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26–205PS 2006

HEALTH CARE INFORMATION TECHNOLOGY:

WHAT ARE THE OPPORTUNITIES FOR AND

BARRIERS TO INTER-OPERABLE HEALTH

INFORMATION TECHNOLOGY SYSTEMS?

FIELD HEARING

BEFORE THE

SUBCOMMITTEE ON ENVIRONMENT, TECHNOLOGY,

AND STANDARDS

COMMITTEE ON SCIENCE

HOUSE OF REPRESENTATIVES

ONE HUNDRED NINTH CONGRESS

SECOND SESSION

FEBRUARY 23, 2006

Serial No. 109–37

Printed for the use of the Committee on Science

(

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

(II)

COMMITTEE ON SCIENCE

HON. SHERWOOD L. BOEHLERT, New York, Chairman

RALPH M. HALL, Texas

LAMAR S. SMITH, Texas

CURT WELDON, Pennsylvania

DANA ROHRABACHER, California

KEN CALVERT, California

ROSCOE G. BARTLETT, Maryland

VERNON J. EHLERS, Michigan

GIL GUTKNECHT, Minnesota

FRANK D. LUCAS, Oklahoma

JUDY BIGGERT, Illinois

WAYNE T. GILCHREST, Maryland

W. TODD AKIN, Missouri

TIMOTHY V. JOHNSON, Illinois

J. RANDY FORBES, Virginia

JO BONNER, Alabama

TOM FEENEY, Florida

BOB INGLIS, South Carolina

DAVE G. REICHERT, Washington

MICHAEL E. SODREL, Indiana

JOHN J.H. ‘‘JOE’’ SCHWARZ, Michigan

MICHAEL T. MCCAUL, Texas

VACANCY

VACANCY

BART GORDON, Tennessee

JERRY F. COSTELLO, Illinois

EDDIE BERNICE JOHNSON, Texas

LYNN C. WOOLSEY, California

DARLENE HOOLEY, Oregon

MARK UDALL, Colorado

DAVID WU, Oregon

MICHAEL M. HONDA, California

BRAD MILLER, North Carolina

LINCOLN DAVIS, Tennessee

DANIEL LIPINSKI, Illinois

SHEILA JACKSON LEE, Texas

BRAD SHERMAN, California

BRIAN BAIRD, Washington

JIM MATHESON, Utah

JIM COSTA, California

AL GREEN, Texas

CHARLIE MELANCON, Louisiana

DENNIS MOORE, Kansas

VACANCY

SUBCOMMITTEE ON ENVIRONMENT, TECHNOLOGY, AND STANDARDS

VERNON J. EHLERS, Michigan, Chairman

GIL GUTKNECHT, Minnesota

JUDY BIGGERT, Illinois

WAYNE T. GILCHREST, Maryland

TIMOTHY V. JOHNSON, Illinois

DAVE G. REICHERT, Washington

JOHN J.H. ‘‘JOE’’ SCHWARZ, Michigan

VACANCY

SHERWOOD L. BOEHLERT, New York

DAVID WU, Oregon

BRAD MILLER, North Carolina

MARK UDALL, Colorado

LINCOLN DAVIS, Tennessee

BRIAN BAIRD, Washington

JIM MATHESON, Utah

BART GORDON, Tennessee

AMY CARROLL Subcommittee Staff Director

MIKE QUEAR Democratic Professional Staff Member

JEAN FRUCI Democratic Professional Staff Member

OLWEN HUXLEY Professional Staff Member

MARTY SPITZER Professional Staff Member

SUSANNAH FOSTER Professional Staff Member

CHAD ENGLISH Professional Staff Member

JAMIE BROWN Majority Staff Assistant

(III)

C O N T E N T S

February 23, 2006

Page

Witness List ............................................................................................................. 2

Hearing Charter ...................................................................................................... 3

Opening Statements

Statement by Representative David G. Reichert, Subcommittee on Environment, Technology, and Standards, Committee on Science, U.S. House of

Representatives .................................................................................................... 11

Written Statement ............................................................................................ 12

Statement by Representative David Wu, Ranking Minority Member, Subcommittee on Environment, Technology, and Standards, Committee on

Science, U.S. House of Representatives ............................................................. 12

Witnesses:

Mr. William Jeffrey, Director, National Institute of Standards and Technology

Oral Statement ................................................................................................. 14

Written Statement ............................................................................................ 16

Biography .......................................................................................................... 22

Dr. Jody Pettit, M.D., Project Chair, Portland Health Care Quality Corporation, Portland, Oregon

Oral Statement ................................................................................................. 23

Written Statement ............................................................................................ 25

Biography .......................................................................................................... 30

Ms. Diane E. Cecchettini, President and CEO, MultiCare Health System,

Tacoma, Washington

Oral Statement ................................................................................................. 30

Written Statement ............................................................................................ 32

Biography .......................................................................................................... 46

Mr. John Jay Kenagy, Chief Information Officer, Oregon Health and Science

University

Oral Statement ................................................................................................. 46

Written Statement ............................................................................................ 48

Biography .......................................................................................................... 54

Dr. Homer L. Chin, Medical Director, Clinical Information Systems, Kaiser

Permanente; Northwest Chief Information Officer, Oregon Health and

Science University

Oral Statement ................................................................................................. 54

Written Statement ............................................................................................ 56

Mr. Luis Machuca, President and CEO, Kryptiq Corporation, Hillsboro, Oregon

Oral Statement ................................................................................................. 59

Written Statement ............................................................................................ 60

Biography .......................................................................................................... 65

Mr. Prem Urali, President and CEO, HealthUnity Corporation

Oral Statement ................................................................................................. 65

Written Statement ............................................................................................ 67

Biography .......................................................................................................... 69

Discussion ................................................................................................................. 70

Government Role in Health IT ........................................................................ 71

Page

IV

Discussion —Continued

Training on IT Systems ................................................................................... 74

Role of Patient in Health IT ............................................................................ 76

Privacy Issues ................................................................................................... 77

Unique Patient Identifier ................................................................................. 78

Questions From the Audience ......................................................................... 81

Top-down or Bottom-up Approach .................................................................. 84

HIPAA ............................................................................................................... 87

Appendix: Additional Material for the Record

HEALTH INFORMATION TECHNOLOGY: HHS Is Taking Steps to Develop

a National Strategy, United States Government Accountability Office, Report to the Chairman, Committee on the Budget, House of Representatives . 94

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HEALTH CARE INFORMATION TECHNOLOGY:

WHAT ARE THE OPPORTUNITIES FOR AND

BARRIERS TO INTER-OPERABLE HEALTH

INFORMATION TECHNOLOGY SYSTEMS?

THURSDAY, FEBRUARY 23, 2006

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON ENVIRONMENT, TECHNOLOGY, AND

STANDARDS,

COMMITTEE ON SCIENCE,

Washington, DC.

The Subcommittee met, pursuant to call, at 12:18 p.m., at the

Providence St. Vincent Medical Center, Souther Auditorium, 9205

S.W. Barnes Road, Portland, Oregon, the Honorable David Reichert

presiding.

2

3

HEARING CHARTER

SUBCOMMITTEE ON ENVIRONMENT, TECHNOLOGY, AND

STANDARDS

COMMITTEE ON SCIENCE

U.S. HOUSE OF REPRESENTATIVES

Health Care Information Technology:

What Are the Opportunities For and

Barriers to Inter-operable Health

Information Technology Systems?

THURSDAY, FEBRUARY 23, 2006

12:00 P.M.–2:00 P.M.

PROVIDENCE ST. VINCENT MEDICAL CENTER

SOUTHER AUDITORIUM, 9205 S.W. BARNES ROAD,

PORTLAND, OREGON 97225

Purpose

On February 23, 2006 at 12:00 p.m. in Portland, Oregon, the Subcommittee on

Environment, Technology, and Standards of the House Science Committee will hold

a field hearing about the opportunities for and barriers to inter-operable health information technology (IT) systems.

The purpose of this hearing is to learn about the potential benefits of IT to health

care providers and consumers, the impact of IT on health care costs and quality,

and about the major challenges to implementing a national health information technology system. The hearing will review federal, State and private-sector efforts to

promote connectivity, which would enable health care providers to access patient

data from any location. The hearing will examine efforts to develop standards for

security, privacy and inter-operability, which are crucial to the adoption of nationwide health IT systems.

The Committee plans to examine these overarching questions:

1. What are the potential benefits of information technology to the health care

industry and health care consumers?

2. What should Federal and State governments and the private sector do to foster the development of better health IT systems? What is preventing the

widespread adoption of these systems?

3. What is happening in the states of Oregon and Washington to help insurers,

hospitals, doctors, and other providers develop more comprehensive health IT

systems? What role has the Federal Government played? What else needs to

be done?

Witnesses:

Dr. William Jeffrey, Director of the National Institute of Standards and Technology (NIST). NIST’s mission is to promote U.S. innovation and industrial competitiveness by advancing measurement science, standards, and technology in ways that

enhance economic security and improve our quality of life. NIST has a memorandum of understanding with the Department of Health and Human Services

(HHS) to collaborate on the development of health IT infrastructure and standards.

Dr. Jody Pettit, Project Chair, Oregon Health Care Quality Corp (QCorp). The Oregon Health Care Quality Corp provides both a forum for sharing information and

best practices and a mechanism to identify strategic projects for improving health

care through community based activities. Dr. Pettit chairs the Oregon Health Information Infrastructure (OHII) Project for the QCorp. The OHII seeks to create an

Oregon multi-stakeholder collaboration to apply health care information and communication technology so that care is timely, effective, efficient, safe, equitable and

patient-centered.

4

1 Annals of Family Medicine. July/August 2004. 2 Health Affairs. January 2005. ‘‘The Value of Health Care Information Exchange and Interoperability,’’ by Jan Walker et al. 3 ‘‘Health Information Technology: HHS is Taking Steps to Develop a National Strategy,’’ GAO

Report to the Chairman, Committee on the Budget, House of Representatives. May 2005.

Mr. Luis Machuca, President and CEO of Kryptiq Corporation. Kryptiq makes

software products for health care providers for secure messaging, electronic prescribing, disease management and contract management.

Dr. Homer Chin, Medical Director for Clinical Information Systems, Kaiser

Permanente Northwest. Kaiser Permanente is America’s leading integrated health

care organization, with 8.2 million enrolled members. Kaiser Permanente Northwest

started a pilot health IT system in 1994 and rolled out a full system in 1998.

Mr. Prem Urali, President and CEO of HealthUnity Corporation. HealthUnity

makes software and hardware health IT products for health care providers.

Ms. Diane Cecchettini, RN, President and CEO of MultiCare Health System.

MultiCare Health System is the largest provider of key medical services in Pierce

County, south King County and much of southwest Washington State. MultiCare

has adopted a comprehensive health IT system throughout its network of providers.

Mr. John Jay Kenagy, Chief Information Officer, Oregon Health & Science University (OHSU). OHSU offers instruction in health care, biomedical science, environmental engineering and computer science for more than 3,900 students, interns,

residents, fellows and clinical trainees each year. Furthermore, the University provides education and training for about 18,000 health professionals through its continuing education programs. OHSU is currently implementing an electronic health

record system for its patients.

Background:

What Are Inter-operable Health IT Systems?

Inter-operability allows different information technology systems and software applications to communicate, exchange data, and use that information. Inter-operable

health IT systems can involve the use of and the ability to share: up-to-date patient

electronic health records (EHRs); electronic physician orders for drug prescriptions

and lab tests; electronic referrals to specialists and other health care providers; and

electronic access to current treatments and research findings. For these systems to

share information, especially if they are different IT systems, they must use common standards for data transmission, medical terminology, security, and other features.

Potential Benefits of Health IT Systems

Studies suggest that eliminating errors related to paperwork and enabling better

communication between health care providers could improve treatment and lower

costs in the health care industry. For the purposes of this charter, health care providers include both individuals (such as physicians, nurses and lab technicians) and

institutions (such as hospitals and medical practices). According to a study in the

Annals of Family Medicine, miscommunication is a major cause of 80 percent of

medical errors, including poor communication between physicians, misinformation

in medical records and misfiled charts.1 Providing doctors with access to EHRs could

reduce duplicate medical tests and adverse drug interactions. A patient’s EHR

would include all of his or her lab tests and/or drug allergies, thereby reducing the

chance for error. In addition, EHRs could provide health care workers with the ability to access a patient’s medical history at short notice in emergency situations.

Inter-operable health IT systems could allow physicians to: share patient medical

information and lab results between hospitals, labs, and clinics; order drug prescriptions; and alert patients of drug recalls much faster than by sharing paper records.

Several health associations estimate that the potential savings of greater IT adoption by the health care industry run into the tens of billions of dollars. A recent

study in the journal Health Affairs estimates that a fully inter-operable national health IT network could yield $77.8 billion per year in savings, or five percent of

America’s annual health care spending.2

Barriers to Adoption of Health IT Systems

The adoption of EHRs and other health-related IT has been slow. According to

a May 2005 Government Accountability Office report on the subject, the Department

of Health and Human Services (HHS) has identified the health care industry as the

largest part of the U.S. economy that has not fully embraced IT.3 An expert at

5

4The Economist, April 28, 2005. ‘‘The No-Computer Virus.’’ 5 Health Affairs. September 2005. ‘‘Medical groups’ adoption of electronic health records and

information systems,’’ by D. Gans et al.

Brigham and Women’s Hospital in Boston, found that the health care industry invests only about two percent of its revenues in IT.4 Other information-intensive industries invest approximately 10 percent of revenues. There are many reasons for

this relative lack of adoption including: cost of purchasing IT systems and institutional resistance to the adoption of new technology; contradictory incentives

for health care providers and payers; concerns about security systems for patient records; and the lack of standards necessary for uniform data entry and

exchange, software, and terminology.

Estimates of the number of providers who currently utilize EHRs range from five

percent to 20 percent nationwide, meaning that the remainder rely on paper-based

records that must be faxed or mailed if a doctor outside of a medical office or provider network wants to see a patient’s history. According to a study in Health Affairs, only 12 percent of practices with five or fewer full-time-equivalent physicians,

where most physicians work and most patients receive care, use EHRs.5 A major

reason for low rate of utilization is the cost of IT systems. Large health care providers and hospitals have a distinct advantage over smaller and rural practices because they have greater access to capital to purchase new technology, more integrated offices, and larger physical concentrations of doctors and patients. In addition, many physicians have used paper records and files for years, and are uncomfortable abandoning this system to use IT.

A typical medical practice in the U.S. has five doctors handling approximately

4,000 patient visits in a year. The Markle Foundation in New York finds that these

practices would lose money if they had to invest in, and learn how to use an interoperable health IT system. Furthermore, the current medical reimbursement system

creates a contradiction between insurers and patients on the one hand, who would

benefit from IT adoption, and health care providers on the other hand, who would

have to pay for IT adoption. Providers do not necessarily have the economic incentive to adopt these systems, even if they are more convenient to use. Currently,

most health care providers operate on a financial reimbursement system, which does

not reward efficiency. For instance, a physician may wish to order a duplicate test

for a patient rather than wait for the physical transfer of the patient’s test results

from another practice. The patient’s health plan or insurance company will reimburse the provider for this additional test. Use of an IT system could reduce this

inefficiency by providing remote access to the patient’s original test results. HMOs,

such as Kaiser Permanente, are exceptions to this model and have incentives to

adopt IT because the payer and provider exist in a single financial entity.

In 2005, ChoicePoint informed approximately 163,000 people that their personal

information, including names, addresses, birth dates, social security numbers and

credit summary information were obtained by suspected criminals posing as legitimate business people. This data breach highlights security concerns for IT. Most

patients want to restrict access to their medical records, which contain sensitive personal information, to their doctors and to other vital medical personnel. Whereas

paper files may not provide ideal security, breaches require deliberate action, and

even then the bulk of paper records prevents or discourages large-scale mischief.

With EHRs, it is easier to access a lot of information quickly because data can be

distributed to hundreds or even thousands of people at the click of a button. Last

February, for example, the names and addresses of over 6,000 HIV carriers were

accidentally e-mailed to all 900 staff members of the Palm Beach County Health Department. For these reasons, system designers must ensure that passwords and

encryption provide adequate security to prevent hackers and other unauthorized

users from gaining access to sensitive personal information. The system design itself

must also include checks that protect this information from inadvertently being

transmitted to inappropriate recipients.

Some health care networks, organizations, municipalities and states have been

working to develop health IT systems. They recognize the need for connectivity

using agreed-upon inter-operability standards. Comprehensive health care networks, such as Kaiser Permanente Northwest and the Veterans Health Administration, have sophisticated IT systems, which allow extensive connectivity within their

networks. However, these are closed systems which cannot share electronic patient

information with outside providers. Some cities have implemented pilot programs

which allow interconnectivity at various levels, but this often involves the exchange

of information in PDF form. PDF files are not easily transferred into searchable

databases. If agreed-upon standards existed for EHR data exchange, these burVerDate 11-MAY-2000 14:54 Jun 23, 2006 Jkt 026205 PO 00000 Frm 00009 Fmt 6633 Sfmt 6621 C:\WORKD\ETS06\022306\26205 SCIENCE1 PsN: SCIENCE1
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geoning systems could adopt them, making seamless and efficient connectivity between them much easier.

Federal Initiatives:

In April 2004, President Bush established a national goal that most Americans

have EHRs within 10 years. To carry out the President’s goal, HHS, in partnership

with the National Institute of Standards and Technology (NIST), has embarked on

a number of initiatives, with both public and private entities, to facilitate health IT

adoption without directly mandating standards.

Office of National Health Information Technology Coordinator

In April 2004, President Bush signed an executive order establishing the position

of the National Health Information Technology Coordinator (National Coordinator)

in HHS. The National Coordinator was charged to develop a plan to ‘‘guide the nationwide implementation of inter-operable health IT in both the public and private

health care sectors that will reduce medical errors, improve quality, and produce

greater value for health care expenditures.’’

On May 6, 2004, Dr. David Brailer was appointed as the National Coordinator

for Health IT. Dr. Brailer previously served as a Senior Fellow at the Health Technology Center in San Francisco, CA, a non-profit research and education organization that provides advice to health care organizations about the future impact of

technology in health care delivery. Dr. Brailer announced a plan to achieve health

inter-operability nationwide, which includes having NIST work with the National

Coordinator’s Office to oversee the development of standards to facilitate this process. HHS and NIST signed a Memorandum of Understanding, which transfers $6

million from HHS to NIST to pay for its health IT work. The National Coordinator’s

Office and NIST are collaborating with industry, standards organizations, consortia,

and government agencies to build tools and prototypes to advance the adoption of

IT within health care systems.

In his 2006 State of the Union address, President Bush called for the ‘‘wider use

of electronic records and other health information technology, to help control costs

and reduce dangerous medical errors.’’ The President’s 2007 budget requests $116

million for the Office of the National Coordinator for Health Information Technology, an increase of $55 million or 90 percent over the FY 2006 enacted level.

Funding will support strategic planning, coordination, and analysis of technical, economic, and other issues related to public and private adoption of health IT. The

total FY 2007 budget request for health IT initiatives in HHS is $169 million, an

increase of $58 million or 52 percent over the FY 2006 enacted level.

NIST

NIST is the Nation’s oldest federal laboratory and conducts research in a wide

range of physical and engineering sciences. NIST researchers collaborate with colleagues in industry, academic institutions, and other government agencies to support the development of standards for a broad array of technical fields including

software, hardware, communications, and computer security. NIST activities to support the President’s health IT goals include participation in key standards-related

efforts, developing performance and conformance metrics for health IT, developing

procedures for certifying conformance to consensus-based standards, and helping to

secure sensitive information and information systems. NIST has extensive experience working with industry on standards development, conformance testing, and

other aspects of standards. In particular NIST has worked with the IT industry on

standards for inter-operability and computer security, which would be a significant

component of health IT. NIST helped HHS develop Requests for Proposals for contracts on heath IT, and it continues to work on these projects, providing technical

advice and other support to the participants.

HHS Contracts for Health IT Development

On October 6, 2005, Secretary Michael Leavitt announced that HHS has let three

contracts to develop a Standards Harmonization Process, a Compliance Certification

Process, and Privacy and Security Solutions. On November 10, HHS awarded contracts to four groups of health care and health IT organizations to develop a Nationwide Health Information Network.

Standards Harmonization Process: $3,300,000 annually for three years

HHS awarded a contract to the American National Standards Institute, a nonprofit organization that administers and coordinates the U.S. voluntary standardization activities, to convene the Health Information Technology Standards Panel

(HITSP). The HITSP will bring together U.S. standards development organizations

and other stakeholders to develop, prototype, and evaluate a harmonization process

7

for achieving a widely accepted and useful set of health IT inter-operability standards. NIST staff will work with the HITSP during the standards harmonization

process.

Compliance Certification Process: $2,700,000 total over three years

HHS awarded a contract to a non-profit organization, the Certification Commission for Health Information Technology (CCHIT) to develop criteria and evaluation

processes for certifying EHRs and the infrastructure or network components

through which they inter-operate. More than 200 EHR products are on the market,

but there are no criteria for prospective buyers to objectively evaluate them. This

hinders informed purchasing decisions and further discourages the widespread

adoption of health IT systems. CCHIT submitted recommendations to HHS for ambulatory EHR certification criteria in December 2005, and developed an evaluation

process for ambulatory health records in January 2006. The CCHIT is currently developing pilots for these projects. A cross disciplinary team of NIST researchers

serves as a technical advisory committee to support the CCHIT. An optional extension to continue refinement and assessment of the processes during a fourth year

will be up for consideration as the base period is completed.

Privacy and Security Solutions: $11,500,000 total for 18 months

Regulations promulgated pursuant to the Health Insurance Portability and Accountability Act (HIPAA) established baseline health care privacy requirements for

protected health information and established security requirements for electronic

protected health information. Many states have adopted policies that go beyond

HIPAA. In addition, the manner in which hospitals, physicians and other health

care organizations implement required security and privacy policies varies and is

tailored to meet their individual organizations’ needs. These variations in policies

present challenges for widespread electronic health information exchange, due to the

lack of common standards.

HHS awarded a contract to the Research Triangle Institute International (RTI),

a private, nonprofit corporation to oversee the Health Information Security and Privacy Collaboration (HISPC). HISPC is a new partnership consisting of a multi-disciplinary team of experts and the National Governors Association. The HISPC will

develop plans to harmonize the variations in business policies and state laws that

affect privacy and security practices. NIST will provide expertise to help ensure that

the systems being developed are secure and address privacy.

Nationwide Health Information Network: $18,600,000 total for one year

HHS awarded contracts to four groups of health care and health IT organizations

to develop pilot projects for secure information sharing in a nationwide health IT

system. The four consortia are led by Accenture, Computer Science Corporation,

IBM, and Northrop Grumman. NIST will create an architecture management system to serve as a repository for the content of the four prototypes being proposed.

Health IT Adoption Initiative

The National Coordinator’s Office is partnering with the George Washington University and Massachusetts General Hospital/Harvard Institute for Health Policy

through a contract on the Health IT (HIT) Adoption Initiative. The new initiative

is aimed at better characterizing and measuring the state of EHR adoption and determining the effectiveness of policies aimed at accelerating adoption of EHRs and

inter-operability. These institutions will examine the current state of metrics for assessing EHR adoption measurement and make publicly available the gaps in adoption measurement data and the currently known gaps in actual adoption. The HIT

Adoption Initiative will provide not only a baseline measurement on EHR adoption

rates but also a quantifiable method for measuring the anticipated increased uptake

of health IT. Beginning in the fall of 2006, an annual report will synthesize multiple

surveys using the methodologies developed under the HIT Adoption Initiative, and

ultimately provide metrics with which to assess the progress of the entire program.

American Health Information Community

The April 2004 Executive Order called on the National Coordinator to coordinate

outreach and consultation by the relevant branch agencies (including federal commissions) with public and private parties of interest, including consumers, providers,

payers, and administrators. As part of this collaboration, Secretary Leavitt created

the American Health Information Community (AHIC) on September 13, 2005. The

AHIC provides input and recommendations to HHS on how to make health records

digital and inter-operable, and assure that the privacy and security of those records

are protected, in a smooth, market-led way. Membership includes officials from HHS

and its component agencies, and other federal agencies, including the Department

8

of Veterans Affairs, Office of Personnel Management, Department of Commerce, Department of Treasury, and the Department of Defense. Other members include physicians, health care providers, a patient advocate, payers, purchasers, public health

experts and business officials. The AHIC was chartered for two years with the option to renew, and will have a duration of no more than five years. A list of Community members can be found at: www.hhs.gov/healthit/ahic.html

State of Washington Initiatives:

The State of Washington has recently implemented a Health Information Technology and Electronic Medical Records Initiative. The initiative will develop a strategy for the adoption and use of electronic medical records and health information

technologies.

The Washington State Health Care Authority (HCA), together with the Health Information Infrastructure Advisory Board (HIIAB), will develop the health information and technology strategy. In addition to the HIIAB, the HCA is also creating

a Health Information Infrastructure Stakeholder Advisory Committee (HIISAC) that

will provide feedback and input to the HIIAB. Unlike the HIIAB, the HIISAC will

represent a broad variety of stakeholder groups such as consumers, clinicians, business, payers of health care, employers, and health care organizations (hospitals, carriers, long-term care facilities).

State of Oregon Initiatives:

The Oregon Health Policy Research (OHPR) office has been working closely with

key health care experts and stakeholders around the state on electronic health

records and data connectivity issues through its staffing of the Oregon’s Health Policy Commission (OHPC). The OHPC is directed by statute to develop and oversee

health policy and planning for the state and includes key health leaders from both

the private sector and the State legislature. The Commission’s recent Subcommittee

on Electronic Health Records and Data Connectivity, developed key recommendations to move the state’s health information technology agenda forward. The Oregon

Healthcare Quality Corporation (QCorp) acts as a non-profit private sector partner

with the OHPR.

QCorp has worked in partnership on a number of state initiatives for health IT

including the Oregon Chronic Disease Data Clearinghouse. The Clearinghouse

merged data from 11 health plans on 150,000 patients with asthma and diabetes

for use in developing reports for physician practices. On a 10-point rating scale, clinicians and practice managers rated the value of the merged, single source and format reports from the Clearinghouse as 8.4 (highly favorable) compared to 1.4 (highly unfavorable) for the traditional approach with multiple report sources and formats. QCorp also works on the Electronic Health Record Inventory. An important

part of this work is assessing the current state of EHR adoption. In addition, QCorp

is currently working with the Oregon Business Council EHR Leadership Team to

develop next steps for health data exchange.

Witness Questions:

The witnesses were asked to answer the following questions in their testimony.

Dr. William Jeffrey, Director of NIST

1. What are the most significant standards-related barriers to the widespread

adoption of information technology within the health care industry?

2. What is NIST’s role in removing these barriers and what is the expected

time line for the completion of these activities?

3. How is NIST working with the health-care industry, information technology

companies, federal agencies, states and other stakeholders to facilitate this

process?

4. What role will NIST play in the HHS National Health Information Infrastructure? What responsibilities has HHS assigned NIST?

Dr. Jody Pettit, Project Chair, Oregon Health Care Quality Corp.

