myself have offered a piece of legislation that suggests a way to go

about implementing IT in our medical system in this country. Everybody has recognized the need to do this, but now we have to actually do it, Mr. Chairman. That I think is our challenge here.

As you all are able to do this through showing how Government

can be a model for the rest of the country, I think it is an important role that you will play in this debate, because the Federal Employees Health Benefits program is going to be a program that will

be looked to as a model. And so I encourage you to continue to talk

about how you are intending to do that. I look forward to coming

back when you have successive hearings to be able to comment further about ways that you might do that.

I thank you for holding this hearing and focusing the attention

that you are focusing on this very important subject.

[The prepared statements of Hon. Patrick Kennedy And Hon.

Tim Murphy follow:]

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Mr. PORTER. Thank you, Congressman. We appreciate your leadership in a bipartisan nature with Congressman Murphy, who is

sick today.

Mr. KENNEDY. That is right.

Mr. PORTER. Here we are talking about health care, and my

friend Tim decides to be ill. But certainly we appreciate what you

are doing and we look forward to working with you and applaud

you for your leadership. Thank you very much.

Mr. KENNEDY. Thank you very much, Mr. Chairman.

Mr. PORTER. We will now go into recess until our votes are concluded.

Thank you.

[Recess.]

Mr. PORTER. I would like to bring the meeting back to order.

For those that have attended a few of our subcommittee hearings

in the past, I have been promising to hold our hearings in Las

Vegas. Well, I think I am not sure whether it is cooler here or in

Las Vegas today. We will be having a hearing in Las Vegas some

time in August, so you are welcome to join us around the 12th. If

you are looking for a reason to come to Nevada, we are going to

be having a hearing in the dry, wonderful southwest.

Thank you for your patience. We will bring the meeting back to

order.

I would like to turn to Mr. Davis for any opening comments.

Mr. DAVIS OF ILLINOIS. Thank you very kindly, Mr. Chairman.

Let me thank you for calling this hearing. This is a very timely

subject for the subcommittee to be considering.

The utilization of information technology to improve the Nation’s

health care system has gained a great deal of momentum since the

Institute of Medicine released its 1996 report on health IT: ‘‘To Err

Is Human: Building a Safer Health System.’’

As a matter of fact, health IT is featured in the August 1, 2005,

issue of Health and Medicine section of U.S. News and World Report. One of the articles in the magazine, ‘‘Can High Tech Save

Your Life?,’’ listed 47 hospitals that earn two impressive distinctions: first, the hospitals were listed among America’s best hospitals, U.S. News and World Report’s ranking of hospitals that is

based on expertise, ability to save lives, reputation among specialists, commitment to nursing excellence, and several other factors.

Those hospitals also made the 100 Most Wired List compiled by

hospitals and health networks and published by the American Hospital Association. It is a list that identifies the hospitals and health

systems that have the most complete information technology. It

would appear that those hospitals have successfully used health IT,

the technology used to collect, store, retrieve, and transfer health

information electronically to improve the quality and safety of

health care for their patients.

When compared to other institutions, the mortality rate of the

100 Most Wired Hospitals was 7.2 percent lower on average. While

there seemed to be a connection between improved patient outcomes and health IT, matters of patient privacy, continued human

care, and the accessibility of online medical data should be addressed by health care providers as they adopt IT policies and systems.

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I might just add, Mr. Chairman, that you really appreciate our

looking into this matter. I have had a long and intimate association

with health care, representing more hospital beds than any other

Member of Congress in the United States, having many of the finest hospitals in the country and medical schools in my Congressional District. As a matter of fact, there are four of them—Northwestern University, University of Illinois at Chicago, Rush Presbyterian, St. Luke’s Medical Center, Loyola University—as well as

a number of smaller community hospitals threaded throughout the

area.

I have also spent a great deal of my personal career involved in

health care. As a matter of fact, I have sat on the boards of hospitals, I have worked in community health centers, I have been an

active member of the American Public Health Association. As a

matter of fact, I wrote my doctoral dissertation on the health care

needs of black Chicago. I have worked with doctors and hospitals

and been on a couple of Federal commissions that I was appointed

to, one by President Carter and some other people. So health has

been pretty much my life, and the most exciting part of my life.

So as we try and find ways to improve the quality of care and

find new ways to protect our public, it is exciting and challenging,

and so I certainly thank you for delving into this arena and look

forward to the testimony of our witnesses.

I yield back.

Mr. PORTER. Thank you, Mr. Davis.

Mr. DAVIS OF ILLINOIS. And the medical center that you are talking about out in Vegas, my good friend is the director, a fellow

named Lacy Thomas, who used to work for me.

Mr. PORTER. You trained him very well. He is doing a great job.

Mr. DAVIS OF ILLINOIS. I am glad to know that he is doing well.

Mr. PORTER. He is doing real well. So maybe when you are out

for the meeting in August we can stop and see him.

Mr. DAVIS OF ILLINOIS. Absolutely.

[The prepared statement of Hon. Danny K. Davis follows:]

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Mr. PORTER. With that, I ask unanimous consent that all Members have 5 legislative days to submit written statements and questions for the record, and the answers to written questions provided

by the witnesses also be included in the record.

Without objection, so ordered.

I ask unanimous consent that all exhibits, documents, other materials referred to by Members and witnesses may be included in

the hearing record and that all Members be permitted to revise and

extend their remarks.

Without objection, so ordered.

It is also the practice of this subcommittee to administer the oath

to all witnesses. If all witnesses would please stand, I would like

to administer the oath.

[Witnesses sworn.]

Mr. PORTER. Let the record show that the witnesses have answered in the affirmative.

We have four panels today. As you know, we started with one,

which was very brief for politicians. We appreciate Congressman

Kennedy for his leadership and we certainly will have him a part

of our additional hearings and will also have Congressman Murphy

joining us.

So what I would like to do now is move into our second panel.

Our second panel, we will hear from Linda Springer, the Director

for Office of Personnel Management. In fairness, Ms. Springer and

I have met numerous times over the past month or so, but we note

that this is her first hearing with our committee. We are honored

to have her.

I know that in the brief amount of time that you have had on

the job you have been getting a lot of things together, and I know

that even prior to being in a new position you were aware of a lot

of these issues. We welcome you and understand that, in your long

term of serving the business community and the public sector, you

have had a very distinguished career, and we appreciate your being

here today.

You have 5 minutes. We look forward to having you come back.

STATEMENT OF LINDA M. SPRINGER, DIRECTOR, OFFICE OF

PERSONNEL MANAGEMENT

Ms. SPRINGER. Thank you, Mr. Chairman. It is a privilege to be

here with this committee today with you and Representative Davis

on what we consider at OPM to be a very important issue, and that

is the efforts of OPM particularly in helping the community to

adopt the provisions of the health information technology, particularly in the FEHB program.