1. What role or potential role does health information technology play in improving the delivery of health care in Oregon?

2. What role does the Oregon Health Care Quality Corporation play in this

process?

3. What incentives and barriers exist to the adoption of information technology

in the health care industry, and are these financial, technical, or of some

9

other nature? What has been the experience of the State of Oregon in this

regard?

4. What specific measures can the Federal or State governments take to encourage broader adoption of health information technology?

Mr. Luis Machuca, President and CEO of Kryptiq Corp.

1. What role or potential role does health information technology play in improving the delivery of health care in Oregon?

2. What benefits have been realized or are expected from the widespread adoption of information technology in the health care industry?

3. What incentives and barriers exist to the adoption of information technology

in the health care industry, and are these financial, technical, or of some

other nature? What has been Kryptiq’s experience with these incentives and

barriers?

4. To what extent have the Department of Health and Human Services and

NIST reached out to businesses like yours in its effort to develop a national

strategy on Health IT?

5. What specific measures can the Federal or State governments take to encourage broader adoption of health information technology?

Dr. Homer Chin, Medical Director for Clinical Information Systems, Kaiser

Permanente Northwest

1. How does Kaiser Permanente use health care-specific information technology? What benefits has Kaiser Permanente realized so far? What future

benefits are expected from the further adoption of this kind of technology?

2. What incentives and barriers exist to the broader adoption of information

technology in the health care industry, and are these financial, technical, or

of some other nature? What was Kaiser Permanente’s experience with these

incentives and barriers?

3. How does Kaiser Permanente differ from other non-HMO providers? Do

these differences affect the incentives for adoption of health care IT?

4. To what extent have the Department of Health and Human Services and

NIST reached out to businesses like yours in its effort to develop a national

strategy on Health IT?

5. What specific measures can the Federal or State governments take to encourage broader adoption of health information technology?

Mr. Prem Urali, President and CEO of HealthUnity Corp.

1. What role or potential role does health information technology play in improving the delivery of health care in Washington?

2. What benefits have been realized or are expected from the widespread adoption of information technology in the health care industry?

3. What incentives and barriers exist to the adoption of information technology

in the health care industry, and are these financial, technical, or of some

other nature? What has been HealthUnity’s experience with these incentives

and barriers?

4. To what extent have the Department of Health and Human Services and

NIST reached out to businesses like yours in its effort to develop a national

strategy on Health IT?

5. What specific measures could the Federal or State governments take to encourage broader adoption of health information technology?

Ms. Diane Cecchettini, RN, President and CEO of MultiCare Health System

1. How does MultiCare use health care-specific information technology? What

benefits has MultiCare realized from adoption of health IT? What future benefits are expected from the further adoption of this kind of technology?

2. What incentives and barriers exist to the broader adoption of information

technology in the health care industry, and are these financial, technical, or

of some other nature? What has been MultiCare’s experience with these incentives and barriers?

10

3. To what extent have the Department of Health and Human Services and

NIST reached out to businesses like yours in its effort to develop a national

strategy on Health IT?

4. What specific measures can the Federal or State governments take to encourage broader adoption of health information technology?

Mr. John Jay Kenagy, Chief Information Officer, Oregon Health & Science University (OHSU)

1. How does Oregon Health and Science University (OHSU) use health carespecific information technology? What benefits has OHSU realized so far?

What future benefits are expected from this kind of technology?

2. What incentives and barriers exist to the broader adoption of information

technology in the health care industry, and are these financial, technical, or

of some other nature? What has been OHSU’s experience with these incentives and barriers?

3. To what extent have the Department of Health and Human Services and

NIST reached out to institutions like yours in its effort to develop a national

strategy on Health IT?

4. What specific measures can the Federal or State governments take to help

the broader adoption of health information technology?

11

Mr. REICHERT. Well, good afternoon. It’s a pleasure to be here.

Someone asked me, earlier if I had—if this is my first time to Portland, and it’s not. I went to college here in Portland, at Concordia

University, so I’ve been here a little while. It’s nice to be back

again.

This hearing will now come to order. Good afternoon and welcome to today’s hearing entitled ‘‘Health Care Information Technology: What Are the Opportunities For and Barriers to Inter-operable Health Information Technology Systems?’’

Today we are here to discuss the potential benefits of IT to

health care providers and consumers, the impact of IT on health

care costs and quality, and the major challenges to the widespread

use of IT in the health care industry. We will learn about federal,

State, and private sector efforts to promote electronic systems that

enable health care providers to access patient data from any location.

Information technology has profoundly changed the way we live

and work. Computers are everywhere, and we increasingly expect

their convenience to touch on every aspect of our daily lives. However, go into a doctor’s office and in most cases, the records of that

visit, the prescriptions that are written, and referrals to specialists

will all be made on paper. Many health experts tout the benefits

of converting to electronic records for billing, referrals, and prescriptions. Experts claim that not only would it be cheaper in the

long run and more convenient, but the conversion to electronic

records will also enable doctors to share patient data more easily,

which would make for better diagnosis and treatment, prevent

deaths from drug interactions and allergic reactions, and help public health agencies track diseases in populations.

In addition to serving on the Science Committee, I also chair the

Subcommittee of Emergency Preparedness Science and Technology.

And this is under the Homeland Security Committee. During one

of our recent hearings we held on pandemic flu, we heard testimony on the real-world benefits of IT in the health sector. One of

the best ways to slow the spread of pandemic is to quickly identify

health trends in an area. Health IT enables us to do that. We must

recognize that we are incapable of storing, moving, and accessing

information in times of crisis.

Health IT would have been beneficial in the aftermath of Hurricane Katrina as well, while a lack of electronic patients’ medical

records contributed to the difficulties and delays in the medical

treatment of evacuees.

There are many challenges to the widespread adoption of electronic health records and linking health care providers to computers to exchange information. These systems are often very expensive and complicated to implement. Standards are needed to

allow different systems to talk to each other. There are serious security and privacy concerns associated with putting sensitive patient data on computers. Experts must consider these and other

factors when thinking about the use of IT in health care.

I want to thank Congressman David Wu, the Ranking Member

of the Subcommittee on Environment, Technology, and Standards,

for suggesting this topic for discussion this afternoon, which is a

matter of great interest to myself and my constituents, and I’m

12

sure it is to Mr. Wu’s as well. I also want to thank our witnesses

today who have taken time out of their busy schedule. I look forward to learning more from our witnesses from the region and

what they are doing to help with health care in the Pacific Northwest to become more IT enabled and how the lessons learned can

be applied nationwide. The Chair now recognizes Mr. Wu.

[The prepared statement of Mr. Reichert follows:]

PREPARED STATEMENT OF REPRESENTATIVE DAVID G. REICHERT

Good afternoon. Welcome to today’s hearing entitled ‘‘Health Care Information

Technology: What Are the Opportunities For and Barriers to Inter-operable Health

Information Technology Systems?’’

Today we are here to discuss:

• the potential benefits of IT to health care providers and consumers,

• the impact of IT on health care costs and quality, and

• the major challenges to the widespread use of IT in the health care industry.

We will learn about federal, State and private-sector efforts to promote electronic

systems that enable health care providers to access patient data from any location.

Information technology has profoundly changed the way we live and work. Computers are everywhere, and we increasingly expect their conveniences to touch on

every aspect of our daily lives. However, go into a doctor’s office and in most cases,

the records of that visit, the prescriptions that are written and referrals to specialists will all be made on paper. Many health experts tout the benefits of converting

to electronic records for billing, referrals and prescriptions. Experts claim that not

only would it be cheaper in the long run and more convenient, but the conversion

to electronic records would also enable doctors to share patient data more easily,

which would make for better diagnosis and treatment, prevent deaths from drug

interactions and allergic reactions, and help public health agencies track diseases

in populations.

In addition to serving on the Science Committee, I also Chair the Subcommittee

on Emergency Preparedness under Homeland Security. During one of our recent

hearings we held on the Pandemic Flu, we heard testimony on the real world benefits of IT in the health sector. One of the best ways to slow the spread of a pandemic

is to quickly identify health trends in an area. Health IT enables us to do that. We

must recognize that we are incapable of storing, moving and accessing information

in times of crisis. Health IT would have been beneficial in the aftermath of Hurricane Katrina as well, when a lack of electronic patient medical records contributed

to difficulties and delays in the medical treatment of evacuees.

There are many challenges to the widespread adoption of electronic health records

and linking health care providers’ computers to exchange information. These systems are often very expensive and complicated to implement. Standards are needed

to allow different systems to ‘‘talk’’ to each other. There are serious security and privacy concerns associated with putting sensitive patient data on computers. Experts

must consider these and other factors when thinking about the use of IT in health

care.

I want to thank Congressman David Wu, the Ranking Member on the Subcommittee on Environment, Technology, and Standards, for suggesting the topic for

this hearing, which is a matter of great interest to myself and my constituents, as

I am sure it is to Mr. Wu’s. I also want to thank our witnesses, who have taken

time out of their busy schedules to testify before us today. I look forward to learning

more about what our witnesses from the region are doing to help health care in the

Pacific Northwest become more IT-enabled, and how the lessons learned here can

be applied nationwide.

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

I want to welcome everyone to this afternoon’s hearing, and I

would like to begin by thanking Representative Reichert for traveling from the Puget Sound area to take part in this hearing. I also

want to thank Dr. Bill Jeffrey, the Director of the National Institute of Standards and Technology, for traveling from Washington,

D.C., out of a snowstorm, to take part in this hearing as well.

13

Health care costs and efficiency have become the issue of the moment and will be the issue of tomorrow. The most recent report by

the Centers for Medicare and Medicaid Services predicts that

health care costs could consume close to 20 percent of our GDP

within ten years. There’s general agreement that increased utilization of information technology in the health care industry may save

billions of dollars in costs and save thousands of lives each year.

It will certainly improve the patient experience and provide a better work environment for health care providers.

This hearing is a follow-up to a round table discussion that I held

in August of 2005. Before that round table, the solution seemed obvious: To get all patient information out of paper files and onto

electronic databases that can be connected with each other; in this

way, our health care providers can access all the information that

they need to help any given patient, at any time, in any place. In

other words, we would create an inter-operable system of doctors,

hospitals, laboratories, pharmacies, and insurers.

If I can use any ATM in almost any place in the world, and international financial markets operate seamlessly and transparently—

well, much of the time—why must I fill out a patient information

form every time I am referred to a medical specialist?

The initial round table we held last August made me aware of

not only the technical barriers but also the system and financial

barriers to the widespread adoption of IT in the health care industry. Today’s field hearing will focus on the technical barriers to developing a comprehensive health care IT system. Technical standards are critical not only to issues of inter-operability of systems,

but also to the privacy and security of electronic health records.

I hope our witnesses will identify some of the stumbling blocks

to the development of the required standards and make recommendations on how we can best move forward together. We need

technical standards to create a functional IT network; however, in

order to reap the benefits of a comprehensive health care IT network, it must fully—it must be fully utilized in all health care settings.

There is agreement that IT use lags in the health care industry,

with only 10 percent of hospitals and five percent of doctors using

IT effectively. Anecdotally, the health care industry apparently has

the same percentage of gross revenues devoted to IT as the mining

industry, and these two industries are at the lowest level of investment in IT.

We need to understand these nontechnical barriers to the adoption of IT by our health care industry. And I hope that our witnesses will address factors such as capital costs, training and education of medical personnel, reimbursement structure, patient confidence and confidentiality, in their testimony. If we want to be

successful in our efforts, we need to address these issues early on

in the process.

Many of you will be wondering about the Science Committee’s involvement in health care IT issues. The Science Committee in the

mid-1990s held hearings on the technical aspects surrounding the

security and privacy issues of the Health Care Insurance Portability and Accountability Act, which you all—which everyone

knows as HIPAA. As a result of those hearings, the National InstiVerDate 11-MAY-2000 14:54 Jun 23, 2006 Jkt 026205 PO 00000 Frm 00017 Fmt 6633 Sfmt 6601 C:\WORKD\ETS06\022306\26205 SCIENCE1 PsN: SCIENCE1
14

tute of Standards and Technology, NIST, assisted HHS in the development of some of those regulations, which many of you came

to discuss with me in my offices prior to their implementation.

I was pleased that HHS turned to the NIST early on in the development of the President’s health information technology plan.

NIST has a long history of working with the private sector in the

development of standards for the IT industry as well as many other

industries.

In the Pacific Northwest, we have a group of experts who have

been working on these health care IT issues, and just a few of them

are represented by the panelists here today. I intend to profit from

their experience and knowledge as federal efforts move forward. I

want to thank all of the witnesses for taking time from their busy

schedules to appear before us. We value your expertise and we are

looking forward to your guidance.

Mr. Chairman.

Mr. REICHERT. Thank you, Mr. Wu.

At this time, I’d like to introduce our witnesses. The first is Dr.

William Jeffrey; he’s the Director of the National Institute of

Standards and Technology, also known as NIST. Second, Ms. Diane

Cecchettini is the President and CEO of MultiCare Health System,

headquartered in Tacoma, Washington. And third, Mr. Prem Urali

is the President and CEO of HealthUnity Corporation,

headquartered in Bellevue, Washington.

And for the purpose of introductions, the Chair yields to the

Ranking Member, Mr. Wu.

Mr. WU. Thank you.

Dr. Jody Pettit is Project Chair at the Portland Health Care

Quality Corporation, based in Portland, Oregon.

Luis Machuca is the President and CEO of Kryptiq Corporation,

based in Hillsboro, Oregon.

Dr. Homer Chin is the Medical Director for Clinical Information

Systems at Kaiser Permanente Northwest. And I have to say that,

as a Kaiser patient, I appreciate your hard work and the availability of that data.

Mr. John Kenagy is the Chief Information Officer at Oregon

Health and Science University, in Portland, Oregon.

Mr. Chairman.

Mr. REICHERT. Thank you, Mr. Wu.

As our witnesses should know, spoken testimony is limited to

five minutes each; after which, the members of the science committee will have five minutes each, to ask questions.

And we will start by hearing the testimony of Dr. Jeffrey.

STATEMENT OF MR. WILLIAM JEFFREY, DIRECTOR, NATIONAL

INSTITUTE OF STANDARDS AND TECHNOLOGY

Dr. JEFFREY. Thank you very much, Representative Reichert and

Representative Wu. I’m very pleased to be here today to take part

in this important hearing. And I’m also very pleased to be in Portland, which is the first time I’ve been here, and I’m very impressed

with what I’ve seen.

With your permission, I ask that my full statement be put in the

record so that I can summarize it in the short time frame.

Mr. REICHERT. Without objection.

15

Dr. JEFFREY. Americans expect the world’s best health care, and

whereas our current health care system is second to none, we can

make it even better. Today Americans spend an increasing share

of their income on health care. In fact, when I was born, in 1960,

the U.S. spent five percent of its GDP on health care; and as Representative Wu said, that is supposed to go up to—it’s estimated

to go up to 20 percent by the year 2015.

In addition to increase in costs, there are indications that lack

of information or confusing information reduces the quality of care.

The Institute of Medicine estimated about five years ago that between 44,000 and 98,000 Americans die each year from inpatient

medical errors. The Agency for Health Care Quality and Research

estimates more than 770,000 people are injured or die each year

in hospitals from adverse drug effects; and a significant cost is

borne for treatments and tests that may not improve health, may

be redundant, or may be inappropriate.

Health care is a critical issue facing the Nation, impacting our

economic security and quality of life. In the most recent State of

the Union Address, President Bush proposed a comprehensive

agenda to make health care in America more affordable, portable,

transparent, and efficient. The portion of the President’s plan that

I’ll touch upon today is the incorporation of IT into routine health

care, with the goal of lower costs, fewer medical errors, and improved quality.

In 2004, the President launched an initiative to make electronic

health records available to most Americans within the next ten

years, and for the development of a nationwide health information

network to connect patients, practitioners, and caregivers.

So how might this work? Let’s say, hypothetically, that a visitor

from Washington, D.C., ends up getting sick and going to the emergency room in Portland. Well, the patient’s electronic health record

can be accessed by the ER physician, removing the burden from the

patient of having to accurately remember his or her entire medical

history. Vital signs are monitored, tests run, and the results added

to the electronic record. The data is transferred to a consulting

physician, who orders a battery of tests. Several of these tests may

have already been conducted, and so the data is called up rather

than repeating the tests, which could be costly or uncomfortable for

the patient. Medication may be suggested; but before ordered, the

medication is checked against the patient’s known allergies and

other known medications, to avoid the adverse reactions. The prescription is then electronically sent to a nursing station, avoiding

the risk—if there’s any nurses here—of deciphering the doctor’s

handwriting. And all of this information is securely sent to the

hometown physician for follow-up care.

So in this kind of vision, IT can clearly add to the quality of the

patient’s life, can save money and potentially save time in the diagnosis. So the administration is taking steps toward making this vision, including establishing the position of the National Coordinator for Health Information Technology and providing funds for

projects harmonizing standards for electronic information exchange, developing certification criteria to ensure health IT investments meet proper standards, addressing privacy and security

issues, and developing models for a nationwide Internet-based

16

health information system. And through the American Health Information Community, the administration and the private sector

are working together to provide input and make recommendations

to HHS, Health and Human Services, on how to make health

records digital and inter-operable and to ensure that the privacy

and security of the records are protected.

While the Department of Health and Human Services naturally

takes the lead in this initiative, it’s clear that in this area, as the

President put it, step 1 is to set the standards. NIST has a long

and effective history of working with health related standards organizations to improve our nation’s health care system. Because of

these collaborations, NIST and HHS signed an interagency agreement in September of 2005 for us to support the office of the National Coordinator for Health IT office, known as ONC.

Since signing of that agreement, NIST has been collaborating

with the ONC in standards harmonization, conformity assessment,

developing the architectural management system for the health information network, and privacy and security.

As you know, the efforts to develop a nationwide health IT infrastructure is highly complex, with dozens of players. We are therefore actively involved with the key health IT standards, including

ANSI, ASTM, IEEE, the American Telemedics Association, Health

Level 7, and scores of others. Because there are so many different

relevant standards in existence and under development, we’re collaborating with the community to develop and demonstrate a prototype health care standards landscape.

The landscape, as we call it, is a Web based repository of information on health care standards and resources that can assist in

the development, implementation, and hopefully the adoption of

standards by the stakeholders. In addition to the standards, we’re

helping to address conformity assessment. Conformity assessment

activities form a vital link between standards and the performance

of the products themselves. NIST is collaborating with the ONC to

enable performance testing, to provide assurances that health care

information technology products deliver the functionality necessary

for inter-operability. This activity is important, because there are

more than 200 electronic health record products on the market,

that criteria exists for objectively evaluating product capabilities.

The challenges are great but they’re not insurmountable. Working closely with the Office of the National Coordinator of Health IT,

NIST is happy to play our part in realizing the President’s vision.

As he said two years ago, at the outset, by introducing information

technology, health care will be better, the cost will go down, and

the quality will go up.

Thank you, and I’d be happy to answer any questions.

Mr. REICHERT. Thank you, Dr. Jeffrey.

[The prepared statement of Dr. Jeffrey follows:]

PREPARED STATEMENT OF WILLIAM JEFFREY

Introduction

Representative Wu and Representative Reichert, I am William Jeffrey, Director

of the National Institute of Standards and Technology (NIST), part of the Technology Administration of the Department of Commerce. I am pleased to be offered

the opportunity to add to this discussion regarding health information technology.

17

1Smith, Cynthia, Cathy Cowan, Stephen Heffler, Aaron Caitlin and the National Health Accounts Team, National Health Spending in 2004: Recent Slowdown Led By Prescription Drug

Spending. 25 HEALTH AFFAIRS 186 January/February 2006. 2Kohn, L.T., J. Corrigan, and M.S. Donaldson. To Err Is Human: Building a Safer Health

System. National Academy Press: Washington, D.C., 2000. 3 Agency for Healthcare Quality and Research, http://www.ahrq.gov/qual/aderia/aderia.htm.

I will focus my testimony on NIST’s role in meeting the challenges we are facing

as we incorporate advances in information technology to the health care enterprise,

critical to improving values in the Nation’s health care spending, now over 16 percent of the GDP.1

Our nation enjoys the best medical care and the brightest medical personnel in

the world. Nonetheless, the enterprise is fraught with poor coordination, inefficiencies in administration, and avoidable medical errors. Studies suggest that between

44,000 and 98,000 Americans die each year from inpatient medical errors;2 more than 770,000 people are injured or die each year in hospitals from adverse drug

events, which may cost up to $5.6 million each year per hospital depending on hospital size;3 and a significant annual expenditure on treatments that may not improve health, may be redundant, or may be inappropriate.

Today, we have new technological opportunities to address these problems. The

President’s Health Information Technology Plan, with the ultimate mandate of making our country’s premier health care system safer, more affordable, and more accessible through the utilization of information technology (IT), is designed to overcome

all of these trends, which are closely related to failure to adequately develop and

adopt information technology for the health care system. In particular, the President

has called for ensuring that most Americans have electronic health records within

the next ten years and for the development of an Internet-based Nationwide Health

Information Network to connect patients, practitioners, and payers. These initiatives will reduce redundancies and save administrative time, and could greatly improve patient safety and quality of care.

When the President’s vision is realized:

• consumers will have their choice of providers and will be able to move

seamlessly between practitioners without loss of information;

• clinicians will have information needed when and where it is needed, that is,

at the point of care;

• payers will benefit through the economic efficiencies of fewer errors and less

redundant testing; and

• public health officials will benefit from more efficient and effective reporting,

surveillance, and quality monitoring.

To meet these goals, the Office of the National Coordinator for Health Information

Technology (ONC) was created in the Department of Health and Human Services

in response to Executive Order 13335, April 27, 2004. I am pleased that NIST has

the opportunity to assist ONC realize this vision. NIST is contributing through

NIST laboratory activities in measurement and consensus based standards and by

direct collaboration with ONC.

Standards and measurements go directly to the heart of NIST’s core mission. In

fiscal year 2005, NIST health related projects encompassed many areas of the

health care sector, including screening and prevention, diagnostics, treatments, dentistry, quality assurance, bioimaging, systems biology, and clinical informatics. Also,

NIST has a long and effective history in working with health-related organizations

to improve our nation’s health care system. Building on those collaborations, NIST

and HHS signed an interagency agreement in September 2005 to support ONC in

realizing the President’s health IT goals. Since the signing of the interagency agreement, NIST has been providing technical expertise to the ONC in areas such as

standards harmonization, developing procedures for certifying conformance, developing performance and conformance metrics, developing the architecture management system for the nationwide health information network.

NIST Laboratory Activities in Health IT

NIST works with industry, government, and academia to establish consensusbased standards, develop associated test metrics to ensure that devices perform according to the defined standards, and establish comprehensive certification capabilities for the IT industry. NIST has for many years focused on developing metrics for

the information technology industry. We develop tests and diagnostic tools for building robust and inter-operable systems. Applying such tools early in the life cycle

process helps industry determine whether its products conform to the standard, and

ultimately, will inter-operate with other products. In addition, the development and

18

use of these metrology tools fosters thorough review of the standards, which will,

in turn, aid in resolving errors and ambiguities.

a.) Standards Harmonization

In accordance with the National Technology Transfer and Advancement Act of

1995 (Public Law 104–113) and Administration policies, NIST supports the development of voluntary industry standards both nationally and internationally as the

preferred source of standards to be used by the Federal Government. NIST collaborates with national and international standards committees, users, industry groups,

consortia, and research and trade organizations, to get needed standards developed.

As a matter of policy, NIST encourages and supports participation of researchers

in standards developing activities related to the mission of the Institute. More than

a quarter of NIST’s technical staff—381 employees—participate in standards developing activities of 97 organizations. These include U.S. private sector standardization bodies, industry consortia, and international organizations. NIST staff members

hold 1,328 committee memberships and chair 161 standards committees.

NIST is helping ONC in establishing the Health Information Technology Standards Panel. Supported by an ONC contract with the American National Standards

Institute (ANSI), the Panel is working to harmonize standards in the health IT

arena, the NIST staff also participates in the following key IT standards-related efforts:

• American National Standards Institute (ANSI) Healthcare Information Technology Standards Panel (HITSP)

• ASTM International—Operating Room of the Future

• American Telemedicine Association (ATA)

• Federal Health Architecture/Consolidated Health Informatics (FHA/CHI)

• Medical Device Communications, Wireless Networks of the Institute of Electrical and Electronics Engineers (IEEE)

• Healthcare Information and Management Systems Society/Integrating the

Healthcare Enterprise (HIMSS/IHE)

• Health Level 7 (HL7)

b) Performance and Conformance Metrics for Health Information Technology

NIST works with industry to establish credible, cost-effective metrics to demonstrate software inter-operability and conformance to particular standards. These

metrics often form the basis or criteria upon which certifications are based. Typical

NIST metrics include models, simulations, reference implementations, test suites,

and testbeds.

Specific activities in support of health information technology include:

Electronic Health Records (EHR): Having access to complete patient health

information is critical to improving clinical care and reducing medical errors

and costs of care. The EHR is a longitudinal collection of patient-centric, health

care information, available across providers, care settings, and time. It is a central component of an integrated health information system. NIST is collaborating with organizations in both the public and private sectors in achieving the

benefits of EHRs and overcoming the barriers to their acquisition and use. In

particular, NIST leads the effort in HU to define conformance and develop conformance criteria for EHR systems. NIST authored the conformance chapter of

the draft standard for trial use and developed guidance (a How to Guide) for

writing conformance criteria, thus teaching the community how to do this for

themselves. The EHR conformance criteria and those being developed by the

Certification Commission for Health Information Technology (CCHIT) form the

basis for HER certification efforts.

HIMSS/IHE: A key problem today in the realization of Electronic Health

Records for the patient’s continuity of care is the inability to share patient

records across disparate enterprises. To address this problem, NIST is collaborating with industry to develop standardized approaches to sharing electronic

clinical documents across health care organizations and providers. NIST staff

have built reference implementations and developed validation tools to demonstrate the feasibility and correctness of implementations, and worked with

implementers to create integrated solutions based on these approaches. In particular, NIST is collaborating with the ‘Integrating the Healthcare Enterprise’

(IHE) project sponsored by the Radiological Society of North America,

Healthcare Information and Management Systems Society (HIMSS) and the

19

4 Bock, C., L. Carnahan, S. Fenves, M. Gruninger, V. Kashyap, B. Lide, J. Nell, R. Raman,

R. Sriram. Healthcare Strategic Focus Area: Clinical Informatics. National Institute of Standards and Technology: NISTIR 7263, 2005.

American College of Cardiology. The goal is to develop an approach called

Cross-Enterprise Document Sharing (XDS). This standards-based approach provides a mechanism to access a patient’s multi-faceted clinical information, regardless of where it is physically located, while maintaining local control and

ownership of that information and without compromising the privacy and security of the patient’s health information.

HL7 Messaging Standards: Health Level 7 is a standards development organization that provides standards for the exchange, management, and integration of data that support clinical patient care and the management, delivery,

and evaluation of health care services. NIST is collaborating with HL7 to improve current and future deployment of HL7 and to achieve health care information systems inter-operability and sharing of electronic health information.

To achieve this goal, NIST leads the effort to ensure that HL7 conformance can

be defined and measured at appropriate levels, by: 1) defining conformance for

standards and ensuring that requirements are precise and testable; and 2)

building tools that will promote consistent definitions and use of messages. Additionally, NIST is developing a conformance-testing tool that automatically

generates test messages for HL7 Version 2 message specifications.

Medical Device Information: In a typical intensive care unit (ICU), a patient

may be connected to one or more vital-sign monitors and receive medicine or

other fluids through multiple infusion pumps. Devices such as ventilators,

defibrillators, or hemodialysis machines may also support more acutely ill patients. Each of these medical devices has the ability to capture data. NIST is

collaborating with the Institute of Electrical and Electronics Engineers (IEEE)

Medical Device Communications work group and the IHE Patient Care Device

project, sponsored by IHE and the American College of Clinical Engineering to

develop conformance tests and associated tools that facilitate the development

and adoption of standards for communicating medical device data throughout

the health care enterprise as well as integrating it into the electronic health

record.

Operating Room of the Future: It is estimated that 10–20 percent of hospital

errors occur in the perioperative environment (before, during, and after surgery). Technology can play a major role in increasing the overall patient safety

in such situations through the development of the operating room of the future

(ORF). The ORF will consist of a network of inter-operable plug and play medical devices, where the utilization of advanced technologies, such as robot-assisted surgery, sensor fusion, virtual reality, workflow integration, and surgical

informatics, will result in a higher quality of health care by considerably increasing patient safety. NIST is working with the Center for the Integration of

Medicine and Information Technology (CIMIT) in the development of an architectural framework for medical device integration, development of clinical requirements for device plug-and-play standards, identification of current interfaces, and development, testing, and simulation of interfaces.

Clinical Informatics: Building on past experience in information modeling

and research to support interchange standards for the manufacturing industry,

NIST has prepared a comprehensive report of all clinical information-oriented

standards, their development organizations, their scope, and the vocabularies/

ontologies they employ.4 NIST will use the report as the basis for developing

a plan for applying NIST’s experience to assist in clinical information-oriented

standards development and closer harmonization.

WPAN’s for Health Information: NIST is assisting industry in the development of a universal and inter-operable wireless interface for medical equipment,

expediting the development of standards for wireless technologies, and promoting their use in the health care environment. In close collaboration with the

IEEE and the U.S. Food and Drug Administration, NIST developed theoretical

and simulation models for two candidate Wireless Personal Area Network

(WPAN) technologies including the Bluetooth and the IEEE 802.15.4 specifications. NIST evaluated their performance for several realistic health care scenarios and contributed our results to the appropriate IEEE working group.

NIST contributions will constitute the basis of standard requirements on the

use of wireless communications for medical devices.

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c) Certification

NIST has an established history of developing procedures for certifying conformance to consensus-based standards. Conformity assessment activities form a vital

link between standards that define necessary characteristics or requirements for

software products and the performance of the products themselves. Conformity assessment procedures provide a means of ensuring that the products, services, or systems produced or operated have the required characteristics, and that these characteristics are consistent from product to product, service to service, or system to system. Conformity assessment includes: sampling and testing; inspection; certification;

management system assessment and registration; accreditation of the competence of

those activities; and recognition of an accreditation program’s capability. NIST has

been in the certification business since its inception in 1901 and is well positioned

to provide technical guidance in the development of a technical certification regimen, including specific certification metrics, software to perform comprehensive certification tests, and certification procedures.

d) Security

For many years, NIST has made great contributions to help secure our nation’s

sensitive information and information systems. Our work has paralleled the evolution of IT systems, initially focused principally on mainframe computers, now encompassing today’s wide gamut of information technology devices. Our important responsibilities were reaffirmed by Congress with passage of the Federal Information

Security Management Act of 2002 (FISMA) and the Cyber Security Research and Development Act of 2002.

Beyond our role to serve the Agencies under FISMA, our Federal Information

Processing Standards (FIPS) and guidelines are often used voluntarily by U.S. industry, global industry, and foreign governments as sources of information and direction for securing information systems. Our research also contributes to securing

the Nation’s critical infrastructure systems. Moreover, NIST has an active role in

both national and international standards organizations in promoting the interests

of security and U.S. industry. Current areas that are applicable to a Nationwide

Health Information Network (NHIN) include:

• Cryptographic Standards and Applications

• Security Testing

• Security Research/Emerging Technologies

Recent activities specifically related to health IT include:

Guidance for Understanding the HIPAA Security Rule: The Security Rule

issued under the Health Insurance Portability and Accountability Act of 1996

(HIPAA) directs certain health care entities, known as ‘‘covered entities,’’ to

comply with standards for keeping certain health information that is in secure

electronic form. NIST has published a document, An Introductory Resource

Guide for Implementing the HIPAA Security Rule that summarizes and clarifies

the HIPAA Security Rule requirements for agencies that are covered entities.

It also directs readers to other NIST publications that can be useful in implementing the Security Rule.

Health Care Accreditation Guidance: NIST in conjunction with URAC and

the Workgroup of Electronic Data Interchange (WEDI) sponsors the NIST/

URAC/WEDI Health Care Security Workgroup. The group promotes the implementation of a uniform approach to security practices and assessments by developing white papers, crosswalks (of regulations and standards), and educational programs. The group brings together stakeholders from the public and

private sectors to facilitate communication and consensus on best practices for

information security in health care. Ultimately, these best practices will be integrated into accreditation criteria used by hospitals and other health care facilities. The group draws heavily upon information technology security standards

and guidelines developed by NIST.

NIST Collaboration with the ONC

NIST is committed to supporting the ONC in the implementation of the President’s Health IT initiative. Even prior to the interagency agreement NIST and many

other federal departments and agencies provided assistance to the ONC in serving

on the review task force for responses to a Request for Information (RFI) on implementation of a nationwide health information network and in assisting with subsequent Request For Proposals (RFPs) issued by the ONC.

Following are current areas of collaboration:

21

a.) The American Health Information Community (The Community)

HHS Secretary Leavitt has convened the American Health Information Community (the Community) to help advance efforts to reach President Bush’s call for electronic health records and a nationwide health information network. The Community

is a federal advisory committee and will provide input and recommendations to

HHS on how to make health records digital and inter-operable, and to assure that

the privacy and security of those records are protected, in a smooth, market-led way.

The Community agreed to form workgroups in the following areas: biosurveillance, consumer empowerment, chronic care, and electronic health records. These

workgroups will make recommendations to the Community that will produce concrete results that are tangible and offer specific value to the health care consumer

that can be realized within a one-year period. NIST has formal representation on

three of these groups.

b.) Standards Harmonization

HHS has awarded a contract to the American National Standards Institute

(ANSI), a non-profit organization that administers and coordinates the U.S. voluntary standardization activities, to convene the Healthcare Information Technology

Standards Panel (HITSP). The HITSP will bring together U.S. standards development organizations (SDOs) and other stakeholders to develop, prototype, and evaluate a harmonization process for achieving a widely accepted and useful set of health

IT standards that will support inter-operability among health care software applications, particularly EHRs. This activity is fundamental to the success of widespread

inter-operability, the seamless and secure exchange of patient information electronically, and will overcome today’s scenario of many standards for health information

exchange, but with variations and gaps that hinder inter-operability and the widespread adoption of health IT.

NIST, as with many other federal agencies, is a member of the Healthcare Information Technology Standards Panel. NIST is helping ONC in establishing the

Health Information Technology Standards Panel. In addition, NIST is working with

HHS to develop a strategy to promote voluntary consensus standards across both

the private and public sectors. As part of this process towards standardization of

health information, NIST will continue to work with the ONC’s Office of Inter-operability and Standards to develop appropriate implementation strategies for health

care IT standards. This will include consideration of the development, when appropriate, of Federal Information Processing Standards and guidance to agencies

through NIST Special Publications for adopted standards. This will help the government to achieve a greater level of inter-operability of health data.

c.) Assist in the Development of Procedures for Certifying Conformance

HHS has awarded a contract to the Certification Commission for Health Information Technology (CCHIT) to develop criteria and evaluation processes for certifying

EHRs and the infrastructure or network components through which they inter-operate. CCHIT is a private, non-profit organization established to develop an efficient,

credible, and sustainable mechanism for certifying health care information technology products. This initiative addresses the problem that there are more then 200

EHR products on the market, but no criteria exist for objectively evaluating product

capabilities. Similarly, criteria are not available by which communication architectures can be standardized in a way to permit two different EHRs to communicate.

A cross-disciplinary team of NIST researchers serves as a technical advisory committee to support the CCHIT in tasks including functional criteria and test methods,

general test procedures, accreditation, security, selection of jurors, and statistical

tests of juror bias. Additional areas for interaction are being defined as the collaboration continues. In addition, the EHR conformance criteria, developed under NIST

leadership, form the basis for CCHIT’s certification efforts.

d.) Develop Performance and Conformance Metrics

In a Nationwide Health Information Network, consumers, practitioners, researchers, and payers must have tools, systems, and information that are complete, correct, secure, and inter-operable. Compliance to specific standards and regulations is

the key to the development and implementation of this network. In addition, there

must be a way to determine that the standards and regulations have been fulfilled.

This is accomplished through conformance testing, a procedure to provide a means

to ensure that products, services, or systems produced or operated have the requisite characteristics, and that these characteristics are consistent from product to

product, service to service, or system to system.

NIST is collaborating with the ONC to help enable conformance testing to provide

assurances that health care information technology products and infrastructure

22

components deliver the functionality necessary for inter-operability. NIST will work

to help the community understand the current state of conformance testing within

health information technology markets as well as what will be needed to test conformance of products for suitability, quality, inter-operability, and data portability

so that the risk now assumed by health IT purchasers will be mitigated and the

adoption of robust, inter-operable information technologies will be accelerated

throughout the health care system of the United States.

e.) Provide Technical Expertise for a Nationwide Health Information Network

Four groups of health care and health information technology organizations have

been awarded contracts by ONC to develop prototypes for a Nationwide Health Information Network (NHIN) architecture. These four consortia will bring together

hospitals, laboratories, and health care providers with technology developers that

will lead the health care industry to develop a uniform architecture for health care

information that can follow consumers throughout their lives.

To manage the content of the four prototypes being proposed, a NIST team is

working with ONC to create an architecture management system that will serve as

a repository for all the final architectural elements, including but not limited to:

user requirements, conformance testing requirements, functional specifications, and

high level standards used. This system will also help manage the inter-relationships

between all elements, which will aid in the development of the Nationwide Health

Information Network. This architecture management system can be compared to a

blueprint for building a house.

f.) Interagency Health IT Policy Council

Secretary Leavitt has established an Interagency Health Information Technology

Policy Council (the Council) with in ONC to coordinate health information technology policy decisions across federal departments and entities that will drive action

necessary to realize the President’s goals of widespread health IT adoption. The

Council brings together representatives from various entities within HHS and elsewhere in the government for the purpose of advancing both short-term and longterm health IT policy. The initial focus of the Council is to establish a strategic direction for policy and to identify accelerators to support the Community breakthroughs. NIST will participate as a member agency on this Council.

Conclusion

As the Committee can see by the few examples I have cited, NIST has a diverse

portfolio of activities supporting our nation’s health information technology effort.

With its long experience as well as a broad array of expertise both in its laboratories

and in its collaborations with other government agencies and the private sector,

NIST is poised to help facilitate the harmonization of the many ongoing efforts,

which together contribute to achieving the President’s goal for developing both electronic health records and the establishment of a Nationwide Health Information

Network.

Once again thank you for inviting me to testify about NIST’s activities and I will

be happy to answer any questions you may have.

BIOGRAPHY FOR WILLIAM JEFFREY

William Jeffrey is the 13th Director of the National Institute of Standards and

Technology (NIST), sworn into the office on July 26, 2005. He was nominated by

President Bush on May 25, 2005, and confirmed by the U.S. Senate on July 22,

2005.

As Director of NIST, Dr. Jeffrey oversees an array of programs that promote U.S.

innovation and industrial competitiveness by advancing measurement science,

standards, and technology in ways that enhance economic security and improve

quality of life. Operating in fiscal year 2006 on a budget of about $930 million, NIST

is headquartered in Gaithersburg, Md., and has additional laboratories in Boulder,

Colo. NIST also jointly operates research organizations in three locations, which

support world-class physics, cutting-edge biotechnology, and environmental research. NIST employs about 2,800 scientists, engineers, technicians, and support

personnel. An agency of the U.S. Commerce Department’s Technology Administration, NIST has extensive cooperative research programs with industry, academia,

and other government agencies. Its staff is augmented by about 1,600 visiting researchers.

Dr. Jeffrey has been involved in federal science and technology programs and policy since 1988. Previous to his appointment to NIST he served as Senior Director

23

for Homeland and National Security and the Assistant Director for Space and Aeronautics at the Office of Science and Technology Policy (OSTP) within the Executive

Office of the President. Earlier, he was the Deputy Director for the Advanced Technology Office and Chief Scientist for the Tactical Technology Office with the Defense

Advanced Research Projects Agency (DARPA). While at DARPA, Dr. Jeffrey advanced research programs in communications, computer network security, novel

sensor development, and space operations.

Prior to joining DARPA, Dr. Jeffrey was the Assistant Deputy for Technology at

the Defense Airborne Reconnaissance Office, where he supervised sensor development for the Predator and Global Hawk Unmanned Aerial Vehicles and the development of common standards that allow for cross-service and cross-agency transfer of

imagery and intelligence products. He also spent several years working at the Institute for Defense Analyses performing technical analyses in support of the Department of Defense.

Dr. Jeffrey received his Ph.D. in astronomy from Harvard University and his

B.Sc. in physics from the Massachusetts Institute of Technology.

Mr. REICHERT. The Chair recognizes Dr. Jody Pettit.

STATEMENT OF DR. JODY PETTIT, M.D., PROJECT CHAIR,

PORTLAND HEALTH CARE QUALITY CORPORATION, PORTLAND, OREGON

Dr. PETTIT. Mr. Chairman and Mr. Wu, my name is Jody Pettit.

Thank you very much for inviting me to provide testimony on a

subject about which I feel so strongly.

I’m a board-certified internist and I’ve practiced medicine in

Portland for the past 11 years. As a physician, I’ve had the privilege to take care of people and to see our medical system from the

front line. There’s a glaring problem, and it’s the lack of information flow between systems.

I’ll tell you a story about a woman that we saw in a clinic, who

came in with a persistent cough despite treatments. We ordered a

chest X-ray, and it showed a lesion in her right lung. She’d had a

previous chest X-ray several years and remembered it was abnormal in some way but wasn’t sure how. Luckily, she remembered

where she had it done, and so we ordered the old film for comparison. If the lesion looked exactly the same, we could feel comfortable

and watch it over time. So we waited. A week later, we still didn’t

have the film. We called again, because we could save her the

worry, the radiation exposure, the time, the money that she and

her health plan would pay for more tests. We eventually gave up

and ordered a CT-scan, a chest CT, which cost close to a thousand

dollars. A week later, finally, the old film did show up and, in fact,

the lesion was exactly the same after almost four years. But by

now she had spent the time, her 20 percent co-pay, she’d missed

several hours of work, she’d gotten a hefty dose of unnecessary radiation, and she spent weeks in fear that she might have lung cancer.

This story, unfortunately, is not some bizarre exception or rare

occurrence; there are issues of information flow every day. Experiences such as these have led me to refocus my energy. For the past

three years, I’ve been one among hundreds—and they’re here, too,

today—of Oregonians from the private and public sector that want

to find a better way through the use of health information technology. We’ve called this effort, collectively, the Oregon Health Information Infrastructure, or OHII for short.

The Oregon Health Care Quality Corporation has provided the

nonprofit multi-stakeholder home for OHII. The State of Oregon reVerDate 11-MAY-2000 14:54 Jun 23, 2006 Jkt 026205 PO 00000 Frm 00027 Fmt 6633 Sfmt 6601 C:\WORKD\ETS06\022306\26205 SCIENCE1 PsN: SCIENCE1
24

cently created a position in the Office of Health Policy and Research for health information technology coordinator, and I will be

serving in that role.

The vision is fourfold: A person’s health information available to

them anywhere, any time that they need it. It’s private and secure

and under their control. Health information infrastructure is designed with the patient at the center. And that it’s used to assure

high-quality, cost-effective, personal and population-based care.

There are many barriers to overcome and achieve this vision. And

I think we’re all well-versed in the EHR adoption issues, the technical issues, standards, privacy and security, business case, and

sustainability issues—and not the least of which, political will, governance, stakeholder cooperation, data sharing, and just plain old

trust.

So what are the roles of the Quality Corporation and the State

and the Federal Government in resolving these issues? The Quality

Corporation, with lots of partners, has helped bring attention to

this issue by bringing people together from around the state and

has completed a data sharing project with 12 health plans. We’re

working on assessment of EHR adoption and currently engaged in

a joint effort with the Oregon Business Council’s EHR and interoperability committee. The goal of OHII is to catalyze the formation of a regional health information organization, or RHIO.

The state, likewise, has given attention to this issue. The Oregon

Health Policy Commission appointed a subcommittee to give recommendations to the state; that report is available here today. The

Oregon Office of Health Policy and Research has committed to resources for coordination. And the Governor’s Office is applying for

a federal contract—subcontract to examine privacy and security

laws and practices in Oregon.

With regard to the federal role, the answers for all the issues

are, clearly, not worked out yet; but what we do have is a forum

for discussion and an appropriate framework in the Office of the

National Coordinator for Health Information Technology. And the

good news is, the agenda is moving forward. National level activities are underway but state levels are not well supported. Exceptions are communities that have already received federal funding

or have been working on this for well over a decade.

The expectation is not for the government to fund this indefinitely. There are RHIO business models being studied in several

communities, but assistance or start-up capital would be helpful. A

good example of this is the federal contract process. The HISPC,

the Health Information Security and Privacy Collaboration, where

RTI serves as a prime contractor and the states as subcontractors.

This allows contract money to be awarded to states but with some

coordination at the national level. Working through the Governor’s

Office is an effective way to gain state leadership. The process

takes some leadership and some followership.

I will close with these points. Number one, there is a critical

need for better information flow for better care.

Number two, real change involves rearranging the system such

that the patient is truly at the center. Until we do this, the

changes are incremental and not transformational. There is a need

for the data holders to share their data for the good of the patient.

25

We need to resolve these issues regarding—or arguments regarding

data ownership. A person’s data needs to be available to them

without question. It’s understood that data holders, i.e., providers,

health systems, and health plans, need to keep a copy for their own

records; however, they should endeavor to make patient centered

data sharing arrangements.

Number three, the Office of the National Coordinator is a vehicle

that’s working. It has some money for national coordination but

very little to pass through to the states and communities for RHIO

information. Start-up capital could help to build the infrastructure

that’s necessary to derive value and ultimately achieve financial

sustainability.

We all need to have courage to make this happen. We’re building

something that hasn’t existed before, but it needs to exist as soon

as possible, for all of our sakes.

Mr. Chairman and Ranking Member, thank you for coming to

the Great Northwest to listen to our concerns.

Mr. WU. Thank you.

Mr. REICHERT. Thank you, Dr. Pettit.

[The prepared statement of Dr. Pettit follows:]

PREPARED STATEMENT OF JODY PETTIT

Introduction:

Thank you very much for inviting me to provide testimony on a subject about

which I feel so strongly. I am a board-certified Internist and have practiced medicine in Portland for the past 11 years. As a physician, I have the privilege to take

care of people and to see our medical system from the front line. There is a glaring

problem—and it is the lack of information flow.

Let me tell you a story about a woman that I saw in clinic who came in with a

persistent cough. We had tried several treatment regimens but her cough continued.

We ordered a chest x-ray and it showed a lesion in her right lung.

She had a previous chest x-ray several years ago and she told us it was abnormal

in some way but wasn’t exactly sure how. Fortunately, she remembered where she

had it done, so we called over to that facility to get the old chest x-ray for comparison. If the lesion still looked exactly the same after several years then we wouldn’t

have to worry as much and we could watch it.

So we waited.

A week later we still didn’t have the film. We called again because we could save

her the worry, the radiation exposure of more tests, the time and the money that

she and her insurer would pay for more tests. We called again, but eventually the

resident gave up and ordered a chest CT. A chest CT costs a little less than $1,000.

The following week, the old film finally made it over and indeed the lesion was exactly the same after almost four years. But by now she spent the time, her 20 percent co-pay, missed several hours of work, got a hefty dose of unnecessary radiation

via CT and spent a weekend in fear that she might have lung cancer.

A chest x-ray ∂ a lack of information could equal a chest CT ∂ biopsy could =

a pneumothorax, a chest tube, an ICU admission, a hospital-acquired infection and

sepsis. And a $50,000 hospital bill. Or a chest x-ray ∂ timely information = reassurance and prevention of a hospitalization.

This story is not some bizarre exception, or a rare occurrence—there are issues

of information flow every time I go to clinic.

I could tell you countless stories of scrambling for information—phone calls to

medical records clerks in the wee hours of the morning while the 50 yo man with

chest pain is being wheeled down the hall to the cath lab—we didn’t have an old

ECG for comparison or his previous cath report—we didn’t know if the ECG changes

were new so he was going to have a catheter pushed up through his groin into his

heart to look at his coronary arteries.

Any case could follow one of two equations:

Clinical condition ∂ unattainable information = cascade of unnecessary tests, possible complications and avoidable cost

26

Clinical condition ∂ timely information = accurate, well-informed medical decisions and efficient medical care. (cost-effective)

Experiences such as these have led me to refocus my energy.

For the past three years, I have been one among hundreds of Oregonians from

the private and public sector that want to find a better way with the use of information technology. We call this collective effort the Oregon Health Information Infrastructure or OHII for short. The Oregon Healthcare Quality Corporation has provided the non-profit, multi-stakeholder home for OHII. The State of Oregon recently

created a position in the Oregon Office of Health Policy and Research for a Health

Information Technology Coordinator and I will be serving in that role.

The Vision:

The vision of better information flow in health care is four-fold:

• A person’s health information is available to them anywhere, anytime they

need it.

• Health information is private and secure and under the control of the individual.

• Health information infrastructure designed with the patient at the center.

• Health information is used to assure safe, high quality, cost-effective personal

and population-based health care.

The Issues:

There are many barriers to overcome to achieve this vision.

EHR adoption issues—Clinicians aren’t adopting EHR because of a lack of financial

incentives, expense, risk of implementation failure and lack of inter-operability

which makes for expensive interfaces and prohibits migration to different system.

Technical issues—The optimal technical architecture for inter-operability and health

data exchange is still being explored. Vendors are just starting to create products

to perform this function and engines are operating only in experimental settings.

Standards issues—There are numerous standards organizations in competition for

becoming the standard. There is a need for harmonization of these standards. EHR

vendors have some but not all data in proprietary formats and new standards would

require largely require retrofitting into their software.

Privacy & Security issues—Inappropriate disclosure of health information is one of

the top concerns for consumers. Fear of discrimination especially from employers

makes people cautious about sharing their health information. Among the many

issues, patient control over access is a prominent one.

Business case and sustainability issues—It is well-recognized that in order for the

building of information technology systems to be funded that the investors must recognize some value or return on their investment. Furthermore, operating expenses

of these systems must be offset by a revenue source in order to be financially sustainable. Studies of the value of HIT and projections regarding whom benefits and

how much have been published in the past couple of years. Sustainability models

are likewise being devised and tested in some communities are around the U.S. The

answers in this realm are not readily apparent and the question of who will pay

is still largely unanswered.

Political will, governance, stakeholder cooperation, data sharing and trust issues—

Part of the challenge of moving from an institution-centric model to a patient-centered model is that it requires that data holding entities share information. Patients

almost never get all of their medical care in a single location and thus it is inadequate to maintain walled off silos of data at the various points of care. However,

institutions may view holding onto the records as a means of holding onto the patient. Thus competitive issues between health care entities may lead to an unwillingness to share. Establishing a governance in which the various entities have a

seat at the table and agree to rules for decision-making and data sharing is one of

the major challenges.

Role of the Oregon Healthcare Quality Corporation:

The Oregon Healthcare Quality Corporation (QCorp) has four initiatives, all of

which relate directly or indirectly to the use of health information technology.

27

Chronic Disease Data Clearinghouse

This proof-of-concept pilot demonstrated that 12 health plans, working together,

can provide helpful tools that physicians will use to manage care for patients with

diabetes and asthma.

Analysis is providing answers about where people receive their care to guide decisions about how to reduce fragmentation through common data systems.

Common Practice Measurements

Providers, health plans and purchasers are working together to identify a shared

set of appropriate out-patient practice quality measurements. These will be used by

multiple stakeholders for assessing, reporting and rewarding quality care in Oregon.

Advocacy and Education

Legislative testimony, serving on multiple Health Policy Commission committees

and cross-organization board memberships are a few of the ways that Quality Corporation staff advocate for a collaborative quality agenda. Sponsoring and participating in numerous conferences bring Oregonians together for a shared agenda for

quality improvement.

Oregon Health Information Infrastructure (OHII)

A strategic plan, developed through stakeholder meetings, is setting the agenda

to encourage adoption of electronic health records and systems for securely and efficiently getting information to where it is needed. OHII work (with partners) has included: multiple state-wide conferences, CIO/CMIO forums, a pilot project proposal,

EHR inventory to establish a baseline. The Quality Corporation is working to foster

the formation of a regional health information organization (RHIO). The Office of

the National Coordinator for Health Information Technology (ONCHIT), has called

for at least one RHIO per state and one overarching RHIO. In Dr. Brailer’s view,

a RHIO provides governance and oversight. He believes it is essential to develop a

process for making decisions in public and RHIOs should have this public governance process. The OHII effort endeavors to play a role in establishing an open, neutral, inclusive governance process for Oregon and is engaged in dialogue with top

health care leaders including those in the Oregon Business Council’s EHR and

Inter-operability Subcommittee.

Role of the State of Oregon:

The following is taken from the report to the Oregon Health Policy Commission

entitled ‘‘Report to the 73rd Legislative Assembly: Electronic Health Records & Data

Connectivity,’’ http://egov.oregon.gov/DAS/OHPPR/HPC/docs/

EHR¥LegReport¥March05.pdf

The report made recommendations regarding the State’s possible roles:

• Convene stakeholders

• Assess EHR adoption and community inter-operability efforts

• Sponsor meetings

• Examine State laws regarding HIT

• Collaborate with Public Health

• Engage the public

• Coordinate efforts around the state

• Provide funding, if possible

• Partner with the private sector

• Incentivize HIT adoption in role as Payer through Oregon Medical Assistance

Program (OMAP)

• Incentivize HIT adoption in role as Purchaser through Oregon Public Employees Benefits Board (PEBB).

Role of the Federal Government:

The Office of the National Coordinator for Health Information Technology

(ONCHIT) is organized into the following offices:

Office of HIT adoption

Office of Inter-operability and Standards

Office of Programs & Coordination

Office of Policy & Research

28

They have the following as their major initiatives with the corresponding roles:

A Recommendation for Action:

We don’t have the answers to all the issues but what we do have is a framework

and a forum for discussion in the Office of the National Coordinator for Health Information Technology (ONCHIT). The good news is things are progressing in the

ONCHIT agenda but the missing piece is significant money flowing to the states.