I want to provide a little context for my remarks about that

adoption and in the way of background of the FEHB program and

OPM’s role as the administrator.

There are approximately 8 million Federal employees, retirees,

and dependents who are covered by that program. The program allows OPM to offer competitive health benefits for Federal workers

in a similar fashion that large employers are able to procure that

in the private sector.

We administer the program by contracting directly with private

sector providers, but not with the doctors, themselves, so we do not

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have specific oversight there, but indirectly we do through the

health programs.

Now, with that background I would like to talk a little bit about

the direct subject of this hearing and our related activities with the

FEHB program.

Under the Executive order issued by President Bush related to

the health information technology, there were several areas where

OPM was directed to provide information and to work closely to

promote its enactment. The order underscored really the importance that the President places on the development of this type of

capability nationwide and to have health information technology

infrastructures in place that will improve quality, safety, and efficiency of health care.

In order to help fulfill the President’s vision, OPM, working also

with the Veterans Affairs Department and also Department of Defense, was directed to submit a report within 90 days of the Executive order on various options and incentives that we could put into

place in the FEHB program to try and promote adoption of these

health information technology opportunities.

In July 2004 OPM fulfilled that requirement and issued a report

to the President outlining various options to provide incentives in

the FEHB program. Among those options were the following: Encouraging health plans to provide incentives for the adoption of

interoperable health information technology systems under the

FEHB contracts. Consider basing part of the service charge or profit for the fee for service plans and other experience rated plans and

consider introducing performance goals for health maintenance organizations—this is where you really are putting your money

where your mouth is when you start talking about their service

fees. Introducing incentives and other performance goals for plans

that contract with networks of providers to make records accessible

through secure—and I want to underscore secure—and other

HIPPA compliant interoperable HIT systems. Introducing incentives and performance goals for plans that integrate their provider

networks with local and national health information infrastructure

initiatives. Also encouraging and rewarding carriers that contract

with pharmacy benefit managers that are providing incentives for

e-prescribing and health information technology linkages.

Earlier this year OPM staff met with Dr. Brailer, HHS’ national

health information technology coordinator, and his staff on how we

could work closely with them to help promote and to move forward

the agenda that they have. In April 2005, Dr. Brailer was the keynote speaker at our annual FEHB carrier conference. His staff also

had a followup workshop at the conference to provide more indepth information for the plans that are participating in the FEHB

program. Again, the idea there was to have direct contact without

any intermediary for the members of the FEHB program and Dr.

Brailer.

Following this conference, OPM issued the annual Call Letter to

the carriers that are in the FEHB. This carrier letter provides

guidance and negotiation objectives for benefit and rate proposals

for the FEHB program for the next contract term. I have a copy

of that Call Letter here, but if you look at the Letter you will find

that about a page, a solid page of this is in the Letter this year

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that would not have been here in the past were it not for the new

initiatives on HIT. So clearly OPM is taking some very concrete actions with respect to our carriers.

The Call Letter requested that plans describe their HIT initiatives, including any currently in place for the doctors and pharmacies to use e-prescribing and for contracting hospitals to use

electronic registries, electronic records, and e-prescribing. We have

received responses from the FEHB plans, and we are in the process

of reviewing them right now to establish a baseline from which we

can measure progress on how they are doing.

OPM’s Web site is another important vehicle for communicating

with all of the members of the FEHB program. On that Web site

page for participating plans there are links to HIT-related information such as regional health organizations, and the focus on HHS’

HIT initiatives and technology groups.

OPM has affiliated itself with a variety of other organizations so

that we can stay current on the efforts that are undertaken to

again develop this technology capability. We are members of the ehealth initiative, Employer and Purchaser Advisory Board, and we

are on other various public/private partnership organizations that

are focused on quality assurance and quality forums that are focused on patient safety, health care quality, and privacy issues.

With regard to current privacy protections, FEHB enrollees have

the same privacy protections as all Americans do in their private

plans. All program contracts require health plans to be in complete

compliance with HIPPA requirements, and as new interoperable

systems are developed OPM will ensure that FEHB plans comply

with any Federal requirements with respect to privacy of health information.

We look forward to continuing to work with HHS and with our

FEHB participating health plans on our initiatives. We are strongly committed to working forward alongside of the industry and private partners in accomplishing this important objective.

This concludes my testimony, but I appreciate the opportunity to

answer any questions that you may have, Mr. Chairman.

Mr. PORTER. Thank you very much.

[The prepared statement of Ms. Springer follows:]

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Mr. PORTER. I am going to forego my questions at this time because the element of time is limited. I know we communicate frequently, so I will save my questions.

Mr. Davis, do you have any questions?

Mr. DAVIS OF ILLINOIS. I only have one question.

How do you see patient privacy being handled with the development of the centralized data base?

Ms. SPRINGER. I think that patient privacy, first of all, is really

the key to acceptance of this type of thing. If we could have all the

technology in the world and all the information in the world, but

if the privacy is not there we are really wasting our time because

it will not be usable. People will not accept it. All of these things

require, as I understand it, permission from the patient. They are

optional. They are not a mandatory type of thing.

So we have to show that the privacy safeguards are in place,

similar to any other type of thing where personal, private information is used electronically. I think, as the chairman mentioned in

his opening statement, there are any number of capabilities that

are in place today where information is available. Health care is

one of the last frontiers, if you will.

So we have to look to those areas to find out what they are doing

to ensure privacy and to make sure that it is there, whether it is

technologically or the kind of oversight certification possibly that

might be required. But I think it is clear that without the privacy

protections these efforts will not be successful.

Mr. DAVIS OF ILLINOIS. Thank you.

Mr. PORTER. Thank you. Thank you, Ms. Springer. We appreciate

it and look forward to working with you.

Ms. SPRINGER. Thank you.

Mr. PORTER. On panel three we have Dr. David Brailer, our

newly appointed National Health Information Technology Coordinator at HHS; Dr. Carolyn Clancy, the Director for the Agency for

Health Care Research and Quality, also a division of HHS. Thank

you very much for being here.

It is going to help the subcommittee as well as Congress as we

move forward. You each will have 5 minutes. We start with Dr.

Brailer.

STATEMENTS OF DAVID BRAILER, M.D., PH.D., NATIONAL

HEALTH INFORMATION TECHNOLOGY COORDINATOR, DEPARTMENT OF HEALTH AND HUMAN SERVICES; AND CAROLYN M. CLANCY, M.D., DIRECTOR FOR THE AGENCY FOR

HEALTH CARE RESEARCH AND QUALITY, DEPARTMENT OF

HEALTH AND HUMAN SERVICES

STATEMENT OF DAVID BRAILER

Dr. BRAILER. Thank you, Chairman Porter and Ranking Member

Davis.

I have submitted my testimony in advance, and with your consent I will just give brief remarks and then answer any of your

questions.

Efforts are well underway to advance health information technology. There are numerous initiatives across the United States in

the Administration, which I will detail today, in many States drivVerDate 11-MAY-2000 12:41 May 01, 2006 Jkt 000000 PO 00000 Frm 00034 Fmt 6633 Sfmt 6633 D:\DOCS\26656.TXT HGOVREF1 PsN: HGOVREF1
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en by Governors and legislatures, in local and regional grassroots

projects, and in the private sector. We certainly welcome the interest of health IT in this subcommittee and elsewhere in Congress.

We have set the foundation for health information technology

that is long-term, market-based, non-regulatory, and with a primary focus on attributes that America’s consumers need: safety

and quality, cost effectiveness, consumer management, and threat

preparedness.

Briefly, the foundations of our efforts fall into three categories.

First, clinically, we want to ensure that clinicians have access to

the kinds of information they need to prevent errors and deaths,

to make evidence-based treatment decisions, and to reduce redundant treatments and unnecessary treatments.

We want to bring disparate clinicians together because of the

overwhelming evidence that team-based care and collaborative care

improve patient’s health status. We want to get information to consumers so they can make their own treatment decisions, be involved in critical management of their own health, and choose providers who suit their own needs.

There is a business foundation, as well, that arises from strong

support in the private sector for the use of health information technology to improve the competitiveness of our industry, to improve

health status of employees, and to bring productivity to the U.S.

health care industry that is not unlike productivity improvements

we have seen in other sectors of the economy, and, as an added

benefit, to develop high-technology jobs in the health care industry

across our providers in the United States.

The Federal Government has been called upon by private sector

leaders to be a catalyst and convener of this change—and our actions reflect this orientation—and ultimately to use our purchasing

power to drive results. To that end, we have had a very collaborative and positive relationship with OPM to be able to accomplish

that goal.

The technology foundations have been set by a recent RFI that

we have published which asks how do we accomplish the goals of

the Administration. Some of the key findings were: it should be collaborative, with public and private players involved; information

should ultimately be patient centric, about the patient, not about

the doctor or the hospital; there should be very strong privacy safeguards; the information should be decentralized and regionally governed; and there should be a nationwide communication, architecture, and standards.

There are two fundamental aspects of our strategy. One is interoperability and the other is electronic health record adoption.

Interoperability is ultimately about getting information where it

is needed and when it is needed. Most of the clinical value that we

discuss is tied up in the ability to get information to clinicians

when they need it and have it be full, complete, and accurate; yet,

today there is very little sharing of information and most of it that

is done is patchy and proprietary. There is very little portability of

health information toward consumers, and we cannot empower

them without getting their information together in a useful way.

The other component of our strategy is about electronic health

record adoption, and later the adoption of other health information

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technology. There is a large gap in adoption between large health

care systems, large hospitals large physician offices, and small

ones. Large providers have the know-how and resources to buy, develop, invest, implement, and use advanced health information

technology, and they are driving most of the reported adoption.

Smaller providers, small physician offices, small hospitals have

substantial barriers to the adoption and use of health information

technology. They are lagging behind.

We are placing our primary efforts on ensuring that health information is interoperable so that it can be seamlessly following the

patient. We are doing this because many scientists and clinicians

view that this is a key component of the health care of the future,

and it is something that we believe has very strong support from

the nearly unanimous recommendations from the respondents to

our RFI.

There are several other reasons for this approach, however. It is

a one-time chance. Before there is large-scale adoption of electronic

health records in the United States, we have a chance today to put

in the foundations for information sharing so we can overcome

fragmentation of health care. We can enable portable health information and personal health records for our consumers, we can

stimulate electronic health record adoption without subsidies, because interoperability lowers the cost and increases the benefits of

electronic health records.

We can increase the industry’s capacity to implement these tools

by eliminating the labor-intensive and risky components of implementation to make products more plug and play. And we can promote innovation and fundamental research by developing new

areas where technology can have promise for our clinicians. We have allocated $861⁄2 million to achieve these goals in fiscal

year 2005, and we have requested $125 million to advance this

work further in 2006.

I appreciate your interest in the topic and I look forward to further discussion and answering your questions. Thank you.

Mr. PORTER. Thank you, Doctor. We appreciate it.

[The prepared statement of Dr. Brailer follows:]

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Mr. PORTER. Dr. Clancy, please.

STATEMENT OF CAROLYN M. CLANCY

Dr. CLANCY. Good afternoon, Mr. Chairman. I am delighted to

outline the ways in which the Agency for Health Care Research

and Quality [AHRQ], is advancing the adoption, implementation,

and effective use of health information technology.

I have asked that my written testimony be submitted for the

record.

AHRQ’s research portfolio will help the Nation meet three vital

objectives: reducing medical errors, improving the quality of patient

care, and reducing the cost of health care. For nearly three decades

AHRQ has funded the basic science of health IT by supporting the

pioneers and innovators so that many of the Nation’s leading

health IT systems have actually been established from AHRQ-supported research. Our task now is to spread the knowledge and experience that we have gained more broadly throughout the health

care system, and we also need to support research targeted to address some critical gaps.

In fiscal year 2004, AHRQ announced an investment of $139 million over 5 years to achieve these goals. This national initiative is

now supporting 108 grants and contracts in 43 States with over

half of the projects based in rural and small hospitals and clinics.

All told, this investment will affect more than 40 million Americans. My written statement details extensively these projects, but

I would like to provide some highlights now.

First, I would like to note briefly the important role that consumers can play in improving health care. Informed and engaged consumers who work in partnership with clinicians I think are an untapped resource. We need to make sure that they have the tools

they need to make choices using evidence-based information. We

have made it a priority to develop evidence-based information for

consumers and are very pleased that our partner, OPM, is the

leading edge of making this information available for its customers.

Mr. Chairman, as a Federal employee you can go to the FEHB

Web site and use an AHRQ-developed tool called CAPS, which

stands for the consumer assessment of health plan survey, to help

you choose your plan.

So we are now looking to the power of health IT to customize evidence and information about treatment choices, diagnostic options,

and to put that into the hands of consumers and providers.

Under the Medicare Modernization Act, section 1013, AHRQ is

working with other Federal agencies to create a program to evaluate the comparative effectiveness of products and procedures. The

results of those evaluations will be made available to the Medicare

and Medicaid progress, as well as to other Federal programs, such

as the FEHB and the general public. Our goal here is to organize

the information so consumers can get it in a timely manner and

use it to make informed decisions about their health care.

We are also exploring new technologies that allow consumers to

gain access to their personal health information securely over the

Internet, such as their medicine lists. Access to trusted information

like this on the Web, particularly if it is delivered in a timely fashion, will revolutionize health care.

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For providers, as you have pointed out, health IT offers great intermediate potential to improve patient safety by reducing medicine errors. The value, as you have noted, seems obvious: reducing

handwriting errors, cross-checking prescribing errors, and identifying dangerous interactions before they occur.