The activities that need to take place at the national level are underway but the

activities that need to occur at the state level are not well-supported. Exceptions are

communities that have received funding or have already been working on this for

over a decade. The expectation is not for the government to fund this indefinitely,

but assistance with start-up capital could be helpful. There are business models

being studied and demonstrated in some communities in the country.

An example of a working model for government funding is the Federal contract

process, e.g., with Research Triangle International (RTI) and the Health Information Security and Privacy Collaboration (HISPC). RTI serves as a prime contractor

and states as subcontractors. This allows contract money to be awarded to states

in a semi-competitive process with coordination at the national level. Working

through the Governor’s office is an effective way to engage state leadership.

So this process requires some leadership and some followership.

Economic Analysis of Health Information Technology impact:

Several groups have begun to tackle some of the economic issues relating to the

adoption of HIT, the implications for inter-operability and the use of clinical decision

support tools. Below are some high-level numbers that have been cited as relevant

to the discussion.

U.S. health care industry expenditures = $1.7 trillion per year

RAND estimates $81 billion per year savings with EHR implementation and networking.

The Center for Information Technology Leadership (CITL) estimates fully standardized health information exchange and inter-operability of could yield a net value

of $77.8 billion per year once fully implemented. Combined with potential savings

from adoption of CPOE in office EHR of $44 billion, the CITL suggests adoption of

HIT could save approximately five percent of health care expenditure.

A study out of Harvard published in the Annals of Internal Medicine last year

estimates the cost to build the National Health Information Network at $156 billion

29

in capital investment over five years and $48 billion in annual operating costs. (Annals of Internal Medicine 2005; 143:165–173.)

The Bush Administration has requested $169 million for health information tech- nology in the 2007 Health and Human Services Department budget, a $58 million

increase from the $111 million allocated for health IT in the fiscal 2006 budget

passed last month. The health IT funding line includes a requested $116 million for

ONCHIT, $50 million for the Agency for Healthcare Research and Quality and $3

million for the HHS assistant secretary for planning and evaluation’s budget.

(Source: Government Health IT, Feb. 6, 2006)

U.S. health care industry expenditures = 1.7 trillion/yr

Estimated Operating Savings = $124 billion/yr

Estimated Operating Cost = $48 billion/yr

Net Operating Savings = $ 76 billion/yr

The CITL suggests adoption of HIT could save approximately five percent of health

care expenditure.

ONCHIT budget = $169 million/yr

The estimated capital investment is $156 billion, the proposed budget is $169 million—this is 1/1,000th of the necessary funding.

These figures help to make the argument for federal funding to help move this

effort forward and for CMS in it’s role as a payer to incentivize HIT adoption.

Closing Comments:

I will close with these points:

1. There is a critical need for better information flow in health care to achieve

safe, efficient and high quality care.

2. Real change involves rearranging the system such that the patient is at the

center. Until we do this, changes are incremental, not transformational.

There is a need for the data holders to share their data for the good of the

patient. We need to resolve the arguments regarding data ownership. A person’s data needs to be made available to them without question. It is understood that the data holders, i.e., providers, health systems and health plans

need to keep a copy for their own records, however they should endeavor to

make patient-centered data sharing arrangements.

3. The Office of the National Coordinator for HIT is a vehicle already in place

for change and to a great degree it is working. We have a forum for discussion and a framework for strategic action. The ONCHIT has been able provide some money for national coordination but very little money to pass

through to the states and communities for RHIO formation. What we’re lacking is the real financial commitment for this effort at a state level. Startup capital could help to build the infrastructure that is necessary to derive

value and ultimately achieve financial sustainability.

4. Support legislation that authorizes the Secretary of Health and Human Services to make health information technology grants or contracts for the development of information sharing infrastructure and collaborative efforts to

spur adoption by small physician groups and others.

ADDENDUM:

Specific examples of issues or barriers:

Solicitation of some health information technology colleagues in Oregon yielded

the following specific examples:

Example of lack of regulatory harmonization: A health IT colleague ‘on the ground’

implementing systems points to regulation from various compliance organizations,

e.g., JCAHO, NEC, UL, EOC, etc., that result in layers and layers of regulations.

There is apparently a need for harmonization of these sometimes contradictory and

stifling combinations. It was conveyed that the regulations make sense in isolation

but become nearly unimplementable when several overlap. There is also a concern

that increasing regulation increases the cost of implementation of systems.

Example of vocabulary standards issue or need: Colleagues at Oregon chapter of

the American Health Information Management Association (AHIMA) have brought

this issue to the fore. They feel that the U.S. needs to adopt and begin implementing ICD–10 clinical coding systems in order to improve the quality of health

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data and patient care. Their concern it that current classification system, ICD–9–

CM is obsolete. Developed nearly 30 years ago, they assert that it cannot accurately

describe the diagnoses and inpatient procedures of care delivered in the 21st century. Furthermore, they point out that the U.S. is the only industrialized country

in the world that has not adopted it. Ninety-nine other countries have preceded the

U.S. thus far.

Example of potential legislative need: The U.S. might consider lengthening the

statue of limitations on keeping a medical record from seven years to 107 years. The

rationale is that records need to be available for the duration of a person’s life.

BIOGRAPHY FOR JODY PETTIT

Dr. Pettit is working in a dual role regarding health IT in Oregon. She was recently selected by the Oregon Office of Health Policy and Research to serve in the

role of Health Information Technology Coordinator.

She is the Director of the Oregon Health Information Infrastructure project of the

Oregon Healthcare Quality Corporation, a multi-stakeholder collaborative dedicated

to improving health care quality. The organization has as one of its primary goals

to foster the building of an Oregon Regional Health Information Organization.

She is a Board-Certified Internist practicing part-time as faculty with the Department of Medical Education at Providence Ambulatory Care and Education Center,

the Department of Medicine Faculty Practice at St.Vincent’s and with Legacy

Health Systems in Portland.

She was the Medical Director of the InterHospital Physicians Association (IPA)

in Portland, Oregon from 2001–2005.

Dr. Pettit worked in the role of clinical consultant for the electronic health records

company MedicaLogic in Hillsboro, Oregon from 1999–2001.

She is a Clinical Assistant Professor at the OHSU Department of Medical

Informatics and Clinical Epidemiology.

She has been on the Board of the Oregon Healthcare Quality Corporation (QCorp)

since 2001 and served as the Chairperson of the Chronic Disease Data Clearinghouse.

Dr. Pettit served as Chair of the Electronic Health Records and Healthcare

Connectivity Subcommittee for the State of Oregon, under the Oregon Health Policy

Commission 2005.

She participated in the State of Oregon Evidence-based medication review process

in three subcommittees, acting as Chair of the Triptan subcommittee.

She earned her Medical Degree from Medical College of Virginia and a Master’s

Degree in Health and Wellness Administration and a BS in General Science from

the University of Iowa.

Mr. REICHERT. The Chair recognizes Ms. Diane Cecchettini.

STATEMENT OF MS. DIANE E. CECCHETTINI, PRESIDENT AND

CEO, MULTICARE HEALTH SYSTEM, TACOMA, WASHINGTON

Ms. CECCHETTINI. Thank you, Mr. Chairman and Mr. Wu.

I’m Diane Cecchettini. I’m a registered nurse and I’m currently

serving as President and CEO of MultiCare Health System.

To give you a frame of our organization: We’re a not-for-profit,

community-governed health care system who operates two adult

hospitals and a pediatric hospital, 593 licensed beds, six ambulatory care centers, six urgent care, and we employ 200 physicians

in our care system.

Over the past eight years, MultiCare Health System has invested

over $50 million implementing an electric health record in our ambulatory center. Currently, we’re implementing the electronic

health record in our inpatient hospitals, and it’s $50 million and

counting. One of the huge barriers to the implementation is the

huge training costs of all of our staff, plus the redesign of work

flow so that we really achieve a transformation of the health care

system, centered around patient, centered around information flow.

We believe in these investments. We are funding this out of operVerDate 11-MAY-2000 14:54 Jun 23, 2006 Jkt 026205 PO 00000 Frm 00034 Fmt 6633 Sfmt 6601 C:\WORKD\ETS06\022306\26205 SCIENCE1 PsN: SCIENCE1
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ating earnings and reserves because it’s the right thing for the next

level of care.

Our patients are already starting to see the benefit of this. Our

patients now can see—they have access to their medical records

through secure electronic access. They can view their medical problems, they can see lab work results, make appointments, review

education specific to their disease, and even refill prescriptions. So

we’re on that first step of access.

Since we’ve been in the ambulatory clinics for so many years, we

looked at what are the results of providing physicians with information technology tools to really better manage complex diseases.

We’ve studied the 5,316 diabetic patients and have seen significant

clinical outcome results. When you’re able to provide physicians

consistent data in terms of how they are achieving hemoglobin

A1C—and that’s how you manage and control blood glucose, how

you manage blood pressure—we consistently monitor this with our

patients and so it’s a continuous stream of measuring outcomes.

We know—and we’ve extrapolated the data—that we have prevented heart attacks, we have prevented ED admissions, and we

have decreased morbidity and mortality from this disease.

Our goal is ultimately to establish one health record across the

continuum and decrease the fragmentation that exists in health

care with patients not having the data flow with redundant imaging tests, by being able to direct the patient at the right site with

the right information needed for care of the patient. We’re already

seeing that impact in our emergency department. When people in

our clinics come to the ED, we can immediately access the history,

the medications, and expedite treatment.

We also see that we’re able to recall patients when there are

drug alerts, when we find more information about drugs that we

need to change therapy. So with the recent Vioxx, we were able to

immediately contact our patients and change therapy. We were

able to address our 15,000 women with the hormone replacement

therapy that were issues. With preventative measures, we’re able

to achieve a 100 percent childhood immunization rates in our clinics, and our mammogram compliance rate exceeds 97 percent.

We believe, with all the barriers and challenges, that payment

incentives are key to the doctors of technology in order to achieve

successful expansion. So we’re very interested in payment incentives. We have concerns about pay for performance, but my concern

is that pay for performance needs to be tied to clinical outcomes.

We have a number of primitive efforts in Washington state, where

the commercial insurers data is corrupted, and it’s from claims history. So it really needs to be tied to clinical outcomes.

We also have concerns—We’re ready to extend our electronic

health records to smaller physician and independent physician

practices and other hospitals. And so we encourage CMS to continue to examine its interpretation of the Stark Law in order to encourage connectivity in regional networks at a fair market value.

That will allow us all to get there quicker.

And, finally, I think it’s important to consider the implications of

the electronic health record on access to and recovery of data during a disaster such as Hurricane Katrina. Of all the lessons

learned, area hospitals that already had electronic health record

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capacity lost virtually no patient data. So implementation and

inter-operability standards facilitating safe information exchange

and appropriate redundancy planning in case of another disaster is

critically important.

Thank you, Mr. Chairman. That completes my statement.

Mr. REICHERT. Thank you.

[The prepared statement of Ms. Cecchettini follows:]

PREPARED STATEMENT OF DIANE E. CECCHETTINI

Thank you Mr. Chairman and Members of the Subcommittee. My name is Diane

Cecchettini. I’m the President and CEO of MultiCare Health System in Tacoma,

Washington, and I’m also a registered nurse. Thank you for inviting me here today

to discuss the benefits of Information Technology (IT) to providers and consumers

of health care, the impact of IT on quality and costs, and the incentives and barriers

that exist to the broader adoption of IT in the health care industry.

MultiCare operates two adult and one pediatric hospital and we serve as a Level

II trauma center for both children and adults. We have 593 licensed beds, five ambulatory surgery centers, six urgent care centers, and a certified home health agency and hospice program. We also employ 200 physicians in our MultiCare Medical

Group. Over the last eight years, MultiCare has invested 50 million dollars implementing an electronic health record in our ambulatory physician practices. Currently, we are implementing the electronic health record (EHR) in our three inpatient facilities which will cost another 50 million dollars. We believe this is a critical

investment to support improvements we’ve seen in patient care, but the costs are

truly monumental. With the EHR we have a much greater ability to track our care

processes using evidence-based guidelines, communicate among different providers

who care for the same patient, and improve patient outcomes because of our ability

to track and study data trends. Our patients also see specific benefits. Most importantly, they can participate in their care through secure electronic access to their

medical record to view medical problems, see lab work results, make appointments,

review educational materials specific to their diagnoses and even refill prescriptions.

In 2001–2002, MultiCare conducted a study of 5,000 diabetic patients in

MultiCare Medical Group and estimated that as a result of implementing specific

physician practice guidelines, which included tracking and reporting of certain lab

values like blood glucose and cholesterol, along with blood pressure, 33 heart attacks and 28 deaths were prevented in one year. This of course has the downstream

effects of less Emergency Department (ED) visits, less Coronary Care Unit stays

and fewer cardiac catheterizations to name a few, all of which can cost tens of thousands of dollars each. The potential annual cost savings in this group of 5,000 diabetic patients alone had an estimated downstream savings to Washington State

health care of 4.3 million dollars annually (Reed and Bernard, 2005). The journal

article describing the study is attached to my written testimony. We believe firmly

that while terribly expensive on the front end, EHRs save lives and will save the

national health care system significantly over the long run.

Our mission is quality patient care. Because, ultimately, it is the patient who

owns their clinical data, our goal is to establish one health record that spans the

continuum of our services. Physicians in our EDs have access to medications and

past medical history via the ambulatory record. Our ambulatory physicians and

home health nurses are able to see the course of treatment when a patient is in

the hospital. Our community physicians are able to remote into our system using

a secure connection. Now, instead of relying on just faxes and mail, our medical

records department is beginning to work with physician offices to access patient information electronically. This is much more efficient to the physician and to our hospital. Secure access for our providers can even be extended to them at home, meaning they can see important lab and radiology results as soon as they are available,

even at night or on weekends. This is good for care continuity and it also saves

money because duplicate lab tests or other interventions that might be repeated, are

not. Another real advantage of an EHR is the ability to contact patients quickly

when a drug is recalled or found to have ill-effects for certain populations. For example, as soon as we learned of the potential problems with the drug Vioxx, we

were able to immediately contact our patients receiving the drug and schedule them

to talk with their doctor. When concerns arose about hormone replacement therapy

in 2002, information was targeted to 15,000 women. With traditional paper systems

this would be extremely time intensive, if not impossible.

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Our prevention programs have also seen tremendous improvements with the

EHR. Childhood immunizations have reached 100 percent in some of our clinics.

Our mammogram compliance rate exceeds 97 percent. In 2003, influenza administration reminders were mobilized in seven days for new CDC recommendations.

We feel strongly that Information technology provides our health system with several specific benefits. In particular, it allows us to:

• Practice evidence-based medicine;

• Implement disease management programs that focus on prevention and care

of the chronically ill;

• Lengthen lives and allow patient participation in care;

• Prevent costly hospitalizations; and

• Support public health and biosurveillance.

We equally believe that payment incentives are key for the adopters of technology

in order to achieve successful expansion throughout the country. Specifically, we

would encourage the State and Federal Government to:

• Adopt a common set of operating standards to support inter-operability;

• Provide payment incentives for adopters of technology;

• Ensure protection of consumer privacy by enforcing encryption, user authentication and audit trails;

• Encourage a common set of measures to audit performance among all of the

payers for health care; and

• Support a common, agreed-upon, and detailed vocabulary for all medical terminology, such as SNOMED.

A significant barrier will continue to be how to pay for information technology,

especially for small hospitals, rural providers, and individual physician practices.

While some federal and private grant money has been available for Health Information Technology (HIT) adoption, there simply is not enough to go around. We would

like to extend the use of our EHR to smaller physician practices, and even to hospitals through application service provider arrangements (ASP). I would encourage

CMS to continue to examine its interpretation of the Stark Law, in order to encourage connectivity in regional networks at a fair market value. We would also encourage CMS and other payers to ramp up efforts to expand pay for performance and

reimbursement incentives for organizations that adopt information technology. Once

payment is tied to the use of technology, the urgency of adoption will increase. However, hand in hand with these efforts need to be a uniform set of standards that

vendors must adhere to in order to achieve the inter-operability needed to ensure

patient records are always available when and where they are needed.

It is also important to consider the implications of the EHR on access to and recovery of data during a disaster such as hurricane Katrina. Hospitals, clinics and

other care settings, along with the paper medical record information in those facilities were literally destroyed. As evacuees crowded into shelters with many in need

of medical attention, doctors who treated the patients had to do so with only a rudimentary knowledge of their past treatments. However, area hospitals that already

had electronic health record capacity lost virtually no patient data. Implementation

of inter-operability standards facilitating safe information exchange and appropriate

redundancy planning in case of another disaster can ensure that electronic patient

information can be available much sooner, alleviating many of the challenges faced

by care givers in difficult circumstances.

I have the honor of currently serving as the Chairperson of the Washington State

Hospital Association. As a state, the health systems in Washington have actively

embraced the Institute for Healthcare Improvement’s 100,000 lives campaign. We

firmly believe that technology can improve care quality in our hospitals and save

money. While the return on investment is not immediate, EHRs are key to achieve

the efficiencies and care management so crucial to patient safety in the hospital,

and to address the needs of the chronically ill. The task of developing a National

Health Infrastructure is extremely difficult and complex—it is a long-term endeavor.

However, it is imperative that it be done and I appreciate the leadership of the Subcommittee.

Thank you. Mr. Chairman, this completes my statement. I will be happy to answer any questions that you or other Members of the Subcommittee might have for

me.

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BIOGRAPHY FOR DIANE E. CECCHETTINI

Ms. Cecchettini has served as President and Chief Executive Officer of MultiCare

Health System since 1999. Prior to the CEO role, she worked in various capacities

at MultiCare Health System—Executive Vice President, and Vice President Patient

Services.

Ms. Cecchettini’s previous experience includes multiple leadership positions in 11

years at Sutter Health in Sacramento, and direct clinical experience at UCLA Medical Center in Los Angeles, California. Ms. Cecchettini received a Bachelor’s degree

in Nursing in 1970 from the University of California, Los Angeles, and a Master

of Science degree in Human Resources Management in 1976 from the University of

Utah.

In 1993, Ms. Cecchettini retired as a Lieutenant Colonel from the Air Force Reserve, having served 21 years as a Flight Nurse in Aeromedical Evacuation—serving

in the Vietnam era and as a Troop Commander in Desert Storm.

Mr. REICHERT. And the Chair recognizes Mr. John Kenagy.

STATEMENT OF MR. JOHN JAY KENAGY, CHIEF INFORMATION

OFFICER, OREGON HEALTH AND SCIENCE UNIVERSITY

Mr. KENAGY. Thank you, Mr. Chairman and Mr. Wu. I’m pleased

to be here to present testimony.

We have a lot of people coming from very different perspectives,

and what I’d like to do—I have a longer testimony, but I’d just like

to highlight some of the things from my perspective as an IT professional.

I am the chief information officer for Oregon Health and Science

University and have been in that role since 2001, and also serve

as the Chair of the CIO council for the university health system

consortium of academic medical centers around the United States.

In 21 years’ experience in health care IT, it’s been a wild ride over

those 20 years.

OHSU, as Oregon’s only academic and research center, has sort

of a unique perspective. We’re really in the business, at its core,

of knowledge—creating it through advanced research, imparting it

to students through education, using it in the delivery of health

care, and sharing it through our community service mission. What

we feel is information is really the currency for knowledge. It is the

way that it is developed and analyzed and used and stored. And

as an institution, we’ve spent a lot of money, time, and resources

into developing a very comprehensive IT architecture. Are we there

yet? Far from it.

Since year 2000, we’ve spent about $25 million on different IT solutions. In 2003, we embarked on an electronic health record, like

MultiCare, $50 million and counting. And I appreciate that comment. I think one way to express sort of what we deal with on a

day-to-day basis, I brought a graphic, that you cannot see and cannot really read, but that’s somewhat of the point I want to make.

At OHSU, we have not one electronic health system or, like banking, where you have a core system; we have a significant interaction of about 100 different disparate islands of information that,

every day, day in and day out, patient records are actually not in

an electronic health record—it’s sort of a misnomer in our industry;

we actually have a significant number of these systems—that are

woven together by people who work on my staff and, fundamentally, by paper. So what we’ve been—what we have been using in

terms of our information system is an attempt to use these different islands of information.

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The health care IT industry, for all intents and purposes, is a 40-

year-old industry; but, still, the products are extremely immature,

especially around a comprehensive longitudinal electronic record.

In the paper environment, this situation is not bad; in fact, it is

the way—This is not atypical; it is the way most health care organizations in the United States run—certainly, academic medical

centers, in what we call a best of breed approach. As we approach

the marketplace or approach a need, we actually look at the niche

that is needed and buy an application that meets that niche.

A number of us were in San Diego for the national HIMSS conference, the annual health care IT marketplace. There were over

800 vendors there on the floor, showing their wares, showing different products. In many ways, that’s a great—there’s a lot of interest in this field, there are a lot of—there’s a lot of progress being

made in IT. On that floor, I could see systems that did diabetes

care and cardiology care and intensive care and home care; but as

an institution, we have patients who come in—a woman comes into

our ED with chest pain complicated by diabetes, who needs to go

to the ICU and then eventually be followed up at home. Is it really

reasonable, logical, smart for us to have her record in four different

systems, or six or eight? It’s what we deal with every day, where

standards and inter-operability is an issue. So one of the barriers,

I would say, in adopting electronic health records is not the dearth

of choice; it is the plethora. It is what we face all the time as an

IT professional trying to pull these together.

A couple other barriers, finances and resources, of course, are

mentioned all the time. We were both saying that we’re investing

$50 million of our own institution’s money to put this in. Do I think

the health care IT will make health more cost effective? I think

that’s debatable. It will certainly replace a lot of low paid file clerks

with a lot of high paid IT professionals.

One—certainly some of the issues around the barriers of resources, one is clinician time, and I want to stress that point. As

we implement our electronic health record at OHSU, and as research has shown throughout the U.S., the active involvement of

physicians and nurses and members of the health care team to be

involved in changing the work flow—it’s not a deployment of a

technology, but it’s really the change in the way we practice medicine—requires their time and attention. As we’ve been implementing EPIC electronic health records, we’re actually requiring

physicians to spend 14 hours in classroom to learn how to use the

tool effectively. That’s just to use the tool, let alone designing and

implementing the system.

As Medicare, Medicaid, the insurance company, who works towards cost containment and tries to deal with what is considered

from the outside, run-away health care inflation, we have no extra

time of our clinicians to engage in the change of their practice to

adopt this system. That is a significant—I think it’s the—what’s

under the tip of the iceberg is this clinician time.

The other one that I’m facing right now is the lack of IT professionals—few IT professionals who have this knowledge and experience to come into our field. As a provider organization, I and many

of my colleagues, we sort of look at the consulting—consulting businesses to go to different companies to bring those resources. But

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they also face the same problem, to bring in qualified IT professionals in order to do this.

The final barrier I would highlight, again, as maybe a defensive

CIO, is what I would call the expectations gap. I think there’s an

expectation, certainly within our industry as well as outside, that

IT in health should cost less and should be more effective, it should

be easier and cheaper. Frankly, it isn’t. And we face that all the

time, trying to explain—going to the board to explain cost overruns

and to explain why we are so far behind.

Congressman Wu, I appreciate your mentioning the point about

the investment health care makes. And you’ll see, we at OHSU

spend a little bit less than three percent of our—as most institutions in this industry do, three percent in health care; but banking

and finance, which are used as hallmarks of IT investment, are at

10—eight to 10 to 12 percent. It’s my recommendation.

I think there are a lot of roles that the Federal Government can

play. I think one is to continue and expand research in health care

IT. We do a lot at OHSU, through our Department of Medical

Informatics, which is a leading research institute for this field. I

think there’s a lot of additional study that needs to take place on

how can these be effectively implemented successfully.

I think the other thing that the Federal Government can do is

expand training programs for clinicians and for IT professionals, to

really create the understanding and the body of the pipeline of people who can help. I think there are many economic disincentives

to doing health care IT—like I said earlier, the lack of spare clinician time to be able to invest in this; and cost containment pressures from other parts of the Federal Government make that even

more difficult.

Finally, I do think that there is a requirement for inter-operability. I could make comments about my sense of what the priorities are. I certainly think inter-operability between institutions is

a critical priority; inter-operability within an institution, I think, is

better served by integrated information systems and not a continuation of a hundred different disparate systems.

Thank you for letting me testify.

[The prepared statement of Mr. Kenagy follows:]

PREPARED STATEMENT OF JOHN JAY KENAGY

Chairman Ehlers and Members of the Committee on Science:

On behalf of Oregon Health & Science University (OHSU), I submit the following

written testimony to the Environment, Technology, and Standards Subcommittee of

the U.S. House of Representatives’ Committee on Science. I serve as the Chief Information Officer (CIO) for OHSU, a position I have held since 2001. In that role, I

am responsible for information technology (IT) strategy and implementation for all

missions of OHSU, including health care, education, research, and community service.

As Oregon’s only academic health and science center, OHSU provides high-quality

health care to more than 150,000 patients each year. The OHSU health care system

offers the most comprehensive health care services in Oregon, including many innovative clinical care and diagnostic services. It is nationally recognized for clinical research and education, helping to develop tomorrow’s health professionals.

At its core, OHSU is in the business of knowledge: creating it through advanced

research, imparting it through excellent teaching, using it in effective and safe clinical care, and sharing it in service to the community. Information serves as the currency for knowledge-the method to develop, analyze, store, and distribute it. Effective IT solutions therefore are fundamental to our organization. In 2003, OHSU

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adopted the Strategic Information Plan that establishes a compelling vision for the

IT-enabled organization and sets forth goals and objectives in ten key strategic

areas. Among the key strategic areas are health care, business intelligence, information security and privacy, and technology and infrastructure. OHSU has an extensive IT infrastructure requiring significant, on-going investment to sustain and

grow. The organization invests just under three percent of its operating budget in

IT.

Health care IT has gained significant national attention since the beginning of the

decade. The health care sector, one of the largest in the U.S. economy, lags other

industries in the use of IT to enhance efficiency, improve effectiveness, and achieve

quality. President Bush included it as one of his administration’s goals in the 2004

State of the Union address: ‘‘By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care.’’ Landmark studies by the

Institute of Medicine [To Err Is Human: Building a Safer Health System in 2000

and Crossing the Quality Chasm: A New Health System for the 21st Century in 2001]

called for widespread adoption of IT solutions to enhance patient safety.

While calls for enhanced automation have increased, landmark research from

OHSU demonstrates the lack of progress nationwide. In a 2002 study published in

the Journal of the American Medical Informatics Association, Joan Ash, Ph.D., and

the Provider Order Entry Team surveyed hospitals and found that fewer than ten

percent had a fully implemented CPOE system. Of those, only one-third achieved

a high penetration with more than 90 percent of orders entered through a health

care IT system.

As a health care CIO, I believe that in the absence of a comprehensive health care

IT infrastructure, our industry will be unable to achieve its goals of patient safety,

clinical effectiveness, and operational efficiency. Health care is highly informationdependent. Clinical decisions are made minute by minute and require access to patient-specific data and expert clinical knowledge. An objective that resonates with

our role as an academic health institution, we need to implement systematic tools

so that all of us know what the best of us knows.