Health IT can also greatly improve the overall quality of care by

making the right thing to do the easy thing to do.

As a doctor, when I see a patient who is coughing and has a

fever I can now use an AHRQ-funded electronic tool to help decide

whether to hospitalize that patient. I used to have to leave the

exam room, go look up the information to make treatment decisions. So it is an amazing innovation to have that information

available at your fingertips when it is needed.

We have also taken health IT into settings where traditionally it

has not been available, including nursing homes, pharmacies, waiting rooms, schools, and patients’ homes.

The potential for cost savings from systematic use of health IT

results from removing inefficiencies, improving physician decisionmaking, enhancing communication, and reducing followup care due

to medical errors, use of inappropriate services.

A survey we fielded last fall found that approximately one-third

of patients reported that they have to go back for a second visit because the relevant information was not available with their clinician at the time of their first visit.

Our research has also demonstrated that computerized reminders can reduce hospital charges per admission by approximately 13

percent, and with your support we will continue our efforts to provide sound evidence on the financial benefits of health IT.

Mr. Chairman, I cannot overemphasize how important practical

technical assistance is to the successful adoption and implementation of health IT, and to that end we have created the AHRQ National Resource Center, the largest single commitment to technical

assistance that we have made in our history.

This resource center leverages our investments in health IT by

offering help where it is needed in real-world clinical settings that

may be ill-equipped to meet the health IT challenge. We do this by

facilitating expert and peer-to-peer collaborative learning and fostering the growth of online communities that are planning, implementing, and researching technology. As one of our grantees has

told us, transition to health IT is one part technical and two parts

culture and work process change.

This was designed initially to meet the needs of our grantees,

and we have recently opened this up to the Nation’s community

health centers, and we will also be making it available to providers

working with the quality improvement organizations.

So I would like to conclude by making a couple of brief observations.

First is that health IT alone cannot provide the improvements

needed in our health care system. It has to be integrated into individual clinical practices in an interoperable system, as Dr. Brailer

noted.

Second, for most health care settings, health IT is not yet an outof-the-box or, as Dr. Brailer said, a plug and play solution. It is

very important to remember that health IT applications need to

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meet the needs of clinicians and patients rather than the other way

around.

A third important point is that the financial exposure for providers, when added to concerns about doing it right, increases the

overall risk of making these investments. In order to accelerate the

pace of adoption and implementation, we are committed to making

sure that best practices and new knowledge and experience are disseminated widely in order to maximize the potential for quality improvement and reduce economic risk.

We look forward to working with Secretary Leavitt, Dr. Brailer,

and our other partners to making health care for all Americans

better through health IT.

Thank you. I would be happy to take any questions.

Mr. PORTER. Thank you, Doctor. We appreciate it.

[The prepared statement of Dr. Clancy follows:]

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Mr. PORTER. I am concerned to a point where I felt today was

a critical hearing to start the process as my chairmanship in this

area. I think it is truly the future of health care in America. But

I am also concerned. Government does not always do things very

well. There are some things we do extremely well and some things

we do not do very well. But I believe, from a health care perspective, we can do a lot of things right because of some of the sizes

of our employees, the quantity of our employees, and the size of the

market that we could use as a term now to work with.

But I am concerned outside with the private sector because, as

you have mentioned, there are the small providers and there are

the mid-size and the large. But I have seen so many of the small

providers that are accustomed to doing things the way they have

always done things.

Let me talk about doctors for a second. I know there are a lot

of doctors in this room and some of my best friends are doctors.

They do not always make good business people. They certainly are

practicing medicine and their specialty and they are independent

and they certainly—the bulk are very, very good and some of the

best in the world. But I am concerned that many of them are not

going to be receptive to this change in the way of doing business.

Again, from the Federal perspective I think there are a lot of

things that we can do. But in the private sector what can we do

to help especially the small—I would think that the smaller providers might have a bigger challenge even than the larger ones because of the cost and the change. What can we do from a marketbased approach to help give incentives to these providers, the doctors, the health care professionals to get them to step up to the

plate? I truly believe this is the future of health care. I guess I ask

that of both of you.

Dr. BRAILER. I think your concerns are accurately placed. There

are certainly many large providers today that have the capital, the

know-how, and the capacity to go through this very long-term process of changing their businesses to be more oriented around their

customers, less error-prone, and more efficient. One of the good

things about health IT is we have all those success stories, which

began making, I think, this a very real phenomenon. And we are

leaving behind a large share of providers, and it is not just capital,

it is know-how or human capital.

I think the question comes down to: how do we make sure that

they have the capacity to finance this and they have the human

capital to make it succeed, because it is ultimately not about software, it is about changing the way their practices operate.

Unfortunately, this is probably one case where physicians are

being good business people. It is not in their financial interest to

put these tools in place. They do not get paid for better quality.

They do not get paid for more efficiency. In fact, when they are

more efficient they have less revenue. So for the standard physician the implementation of the electronic health record is a losing

proposition.

So we view this as a three-part equation. How do we increase the

benefits of the electronic health record by allowing them to monetize better quality? I think the efforts that CMS has underway in

pay for performance that are being followed and matched by varVerDate 11-MAY-2000 12:41 May 01, 2006 Jkt 000000 PO 00000 Frm 00063 Fmt 6633 Sfmt 6633 D:\DOCS\26656.TXT HGOVREF1 PsN: HGOVREF1
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ious parts of the private sector are very encouraging. And, by the

way, most of those efforts have up to 20 percent of their program

aimed at health IT subsidies through those efforts.

Second, how do we lower the cost of the technology? One of the

implications of interoperability is that prices become more modular,

products become more modular, and prices I think go down. But

beyond that, one of our initiatives is around certification so you can

compare two electronic health records on their features and know

if they are the same and then ask, if they are the same, why does

one cost more than the other.

Third is lowering the risk, and I think this is where the human

capital equation comes in. How do we make sure that these practices are not just buying software but they are changing the way

decisions are made and communications occur and they engage

with their patients. The QIOs have done a lot with this, the Health

IT Resource Center from AHRQ has done a lot with this. There is

a burgeoning movement of regional projects, local projects, where

providers come together to be able to help provide those resources

through medical societies or hospitals.

One thing that we can certainly do is to remove regulations that

prevent those kinds of collaborations between hospitals and physicians around developing an integrated model of care for their patients with health IT.

So there is a lot we can do, but I think the fundamentals are

moving in the right way and the question is how do we now accelerate it and be able to make sure that it delivers the kind of result

not just for doctors but for consumers.

Dr. CLANCY. Just to add to those points, with which I agree completely, it is incredibly important because something like 60 percent of the Nation’s physicians practice in groups of five or less, so

this is not a problem that can be ignored or that we can envision

will somehow mysteriously transition away.

Many of these small practices provide very high-quality care. I

would agree with David completely that I think consistent demands for quality are likely to set the stage for greater interest

among physicians in small practices.

Recently there has been a collaboration that involves both the

public and private sectors to select and prioritize metrics for reporting on quality and ambulatory care. Private sector organizations

are going to be writing these into their contracts in 2006, and these

are also the same metrics that CMS will use, so that reduces the

burden of reporting at the same time that IT is ultimately going

to make it easier for them to do that, so I think that is going to

be a powerful incentive, in addition to the growing interest in pay

for performance.

And I would echo what Dr. Brailer had to say about practice

strategies. It has been observed by some people that one of the reasons that physicians have been slower to adopt, in addition to the

economic ones, is that there has not been a so-called ‘‘killer application’’ for them in private practice. Yesterday I heard about one

from a small practice. If you are a doctor and you have a patient

for whom you have to get authorization for selective prescriptions

this often involves a 10 to 12-minute wait on the phone. It is a litVerDate 11-MAY-2000 12:41 May 01, 2006 Jkt 000000 PO 00000 Frm 00064 Fmt 6633 Sfmt 6633 D:\DOCS\26656.TXT HGOVREF1 PsN: HGOVREF1
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tle bit hard to be seeing another patient while you are waiting online here.

So a physician whose four-person practice has gone through this

transformation and is very excited about it told me that their nurse

quit last week and this nurse used to actually sit on the phone, and

he figured out a way to automate this using their electronic health

record system, and suddenly, all of his partners were newly re-excited about this. I think that is likely to happen, but I think all of

the efforts that we are talking about here to make it easier to

shorten this transition phase from moving from paper to electronic

records is going to make it easy for small practices.

Mr. PORTER. I know the doctors, and I am fortunate my doctor

I have been seeing for 20 some years is small practice and he has

stayed ahead of the technology curve, but I just see so many that

are overloaded with paperwork, and the file cabinet gestapo comes

in if it is not locked properly, and doctors were getting frustrated,

and many of those that want to change even are having a hard

time paying their medical liability costs and staffing and they are

not encouraging young folks or even those that are changing careers to get into the profession. I see this domino thing happening

in health care.

But two points. One, I look forward to continued discussion. I

hope we can sit down and have a round table discussion some time

that involves some give and take in the future. But it seems to me

in the medical liability end that is the one thing that has brought

doctors together across the country, and especially in Nevada, or

the cost of medical liability insurance has brought doctors together.

We have had a serious crisis in Nevada where you will see a for

rent sign on OB/GYN offices throughout the State because they

cannot afford medical liability insurance. I know Nevada is not isolated. It is happening all over the country. So we are looking at liability caps and different ways to help the doctors.

But maybe something we could consider is finding some incentives for the medical liability carriers to provide some assistance to

the medical doctors and providers that fall into using this new

technology. There is no question the numbers show that there is

life savings and far fewer risk involved with technology, so maybe

that is something we can talk about at some point, incentive for insurance carriers, because I know they are having trouble even staying in business.

But the other thing I touched upon earlier, as a group of Federal

employees we have an opportunity to change culture across this

country because of the massive size of the group, and I would think

some of the things that you are working on and that we are working on to put in place for Federal employees will help create a new

culture because of just the pure size of our group. And we touch

most every major insurance carrier across the country and we

touch families and doctors in most communities. So I look forward

to working with you both as we look at both of those avenues.

I know we now have another Member with us. Any questions or

comments at this point?

Ms. NORTON. Mr. Chairman, I want to apologize because this is

a hearing that I very much wanted to attend. In this last week of

Congress we seem to be chasing our tails, as I think committees

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justifiably try to get in under the August wire but are not leaving

us all of the time to get where we must.

I just want to say one of the things we have to ask ourselves is

why what would appear to help save lives, correct errors in a huge

industry like this has been as slow as it has been to do the IT conversion that others have been quicker to move to. I am led time

and again back to cost. Maybe this is overly simplistic, but if it was

all that much to it you would have thought that the cost/benefit

would have been done and the results would have been in health

care what you see in other places.

The chairman mentioned one reason why, I think, and you add

on to that others. He talked about the cost, for example, physicians,

particularly in a city like this or any big city, have with liability

insurance. You talk about the out-of-control cost of health care, period, outstripping inflation year after year no matter what is done.

There are huge structural problems built into the way we deliver

health care, paying more for health care than anybody else and

providing less health care than any G8 or any advanced nation.

I think one of the concerns in the system that should be the

model, the FEHBP, will be for the average Federal worker or Federal organization will be it is going to cost some money and who

is going to pay for it. The cost of doing what it seems to me inevitably must be done anyway and could have been done far more cost

efficiently had it been done a little at a time beginning some years

ago, but the cost of doing it—and you have to do it now just to keep

up with everything that practitioners and health care organizations, just to keep up with—I mean, just to keep in touch with

those people you are going to have to do it, so the inevitability of

it is clear.

But when it really gets down to it, you are going to find thoughtful people in the Federal work force are asking who will pay for

this, who will they pass the cost on to. Insurance companies? Well,

anybody who has seen the rise even in what we have flattered ourselves to believe is the most efficient of the health care systems in

the country will have to simply snarl at that one.

So I think your major problem or the major problem of the Federal Government is going to be how to accomplish this in a way

that does not result in what almost everybody thinks it will—that

the cost of premiums are going to go up, that when the buck gets

passed it finally gets down to the family who is middle income, cannot afford the health care they have, happen to be in the Federal

work force, and now, on top of rising premiums, have the cost of

the transition, the transaction cost, if you will, into the IT that is

inevitable and now is beginning to occur and beginning to pay for

it.

Have you thought through the—and perhaps I missed everything

important because I am just getting here. Have you thought

through whether that is the basic problem in this entire sector,

and, if it is, how we might begin to get around that obstacle?

Dr. BRAILER. I appreciate your question, and certainly right here

in the District are some leaders in health information technology

who are showing how to do this, but all report the same challenge

you raise. It is quite expensive, and every business person outside

of health care that we explain this to says essentially the same

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thing: it does not make sense. IT makes the bottom line better for

most organizations, so why not do it? And then we explain how

DRGs work and fee for service payments and various discounts and

all the other pieces, and if they are still following at that point they

begin to realize that it is not a very clean slate.

A large health care system can work through that and largely

will make an investment in health IT for strategic reasons, to be

out where they can be in the future. But the standard doctor’s office, small doctor office, small hospital faces significant challenges.

And the challenges I think come down to being able to have what

the doctor does and how they get paid be aligned with how they

produce better care.

This is why I think some of the efforts in pay for performance,

to be able to pay for better health status that is seen by patients,

is something that also incents health IT because it is hard to do

those over the long term without having the information tools in

place, and it is hard to report them and to demonstrate what you

have done without having the tools to document.