From my perspective within a provider organization, the health care IT sector is

beginning to deliver comprehensive IT solutions that effectively meet our needs as

users. Our industry traditionally has developed niche systems (patient financial, patient management/scheduling, laboratory, pharmacy, etc.) that were interfaced

where possible and practical. While much attention is being paid to sharing information across institutional boundaries and among community providers, many systems have been limited in their ability to exchange information within the hospital’s

four walls. The goal of a comprehensive, patient-centered, paperless electronic

health record (EHR) remains a futuristic goal for the vast majority of health care

providers.

1. How does OHSU use health care-specific information technology? What benefits

has OHSU realized so far? What future benefits are expected from this kind of

technology?

OHSU’s health care IT infrastructure supports its patient care functions (ancillary

testing and reporting, pharmacy, digital radiology, order entry); safety and quality

functions (infection control, data warehousing, trend monitoring); and administrative and business functions (admitting/discharge/transfer, scheduling, patient billing). OHSU has been a long-standing user of health care IT dating back to early

internal development efforts in the 1970s. In the mid 1980s, OHSU became one of

the first sites in the country to implement Shared Medical Systems’ (SMS, now Siemens Health Services) Independence system, a platform we continue to rely on

today. Through the Integrated Advanced Information Management System grant

from the National Library of Medicine, we developed a physicians’ workstation as

an early attempt to combine disparate sources of information into one portal. In the

mid 1990s, OHSU deployed the Siemens Lifetime Clinical Record which has grown

to be one of the vendor’s largest longitudinal repositories of clinical data. OHSU also

implemented clerical order entry and communication, effectively eliminating paper

order transmittal from outpatient clinics and inpatient units.

The Information Technology Group (ITG) maintains this extensive health care IT

infrastructure. Roughly two-thirds of our annual $30 million budget supports the

hospital’s IT services. Nearly 120 IT professionals are dedicated to our health care

mission. These individuals maintain over 100 different IT applications on a multitude of hardware and database technologies; design, code, and manage over 80 different interfaces that exchange critical clinical data among the disparate systems;

install and support over 5,000 personal computers deployed throughout the institution; manage over 400 active health care IT projects; and train many hundreds of

physicians, nurses, and other members of the health care team.

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OHSU continues to make considerable investment in health care IT solutions

building upon the core patient administrative and clinical repository system. Our

model remains to implement commercially available software solutions (‘‘buy’’ versus

‘‘build’’) and to make limited but necessary local modifications and customizations.

Since Year 2000, OHSU has invested over $50 million in capital for both enterprise

and departmental health care IT solutions. As is common with academic health centers, we historically have been ‘‘best of breed’’ in our approach to commercial software, seeking the optimal solution for each unique application and interfacing it to

the common core. Supported by positive industry developments, however, OHSU is

embracing a strategy that minimizes data interfaces and strives for integration.

Early this decade OHSU make the strategic decision to invest in an electronic

health record (EHR), starting with ambulatory care and then proceeding to inpatient care and the emergency department. This strategy contemplates a fundamentally different use of IT in health care—rather than being a passive repository of

clinical and administrative data, the delivery of health care itself will be transformed using IT. Members of the interdisciplinary health care team will document,

order, and plan treatment on line. As significant as OHSU’s past IT investments

have been, health care practice is still based on paper charts. A single stay in the

hospital may generate upwards of 100 pages of documentation, orders, vitals, and

other relevant clinical data. To eliminate filing and improve ready access to information after the fact, OHSU implemented a document imaging solution to scan every

piece of paper after discharge, but active inpatient care still relies on paper.

OHSU selected Epic Systems to provide our ambulatory EHR and have now deployed this advanced clinical IT solution in seven outpatient practices. Before the

$22 million investment was approved, an extensive return on investment calculation

was performed. The project showed a positive net present value considering only

hard benefits. These benefits included transcription savings, staff savings (reduced

charge entry, medical records, and support staff), supplies and storage savings. So

far, the results have validated—and in some cases, exceeded—the anticipated benefits. For instance, Family Medicine showed a reduction in transcription lines per

month from a pre-live high of 94,093 to post-live of 1,743.

Quality outcomes are difficult to quantify as hard financial savings, but present

the real strategic benefits of EHR. As OHSU moves to implement an enterprise

EHR across inpatient, outpatient and ED, we anticipate significant benefits to patient care. We will provide direct, secure, on-line access to records by patients. Clinical decision making will be supported by best practice guidelines. Decision support

rules will provide timely, data-driven input to physicians when ordering tests and

treatment.

A personal story (note: no HIPAA implications) may illustrate the real benefits

to patient care of this IT investment. Not only am I OHSU’s CIO, I am also a patient. Since 2000, one focus of our investment has been diagnostic imaging services,

with advanced technologies such as an entirely digital enterprise repository (Picture

Archiving and Communication System), voice recognition, digital radiography, and

secure external communication. Each was a major IT and clinical re-engineering

project. Overall, they have taken multiple years and countless hours of work. After

all this effort, the results for patient care are clear. When I was recently referred

for an X-ray exam, my physician was able to review and share with me the completed results just 11 minutes after the study (all digital capture and read, voice

recognition transcription, and secure e-mail transmission of final results). Eighteen

months prior, this normal exam would have taken at least 48 hours to be completed.

While OHSU’s investments have been successful and the benefits real, we have

yet to achieve what should be possible with a comprehensive EHR at OHSU. As

early as 1970, Morris Collen, M.D., published a seminal paper on the characteristics

of a medical information system. A third of a century later, our industry has yet

to witness widespread adoption of IT.

2. What incentives and barriers exist to the broader adoption of information technology in the health care industry, and are these financial, technical, or of some

other nature? What has been OHSU’s experience with these incentives and barriers?

From my perspective from helping craft our strategic vision for health care IT,

the most significant incentive to a broad adoption of IT is the strongly held belief

that IT is essential for the practice of medicine in the 21st century. As this institution planned to build health care facilities for the future, there was near unanimous

approval for significant investment in an EHR solution. A compelling question was

posed as we began to design the space: Should we really carve out clinical space

in 2006 for a large paper file room in each practice setting? The EHR also was seen

as vital to patient-centered care. Our tech-savvy customers in the Pacific Northwest

51

are starting to expect the ability to e-mail their physicians, schedule an appointment, review their child’s immunization record, and pay their bill on line. This was

an important incentive for OHSU’s strategic decision to direct scarce capital dollars

into IT.

While not an incentive per se, another source of support for widespread health

care IT adoption comes from our role as an academic health center. Today’s medical,

nursing, and dental students were born after the invention of the personal computer

and have grown up in the high-speed information age. In fact, to our X-box-generation residents, our systems sometimes feel as antiquated as Atari PONG. A techsavvy workforce makes IT-enabled clinical practice an expectation.

To date, there have been few financial incentives to adopt EHRs within an institution or share data through Regional Health Information Organizations (RHIOs).

While health care IT may enhance clinical quality and effectiveness, cost containment continues to be a driving factor in health care. Pay for performance, Federal

Government funding, and other programs have been debated, but nothing to date

has translated into an economic support for this IT investment.

As studies have shown, only pioneering institutions have implemented comprehensive health care IT solutions—and some have resulted in significant failure.

An article in the LA Times in 2003 reported the suspension of the multi-milliondollar computerized system for doctors at Cedars-Sinai Medical Center after significant physician complaints. A number of practitioner articles and scholarly studies

have attempted to address barriers to successful implementation of EHR and health

care IT solutions. I would propose that the major barriers include the expectations

gap, technology barriers, and resource barriers—though the latter two may not be

the traditional definition of these type of barriers.

In my opinion, a serious issue facing health care CIOs is an expectations and perception gap between the IT department and IT users and their senior leadership.

Hospital leaders often believe IT should cost less and deliver more. It simply ought

to be much easier; it is not. Complicating this gap is the extent of IT project failure

or cost overruns. Any IT project has inherent risks and challenges; enterprise health

care IT projects are extremely complex with competing requirements, multiple

users, different data types, and complicated work flows and information needs.

Looking broadly at all IT projects in the public and private sector, the Standish

Group reported that only 16 percent of IT projects completed on time, budget, and

scope. They estimated that U.S. companies and government agencies would spend

$81 billion on canceled software projects in 1995 alone. Health care organizations

may not recognize their extent of investment (time, resources, and capital) required

or may not trust their IT department to deliver successfully.

OHSU is addressing this barrier in our ambulatory EHR deployment, though it

is an on-going effort requiring continual dialogue. We have faced budget challenges—underestimating the complexity of system-to-system interfaces and the resources required to support such dramatic clinical practice transformation. We have

built trust and mutual understanding, but this takes attention to sustain the relationship.

Another major barrier relates to technology. It is evident in the focus on interoperability standards and data exchange. I argue however that this focus addresses

the symptom and not the underlying condition. From the perspective of a provider

organization CIO, our industry suffers from too many ‘‘choices’’ rather than too few.

Hospitals and physician groups face a staggering array of options for health care

IT. IT units are often confronted with the Herculean task of trying to tie together

these islands of information. At the Health Information and Management Systems

Society (HIMSS) exposition in San Diego last week, there were over 800 different

vendors showing IT software. You could purchase individual systems tailor-made to

support diabetes care, cardiology care, intensive care, and home care. But what

about the patient admitted with chest pain and complications from diabetes who requires an ICU stay and follow-up back at home? Should her record really be in four

different systems (at best)? Can I guarantee that relevant clinical data from each

is readily available to all?

With the paper record as the common denominator to all, this situation was not

uncommon or particularly troublesome. Each system printed final documents and

these were all filed in the integrated paper chart. (Relevant documents from outside

providers were handled in the same manner.) Yet as we embrace the EHR, we are

faced with the option of implementing a comprehensive, integrated platform or managing and interfacing multiple disparate solutions. Both paths have their challenges. As I stated earlier, OHSU is now starting to support the concept of global

optimization, though sometimes sacrificing local customization. Changing our health

care IT paradigm, however, is difficult—clinical users can make strong cases for

52

their targeted, niche solution. Fortunately, the vendor marketplace is now producing

products where integration does not require significant trade-offs in functionality.

Resources present another significant barrier to adoption and diffusion of health

care IT. On the surface, one barrier is simply the cost of the software and hardware

itself. Health care organizations face the challenge of diverting funds from facilities

and clinical technology to invest in IT—often with a significant leap of faith. This

investment is indeed significant. For OHSU, it was over $7 million.

The more significant resource barrier in my opinion is human resources: the clinician time to help design, develop, and implement a successful tool and the IT professionals to build and maintain the technology. Many studies of health care IT successes and failures have pointed to the need to engage clinicians in all aspects and

phases of the project. EHR represents a significant modification to the work of all

clinicians; they must be actively engaged to adopt the new tools. At OHSU, physicians must participate in 14 hours of classroom training just for the ambulatory

EHR. We have found that this participation alone is not adequate. It requires a rethinking of the outpatient clinic encounter, their interaction with data, and their

workflow. Each clinical specialty also requires up front design and build effort as

well. Extensive work also will be required for our inpatient implementation, especially around nursing care.

With constant pressures to cut costs, there is little spare time for physicians,

nurses, pharmacists, and other members of the health care team to engage in designing and implementing health care IT solutions. This may be a major hidden cost

of implementation. As OHSU deploys our EHR to more ambulatory practices, we

continue to find this barrier to success.

The other human resource barrier is finding IT professionals to assist with implementation. With more organizations planning for major EHR implementations, I

have personally witnessed a growing shortage of qualified health care IT professionals to fill vacancies and hit the ground running. Hospitals turn to vendors and

consulting firms to help, though they appear to face the same problems with recruitment and retention. OHSU’s role as an academic health center may help—our department of medical informatics and clinical epidemiology can build the staff pipeline and I hope to develop with them some innovative programs to train individuals

for advanced health care IT roles. However, I see a very significant problem looming

as the industry at large embraces IT solutions.

Finally, I would like to make a comment about the barrier to RHIOs and sharing

data across organizational boundaries. There are a host of technical, financial, legal,

and regulatory barriers. Who benefits and who will pay? Is funding a duplicate,

though clinically necessary, CT scan a disincentive to sharing clinical data? How do

we ensure patient security under HIPAA’s generally defined guidelines? How do I

know that this ‘‘John Kenagy’’ is the same as that ‘‘John Kenagy’’? With the right

attention, priority, investment, and perseverance, these barriers can be overcome.

The more critical barrier today is that I cannot exchange what I do not have electronically in the first place. While the Portland market (and the Pacific Northwest

in general) represents some of the most advanced IT systems in the U.S., we each

have major EHR projects underway that will last through the end of the decade and

serve as the core foundation piece for extensive data interchange. We need to proceed with our internal IT implementations in order to have the data to share. Nonetheless, the health care CIO community here is engaged in active dialogue to take

demonstrable steps forward.

3. To what extent have the Department of Health and Human Services and the National Institute of Standards and Technology reached out to institutions like yours

in an effort to develop a national strategy on Health IT?

OHSU has contributed significantly to the body of knowledge in health care

informatics research and our Provider Order Entry Team (www.cpoe.org) has been

awarded a number of grants for evaluating, interpreting, and disseminating evidence of computerized provider order entry success.

Apart from these research programs, OHSU’s ‘‘production IT unit’’ with responsibility for implementing and maintaining our health care IT infrastructure has had

little direct input into HHS or NIST efforts. Through a partnership with the Oregon

Chapter of HIMSS, OHSU has been involved with several local efforts to understand and contribute to efforts such as the Certification Commission for Healthcare

Information Technology (CCHIT) and other initiatives. However, these have mainly

focused on education and awareness.

As a CIO who relies on the commercial marketplace for health care IT solutions,

I believe that HHS and NIST needs to focus attention on the vendor community for

standards adoption. As an institution, OHSU will not adopt the standards per se,

but will look toward our product suppliers to be compliant and take advantage of

53

the functions. Nonetheless, I recognize my power as a consumer—vendors are more

likely to adopt standards if they feel it is an important requirement that makes a

difference in product sales.

From my perspective at a major tertiary referral site, I am most keenly interested

in basic data exchange between disparate information systems, especially as more

hospitals and physician groups adopt EHRs. OHSU needs to receive relevant clinical

data that led to a referral to our site and we need subsequently to transmit the results and follow-up plan of care to the referring physician. Exchange standards

should be set to a lowest common denominator—even using Adobe portable document format and a manual process to match patients to enable information exchange now. My concern is that our industry will attempt to design the ‘‘perfect’’

IT solution that either cannot be implemented or assumes too much technology overhead (e.g., a regional or national patient index).

Developing standards for inter-operability of health care data is an unbelievably

complex undertaking and is fundamentally driven by expectations and requirements. For instance, does inter-operability mean that I can begin my nursing documentation in a stand-alone ED system, continue it in an OR system, and add to it

in an inpatient EHR? Is the allergy I document in one system replicated to everything else? Is that the desired level of inter-operability? In implementing OHSU’s

ambulatory EHR, I face this problem today. Interfacing systems for simple demographic information (e.g., keeping patient address in synch) has been challenging

and a resource drain. We were unable to address data exchange for patient allergies

and stepped back to paper documentation on the inpatient side. With this experience, I have strongly encouraged OHSU to move toward a single integrated system.

Even between sites with the same core vendor (Kaiser Northwest, OCHIN, and

OHSU all have Epic) we cannot exchange data electronically. I am challenged to

think that complete inter-operability is possible, even if desirable.

It would be worthwhile for provider institutions like OHSU to play a more active

role in establishing requirements and priorities, sharing our perspectives from the

front line of dealing with multiple systems. I suggest that our involvement with

HHS and NIST is not due to their lack of interest or mechanisms for input, but our

time constraints and challenges at the local level. Standards seem so far off and I

have end users needing attention now. Piqued by this question, however, I encourage HHS and NIST to make a greater concerted effort to seek provider CIO input.

I will do my part to share my perspective as well.

4. What specific measures can the Federal or State governments take to help the

broader adoption of health information technology?

The Federal and State governments play many roles in the health care sector. I

suggest several important steps to enhance incentives to adopt health care IT.

• Continue and expand research funding in health care informatics. As EHRs

and CPOE become more prevalent, these offer unparalleled opportunities to

study the antecedents of and barriers to success.

• Expand support for training programs to develop clinical and IT professionals

in the field of health care informatics. If the 90 percent of U.S. hospitals that

do not have CPOE start to implement these systems, I fear we do not have

the human resources to meet the need.

• Address the economic disincentives to invest in health care IT. The constant

pressure to cut health care costs by reducing payments to hospital and doctors stands in direct opposition to requiring these entities to invest millions

of dollars of capital and, more importantly, scarce clinical time in designing,

testing, implementation, and using advanced IT systems.

• Work in partnership with the vendor community to address exchange of data

among disparate EHRs and with emerging standards of personal health

records (PHRs). I personally do not think strong government regulation of

this industry is needed (e.g., FDA regulation of EHRs), but believe the market

cannot and ultimately will not sustain the number that currently exist.

Thank you for the opportunity to share my perspectives as a provider-institution

CIO. With 20 years experience in health care IT, I am very encouraged by recent

developments. There is increasing attention and awareness of the important role IT

must play in health care quality, safety, effectiveness, and efficiency. At the same

time, the marketplace is maturing and products are emerging that can deliver comprehensive, patient-centered electronic health records. Barriers and challenges remain, but the ultimate goals compel us to strive ahead.

54

BIOGRAPHY FOR JOHN JAY KENAGY

John Jay Kenagy, MHA, FHIMSS, is Chief Information Officer at Oregon Health

& Science University (OHSU), in Portland, Oregon, serving in this role since July

2001. His responsibilities include developing the information technology strategy

and directing the IT department for the health care, academic, research, and community service missions of the university. From 1999 to 2001, John served as Associate CIO for OHSU. The Information Technology Group has an annual operating

budget of $30 million and a capital budget of $10 million. The department of 325

staff maintains a complex information technology and telecommunications environment.

As an academic health system CIO, John has served on a number of national and

regional IT bodies. He serves as the Chair of the University HealthSystem Consortium Chief Information Officer Council (2005–2006). He was elected as president of

the Oregon Chapter of the Healthcare Information and Management Systems Society (2003–2004). He has served on the board of Siemens Customer Health Information Executive Forum.

In 2003, John was appointed to Fellow status in the Healthcare Information and

Management Systems Society. He is also a Certified Professional in Healthcare Information and Management systems.

John is pursuing a Doctor of Philosophy degree from Capella University’s School

of Business. His doctoral research is focused on health care information technology

implementation success. John earned his Bachelor of Science degree in electrical engineering at Stanford University. He was awarded a Master’s degree in Healthcare

Administration at University of Southern California and received the Alexander

Cloner Outstanding Student Award at graduation.

In addition to the IT operational responsibilities, John has enriched his experience

and knowledge through teaching and mentoring. He has an appointment as Assistant Professor in the Department of Medical Informatics and Clinical Epidemiology

in the OHSU School of Medicine. John has taught at the University of Oregon and

University of Southern California.

Prior to joining OHSU, John worked for thirteen years at the Department of Veterans Affairs, most recently as Chief Information Officer for the VA Desert Pacific

Healthcare Network in Long Beach, California. John directed major IT projects and

strategy for this extensive network of health care facilities and served on several

national IT committees.

Notable awards include a U.S. Department of Veterans Affairs Commendation

and American Legion Medal of Valor for deeds following the 1994 Northridge Earthquake and the 1999 Emerging Leader Award by the USC Health Services Administration Alumni Association.

Mr. WU. Thank you.

Mr. REICHERT. Thank you. Now we’re going to just pause for a

minute while we play musical chairs. The Chair recognizes Dr.

Chin.

STATEMENT OF DR. HOMER L. CHIN, MEDICAL DIRECTOR,

CLINICAL INFORMATION SYSTEMS, KAISER PERMANENTE;

NORTHWEST CHIEF INFORMATION OFFICER, OREGON

HEALTH AND SCIENCE UNIVERSITY

Dr. CHIN. Good afternoon, Mr. Chairman and Congressman Wu,

ladies and gentlemen.

My name is Homer Chin. I’m the Medical Director for Clinical

Information Systems for the Kaiser Permanente northwest region.

Kaiser Permanente serves over eight million members in eight

separate regions. My comments today about our experience relate

specifically to the northwest region.

In 1998, Kaiser Permanente Northwest completed the implementation of a comprehensive electronic medical record that allows

physicians to document, prescribe, order, refer, and to message

other health care providers. We no longer create, move, or file

paper medical records. We also provide patients direct, secure

55

Internet access to parts of their medical record and the ability for

them to directly message their physicians.

Along with the usual benefits of IT systems that were mentioned

by Diane earlier, our system embeds clinical decision support to

help guide physicians as they deliver care, provides a comprehensive database that allows us to monitor and to provide care across

the population, and allows for modalities of care such as self-service appointing and additional ways for patients to access care and

communicate with their physicians.

What distinguishes Kaiser Permanente from other health care

organizations is, number one, our integrated comprehensive health

care system where all services for our members, both inpatient and

outpatient, are delivered under one umbrella; and, number two,

prepaid capitated health insurance. These two aspects of Kaiser

Permanente provide both a structure and incentive for us to fully

leverage information technology in the delivery of health care services.

In my view, there are two significant barriers to the adoption of

IT in health care. The main barrier is the lack of incentives to be

efficient and effective at producing the product, health. Organizations may be efficient at producing office visits, radiology tests, laboratory tests, procedures and prescription, but they’re not incented

to produce health and they’re certainly not incented to work with

other organizations that they compete with, to reduce the overall

cost of health care.

A second barrier is the information intensive and complex, subjective and changing nature of health care itself. Unlike other industries that are relatively more static, medical knowledge, practice, regulation, and technology are constantly changing, making it

necessary to build complex yet flexible and modifiable systems to

meet the different and constantly changing environments. As a consequence, there are few well-charted paths to implementing health

care IT, at least in the clinical arena. Unlike installing a refrigerator, where you buy it, you bring it home, plug it in and derive

refrigeration, implementing health care IT is still more of an art

than a science.

Although health care IT holds great promise, we must remember

that the systems are not ends in and of themselves.

A good implementation will improve things; but a bad implementation may fail, may yield few benefits, or make things worse. We

must remember that health care IT is just the enabling means and

not an end in and of itself.

Finally, what can the federal and state governments do? Number

one, and I would say most importantly, they should—they should

provide incentives for health care organizations to implement IT

and to share that information between institutions. And, number

two, they should require standards or at least facilitate the means

to allow the identification of individuals between health care entities; that will allow you to aggregate information between individuals, across organizations. Any further standards should be evaluated in terms of the benefits and costs of developing and imposing

that particular standard. At a minimum, standards that require

each piece of information to be indexed by date and the type of inVerDate 11-MAY-2000 14:54 Jun 23, 2006 Jkt 026205 PO 00000 Frm 00059 Fmt 6633 Sfmt 6601 C:\WORKD\ETS06\022306\26205 SCIENCE1 PsN: SCIENCE1
56

formation, will allow at least the merging of information between

separate entities into a single view.

Thank you for allowing me to testify today. I’d be happy to answer any questions.

Mr. REICHERT. Thank you, Doctor.

[The prepared statement of Dr. Chin follows:]

PREPARED STATEMENT OF HOMER L. CHIN

Introduction:

Good afternoon, Mr. Chairman and Members of the Subcommittee. My name is

Homer Chin. I am the Medical Director for Clinical Information Systems for the

Kaiser Permanente Northwest Region, which is one of eight Kaiser Permanente Regions that together make up the Kaiser Permanente Program.

Kaiser Permanente is the Nation’s largest nonprofit health plan. Over 140,000

employees and 11,000 physicians serve 8.4 million members in over 30 hospitals and

430 medical office buildings.

Kaiser Permanente is actually made up of two separate but closely aligned entities: Kaiser Foundation Health Plan and Hospitals, which is responsible for administering the prepaid insurance and for running much of day-to-day operations, and

The Permanente Medical Groups, who are responsible for the delivery of professional medical services.

What distinguishes Kaiser Permanente from most other health care organizations

is:

1. Integrated comprehensive health care where primary care, specialty care, inpatient outpatient and ancillary services are delivered under one umbrella,

and

2. Prepaid health insurance—which encourages us to keep our members

healthy, prevent disease, and improve the effectiveness and efficiency of our

care delivery system.

These two aspects of Kaiser Permanente—comprehensive integrated care and prepaid health insurance—provide both the structure and incentive for us to fully leverage information technology in our delivery of health care services.

Kaiser Permanente Northwest and Health Care Information Technology:

Although some of my comments today are about the Kaiser Permanente Program

as a whole, many of the more specific examples and comments relate specifically to

our experience here in the Kaiser Permanente Northwest Region.

In 1994, KPNW embarked on the implementation of a single integrated EMR for

all members of this region. This system is not only an electronic version of the outpatient medical record, it also automates all information transmission processes in

the outpatient setting. Physicians use this system to document, prescribe, order,

refer, and to message other health care providers. By 1998, we had completed our

implementation of an entirely electronic medical record throughout our region, and

from that point forward we no longer created a paper medical record for members

that joined our program. In 1999, we created an Internet portal for members to provide them with a wealth of health information along with the ability to request appointments and refill their medications on-line. In 2002, we provided patients direct

access, through a secure Internet connection, to parts of their medical record along

with the ability for them to directly electronically message their physicians. That

system, KP HealthConnect Online, is now being used by over 100,000 members in

this region—roughly 20 percent of our membership.

Over the years we have studied and published results of the many benefits of having an integrated electronic medical record. Benefits can be general classified into:

1. Integrated and Comprehensive Lifetime Clinical Record. All medical information from all sources is accessible electronically in an integrated system.

2. Multiple users in multiple locations can simultaneously access the chart.

3. Time and location independent interaction between providers, and between

providers and patients.

4. Embedding of best practices and guidelines into the processes of care.

5. Embedding alerts and reminders into the care process.

57

6. Identifying patients for specific interventions, such as identifying all patients

that were given Phen-Fen weight loss treatment, and requesting that they

come in for a screening cardiac ultrasound.

7. Ability to carry out systematic population care strategies, such as notifying

all patients who are overdue for screening mammography, or identifying all

patients with diabetes that need more aggressive treatment of their cholesterol.

8. Improved new modalities of care, such as self-service appointing and electronic methods of communication.

9. Databases that can effectively monitor and improve overall organizational

performance.

In 2003, The Kaiser Permanente Program embarked on the implementation of an

integrated health care information system called KP HealthConnect, at an estimated cost of over $3 Billion over ten years. This system is envisioned to be a comprehensive integrated system covering practice and hospital management, inpatient

and outpatient electronic medical records, data warehousing, health plan administration, and patient self-service and communication systems. All eight Kaiser

Permanente Regions have already implemented significant portions of this system.

Incentives and Barriers to the Adoption of Information Technology in

Health Care:

There are three significant barriers to the adoption of IT in Health Care.

One of the main barriers to the adoption of information technology in health care

is the lack of incentives for organizations to be efficient and effective at producing

the product ‘‘health.’’ Organizations may be effective at producing office visits, radiology tests, operations, prescriptions, but they are not incented to produce ‘‘health,’’

and are certainly not incented to work with other organizations that they compete

with to reduce the overall cost of health care.