There are also a lot of ideas about how to lower the cost of these

technologies, and there are a variety of proposals in this area, but

the simplest and most accessible ones are letting the physicians

have better access to market forces, to use their negotiating power

and the tools that they can use to get better tools for their demand.

There is one area where I think we are concerned about, and

that is for very small physician practices, between one and five

physicians, that they do not have the kinds of tools available to

them at a good price. This is the area where we have targeted the

Medicare’s Vista Office DHR product, which is a much lower-cost

solution for those practices.

So I think there is a lot that can be done, but I think your comments are directly in the spirit of thism it is a very long-term

change, and no matter how fast we go it is going to be a series of

hopefully radically incremental steps, but certainly incremental

steps in their own right.

Ms. NORTON. Finally, let me say if your view is as mine is, if

anybody can afford to be the model it is the FEHBP, it is the Federal Government, then the first thing you want to erase from your

vocabulary is the word ‘‘radical.’’ Government does not operate in

that way. And what it seems to me can be most useful to us is for

those of you—is this Mr. Clancy?

Dr. BRAILER. It is Dr. Brailer.

Ms. NORTON. Dr. Brailer, I am sorry. It is Dr. Clancy. Those of

you who have been thinking this through can, for a moment, posit

the real world in which we live. We do not live in a world in which

market forces determine health care. See? You are all waiting for

that. You are going to have to wait perhaps longer than any transformation to IT occurs. There are too many competing interests and

views about health care.

The Federal Government has, in fact, led the way in doing a lot

of things, but it has never taken huge steps. We have been willing

to take steps using agencies, parts of agencies. We have been willing to do pilots. So if you want to frame this issue the way you did

in answering my question about how we have to let physicians

have more access to market forces and we have to understand that

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people, in order for people’s insurance to be based on the state of

their health care, which lots of younger people want, that you are

going to have to have information to the data.

If that is the way, if that is the futuristic way in which you want

to frame it, then I can guarantee you that the incremental steps—

and the words ‘‘radical’’ and ‘‘incremental’’ is very good for the private sector, does not work over here.

The kinds of tough thinking we need is how to hook us up. It

might be through those parts of the health care system that we

have some control over. That is why I mentioned FEHBP. But you

could also mention parts of the Medicaid system, you could mention

parts of the Medicare system. You could take parts of that system

where you do not put democrats against republicans by having

coming out of your mouth ‘‘market forces.’’

If you are going to talk that way, you are going to get people like

me to say, what are you going to do about 43 percent of the people

that do not have any health care? You are going to get people like

me to say, and I can give you another 40 percent who have it, cannot afford it, and are giving it up every day.

You need to help us think through a way to move the health care

sector gradually here by having Uncle Sam, who is in the best position to take a giant step, prove that it can work by carving out so

that we can see how to make it work, what works, and what does

not work, carving out some part of what we have some control over

and then going ahead to doing it.

So I am just asking you not to put all of your ideas on the table

in one point, because all you do is divide us then. You have terrible, terrible divisions here on health care. If what we are talking

about is what brings us all together is what Newt and Hillary are

talking about, that IT’ing all of this can help save lives and even

ultimately reduce cost, then you have a huge laboratory over here.

Find parts of it, recommend to the chairman an agency, part of

the health care systems that we operate for Medicare to Medicaid

to FEHBP. I would be most open to working with the chairman

and to any others who are interested in bringing the Federal Government as a pathbreaker into IT, saving lives and saving money.

Dr. BRAILER. Thank you. Congresswoman Holmes Norton is my

Congresswoman and the point is well taken. Thank you. I look forward to working with you.

Ms. NORTON. Obviously he lives in D.C. and he knows he had

better not cross me. [Laughter.]

Mr. PORTER. Again, we thank you and we will conclude this portion.

Dr. Clancy, Dr. Brailer, we appreciate it. I have another hundred

questions, but I will save those for some other time. I look forward

to working with you in the future.

Thank you.

Our fourth panel, we will hear from Dr. Harvey Fineburg, president of the Institute of Medicine; David St. Clair, founder and CEO

of MEDecision, Inc., and Jan Walker, the executive director for the

Center for Information Technology Leadership.

Welcome. We appreciate your being here today. If you would,

keep your comments to about 5 minutes.

We will start with Dr. Fineburg. Thank you for being here.

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STATEMENTS OF HARVEY FINEBURG, M.D., PH.D., PRESIDENT,

INSTITUTE OF MEDICINE; DAVID ST. CLAIR, FOUNDER AND

CEO, MEDECISION, INC.; AND JAN WALKER, RN, MBA, EXECUTIVE DIRECTOR, CENTER FOR INFORMATION TECHNOLOGY

LEADERSHIP [CITL]

STATEMENT OF HARVEY FINEBURG

Dr. FINEBURG. Good afternoon. It is a pleasure for me to be here.

I am delighted to be here this afternoon, Mr. Chairman. I thank

you for the privilege of testifying before the committee today.

You have a very important subject that you are tackling, and I

would like to just offer a few observations orally. I have submitted

my written testimony to the committee.

The first point I would like to make, Mr. Chairman, is to reiterate a point that came up earlier, that when we are talking here

about the quality of health care and the safety of individuals, information technology is a tool, but it is a tool that has to be embedded

in a complete system dedicated to higher quality and greater safety

of care.

Rather than thinking about devising a training program that can

prepare physicians and other health professionals who are capable

of delivering high quality care that is safe, doing the right thing,

we ought to be designing systems of care that are incapable of

doing the wrong thing. If you want a fail safe health care system,

information at the time you need it that is accurate and relevant

to the decisions that are being taken is an essential part of that

puzzle.

So information technology in its own right has a great deal to

contribute to making the system a safer and a high quality system.

The second point that I would like to suggest is that, as you look

at the opportunities for the Federal Employees Health Benefits

Program, both for the welfare of those employees who are entrusted to this committee and also as a model for the Nation, there

are many opportunities, I believe, that you can extend on the important initiatives that were described earlier today by Director

Springer and others.

For example, the FEHBP can make a commitment to recognize

only certified IT products at the time national certification comes

online. It can hasten, in other words, the adoption and reliance

upon products that meet common standards.

Second, the FEHBP can do more to insist upon the collection and

reporting of quality measures using data that is electronically

available and demonstrate improved performance for the members

of FEHBP. It can do this in a way that also utilizes pay for performance that depend upon the success of interventions to meet

standards of quality.

The health informatics available through the FEHBP can be applied to deliver the best quality care for the patients in the program, regardless of whether they are in acute care hospitals, in

chronic care facilities, in ambulatory settings. It can encourage

those data systems that can also be used to reduce the likelihood

and to increase the detection of fraud and abuse in the system. And

the particular advantage that is has, Mr. Chairman, is that the

FEHBP, while a Federal program for Federal employees, is embedVerDate 11-MAY-2000 12:41 May 01, 2006 Jkt 000000 PO 00000 Frm 00069 Fmt 6633 Sfmt 6633 D:\DOCS\26656.TXT HGOVREF1 PsN: HGOVREF1
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ded nationwide in the private sector and the private insurance system, and therefore it is a perfect case in point where initiatives of

this type can encourage and can hasten the adoption of appropriate

information technology.