A second significant barrier to IT adoption is the relative immaturity of the field

of health care IT. There are few well trodden paths that organizations can follow

to get from here to there in the implementation of electronic medical record systems.

A third significant barrier is the inherent complex, subjective, and changing nature of health care. Unlike other industries that are relatively more static or certain, medical knowledge, practice, regulation, and technology are constantly changing. The implementation of an Electronic Medical Records is not like installing a

refrigerator, where you buy it, plug it in, and derive the benefits. The implementation of an EMR is currently still more of an art than a science. A good implementation will improve the efficiency of a functional process, but a bad implementation

may fail, have unintended negative consequences, or worsen existing processes. Because medicine is inherently uncertain, changing, and not well defined, a good implementation of IT in health care requires a certain skill-set and the right conditions. Although there are many instances of health care IT systems that have been

successfully implemented with significant benefit, there are also many instances of

implementations that failed or resulted in little or no benefit.

Reasons for Successful Health Care IT Implementation at Kaiser

Permanente Northwest:

KPNW was successful because it had:

1. Aligned incentives to maximize effectiveness and efficiency in maintaining

health.

2. One unique patient identifier (the insurance number is also the health record

number), allowing for the easy aggregation of information across systems.

3. Minimal issues with terminology or data standards. In most cases, KPNW

had a single instance of most systems—for example, a single Pharmacy System, Radiology System, Lab System, etc. The terminology that the particular

single system used became the defacto standard for the enterprise. There

was no need to impose a terminology or data standard or translate data between the various systems.

4. An integrated implementation team partnering physicians, project management staff, and IT professionals.

Implications for other health care systems:

There must be incentives for health care organizations to share information.

KPNW has contracts with several non-KP hospitals in the community where we

hospitalize our patients. All transcribed information on our patients in those facilities is electronically sent to us and integrated with other information in our ElecVerDate 11-MAY-2000 14:54 Jun 23, 2006 Jkt 026205 PO 00000 Frm 00061 Fmt 6633 Sfmt 6621 C:\WORKD\ETS06\022306\26205 SCIENCE1 PsN: SCIENCE1
58

tronic Medical Record. The incentive for organizations to send us this information

is clear—it is a requirement for us to do business with them.

A minimum requirement to support the interchange of health care information between entities is to be able to identify specific individuals between health care entities. This implies either a unique patient identifier, or demographic standards that

will allow the identification of the same individual between health care entities with

reasonable certainty.

The optimal level of information standardization, beyond that minimum requirement of patient identification, is unclear. At one end of the spectrum, scanned images of the paper record could be electronically transferred from one health care entity to another. That would require minimal changes in each system but would not

allow for any significant integration of data between the two entities. At the other

end of the spectrum, a very rigid and detailed standard at a very atomic level could

be defined that would allow for complete integration of information between entities,

but would require significant work in each organization, and would require significant on-going maintenance and organizational adaptation.

Such a rigid detailed atomic standard for all data in medical care is unlikely to

be successful because of the changing nature and variation in the practice of medicine between locations and over time, and the enormous cost involved in migrating

existing systems and terminologies into a rigid standard and the cost required to

adapt to ongoing changes. Because of the inherent uncertainty and subjective

‘‘fuzzy’’ judgment involved in health care, requiring adherence to a rigid detailed

standard in all areas may also introduce more problems than it will solve.

On the other hand, imposition of higher level standards will greatly increase the

ability to integrate information between health care entities at a relatively low cost.

For instance, the requirement to date stamp and label pieces of information into

broad categories such as: Lab Result, Radiology Report, Progress Note, Medication,

etc., would allow the merging of the information between institutions into separate

electronic ‘‘tabs’’ and display that information in chronologic order.

Within each area of medical data, there are varying levels of cost and benefit to

the various levels of standardization, so the optimum level of standardization will

vary depending on the specific area and situation.

Summary:

In summary, the key to improving information sharing between entities is to provide incentives for organizations to share that information.

At a minimum, a mechanism to identify specific individuals between entities is

needed. Beyond that, minimal further standard specification will allow the merging

of clinical information between entities in a useful way at minimal cost.

Thank you for allowing me to testify today. I would be happy to answer any questions.

Limited Bibliography

Chin HL. The Reality of EMR Implementation: Lessons from the Field. The

Permanente Journal Fall 2004; 8(4):43–48.

Chin HL, Dworkin L, Krall MA, et al. The Comprehensive Computer-Based Patient

Record (CPR). The Permanente Journal Summer 1999; 3(2):13–24.

Chin HL; Wallace P. Embedding guidelines into direct physician order entry: simple

methods, powerful results. Proc AMIA Symp 1999;:221–5.

Chin HL; Krall MA. Successful implementation of a comprehensive computer-based

patient record system in Kaiser Permanente Northwest: strategy and experience. Eff Clin Pract 1998 Oct-Nov;1(2):51–60.

Chin HL, Brannon M, Dworkin L, et al.: The comprehensive computer-based patient

record in Kaiser Permanente Northwest. In, 4th Annual Nicholas E. Davies

Award, CPR Recognition Symposium Proceedings (Edited by: Overhage JM).

McGraw Hill 1998, 69–129.

Marshall PD, Chin HL. The effects of an Electronic Medical Record on patient care:

clinician attitudes in a large HMO. Proc AMIA Symp 1998:150–4.

Chin HL, Krall MA, Lester S. Adapting clinical coding systems for the computerbased patient record. Proc AMIA Annual Fall Symposium 1997:849.

Chin HL, McClure P. Evaluating a comprehensive outpatient clinical information

system: A case study and model for system evaluation. Proc Annual Symp

Comput Appl Med Care 1995:717–21.

Mr. REICHERT. The Chair recognizes Mr. Machuca.

59

STATEMENT OF MR. LUIS MACHUCA, PRESIDENT AND CEO,

KRYPTIQ CORPORATION, HILLSBORO, OREGON

Mr. MACHUCA. Mr. Chairman, Mr. Ranking Member, and colleagues, good morning—or afternoon, I guess. I’m honored to offer

my thoughts on health care IT adoption. I’m particularly grateful

to you and your committee staff for taking on this very important

topic.

My testimony will illustrate three major points: That the lack of

data mobility in health care is at the heart of the cost and quality

issues there; that the standards-based clinical messaging represents the best opportunity to modernize the system; and that the

technologies to accomplish this are neither complex nor expensive.

Locally, we have recently witnessed a media frenzy regarding the

theft of medical records, but where are the voices of outrage regarding the errors that occur due to the lack of timely patient information? Preventable medical errors are a greater risk to patient

health than car accidents, breast cancer, or AIDS. The average

Medicare patient sees more than six physicians per year, and their

care is not coordinated. And chronic conditions now account for a

majority of health care expenditures, yet 70 percent of patients who

have hypertension, diabetes, or severe asthma are not in treatment

compliance. We get e-mails from our car dealer about our car needing an oil change, but where are the e-mails from our doctors saying we’re overdue for a blood pressure check? The price we pay for

not having data mobility is unsafe care, high cost, and productivity

loss.

And we created Kryptiq to solve that problem.

In just three years, our customer base has grown to over 700 organizations in 48 states. More significantly, the number of secured

clinical messaging customers grew by more than 200 percent last

year alone. Every one of those clinics that purchased connectivity

software did so with a specific intent to collaborate with other clinics, and did so in some cases to collaborate in sharing information

also with their patients. And we also know from the CITL, the Center for Information Technology Leadership, study that two thirds—

that at least two thirds of the potential savings from IT adoption

can only be realized through collaboration, as opposed to internal

office automation.

Much attention has been given to the President’s goal to enable

EHR adoption; however, EHR adoption alone does not result in collaboration. In fact, experience suggests that most EHR implementations create islands of automation no more capable of sharing information than the paper records they replaced. We really need to

look at how we move the data, not just how we store it.

As highlighted by Forrester Research, efforts spearheaded by

ONC to create RHIOs for information sharing have largely stalled,

and largely stalled on issues regarding governments, infrastructures, standards, and sustainability. We believe there’s a smarter

approach. The concept of an organic and incremental RHIO, which

is defined as the exchange of data between providers, using e-mail

and the Internet, enables immediate data mobility in a self- sustaining model. Forrester has coined this concept ‘‘managed clinical

messaging.’’ This approach includes any clinic that has e-mail acVerDate 11-MAY-2000 14:54 Jun 23, 2006 Jkt 026205 PO 00000 Frm 00063 Fmt 6633 Sfmt 6601 C:\WORKD\ETS06\022306\26205 SCIENCE1 PsN: SCIENCE1
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cess, not just those that have EHR; and collaboration begins on day

one, not in a multi-year program.

Personally, I know this model will succeed. I spent 15 years in

Intel at the critical time of PC adoption, and I can tell you that the

transition from early adoption to widespread business use really

happened because of e-mail. More importantly, I know that the organic approach works because I see our customers doing it every

day.

Oregon has been the home to many health care IT breakthroughs. Continuing this tradition, Providence and the Oregon

Clinic recently transitioned to electronic referrals, saving a combined $10 per referral. And further, a comprehensive study at

Providence revealed a 58 percent improvement in diabetes clinical

outcomes through increased patient interventions, with no additional staffing costs.

There are dozen examples—dozens of examples of Kryptiq customers like these across the country, realizing the gains of the organic approach. Some are informal RHIOs and some are just

RHIOs without telling anybody about it. Examples such as these

illustrate that the market is creating the standards for baseline

inter-operability; the next step is a common interchange standard

for patient medical records, such as CCR or CDA, clinical data architecture. This standard should be accessible by both health care

providers and patients, and should also work in both an EHR and

in a non-EHR environment. This should help mediate between

these approaches.

We want to continue to build the success that will drive collaboration. To this end, we recommend the government’s funding for

health care IT address the following among more recommendations

that we have in our full testimony.

Number one, prioritize organic RHIO expansion while limiting

any additional spending on centralized or federated models.

Number two, the government is in the business of public health,

and as such it should fund the implementation of electronic collaboration technologies in the public health settings.

Number three, mediate a standard—a standard for patient medical records as above.

And number four, combine any changes in Stark laws with collaboration mandates that ensure the technology recipients be in an

open network.

We have shown that the benefits of electronic collaboration are

real. We are on the eve of a major breakthrough of technology

adoption to make health care industry safer, most cost-effective,

and more competitive.

Thank you very much.

Mr. REICHERT. And thank you.

[The prepared statement of Mr. Machuca follows:]

PREPARED STATEMENT OF LUIS MACHUCA

My name is Luis Machuca and I am the CEO of Kryptiq Corporation based in

Hillsboro, Oregon. I am honored to offer my thoughts and perspectives on the opportunities and barriers for health information technology adoption. This testimony will

illustrate that secure clinical messaging represents the single biggest opportunity to

quickly and cost effectively modernize our health care system.

61

As residents in the Portland metropolitan area we have just witnessed the media

frenzy regarding the theft of medical records. We have heard the raised voices of

outrage that personal data may have been exposed due to this incident. An Oregonian editorial indicted the health system for its failure to manage health data appropriately.

But where are these voices of outrage regarding the errors in clinical judgment

and decision-making that occur in every health system in every city, in every state,

every day of the year, due to the lack of clinical information being available at the

right time. Why is this not the target of our outrage and concern as a society?

To cite the Institute of Medicine (IOM) Report published in 2000 ‘‘To Err is

Human,’’ our U.S. health system, which is capable of the most miraculous acts of

life-saving, is frequently the source of patient harm. Between 44,000 and 98,000 patients die in hospitals each year from preventable medical error. Preventable, but

unprevented, medical errors are a greater risk to patient health than motor vehicle

accidents, breast cancer, or AIDS. In terms of lives lost, patient safety is as important an issue as worker safety. Every year, over 6,000 Americans die from workplace injuries. Yet this number is exceeded by the 7,000 Americans who die annually from errors in medication prescription or administration.

In addition, our health care system is overwhelmingly expensive. Health care in

the U.S. is estimated to cost up to $2 trillion per year, consuming 13 percent of the

GDP. Centers for Medicare and Medicaid Services (CMS) estimates predict this will

rise to $3 trillion and close to 20 percent of GDP within the next 10 years, or an

average of $10,000 per American resident. Employers will not be able to afford

health benefits approaching $40,000 per year for a family of four, while remaining

competitive in a global economy—nor can they continue to afford the staggering (yet

unmeasured) productivity loss from subjecting workers to an inefficient health care

system.

The decentralized and fragmented nature of the health care delivery system contributes to unsafe conditions for patients, and serves as an impediment to efforts

to improve safety. Even within hospitals and large medical groups, there are rigidlydefined areas of specialization and influence. The average Medicare patient sees

more than six physicians in the course of a single year, but their care is frequently

‘‘silo-ed,’’ and lacks coordination and communication. At the same time, the loose affiliation of most provider groups makes it difficult to implement improved clinical

information systems capable of providing timely access to complete patient information across all providers. Unsafe care, high cost and productivity loss is the price

we pay for not having data mobility in our health care system.

The IOM followed their 2000 report with a 2001 report that boldly stated that

between the health care we have and the care we could have lies not just a gap,

but a chasm.

A highly fragmented delivery system that largely lacks even rudimentary clinical

data mobility results in poorly designed care processes characterized by unnecessary

duplication of services and delays. There is substantial evidence documenting overuse of many services—services for which the risk of harm may outweigh the potential benefits.

Meanwhile we are stuck in a health system that pays for quantity not quality and

is centered on a 400 year model of treating patients when they are acutely sick,

rather than ensuring the services needed to maintain their health. For the last four

decades, the needs of the American public have been shifting from predominantly

acute, episodic care to care for chronic conditions. Chronic conditions are now the

leading cause of illness, disability, and death; they affect almost half of the U.S.

population and account for the majority of health care. Yet these conditions are seriously under managed when it comes to ensuring Americans get the most appropriate evidence-based care that they should expect.

For example, hypertension affects nearly one in three American adults. It is called

‘‘the silent killer’’ due to the strong link between unmanaged hypertension and later

incidents of coronary vascular disease. Yet only 23 percent of diagnosed

hypertensives have their blood pressure under control, despite readily available and

cost-effective medications. Diabetes was referred to in a recent New York Times article as a disease of epidemic proportions, and yet more than 70 percent of diabetics

have unmanaged cholesterol levels, despite readily available cholesterol management treatments. Diabetes is the leading cause of non-traumatic lower limb amputations in the U.S., but barely one in five patients with diabetes receive the recommended annual foot exams that can expose loss of sensation. Additionally, almost

70 percent of our children with severe asthma are not receiving appropriate medications.

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A 737 stays grounded due to safety risks if a tray-table won’t stay in it’s locked

and upright position, but the equivalent of a 737 load of people die every day from

preventable medical errors.

Many of us would not dream of letting our cars go more than 7,000 miles without

an oil change, and in fact get regular notifications about servicing so they don’t

break down on the side of the road. However, we may go years without a blood pressure or cholesterol check, and the first sign of coronary heart disease is when our

bodies break down and we are rushed to hospital with a heart attack or stroke.

As a society, we are outraged about a single occurrence of data being stolen, but

ignore the daily health care crisis when opportunities for continuous and appropriate care are missed due to the lack of basic information systems with data mobility.

The relevant technologies to address these problems are neither complex nor expensive. We don’t need 4–D CAT scanning devices to ensure children receive immunizations and the elderly receive flu shots. We don’t need to solve the genome code

to notify patients in a timely and traceable manner when their lab results are normal or abnormal.

We created Kryptiq to solve these problems.

Today, more than 100 employees at Kryptiq Corporation are focused on enabling

secure connectivity in health care. Last year alone our customer base grew 120 percent to over 700 health care organizations in 48 states. More significantly, the number of secure clinical messaging customers grew by more than 200 percent in that

same time frame. Every one of these clinics who purchased Kryptiq connectivity

software did so with the specific intent to collaborate with other clinics and in many

cases also with their patients. The primary application of Kryptiq software is ‘‘provider-to-provider’’ communication for referrals, lab results, consultations, admissions, and prescriptions. These products also allow ‘‘provider-to-patient’’ communication to deliver secure online access to medical record summaries, lab results, and

administrative data. They enable patients with chronic diseases to ask questions

and provide home monitored data to their physician office, and support eVisits to

provide necessary care without the patient coming into the practice. The growth and

adoption of Kryptiq software tells us that connectivity is not just a ‘‘nice to have’’

capability—it is the best way to unlock the value that is trapped in the information

silos of health care.

Much attention has been given to President Bush’s goal to enable Electronic

Health Records (EHR) for nearly all Americans by 2014. The creation of the Office

of the National Coordinator for Health Information Technology (ONC) has advanced

the cause and awareness of EHR. Among other tangible benefits, Dr. David Bralier’s

efforts have been a positive and significant step forward in moving us away from

paper and establishing a foundation for data storage and management. EHRs are

of great value in organizing and maintaining the accuracy of patient information,

while eliminating the burdens inherent in a paper system. However, EHR adoption

alone does not result in collaboration. In fact the evidence to date suggests most

EHR implementations create islands of automation, no more capable of sharing information than the paper records they replace.

Efforts spearheaded by the ONC to create Regional Health Information Organizations (RHIOs) for information sharing have largely stalled. Yet Kryptiq customers

are delivering significant and measurable gains by combining the EHR systems that

already exist with a readily available and affordable messaging infrastructure to

share information across their communities. Secure clinical messaging represents

the greatest opportunity to modernize and improve health care. Therefore, we believe that in order to truly lower costs and improve quality, we need to look at how

we MOVE patient information, not just how we STORE patient information.

We all know about the growing cost of health care and the burden it is placing

on our citizens, our businesses and our economy. Several studies have shown the

tremendous potential for cost savings and qualitative improvements that can be realized through health care IT adoption. A recent study by the Center for Information Technology Leadership (CITL) at Partners HealthCare reported that if all information exchange between physician, hospitals, pharmacies, radiology centers, and

public health facilities were fully automated in a standardized way, the U.S. health

care system could save in excess of $77 billion dollars each year. The study specifically, and in my opinion rightly, points out that 70 percent plus of the savings opportunities exist through inter-office collaboration as opposed to internal office automation.

The recent RHIO initiatives are an attempt by the government to address the

data mobility issue. However, the ‘‘typical’’ RHIO (not unlike it predecessor, the

CHIN) has a fatal flaw—it essentially requires that all infrastructure, governance,

funding, and standards be agreed to and deployed BEFORE it can be of any use.

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This is analogous to building an entire road system before anyone can drive. In addition, questions about their sustainability have yet to be answered. This leads me

to conclude that the current RHIO concept will require ever-increasing and ongoing

financial support from the government.

There is a smarter approach. The concept of an ‘‘organic’’ or incremental RHIO

fueled by secure messaging technology provides immediate data mobility in a selfsustaining model without the centralized high cost infrastructure and bureaucratic

governance. Forrester Research, reflecting on the early and modest results from initial RHIO efforts, has coined this concept as Managed Connectivity and it is gathering support among industry leaders. Dr. Brailer illustrated this point in a recent

article in Health Data Management, ‘‘Most [people] will want to make local decisions on how data will be shared. . .the less centralization there is, the more value

people will see. . ..’’ The Managed Connectivity concept is predicated on peer-topeer workflow-based collaboration. The technology foundation is e-mail and the

Internet, which is already universally available at a minimal cost.

By definition, this approach includes any clinic that has e-mail access as opposed

to only those that have EHR. At the same time, it will serve to stimulate EHR adoption because electronic records are a place to store and manage data that is sent

and received. The big benefit however is that collaboration begins on day one—there

are no multi-year implementation projects.

I know that this model will succeed. I spent 15 years at Intel at the critical time

of Personal Computer adoption. As many of you may recall, the transition from

early adopters to widespread business use occurred because of e-mail. Collaboration

drove PC adoption, which in turn drove richer applications, and created the industry

that made every industry more competitive and productive. This was referred to as

a ‘‘virtuous technology spiral.’’

More importantly, I know that the ‘‘organic’’ approach works because I see our

customers doing it every day.

Oregon has been the home to many health care breakthroughs, both in the private

and public sector. The Oregon Health Plan, the early electronic medical record developed by Dr. Mark Leavitt, and the wide deployment of EHRs by both Providence

Health System and Kaiser Northwest Permanente are examples of national leadership in health care.

Recently, in partnership with our customers, Kryptiq has established that

connectivity solutions significantly improve care delivery and reduce costs. For example, by transitioning patient referrals from paper-based systems to secure electronic communications, Providence Health System and The Oregon Clinic were able

to save an approximate combined $10 per referral. Faxes and phone calls were replaced by electronic messaging in a matter of weeks. This was achieved without the

need of external forces or government subsidies or multi-agency committees arguing

about every last technical and business detail. In addition to reducing costs, moving

to electronic referrals eliminated the time lag inherent in paper systems and ensured that relevant information was where it needed to be when it needed to be

there.

Meanwhile Providence Medical Group recently released the results of a comprehensive one-year study of significant improvements in patient outcomes using

Kryptiq’s CareManager Diabetes Module. Their ability to unleash the data stored

in their EHR and use it to proactively communicate with chronic patients regarding

their health status, instead of waiting for the next office visit, has lead to remarkable improvements in treatment compliance. They have demonstrated a 58 percent

increase in the number of patients with diabetes who achieved control of their cholesterol and blood pressure levels, significantly reducing the risk of disease complications. They also documented a 250 percent increase in foot screenings, helping

to stem the rate of later amputations. All of this was achieved without any additional staff requirements, and the extra revenue from providing necessary and medically appropriate care in a timely manner allowed the medical group to pay for the

necessary IT investment, while undoubtedly saving the economy many millions of

dollars in hospital visits and other longer-term care costs.

Similar examples exist throughout the country in physician offices adopting

connectivity solutions at their own investment to improve their care services and

generate additional revenue at a lower overall cost. Family Medical Specialists of

Texas (FMS) believed that their busy patients would receive better care if they could

have online consultations with their primary care physician to resolve medical questions and issues without an office visit. Rather than waiting on all the local health

plans to support ‘‘eVisits,’’ FMS now charges individual patients $40 per year for

their eCare program. Patients believe it pays for itself by avoiding co-pays; employers and employees save time by avoiding unnecessary office visits; FMS generates

64

additional revenue without increasing staff costs; and the health plans save money

by shifting office visits to more cost-effective and efficient forms of care.

Memorial Hermann Healthcare System (MHHS) in Houston, Texas has adopted

messaging technology for similar reasons. Dr. David Bauer, Residency Director for

The Family Medicine Residency Program, cites a typical pre-messaging scenario of

a patient calling in with a question regarding a medication she had been prescribed

the previous day. ‘‘She left me a message to call her back. But when I called her

back she was in a meeting so I got her voicemail. When she returned my call I was

busy seeing patients. Over the next 24 hours she spoke to three of my nursing team

without reaching me, having to re-explain her issue each time, and we left each

other seven voicemail messages.’’ Dr. Bauer’s scenario is a common one, happening

all over the country every day, but for him it’s now a thing of the past. ‘‘Now we

use secure messaging, which allows me to communicate with patients and other providers without our needing to be available at the same time.’’

Examples such as these illustrate that the market is creating the standards for

baseline inter-operability. The next logical step in the evolution of such standards

is a common interchange structure for patient medical records that is simple to deploy such as the ASTM Continuity of Care Record (CCR) or the HL7 Clinical Document Architecture (CDA). The standard should be accessible by patients and health

care providers and work in both EHR and non-EHR environments. By contrast,

emerging concepts, such as Cross Enterprise Document Sharing (XDS), promote collaboration but require significant infrastructure, are more complex to deploy and assume certain market outcomes that are still in question.

Because there are competing definitions of a common interchange structure for

patient medical records, health care IT vendors are reluctant to develop inter-operability solutions based on either standard. We believe that it is time for the government agencies such as NIST to help mediate between these competing approaches.

We are also encouraged by NIST’s involvement in developing reference implementations for the XDS standards. These efforts help promote the validity of standards

and their applications.

A common interchange structure for medical records will be a great leap forward

for everyday collaboration. However, other standards will need to be developed to

address more specialized health care-related homeland security needs such as the

aggregation of emergency room data to identify pandemics.

We’ve made great progress in a short period of time and this has led us to a solid

foundation for the critical work that remains to be done. Clearly, we want to continue to build on the successes that will drive collaboration and improve the quality

and delivery of care, while achieving critical cost savings. To this end, we recommend that the Government’s continued and future funding for health care IT follow this direction:

1. Prioritize ‘‘organic’’ RHIO expansion while limiting any additional spending

on centralized or federated models unless they demonstrate scalability and

broad community participation.

2. Fund the implementation of electronic collaboration technologies in public

health settings. Public health is largely funded by the government at a federal, State and local level. To preserve the viability of the public health clinics, they should be the recipients of targeted resources specifically for this

purpose.

3. Mediate a definition of a common interchange structure for patient medical

records to facilitate collaboration. Specifically, settle the debate between CDA

and CCR. CMS could provide incentives for the adoption through its reimbursement processes.

4. Combine any contemplated changes in Stark laws with collaboration mandates that ensure that any recipient of technology can participate in a fully

collaborative and open community-wide network.

5. Continue work towards differential reimbursement to physicians who can

prove better outcomes of care for their patient population.

As we have shown, the benefits of secure electronic collaboration are undeniable.

We are on the eve of a major breakthrough of technology adoption that will make

the health care industry safer, more cost-effective and more competitive. We advocate a network of collaboration that maximizes provider and patient participation,

and provides immediate and secure data mobility in a self-sustaining model without

the high cost and complexity of a centralized system.

Thank you.

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BIOGRAPHY FOR LUIS MACHUCA

Luis Machuca is the President and Chief Executive Officer of Kryptiq Corporation, the leading provider of inter-operability and workflow connectivity solutions for

health care. Mr. Machuca received his BSEE in 1980 and MSIE in 1981, both from

Purdue University. In 1981, he joined Intel Corp., where over a 15-year career, held

a variety of roles in management before becoming co-General Manager of the OEM

Products & Services Division where he established Intel as the number one motherboard supplier in the world. In 1996, he became the Executive Vice President of the

NEC Computer Services Division of PB–NEC Corp. In 1999, Mr. Machuca joined

eFusion Corp. as President and COO and subsequently merged the company with

ITXC. Mr. Machuca currently serves on the Oregon Health & Science University

Foundation Board of Trustees, Lifeworks NW Board of Directors, the Boy Scouts of

America Cascade Pacific Council Executive Board, Catholic Charities of Oregon and

the Jesuit High School Board of Trustees. Mr. Machuca has also served on the Portland Metropolitan Family Services Board of Directors, and was a finals judge for

the 2005 NewVenture Championship business plan competition sponsored by the

University of Oregon’s Lundquist Center for Entrepreneurship. In 1999, Mr.

Machuca received the Outstanding Industrial Engineering Award in from Purdue

University.

Mr. REICHERT. Lastly, we recognize Mr. Urali.

STATEMENT OF MR. PREM URALI, PRESIDENT AND CEO,

HEALTHUNITY CORPORATION

Mr. URALI. Thank you, Chairman Congressman Reichert, Congressman Representative Wu, ladies and gentlemen.

My name Prem Urali. I am the founder and CEO of HealthUnity

Corporation, a 17-month old health information technology company based in Bellevue, Washington.

First let me start by thanking you for giving me the opportunity

to present our company’s views in front of the Subcommittee and

in front of the general public here today.

HealthUnity was founded with the singular vision of providing

the solution for getting the right clinical information to the right

person at the right time. We had two earlier deployments underway: One in the Seattle east side, namely, Bellevue, Washington;

and another one in Baltimore, Maryland. In both of these locations,

we have had early successes in enabling health information exchanges to flourish.

HealthUnity’s approach and early success can be summarized in

the following key points: Our approach is targeted at the grass

roots, namely, we target the clinicians first. They are the knowledge workers who need to be introduced to health information technology right from the outset. If the clinicians are not on board, we

will not achieve the national vision we seek, despite the involvement of others, so that’s why we started the grass roots with the

clinicians.

Secondly, we provide an affordable solution that is also the best

in its class.

And, thirdly, we take care of all the external integration and

communication needs, which is a critical piece, as Luis was pointing out, in our national health IT strategy.

Finally, we believe we have a business model that is scalable and

sustainable.

Now, let me summarize my thoughts on what role health information plays in improving care. Health care is essentially a local,

at best a regional, activity; hence, any approach to solving health

information sharing, it should start at the local or regional level.

66

There are three goals which are central if any of this is to happen. The first goal is improving quality of care. Now, I will limit

my—the value proposition discussion from a clinician’s perspective.

And I’m sure there are various other perspectives on value and

how a network could be beneficial. But, you know, like I said, we

have to start at the grass roots level; and unless the clinicians are

up to it, it doesn’t matter who else is interested in it.

The often quoted figure is that 96,000 avoidable deaths happen,

in the U.S. Alone. By electronically recording, communicating, and

archiving health information and then analyzing de-identified information—meaning the patients identify information that has

been removed from it—we can both benefit the patients as well as

the community and the population health needs and how we can

improve quality of care.

The second goal is addressing provider inefficiencies. Information

technology has the power to reduce cost of doing business for all

the providers involved. Today there is still a ton of paperwork, papers, faxes, phone calls, that keep passing between care providers.

At HealthUnity, we have recognized this as another important area

where our solutions should help improve those inefficiencies.

The third goal is to improve patient experience. We—in our earlier—in other testimony, it came out that we all go through the

frustrating experience where we go see a doctor and we have to—

the first thing we do is we have to fill out the clipboard. Additionally, the patients who see multiple providers have to take it upon

themselves the act of coordinating the health information, and,

physically, in many cases, transporting data between the various

care providers.

Now, let me turn to the topic of incentives and barriers. The key

barriers hampering technology adoption in the physician practices.

Deployment of IT systems requires up-front capital and it also

causes short-term disruption in practice efficiencies. So any solution should address squarely, number one, how to help physician

practices raise the capital they need in order for deploying and operating such; and then, secondly, how do you promote the mass

education of our general public and the IT people so that adopting

these systems can be very inexpensive and the talent to do that is

ubiquitous and it’s widely available.

Here are some practical suggestions on how incentives can be

targeted at these two barriers. Number one, let any interested

party finance physician practice adoption of technology, with no

strings attached. So far, we have had a lot of discussion on why

physicians do not have technology; but any solution or every policy

solution keep coming back has strings attached to it, and hence the

adoption is not being what it needs to be.

Number two, we need to fund education and training so the best

practices on how to implement these technologies become affordable and common knowledge: So we can walk to a community college and get the graduates that are coming out or have been

through the program, and they have the knowledge how to help the

physicians implement the IT solution in their practice.

Now, let me turn to the topic of Federal Government departments and agencies and the role that they have played in health

IT. HHS, the Health and Human Services Department, as well as

67

the Office of the National Coordinator, have done a phenomenal job

in raising the awareness in the industry and setting a national

agenda in terms of the appropriate goals and strategies. This was

done in record time. We commend them for serving the Nation well

in doing so.

In the area of execution we believe we can share some of our experience which might help all of us achieve national goals in a capital as well as time efficient manner.

Our nation owes much of its economic success to its numerous

entrepreneurs, inventors, and workers. Equally importantly, our

nation owes its success to the right policies enshrined in our Constitution, in our laws, and in various administrative and legislative

bodies. Government intervention in the free market should be one

of last resort. We are all for government incentives and removal of

barriers, but we are not for government picking winners and losers

in the health information technology market. We are not that particular about government massively spending and indirectly funding health IT projects, either from Washington, D.C., or the state

capitals.

We understand the urgency within our government and public officials to get things done quickly. We also think there has not been

sufficient progress in creating the right policy environment and

right incentives environment and then letting the private sector innovate. I think that is where we have had deficiencies and we can

definitely use a lot of help from Washington, D.C. We would also

like to see more of the Health and Human Services Department as

well as the Office of National Coordinator’s resources targeted towards addressing these policy and incentive issues.

Addressing the topic of standards in the health care environment, the scenario that is most important at the national level may

be quite different than what is most important at the regional

level. And we’ve only seen that based on some of the recommendations and incentives that are coming from Washington, D.C. Our

focus needs to be at the regional level, the regional scenarios, the

barriers, the incentives, and the policy and legislative needs, at the

grass roots level.

We thank you for the opportunity, and I look forward to answering some questions. Thanks.

Mr. REICHERT. Thank you.

[The prepared statement of Mr. Urali follows:]

PREPARED STATEMENT OF PREM URALI

Good afternoon, Chairman, Members of the Subcommittee, ladies and gentlemen.

My name is Prem Urali. I am the Founder and CEO of HealthUnity Corporation,

a 17-month-old health information technology company based in Bellevue, Washington.

First, let me start by thanking you for giving me the opportunity to present our

Company’s views in front of this subcommittee.

HealthUnity was founded with the singular vision of providing a solution for getting the right clinical information to the right person at the right time. We have

two real-world deployments underway: one in Bellevue, WA, and the other in Baltimore, MD, where we have had early successes in enabling regional health information exchanges to flourish.

HealthUnity’s approach and early successes can be summarized in the following

key points:

1. Our approach is targeted at the grass-roots—we start with clinicians. They

are the knowledge workers who need to be introduced to the health techVerDate 11-MAY-2000 14:54 Jun 23, 2006 Jkt 026205 PO 00000 Frm 00071 Fmt 6633 Sfmt 6621 C:\WORKD\ETS06\022306\26205 SCIENCE1 PsN: SCIENCE1
68

nology world right at the outset. If the clinicians are not on board we will

not achieve the national vision we seek, despite the involvement of others.

2. Secondly, we provide an affordable solution that is also the best in its class.

3. Thirdly, we take care of all of the external integration and communication

needs—a critical piece that has been missing till now. Clinicians want to

communicate electronically with other clinicians, labs, radiology centers, hospitals and patients. Facilitating this communication is what we do best.

4. Finally, we have a business model that is scalable and sustainable, and

which produces the best solution for the clinical communication and collaboration problem.

Let me now summarize my thoughts on the role health information plays in improving care.

Health care is essentially a local, or at best regional, activity. The patients and

their providers (hospitals, labs, physician practices, etc.) are all located within a

given locale or region. Hence any approach must start at the regional level. There

are three goals that are central to regional care providers that also align perfectly

with the national vision. I am limiting my analysis to goals that are relevant from

a provider’s view-point because that is where I believe all discussions around information technology adoption in health care should begin.

The first goal is improving quality of care:

The often quoted figure is that 96,000 avoidable deaths occur in the U.S. each

year. By electronically recording, communicating, and archiving health information

and analyzing de-identified health information, we can help reduce the incidence of

errors and improve quality of care. This can be achieved by providing patient-specific, as well as population-wide, interventions.

The second goal is addressing efficiencies:

Information technology has the power to reduce the cost of doing business for all

the providers involved. Today, there is still a ton of papers, faxes and phone calls

passing between care providers. At HealthUnity we address inefficiencies by automating major workflows, such as patient demographics exchange between health

care entities, automation of the referral process, clinical information sharing, distribution of lab and radiology results, and several other frequently recurring processes. These savings lower the operating costs for care providers and help them run

their businesses better. In addition, by making historical data seamlessly available

to care providers, we reduce the practice of defensive medicine. If prior data is available and easily accessible, providers are less likely to reorder tests and procedures.

This reduces the level of waste in the system. Providers need not be concerned

about overall revenues falling. We need to keep in mind that there is no dearth of

growth in demand for health services with our aging population. By reducing wastage and reducing the unit cost per visit or procedure, providers can treat and meet

the needs of more of our citizens at a lower unit cost to the system.

The third goal is to improve the patient experience:

Today, as patients, we often have frustrating experiences when we visit our doctors and the dreaded clipboard is handed over for us to fill out. Often patients who

see multiple providers may have to fill out the same form multiple times over the

course of a single day. Additionally, patients who see multiple providers appreciate

what it takes to transport medical data between their various care providers, and

consequently they themselves act as coordinators of their own care. Technology can

help the system do what it is supposed to do and make the care delivery process

considerably more patient friendly. Clinicians would love to see this happen at an

affordable cost to them.

I hope I was able to illustrate the core benefits of a connected health care environment. Now, let me turn to the topic of incentives and barriers.

The key barriers hampering technology adoption are in physician practices. The

other health care providers are typically larger and can easily afford new investments or have already made investments in health information technology. Deployment of an electronic medical record system, or EMR, requires up-front capital and

causes a short-term drop in practice productivity. Furthermore, an EMR, coupled

with a practice management system, or PMS, does not completely address the three

goals I spoke of earlier. The third missing piece is the bidirectional external communication solution. Any real solution should squarely address: 1) How to help physician practices raise capital for deployment and operation of an IT solution that addresses EMR, PMS and the bidirectional communication need. And 2) How to proVerDate 11-MAY-2000 14:54 Jun 23, 2006 Jkt 026205 PO 00000 Frm 00072 Fmt 6633 Sfmt 6621 C:\WORKD\ETS06\022306\26205 SCIENCE1 PsN: SCIENCE1
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mote the education of the market on the best practices for adopting those solutions

in a way that minimizes disruption in practice productivity.

In summary the barriers are 1) Capital for deployment and operations and 2)

Practice disruption during implementation. Here are some practical suggestions on

how incentives can be targeted at these two barriers: 1) Let any interested party

finance physician practice adoption of technology, with no strings attached or with

only a minimal requirement that the physician practice match the interested party’s

funds with their own funds, or match the funds in kind. 2) Provide incentives for

standardization and commoditization by implementing the solution such that there

are hundreds of people who have the expertise to implement these technologies for

a low price.

Let me now turn to the topic of the Federal Government departments and agencies, such as the Department of Health and Human Services and NIST, and the role

they currently play and could play in the future. HHS and the Office of the National

Coordinator have done a phenomenal job in raising the awareness in the industry

and setting a national agenda in terms of appropriate goals and strategies. This was

done in record time and we commend them for serving the Nation well. In the area

of execution, we believe we can share some of our experience, which might help all

of us achieve the national goals in a more capital and time efficient manner.

Our nation owes much of its economic success to its numerous entrepreneurs, inventors, and workers. Equally importantly our nation owes its success to the right

policies enshrined in our constitution, our laws and the various administrative and

legislative bodies. When a major challenge such as the adoption of Health IT stares

at us, we go back to the formula that has worked for over 200 years, and that is

that the Government does what it is best at—setting the right legal and policy environment, and the private sector does what it is best at—innovating and creating the

best health information infrastructure in the world, one that is constantly innovating and keeping us at the fore front. Government intervention in the free market

should be the last resort. We are all for Government incentives and removal of barriers. But we are not for Government picking winners and losers in the free market

by massively spending the public’s money on direct Health IT projects managed

from our national and state capitals. We understand the urgency within our government and public officials to get things done quickly. We also think there has not

been sufficient progress in creating the right policy environment and the right incentives environment and then letting the private sector innovate. We would like

to see more of HHS’ and the Office of the National Coordinator for HIT’s resources

targeted towards solving the policy deficiencies and the incentives for private sector

development.

Addressing the topic of standards, NIST has a role to play as standards emerge.

Standards make sense when a value proposition can be clearly articulated and there

is strong consensus around that value proposition. Let me give you the example of

my ATM card. When I travel to Europe, I can withdraw cash from most ATM machines there. However, I cannot call up my bank statement from Europe. The value

proposition here is very clear. When traveling out of your home country, you want

to be able to get cash. However, you don’t particularly care if you are able to get

your last month’s bank statement. Translating this analogy to the health care environment, the scenario that is most important at a national level may be quite different than what is most important at the regional or local level. Our first goal is

to set in motion a policy and incentive framework that will identify the scenarios

that are important at the regional level. When a clear picture emerges at the regional level, we can then identify a subset of the regional scenarios that would be

important at the national level. At this stage our focus needs to be on the regional

scenarios. When a clear value proposition emerges for a given regional scenario then

we can move forward to standardize it at the national level. NIST can play a key

role in this process.

Our observation is that the national standards are being worked on without first

letting the local and regional standards sufficient time to emerge. Again, I clearly

understand the urgency of our government and public officials to achieve tangible

progress. We want to help by providing our candid feedback so that the national

debate includes the voice of a firm which is making progress on the ground at the

regional level.

We thank you for the opportunity again. I look forward to taking some questions.

BIOGRAPHY FOR PREM URALI

Prior to founding HealthUnityΤΜ Corporation, Prem was a Group Manager in the

BizTalk Server division of Microsoft, responsible for the BizTalk Accelerator line of

server products including the HL7 and HIPAA Accelerators (integration engine).

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Prem incubated these initiatives from concept to $10 million in incremental revenue

in three years. Prior to Microsoft, he founded a B2B software company Commercia

Corp, which was acquired by Microsoft in 2000. Prior to that Prem held the position

of CTO of Petopia, now a division of Petco Animal Supplies (NASDAQ: PETC).

Under his leadership, Petopia was ranked by InfoWorld in its e-Business 100 list

in 1999. Previously, Prem worked for four years in the consulting services division

of Microsoft, where he was one of the youngest persons to be elevated to the position

of Principal Consultant in 1998. In this capacity, Prem lead the program that

launched the very first electronic commerce presence for Gap, Baby Gap and Gap

Kids. Prem, has founded companies in India and U.S. in the software consulting and

product areas.

He earned a Master of Science degree from Iowa State University in Computer

Engineering. He also earned an MBA from the Wharton School of the University

of Pennsylvania. Prem has three patents pending in the area of message-oriented

middleware systems.

About HealthUnity Corporation

HealthUnity was founded with the singular mission of providing the right clinical

information to the right person at the right time. HealthUnity is the ‘‘RHIO in a

box’’ company. HealthUnity’s affordable solution can be used to build regional health

information networks that support organic growth from as little as two entities to

hundreds of entities. Our tag line is ‘‘Trust is Earned’’ which reflects our commitment to protecting security and privacy of patient data.

DISCUSSION

Mr. REICHERT. Would the other witnesses come up and try to

find a seat? I know it’s a little crowded.

You know, these hearings, when I—this is my first term, by the

way, in Congress. I was a law enforcement officer in the sheriff’s

office in Seattle, and I was a sheriff in Seattle for eight years. And

I find these things to be very formal and people are a little bit

nervous.

Are you nervous out there? Are you nervous up here?

See, we can relax a little bit now. You’ve got your testimony out

of the way, and Mr. Wu and I will ask a few questions.

I, personally, am not an IT expert and I’m not a health expert,

but what I’ve noticed is some similarities in the field that I came

from, my 33-year career in law enforcement. When you talk about

inter-operability—and I think, you know, you were mentioning

that, first, hospitals and doctors’ offices need to build sort of a system within their own operation before they can kind of reach out

and be inter-operable. Law enforcement has the same problem. I

think back to—oh, by the way, I’m supposed to say, before I start

to talk, that I’m recognizing myself for five minutes. That’s part of

the rule. So I’ve now recognized myself, and I’ve used up some of

my time. Since there are only two of us, we’ll be liberal with our

time today.

Mr. WU. Absolutely.

Mr. REICHERT. I would just like to draw a couple of comparisons

to law enforcement, because we’re all going through this struggle

of just this massive increase in technology and the number of vendors mentioned, 800 vendors. We all are dealing with the fastest

moves.

But in 1982, I was 31 years old, I started to work on the Green

River murder investigation, which brought me to Portland, back to

the Oregon area again. Do you know that in 1982, when I started

to work that case, there were no computers? And what we used—

and I’ve talked to young children about this in grade school and

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junior high, and even high school students, they will raise their

hand and say, when I say, ‘‘This is on Rolodex file,’’ they’ll say,

‘‘What is a Rolodex?’’ And that’s so far—and then DNA and automated fingerprint identification systems, all those things.

So what’s exciting, though, is the Northwest is really leading the

way in a lot of these areas, and in the health IT area, the Northwest once again is leading the way. What you’ve heard from the

expert witnesses today is that we are far ahead.

I’ve had the opportunity to travel to New Orleans and Houston,

and after Katrina and Rita, and interact with the people there.

They are making progress too, don’t get me wrong, but—you know,

we’re a little bit biased here in the Northwest—we are doing a

great job, but there’s so much more we can do. And I’m just happy

to see that all of these bright people are on this problem, because

it is one that needs to be solved.

The other thing that I find very interesting in these discussions

within the Federal Government and state government are all these

acronyms. Let’s see, I just jotted a few down. So we’re just going

to have a little bit of fun.

HHS. NIST, N–I–S–T. ONC. IEEE. HITS. PCC. IH. IT. EHR.

OPI. RTI.

Does everyone know what all those mean? You do? That is scary.

Well, you know, it’s good that you all know what they mean.

Mr. WU. What we have is an inter-operability issue.

Mr. REICHERT. Exactly right.

Mr. WU. It’s a new language.

GOVERNMENT ROLE IN HEALTH IT

Mr. REICHERT. But what I’ve—What my question, now, I lead up

to is: I recognize that some of the problems that were listed were

turf wars, partnerships, and standards, incentives; those are some

things that have been talked about.

What I’d like to know, first of all, what are the three most important things that the Federal Government can do to help? Now, I’ve

heard a lot of suggestions; but if we can just maybe—anyone in the

panel, the three most important things that we can do. I know

there’s a lot.

Dr. PETTIT. I think, as a start, this was a great experience trying

to figure out in writing this testimony, really, and I think everyone

is nodding their head. What can the government do to help us.

Mr. REICHERT. Yeah.

Dr. PETTIT. And I see bringing attention to the matter has done

a tremendous amount in the past year, I believe. Funding is another thing. Supporting legislation is another. And one more—what

was it? Nancy, help me. Programs.

Yeah. Those are the—Those are the four things I see. Oh, and

providing incentives through the government’s role as a payer.

Mr. REICHERT. Yeah.

Mr. MACHUCA. If I could, I’m just going to give you one. I really

believe that embracing an organic approach not only has the benefits that we stated, but I think there’s a paralyzing effect when clinicians and professionals in health care think that somebody else

is figuring out, somebody else is going to pay for it, and in ten

years we’re just going to plug our PC into the wall and all the

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health information is going to come out. Not only is that a fallacy,

but it’s a paralyzing and chilling effect. And people moving in an

incremental way to get the great benefit they can go with immediately, and so I would focus very much on incremental, high yielding steps as opposed to the big vision in the sky ten years from

now.

Dr. CHIN. I would—You know, I would agree with that. And one

of the big things in health care IT is ‘‘don’t let perfect be the enemy

of the good.’’ You know, we’ve got to start somewhere; and rather

than trying to develop the perfect system and the perfect standards, we’ve got to start somewhere.

The number one thing for the Federal Government is really incentives to incent people to put their information into an electronic

form and to be able to share that information. One of the examples

of that is Kaiser Permanente, here in the northwest region, actually contracts out services, hospital services, to four or five hospital

organizations. And we do get that information back, we do get that

information back electronically. And the incentive for those organizations to provide that information is that, unless they provide that

information, we do not use their services. And so that’s certainly

a big incentive for them to provide that information.

The issue is not a technological one; the issue is one of incentives

and making it attractive and reward organizations for engaging in

this behavior of sharing information.

Ms. CECCHETTINI. I agree on the—I agree on the incentives for

early adoption, but also sharing the best practices of early doctors,

because it is about the work flow and how we do change practice

within health care.

Mr. KENAGY. I just want to add, though, the point earlier about

highlighting the issue is important. I think the Federal Government plays a huge role in educating itself, educating the industry,

and educating consumers about how complex this is. And I think

that’s critically important. I agree with the incentives.

I think the focus on inter-operability between institutions is a

huge—you know, we have keen interest within OHSU to automate

our records, to improve care, to improve quality, to improve efficiencies; but as was said by many of the people here today, there

are few incentives to sharing the information.

I think Dr. Chin mentioned it great. There’s a lot of incentive

around being effective in one area, but around health. So I think

that focusing the incentives around sharing information, being able

to export it to the patient themselves, who are ultimately the greatest beneficiaries of this, and between institutions, is a good focus

area.

Mr. REICHERT. Dr. Jeffrey.

Dr. JEFFREY. Well, as the Federal Government representative

here tasking ourselves, I’d like to echo some of the things I’ve

heard, which I completely agree with.

One is the leadership role that the Federal Government can have

in terms of exactly what you just said, increasing the awareness

and the importance of issue at all levels.

Second, it was mentioned the need to provide incentives for technology adoption in policy, especially sort of market-based policy incentives. And one of the things that the Department of Health and

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Human Services—I’ll try to avoid the acronyms—under. Dr.

Brailer’s leadership, they just put out the contract recently to

George Washington University, Massachusetts General Hospital,

and I think it’s the Harvard Institute for Health Policy, to specifically examine government policies and how they may be used to

more effectively help the adoption of some of these technologies. So,

hopefully, that would be one mechanism to try to get more of this

kind of input.

And then the third area is on the same obstructions to interoperability, I agree, across institutions is a critical piece. And that’s

a place where the Federal Government is not mandating but working with the private sector and plays sort of a little bit of the referee and a little bit of the convenor (unintelligible) to try to get to

the right answers.

Mr. REICHERT. Great. You noticed I asked for three and I think

I counted about eight, so that’s good.

The Chair recognizes the ranking member, Mr. Wu.

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

You know, I tend to be a ‘‘glass is half full’’ kind of person; but

after the challenges that we’ve heard today, I think the glass is

kind of a quarter full. But I think that we have some success stories here, or at least some good starts, with Kaiser based here in

the Pacific Northwest, with our local V.A. Hospital, and with the

efforts at OHSU. And I’d like to get into some of the specific reasons for that, and it’ll probably take several rounds of discussion

to get into that.

But we really have a critical mass of providers, payers,

innovators, suppliers, quality organizations, here in the Northwest—in the Portland metro area in Oregon, in the Puget Sound

area in Washington state; and it’s not just because the businesses

exist here and the health care providers exist here, but because, I

think, there’s a spirit of innovation.

And before we let other folks get too far out ahead, as Mr.

Reichert referred to the loss of memory of Rolodexes, which were

so important to us in our prime, you know, in my intellectual property practice, we represented all different sorts of folks, including

financial institutions. And I remember helping financial institutions transition from their in-house IT service to outsourcing their

out—this is before ‘‘outsourcing’’ was a bad word; this was

outsourcing to a nice company in the Puget Sound—and this transition was typically done over a weekend. That is, you shut the

bank down on Friday afternoon and you click over from your inhouse service to this new service provider. And the theory was that

you did all of that work over the weekend and you open up on Monday and nobody notices the difference. And just in my legal career,

I’ve got to tell you that one of these transitions, well, you know,

the client shut the service down on Friday afternoon and on Monday morning the tellers were using shoe boxes and paper records.

So there have been a lot of challenges to a lot of different industries, just in our very short professional life, and so I think that

there’s real room for optimism.

And focusing on the positive first, with Dr. Chin.

Kaiser is an integrated operation. You’ve gone to a paperless system. There have been tremendous problems in giving incentives to

74

health care providers. My understanding is that at Kaiser it’s a bit

tough. It’s basically, if you want to work here, you’re going to use

this paperless system.

But, Dr. Chin, as the designer of the system, you must have

made many decisions to try to make your system more provider

friendly. Could you talk about some of those things in addition to

the stick of ‘‘if you want to work here,’’ what are some of the carrots that you offer.

TRAINING ON IT SYSTEMS

Dr. CHIN. There is a learning—certainly a learning curve for clinicians to learn how to use systems. And I would say, initially,

number one, is the amount of training that we provide them. So

we’ve provided them with 20 hours of training in order to get them

to be used to the system, and then we actually reduced their schedules, initially, when they started using the systems, to enable them

to really learn how to use the system effectively.

After you do that, once you get 90 percent of the clinicians on

board and using the system pretty effectively, then it’s relatively

easy to get the other 10 percent on board and to make—and to

mandate the use of the system; otherwise, they don’t work for Kaiser Permanente.

And one of the interesting things is that we did send a survey

out after we implemented the system, and we said, ‘‘If we gave you

the opportunity to go back to a paper record system, would you

take that opportunity?’’ And over 90 percent of the clinicians said

no, they would not, because they could see the advantages of the

information system.

So I would say, Congressman Wu, that, initially, you do sort of

need a stick and you need to coach people and you need to train

them and you need to make it part of their job; but once they convert over to the electronic systems, the clinicians see the advantages of doing that, and they naturally continue to use it rather

than fall back into paper. So that’s the approach that we’ve taken.

And then, also, if you develop these systems intuitively and well

enough, it can actually make their lives easier, because, number

one, they have access to all the information to all of their patients,

not only in their practices but from other people’s practices. And

physicians recognize the benefit of doing that. And then, secondly,

if you make the system intuitive enough, you can actually build in

things, automated things, that actually make it easier for them to

practice medicine and easier for them to practice good medicine.

And physicians will appreciate that as well. And so those are the

different approaches we’ve taken.

Mr. WU. Your training was about 20 hours per clinician. Mr.

Kenagy mentioned 14 hours at OHSU. So we’re beginning to get

a bracket, if these hours of training did work, and you also reduced

clinical hours.

And, Mr. Kenagy, did you want to add something to this.

Mr. KENAGY. Yeah. Just one thing, before, sort of, I think one

key element to our success, I think, was involving clinicians at

every phase of the selection process. I think you need a tool—to be

successful, you need a tool that will work for physicians and

nurses. They need to be involved in selecting what that is. You

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need to buy and implement a product that is good. And I would

argue that our industry is only now emerging with three or four

or five vendors that can actually meet the needs. And then have

clinicians involved every step of the way.

So to answer your question about, you know, what has been successful—and I think the Pacific Northwest is remarkably successful

in adopting EHRs. We sort of say, ‘‘We’re very wired, and it’s not

just the coffee.’’ I think that—but having—and I’m a non-clinician,

and so having the clinicians engaged throughout that process has

been absolutely critical to our success.

Mr. WU. Well, both of you talked about training the health care

providers and training folks up on the system. I wanted to ask a

follow-up about training in general, training both for the clinicians

and the providers, but also of—I think someone referred to a shortage in personnel in health care IT—because you need to be proficient not just in IT but in health care; and if you’re proficient in

health care, you need to be proficient not only in health care but

in IT.