I would like to conclude by saying that it will take more than information technology to accomplish what information technology,

itself, is aimed to accomplish: the high quality care. It will take

change on the part of those physician practices and the payers of

care, as well as those who are involved in the service and support

functions. But there is a great deal of ingenuity and willingness in

the community all over this country, and putting the incentives in

the right way through FEHBP I believe will encourage the right

decisions at the right time for all of our patients.

Thank you very much, Mr. Chairman.

[The prepared statement of Dr. Fineburg follows:]

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Mr. PORTER. Thank you.

Mr. St. Clair.

STATEMENT OF DAVID ST. CLAIR

Mr. ST. CLAIR. Thank you, Mr. Chairman. Thank you for having

me here.

I guess I would like to start by echoing something that Dr.

Brailer said. As the CEO of a technology company, I would like to

simply state that I agree with his assessment that this is not about

technology. This really is ultimately about improving the quality of

care and managing the cost of care so that it can be available to

more and more of our citizens in the coming years.

Having said that, a lot of the advances that we can make are,

in fact, based in technology, but those are a means to an end, not

the end, itself.

One of the things that I think is important—my testimony has

been submitted in writing and I am going to just sort of make a

half dozen points—conversations about the electronic health record,

the EHR, are not synonymous with talk about electronic medical

records systems. The EMR, the information that is available in

hospitals and doctors’ offices is not the totality of the EHR.

Frankly, discussions as to how and when we should start getting

value from clinical data in terms of clinical decisionmaking at the

point of care should be separated as quickly as possible from discussions about how to explicitly expand the use of EMRs, per se,

because I believe in the near term—in fact, in production today—

are systems that can take clinical data and deliver them to the

point of care to improve patient care, to improve the quality of

care, and reduce cost without the presence of EMRs, without the

presence of high-cost technology in the doctor’s office.

We are, for instance, today in production with systems that take

paid claims data and care management data and pharmacy data

and lab data that are available to the large regional payers, highly

processing that information into what we call a patient clinical

summary, which looks remarkably like an electronic health record

and, in fact, I would argue is the most complete picture of a patient’s health available today.

We are able to deliver that over the Internet in printable form

to a physician’s office, and we are today delivering it to emergency

rooms in the State of Delaware to allow physicians to get a more

complete picture of their patient’s history than would otherwise be

available to them.

This particular approach we believe is particularly important for

the FEHBP because of the fact that it is a step that you can take

essentially immediately to start getting the health care system accustomed to using new sources of information, new sources of data

in the treatment of their patients, and it does not require anything

more than an Internet connection and a printer in any particular

physician’s office.

Furthermore, I think that it is important for us to recognize that

the infrastructure for any national health information system is

going to be paid for ultimately by us being able to take better care

of the 10 percent of the population that is the sickest, that is consuming 80 percent of the resources.

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It is by achieving some substantial return on investment with

that particular population by improving their quality of care, by reducing the amount of duplicative care in their lives, that we are

going to afford to pay for the infrastructure that will support transactions for those of us who are fortunately far less sick.

So there are strategies that are at work today in this country

that allow those folks who essentially are responsible for the payment of care to get healthy returns on their investment in systems

that start to disseminate information to the point of care with very,

very little expense on the provider side. Those tend to work

through emergency departments, through the sickest of the case

and disease management patients, but there are strategies that are

being employed today in the State of Delaware and in other States

that essentially follow that model.

The good news is that those strategies are not in any way inconsistent with Dr. Brailer’s strategy for the national health information network. In fact, the availability of those data sets early on in

the process will help drive adoption of the peer-to-peer networks

and the regional health information networks he wants to see by

giving early users of those networks access to data from the first

day.

Ultimately, we think that we can help share the benefits of HIT

across the breadth of the population without waiting for universal

adoption of EMRs and other technologies in the provider setting.

I believe that technology needs to be available for an extended period of time, because there is going to be some period of delay between the adoption of EMRs by, in effect, the richest provider

groups, and it will slowly then be adopted in the others. We need

to have multiple ways of delivering and gathering information from

the provider setting.

Thank you very much.

[The prepared statement of Mr. St. Clair follows:]

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Mr. PORTER. Thank you, Mr. St. Clair.

Dr. Walker, welcome.

STATEMENT OF JAN WALKER

Ms. WALKER. Thank you and good afternoon.

I am a nurse from Boston with a longstanding interest in understanding patients’ experiences with our health care system. I am

currently executive director of the Center for IT Leadership, which

is a leadership group at Partners Health Care System, and I am

a member of the Health Information and Management System Society [HIMSS]. You invited me today to provide my views on how

the Federal Government can use its buying power to influence the

use of technology in health care.

I brought a written statement to include in the record, and I

would like to make just a few remarks.

Professionally, I believe that information technology will transform care in this country. But I am also a nurse and a private citizen with a family and I would like to tell a personal story.

A few months ago my nephew was diagnosed with thyroid cancer. He lives in a small town in Kansas and goes to a State university about 300 miles away. He needed surgery and he was referred

to a surgeon in a neighboring city. His parents called me for advice.

Should they send their son to this surgeon?

Of course, I wanted to know how many of these types of cases

the surgeon had done and how his patients had fared. To paraphrase Dr. Clancy, I wanted to make an evidence-based decision.

But I could find no information to answer any of these questions,

and in the end we decided to bring my nephew to Boston where I

could depend on my local contacts to find the most experienced doctors.

It sounds simple enough, but it required a barrage of phone calls,

signatures, and faxes to get information from his Kansas workup.

Scans were mailed to the wrong place and had to be sent again.

Results from several lab tests never did arrive and had to be

redone. A Boston pharmacist could not fill a prescription because

he could not reach the Kansas pharmacist by phone until the next

day.

Our studies at the Center for IT Leadership have analyzed how

information technology would address inefficiencies like these,

transforming the cost as well as the delivery of care.

As an example, we found that if all clinics and laboratories ordered and reported lab tests electronically in a standardized way,

we could avoid $4 billion in unnecessary, redundant tests, and $27

billion in paper handling and phone costs every year.

If every clinic in the country adopted computerized order entry

with advanced decision support, we could save $44 billion and

avoid 136,000 life-threatening, adverse drug events every year.

If the main stakeholders in patient care, doctors and hospitals,

labs and radiology centers, pharmacies, public health departments,

and payers, all adopted systems that allowed them to exchange

electronic information in a standardized way, we could save $77.8

billion every year.

I will close with three thoughts. First, as we have seen in multiple studies, the return on investment from HIT is overwhelmingly

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positive. It has the potential to save billions of dollars and dramatically improve the quality of care for all Americans.

Second, HIT costs money. We must prime the pump by giving

providers incentives to invest. The costs of HIT are a huge barrier

to adoption, especially for small offices and small hospitals. A combination of low-interest loans, tax credits, and rewards for using

HIT could help providers make this transition.

Third, none of this can happen without national standards that

allow computers to talk to each other. Most of the dollars we spend

on systems that do not adhere to such standards will go down the

drain. If the Federal Government can use its buying power to support standards development and implementation, to facilitate availability of capital for providers, and to reward providers who use

HIT, we will move closer to transforming care.

This week my nephew returned home to Kansas. I am crossing

my fingers that his Kansas doctors will hear from his Boston doctors. In the end, these inconveniences did not compromise his care,

and I would even say they were relatively minor glitches. Many patients are less fortunate. We feel very lucky.

On behalf of HIMSS, I thank you for this opportunity to speak

with you today. Both HIMSS and the Center for IT Leadership

stand prepared to help you in any way we can.

Thank you.

[The prepared statement of Ms. Walker follows:]

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Mr. PORTER. Thank you very much, Dr. Walker.

I would like to ask all three of you a question. I think it will help

jump start as this committee moves forward.

Right now there are a lot of ideas, a lot of suggestions, but we

keep coming back to having to have what I believe is a plan, a

strategy, and certainly an outcome, and that is to provide the best

health care in the world and to make sure that single mom or that

dad or that senior, no matter their income level, they have the best

in the world.

What would you suggest, or how would you suggest we start this

cultural change? I know that we are really limited on time and we

are going to have additional meetings, but today what would your

message be to this Congress as we try to move forward rapidly but

also thoughtfully in this process of changing our culture in the Federal Government? What would you suggest, Dr. Fineburg?

Dr. FINEBURG. Mr. Chairman, there are many ways to begin. In

fact, I think that the first one I would say is that there is not a

single magic bullet to transform health care in the United States,

so that we should not strive to solve the whole thing with one fell

swoop. But I would say that there are significant opportunities that

you have before you with the tool that you are responsible for—

namely, the Federal Employees Health Benefits Program—to improve care for those beneficiaries and thereby demonstrate what

can be done.

For example, if Director Springer were to be the first to adopt

and insist upon the kind of certification standards that virtually

every witness has testified to, that would be an enormous message

of the importance of high-quality care across the whole country.

Second, looking at ways to align the reimbursement and payment

systems with the kind of behavior that we are seeking on the parts

of patients as well as our care system, to eliminate the advantages

of doing the wrong thing by having more resources given to you,

and instead reverse that so that you are reimbursed for doing the

right thing and having patients better off, that is, I think, a very

important opportunity which comes out of this pay for performance

set of strategies.

And, by the way, no one is absolutely clear what the best way

to do that is, so having in mind that you are going to try different

ways and learn from the experience I think would be a wonderful

frame of mind for the FEHBP, because that would suggest that you

are acting and also committed to improving over time.

Those are two things I would suggest. You have turned to others.

Mr. PORTER. Mr. St. Clair.

Mr. ST. CLAIR. While I would agree that there are many, many

places to start, I guess that I would also like to caution that there

are many places not to start. There is the common statement these

days about boiling the ocean. We cannot try to solve every problem

all at the same time, which is why I think it is useful to try to

break the problem down into its component parts.

I believe that a place to start is with technology that is available

today broadly across the market to take data that already exists

in electronic form and begin to share it now. What we want to do

to start is start. There is information that is available that is tremendously valuable in different settings, like emergency rooms and

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things of that nature, that we could start doing quite literally tomorrow because it is being done today, but to do it more broadly.

And the FEHBP, it is a redundant program, is a tremendous opportunity because you can influence that sort of pilot process across

dozens and dozens of health plans all over the country by getting

them to essentially involve your members within theirs, and that

is essentially going to start drawing in their own participation in

that same program. I happen to like that as one of the places to

start.

But, to your point, without pay for performance you are going to

start and you are going to start to slow down because you are going

to start getting resistance from the provider sector once you get

past the early adopters and their side. So there really are those two

avenues that I would say to move down.

Mr. PORTER. Dr. Walker.

Ms. WALKER. I certainly agree with those points. I guess in a

sense we have already started, and there are a lot of success stories

out there. I think it will help to publicize the success stories. Providers became providers because they want to provide good care.

They are humanitarians at heart. They are really busy, and sometimes I think they do not have time to see the possibilities of HIT,

and I believe publicizing some of the good work that has already

happened might help them get over that conceptual hump, which

we need to accomplish.

Mr. PORTER. Very good. As we have mentioned throughout the

hearing today, we still have the best system in the world, some of

the best doctors. And yes, we really need to recognize those that

are being successful.

Mr. St. Clair, I concur. There are some things we can do right

away. My kids, our kids, we have a lot of folks that understand

technology far better than I do, and there are young folks, senior

folks that could get up to speed really quick on some of the things

that you are suggesting as far as the patients and understanding.

And I agree with what you are saying by separating these areas.

I think that is important.

Mr. Fineburg, I concur wholly with you that the steps have to be

taken as soon as possible, but what I am going to suggest is that

we are going to move forward. I think we, as a Federal Government delivery system, we have some of the most advanced technologically businesses in the world that are providing health care insurance to our employees. They are the most sophisticated when it

comes to investment, they are sophisticated in delivery, they are

sophisticated in the product that they provide because they have

been forced to by a market that is demanding better and better

service.

I have no doubt that we can take some of your ideas, and I hope

that you will join me as we compile some possible legislation. But

I think we have the best and the brightest, of course, in the health

care field, but also in the business community. If we can provide

some incentives that will force some changes in a culture, I think

we can help expedite in technology.

And I say this because I used to work for an insurance company

for 20 years. It is not in the health care. It is property and casualty

company. But I know that it is one of the largest in the country.

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We had to make changes because the market demanded it, and to

be competitive and to provide the best property and casualty insurance we had to do it. We were stuck with having one of the best

computer systems in the 1970’s in the world, and then we threw

bandaids on it through the 1980’s, and all of the sudden we were

so far behind the curve we were forced to make some major

changes.

I think that the Federal employees, as being the largest customer

base in the world, probably, we can provide some incentives to

make sure that the best and the brightest in our partners, the carriers, can help work with the doctors and our employees, which will

set the standard and create a whole new culture for the country.

So, having said all that, we are going to have to conclude the

hearing. I want to thank you all very much for being here. I am

very excited to be a part of this and plan on being very active and

look forward to working with all of you. Thank you all for being

here today. I appreciate it.

[Whereupon, at 4:15 p.m., the subcommittee was adjourned.]

[The prepared statement of Hon. Elijah E. Cummings follows:]

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