Do you see a role here—there was a parallel situation, I believe,

in data security, several years ago, and the Federal Government

provided some sprinkling of funding to train IT professionals in security protocols and to develop an additional personnel in that. Is

there a federal role here to work on that crossover between health

care and IT.

Mr. KENAGY. I would say absolutely, first on just what we’re facing in trying to find good professionals.

I think it’s a good sign that the Pacific Northwest economy is recovering, that when we have positions—I mean, two years ago or

three years ago when I had a vacancy, it was easy for us to have

100 or 150 people looking for that vacancy sort of just saying,

‘‘Well, I never really wanted to work in health care because it’s

such a backwater of technology, but it’s a job.’’ Now we’re having

the problem that people—we don’t have that, we don’t have that

lecture anymore. I think people, good people, have jobs now.

At OHSU we do have a program where we are training health

care IT professionals for the future. It’s part of the pipeline development that, as the operational side of OHSU, I want to work with

the academic side of OHSU to continue that. I think that is a problem. I think understanding the nuances of health care IT.

What can the Federal Government do? I think, as you mentioned, incentives. It’s expensive to train computer professionals. I

think recruiting them, retaining them, and understanding that

health care is an unbelievable career for a health care—for an IT

professional. I think that we just need to have more programs.

The American Medical Informatics Association has a program

called ‘‘Ten by Ten’’ to train 10,000 clinicians by 2010. Again,

OHSU is a part of that effort. I think that’s great. We need a significant number of people in our industry, both to support it—the

ongoing support and the like.

Dr. CHIN. You know, as part of my written comments, not my

spoken comments, one of the things that I mentioned is the reason

for our success was really the partnership of physicians, IT professionals, and project managers working closely together. Certainly,

if you have somebody who’s got medical knowledge and the IT

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knowledge, that will go a long way to ensure the success of a

project. And I think that’s very important.

One of the problems with health care IT is, it is a very specific

body of knowledge and it’s not really acknowledged as such. Unlike

medical care, where you have neurosurgeons that are board-certified, internists that are board-certified in internal medicine, within health care IT, it’s difficult to know who’s qualified and who’s

not qualified. And just like you wouldn’t have neuro—an internist

do neurosurgery, you shouldn’t get somebody who’s knowledgeable

only in IT in a certain area, necessarily, involved and feel that

they’re going to be completely competent in health care IT; because

there are a lot of issue in health care IT that are very specific to

that field, that are not specific to other IT fields.

Mr. URALI. Again, kind of representing sort of the small clinician

practices. I’d like to kind of narrate a recent story we heard from

one of our customers.

We had a big storm about a month back, in the Seattle area. The

DSL connection—basically, the Internet connection—failed for this

physician, and she couldn’t get the connection back up and running

for almost four days. And she had to get the consultant to come in

and spend almost like $150 an hour to get something as basic as

an Internet connection back up again. That just goes to show how

expensive it is to even get something basic as an Internet connection going.

One of the benchmarks should be that, you know, I can open my

community college, you know, class schedule and see a ton of

courses there that I can go take for a hundred dollars that, you

know, I can gain the expertise over a two or three week period,

maybe it’s three evenings for a four-week period or like or something like that.

You know, health IT is not that difficult, you know, honestly. I

mean, I come from a technology background—used to work for

Microsoft for eight and a half years, did not have that much of a

health care IT background up until about four or five years back.

And, you know, we built two products within Microsoft within a literally short time to pick something up. It is possible to get that

knowledge out there in a pretty common manner, and I do certainly believe that. And the more people we have trained that way,

I think it’s going to bring down the cost of that option. We cannot

have $150 consultants coming in just to fix my Internet connection.

Physicians cannot just afford that sort of expensive services.

They’ve got to be able to have their own office staff trained, or

maybe they should be able to hire people who they can pay $20 or

$30 an hour and have them full time on staff and maybe help them

run most of the technology infrastructure.

ROLE OF PATIENT IN HEALTH IT

Mr. REICHERT. Okay. Now we’re back to recognizing the Chair.

Thank you, Mr. Wu. And I have a couple of questions.

I’ve noticed, Dr. Pettit, in your testimony, you referred to—and

this might be kind of a commonsense statement, but an answer

would be a commonsense answer. What do you mean by ‘‘put the

patient at the center’’? I know what it means to me, but what does

77

that really mean, when we try to bring that into the whole health

IT world?

Dr. PETTIT. I’m glad you—I’m glad you asked that.

Mr. REICHERT. We need somebody with some IT experience.

Dr. PETTIT. I really am very, very glad you asked that question,

because it’s something that’s been—a definition that’s been sort of

elusive, and I think you will find different answers from different

people.

Some say, ‘‘Well, we offer a portal to our information, and that’s

patient-centered.’’ But I think the way that I’m defining ‘‘patient

centered’’ is illustrated by this: A friend of mine just today said,

you know, ‘‘Where is my medical record?’’ Where is my medical

record? And then he realized, he goes, ‘‘Well, I don’t have it.’’ So

he said, ‘‘Is it at this clinic and that clinic and that clinic.’’

And I said, ‘‘Yes. It’s in fragments in different places.’’ And so

that’s really sort of institution-centric, meaning the record exists

there, and if you want it, you need to retrieve it, as opposed to having the patient be able to see it, in its entirety, either, you know,

virtually or directly.

I mean, even as I start to explain this, it does get kind of confusing in a hurry, because there are technical ways to bring the information together even though it might exist in different places,

and then there are other ways where you can put it all in a single

database and then it’s essentially right there.

Did I answer your question?

Mr. REICHERT. So is this part of your—because you followed up

in your testimony with a comment about shared data ownership,

so is that kind of what you’re talking about when you talked about

‘‘patient centered’’ when you share the—that the patient has ownership of the shared data? Am I following you right?

Dr. PETTIT. Yes. Yes.

Mr. REICHERT. Okay.

Dr. PETTIT. What we don’t want to do is just make what we’re

already doing just a little bit quicker, you know, because to get a

record from one place to another, you know, we can mail it or we

can fax it or we can e-mail it. But we need to rearrange things so

that you don’t have to go out and get it every time you need it, so

that it’s in a single nonredundant structure, you see.

Because when you seek health care, you have, generally, a history and physical. And in the emergency department, when you’re

admitted to the hospital, in the outpatient setting, there’s a ton of

redundancy in that. I mean, how many times are you asked, ‘‘Have

you had any surgeries? Are you allergic to any medications?’’ You

hear the same thing over and over. That should be documented one

time, and one time only, in her life. If you had an appendectomy

in 1972, document that once; and then it will save health care people unbelievable amounts of time in reasking all those questions.

PRIVACY ISSUES

Mr. REICHERT. Of course the follow-up question to that would be,

and, again, to the entire panel: When you document that once and

the record goes out to all these other entities, then there certainly

is this concern about the whole HIPAA and privacy issue.

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Do you feel that the technology that’s out there today is a technology that does protect the privacy of patients?

Dr. PETTIT. I would say not adequately at this point. And there

are other issues that the—the record is still so undifferentiated, if

you—if I dictate a note on a patient, it might include issues about

their depression and their prostate and their hypertension. It’s just

all in one thing and you can’t really separate it out. But, you know,

the ultimate goal in this patient-centered way is that the patient

can control it, item by item. I mean, we’re a long ways from this,

believe me. But, you know, a person should really be able to say,

‘‘Don’t share the results of that test with this person.’’ Because

your orthopedist may not need to see some embarrassing things

you had, you know, across town.

UNIQUE PATIENT IDENTIFIER

Dr. CHIN. And the technology certainly exists to secure it and

make it private, so the technology isn’t an issue.

The technology is there. But the first step—building on what Dr.

Pettit said, the first step is really being able to identify a person

as the same person in another institution. And even that basic

functionality does not exist. So I don’t know whether the John

Smith that I admitted at Providence is the same John Smith that

was admitted at OHSU the day before. And that would really be

the first step, is to say, ‘‘Okay.

I’m seeing somebody in my institution. What other institutions

does this person have information about? And if I pull that information, is it the same person or is it a different person.’’

Some people have called this the unique patient identifier. And

I would say it doesn’t really have to be a unique patient identifier;

you just need a mechanism to be able to clearly identify a person

as the same person across institutions. Now, whether it’s a unique

patient identifier or some other functionality, it doesn’t make any

difference as long as you have that functionality to be able to identify that person. And that’s the basic thing that we do not have.

Mr. REICHERT. A follow-up, then, with one other question. If I’ve

heard correctly, Doctor, you’ve said that a unique patient identifier

is a first step in this process.

Mr. Machuca, you talked about, in your statement, making incremental high yield steps. So would this be one of those incremental

high yield steps?

Or anyone else on the panel, is there an incremental step that

you see as a high yield, other than this patient identifier? I would

see that as one. What would be some others?

Mr. MACHUCA. Well, along those lines, I think we tend to look

at this through the prism of acute care, which is a 400-year-old

model, and maybe we should start looking at this through the

prism of chronic disease management and chronic care, which is an

entirely different growth path in terms of consumption of resources

and health care.

And through that model, identification and data—the incentives

for the publication of data, whether they’re coming from the patient

or another provider, are based on the value associated with that activity, as opposed to some financial or regulatory incentive I have

to post or publish my data to some unified place. In other words,

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if you look at this through the point of view of—through the prism

of acute care, you now have to solve also the problem of you created

a burden, yet another burden, on an already overburdened health

care system and a clinician, to not only take the data down for

their own benefit but to publish it to—I don’t know how many entities, but let’s just assume there’s one that collects all of that. And

so you at least have to solve that incentive.

And I’m much more at looking into this problem from the—if you

look at it just as an example from the prism of chronic disease

management, where the data that you’re going to enter into the

system of managing that has a very immediate and relevant step

on how you get to compliance, whether it be in your blood pressure

or whether it be in cholesterol or whatever it be in, whatever the

parameters are.

I think the other issues, the notion that I have to have all the

data at my fingertips, all the time, for any possible reason, is a notion that, in my experience so far, I have found as many clinicians

rejecting as too much information is worse than not enough information. And so I would be very careful of trying to wrap everything

around a unified patient identifier. I think the efforts that are

being taken to that are adequate and should move forward, but I

would much more focus on the value associated—what is the data

that needs to be there and what’s the value associated with that

data.

Mr. REICHERT. Sounds like that was Dr. Pettit’s point a little bit

earlier.

Are there other steps that—incremental steps that are high yield

steps? Anyone?

Dr. PETTIT. I will just say one thing about patient identification.

I think that is definitely one of the first steps. There are a couple

of ways to accomplish it and it doesn’t have to be done through the

use of a unique personal identifier, in the fact that I know that’s

been politically a very difficult discussion for a long time.

Mr. REICHERT. Yes.

Dr. PETTIT. I think there was unique patient identifiers options

done like in 1997 and it was shut down practically in the afternoon

after it was presented. But there are technical ways to accomplish

the same thing.

There’s a lot of discussion about record locator services and

matching algorithms and all that sort of thing. So the good news

is that even in the past year, going to HIMSS, seeing real progress

in the technology to do these sort of things, and things that were

more of a theory a year ago are now becoming at least sort of real

in the exhibition booth. But it’s a step. I think someone here described it as a concept car: You can see them but you can’t drive

them yet.

Mr. REICHERT. Yeah.

Dr. PETTIT. But they’re on their way.

Mr. REICHERT. Good. Thank you.

Dr. CHIN. You know, the next incremental step would be to simply take information, medical information, on a patient and label

each piece of information as to the date the information was generated and the type of information. So if it was a medication, label

it as a medication; if it was a radiology test, label it as a radiology

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test. And that way, when you download information from one institution to another, and you say, ‘‘Well, I want to take a look at all

the radiology tests somebody had,’’ you could then filter that information and look at all the radiology tests in reverse chronological

order. That would be relatively easy to do in terms of developing

a standard for that and yet produce enormous benefits. So I would

say, next to being able to identify the patient as the same patient

across institutions, that would be the next step, is to label each

piece of information as to date and the type of information.

Mr. REICHERT. Mr. Kenagy had a comment.

Mr. KENAGY. Just a couple things. One, I think, I can’t exchange

anything electronically if I don’t have it electronically in the first

place. And I think the earlier point that only 10 percent of hospitals and 5 percent of physicians’ offices have anything electronic

in the first place is a much more significant barrier to exchange.

When we—This panel represents very different views.

We do not share the same idea that either a very large national

database of all patient information is either a good or a wise objective or technologically feasible. I don’t know if I think—actually, I

do know that I don’t think an electronic—a unique patient identifier would be the first step. I do think we need incremental ways

to get information out of our systems. That is a significant—even

if it were just a PDF, the ability to extract what is either in paper

or electronically, at first, would be important. Right now, it’s an extremely manual process. Some technology would help that.

Mr. WU. Would the Chairman yield to me for a moment.

Mr. REICHERT. Yes, Mr. Wu.

Mr. WU. I wanted to go back to the subject of a patient identifier.

Are we overthinking this a little bit? I mean, you know, if you

get the patient in the loop, you know, there may be 50 David Wus

in the United States but I can look through that—I mean, if you

say, you know, ‘‘Is this you?’’ If you have a conscious patient, you

know, ‘‘Well, I never had a hospital visit in Des Moines.’’ I mean,

a lot of this can be simplified, can’t it? I mean, am I missing something here?

Dr. PETTIT. Well, when you look at Denmark, they’ve had a universal patient identifier since 1963.

Mr. WU. Yeah, but they’re Danish.

Dr. PETTIT. I know. That’s the issue. You know, that’s—yeah,

and we’re not. Yeah.

Mr. KENAGY. Your earlier point—your earlier point, Jody, about

putting the patient at the center, I think, is the key of what you’re

talking about. And I think in Oregon where we are very individualistic, and the like, if we look at the patient—Intel is very interested in the digital—the personal digital health record. If there was

a way that I could identify that this is, ‘‘I am John Kenagy, I give

you access to this information,’’ and I collate it, I’m the arbiter,

whether that’s the same, I think, is potentially a better way to approach it than thinking of a large national repository.

Mr. URALI. If I can question that a little bit further from my

viewpoint.

There could be 50 David Wu’s, but once you start looking at the

date of birth and the gender and maybe some other types of information such as your current address, you can actually narrow it

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down to potentially even just one person. And there are certain

other identifying information that are already available like, for instance, the state in which your driver’s license was issued and the

driver’s license number is pretty unique. And then, again, maybe

social security number is another additional piece of information

that can help hone in on that.

One of the things we have done is we have, you know, looked at

those types of information and we’ve also tried to make it much

more automated. In other words, if there are five institutions that

want to start automatically sharing information based on those criteria that I mentioned, where we can uniquely identify David Wu’s

data residing in three of those 15 institutions and automatically

share the data.

So that’s the sort of technology that’s already available. And then

so, you know, now we are looking at how, you know, what are the

adoption barriers and just going through the process of implementing it in the Seattle area.

Mr. REICHERT. Mr. Wu.

QUESTIONS FROM THE AUDIENCE

Mr. WU. I just wanted to follow up on the earlier discussion

about adoption of technology and the personnel that it takes. I

want to recognize Dr. Bill Hirsch there who’s training a lot of folks.

And as we talk about adaptation and flexibility, I have to note that

instead of having our table adapt to our people, we’ve had our people adapt to the table that we have available.

And the other thing that’s happened here—and, Mr. Chairman,

I don’t know if there’s anything that we can do at this point, although we do have multiple microphones and I’d be willing to, you

know, flip one of ours out into the audience. We have a lot of experts in the audience; and instead of adapting this the Northwest,

we’ve done the classic Washington thing where there’s a panel of

members of the House of Representatives asking an expert panel

to testify, rather than having a more interactive process. And most

of you all know more than Mr. Reichert or I do about this field.

You’re also learning something by looking at our learning curve

right here. And while that might be an interesting experience for

you, if there is some way that we can quickly work out a way of

sharing microphones, I think that it would be very valuable to get

all of you all participating in this.

And while we’re spreading that out, I just wanted to comment

that in two other adoption arenas, banks and schools, they both

had this experience initially of having a box on a desk. Initially,

when banks computerized, they shoved a box in front of employees,

and they probably didn’t spend enough on training, and they didn’t

integrate it into their core operations.

When schools first, quote, unquote, computerized, again, a box on

the desk. And the curriculum was not integrated around the computer—or, actually, the computer system wasn’t integrated into the

curriculum. And over time, banks have changed, schools are changing, and I think that what many of you all have addressed is the

challenge of having the health care system and this technology integrate with each other. And that is a great challenge of every

transition.

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Are there folks who—I think the microphone is back there; we’ll

bring it up here momentarily.

UNIDENTIFIED SPEAKER. Chairman Reichert, Congressman Wu,

and panelists——

The COURT REPORTER. Excuse me. Excuse me, sir. Would you

mind coming down here and stating your name?

Mr. REICHERT. We want to make sure you’re on TV.

UNIDENTIFIED SPEAKER. I don’t go for that.

Chairman Reichert, Congressman Wu, and panelists, I thank you

for your presentation——

The COURT REPORTER. Would you please state your name?

Mr. BOUCHARD. My name is Mike Bouchard, a former IT wonk,

as it were, and also a patient consumer of health services.

I think the gentleman here who mentioned about the recent loss

of data—it’s an old media that was actually lost, with poor security

applied. Trust is an issue for patients. I didn’t see anyone here advocating patient rights. I think that is very important. The patient

is actually the grass roots person being involved here, other than

the health care providers.

Secondly, OnStar. You push a button, someone contacts you, they

have all your data, it’s kind of a centralized database. With

Katrina, we had loss of a lot of information. There’s no hardened

infrastructure if something happens, like the person who lost their

DSL contact, how to back it up. We have wireless technologies. We

have jump drives. We have many new cards with data chips embedded in them. Biometrics is a big thing.

You mentioned the 50 David Wu’s. Now, with biometrics,

encryption, and other such stuff, other than addresses and social

security numbers—which I lost recently, with Providence, thank

you—it is not always secure. Data security is probably going to be

the biggest thing that will also get the patient involved.

Now you have baby boomers—I’m a late stage, not an early

stage, baby boomer—generations X, Y, Z, and Aa, Bb, you know,

they’ll be coming down the road. You have to have ease of operation scalability, vertical as well as lateral use. That’s going to be

very important. Because my seven year old son is going to be able

to out-Blackberry me and yet I can outdo how to turn on a computer and double-click, right-click with computers better than my

grandparents were. So that has to be scalable also, ease of use.

And, lastly, one of the barriers I’m finding is, there is lack of

budgeting. I have contacted many health care operations. I do ewaste and computer destruction. One of the things that we focus

on is how to get rid of the data in a manner that does not pollute

our environment or in whole drive form being sent to foreign countries, dumped in their landfills, or accidentally falling into the

ocean. If one hard drive has 365,000 records—and I think it was

a tape or a drive or something of that nature—any enemy can garner that information through data mining and computer forensics.

Big business right now. So I would not want OHSU’s information

to be garnered and then used against me.

And, also, with the NSA issues—you have other acronyms, CIA,

FBI, et cetera, et cetera—how is that information going to be protected from privacy issues, as well? You guys have opened up a

panoply of—a veritable cornucopia of subjects that, as an entreVerDate 11-MAY-2000 14:54 Jun 23, 2006 Jkt 026205 PO 00000 Frm 00086 Fmt 6633 Sfmt 6601 C:\WORKD\ETS06\022306\26205 SCIENCE1 PsN: SCIENCE1
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preneur, I’m seeing many opportunities that they use as—that also

has to be opened. How can the small business entrepreneur get involved in this, become a part of the process, as well as capitalize

on it to actually generate new incomes, make new jobs, and actually reap some of the rewards. Thank you.

Mr. REICHERT. Thank you. And back to the kind of the Washington, D.C., format—the Chairman thanks the gentleman for his

statement.

Anyone want to ask a question, we would ask that maybe you

limit yourself to a question, two minutes, so that we can have a

number of people ask questions.

Yes.

Ms. SCHOENE. Sir, go ahead and come down. I’ll meet you right

down here. And, again, please state your name for the record.

Mr. LEAHY. My name is Mike Leahy. I’m with a group called the

Oregon Community Health Information Network. And we do have

a common community health record that we’re building, so I was

hopeful that maybe some of our friends, like my board member, Dr.

Chin, or my buddy, Luis Machuca, or Jody, or John, could comment

on this, because I think there are some specific things we could be

doing.

And then just the general statement, in Oregon we have about

3.6 million people, and while I appreciate all the private initiative

type stuff, the reality is we have about a million people that are

either Medicaid or uninsured. And so, eventually, we have to talk

about kinds of patients and what—who’s covered and who isn’t.

And then regarding the reluctance of the governmental leadership, I would only say that there’s another 800,000 people who are

either Medicare or who get their, quote, commercial insurance paid

for by local, State, and Federal governments. That’s about half of

the folks in this state you’re currently talking about, already depend in some way with leadership or the lack of leadership in

terms of coherent federal, State, and local policies.

So I guess my question to, maybe, your experts is if you could

comment about efforts like what we’re trying to do with common

community health record, where we already have 15 Oregon organizations. Most of them are small organizations in rural clinics in

this area. And if you could maybe comment about some of the ways

that the representatives could help us build the common community health record. Thank you.

Mr. REICHERT. Thank you.

Dr. CHIN. Certainly, organizations like OCHIN provide a great

opportunity, because OCHIN provides services for the medically indigent, for the medically underserved. And the interesting thing

about OCHIN is that institutions that treat members that are

medically indigent actually lose money on those patients, and so

there’s an incentive—there’s a built-in incentive for them to actually share that information.

If they see a patient that comes in, for whom they are not going

to be able to bill and get any revenue, the incentive for them is to

review all the other information and review all the other medical

records that the patient has, so that if the patient needs a radiology test and they’ve had one at another institution, they don’t

have to repeat that test and therefore lose money. And so that’s

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one of the big promises, I think, in terms of incentives, is in organizations like OCHIN that serve the medically indigent.

The way the Federal Government could promote that is really to

support organizations like OCHIN, that are providing services to

the medically underserved. And it’s a win-win situation, because,

in the end, it will cost the government less money to do so.

Dr. PETTIT. Just a brief follow-on comment. But as a clinician, I

can say pretty unequivocally that the patients that OCHIN serves,

the people that are on and off insurance, that suffer the most from

discontinuity and those handoff misses/errors occur routinely; because when people don’t have insurance, they often don’t seek medical care. They don’t get primary care. They might get care, intermittently, through an emergency department; and we all know

that’s not a good way to care for patients.

Mr. MACHUCA. If I could expand, I think, on the earlier point. I

think it’s problematic to think of patients as a single persona in

only one context. And I think that’s where we get our head

wrapped around the asphalt on this issue.

I may be a member of Dr. Chin’s practice, I’m also an employee.

My employer may want to have a community of its employees who

have diabetes participate in a diabetes compliance improvement. So

in that context, I’m a different person than the person I may be at

Kaiser. I’m going to present myself as a patient to multiple places.

And to follow up Mr. Leahy’s question, who’s doing an admirable

job with a set of that community: Those folks are going to be moving in and out of that community, and at times they’re going to be

employees of somebody else who may have a program to help them

move along. And so our emphasis and the incremental approach of

the collaboration in making sure the information gets to establish

at least some level of secure electronic continuity—maybe not in a

record, but the ability to know, at a context level, who are all those

people that—who is the network of this patient and who’s involved

in the care of this person, and you have access to those people and

those resources. I think it’s a much more real-life approach than

sort of say, ‘‘Take everything else out of your desktop and just

leave Google. And just put your name in, and out comes everything

else.’’ And so I think we need all the tools in our desktop, not just

Google.

Mr. REICHERT. Thank you.

TOP-DOWN OR BOTTOM-UP APPROACH

Mr. WU. Mr. Chairman, if I may, I wanted to shift to one topic

that I think we may be at a fork in the road, and it’s pretty important that we get some discussion on this topic so that we guide the

Federal Government down what I hope many of us believe to be a

proper choice at that fork in the road.

Many of you mentioned the temptation to develop an overarching

or perfect IT solution, and we might have difficulty implementing

that because it assumes too much technology or too much training

or too much overhead. And I just wanted to throw open to you all

the discussion of, is this the direction that you see HHS headed in?

Are they looking at a perhaps overarching solution that will someday look like Esperanto in the rear-view mirror? Or is the effort,

you know, sensitive to the bottom-up approach which Mr. Machuca

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is advocating, an incrementalism and adaptive approach? And I

would like the panel to address that, and I would also invite Dr.

Jeffrey to address what NIST has been doing since signing the

memorandum of understanding with ONC in September of 2005.

Mr. MACHUCA. Thank you. To be candid, there are mixed signals

coming from HHS. If you analyze them on a trend basis, Dr.

Brailer and the office seem to be much more embracing of the incremental approach of late. But if you also look at the work of the

four contracts that were awarded for the large national infrastructure, if you look deeper into that, as to the output that is expected

and the consultants that have been engaged, it is troubling in that

effect, because it looks like more of the same will get the big consultant-driven needs, so we can spec out something that costs a lot

more and has an unlimited thirst of funding before it can be seen.

And so, to be quick to your question, is that there are mixed encouraging signals in this direction.

Dr. CHIN. You know, I would definitely support an incremental

approach, because our experience is that an overarching approach

that solves every problem is, for the most part, not successful. And

if you map out the key things that are needed, and I think members of this panel had discussed this, one of the key things is to

make that information accessible electronically. If you don’t have it

accessible electronically, it’s very difficult to move it.

The second thing is that you have to identify a particular person

in one organization as the same person in another organization.

And however you do that would be fine; it doesn’t necessarily have

to be a single patient identifier. You could use other pieces of information.

And then the third thing that would be useful, that would be relatively low tech and easy to do, is to label each piece of information

with the date in which it was generated and the type of information it was. Once you have those three standards, then you can pull

information together and integrate it into a single medical record,

and that’s all you really need. All the other stuff is good to have,

but there’s a cost associated with implementing those standards. So

those are the three things that I would emphasize.

Mr. KENAGY. Maybe a different perspective on this. At the

ground, grass-roots level, I don’t have time to pay attention to what

HHS does.

When you asked—one of the questions that was asked in this

testimony is: Has NIST or HHS contacted us at OHSU to get engaged? And the answer is no. And the first thing I was going to

say was, ‘‘Well, it doesn’t really matter, because it will be so long

before it has any impact on me, positively or negatively.’’ But I

think that it’s a great—it was a very thought provoking question.

I think all of us reflected on all the questions that you asked for

the testimony. But I’m not—there are many people who are directly

engaged.

I’m not a commercial, off-the-shelf deployer of technology, so I

look to my vendor to have the standards or whatever. And the

inter-operability that they’re working on, I don’t know if it’s going

to have a positive impact or not.

I don’t know if it’s well directed or not. I just know that day in

and day out, we have serious concerns.

86

I do want to make one positive comment about the point that

Mike Leahy made. One of the things that they have addressed sort

of in trying to get all these systems together is not doing that

through inter-operability but actually one single database. And we

are working on integrating that large database with ours, but a lot

of the efforts around inter-operability, I don’t know if they’re correctly addressed. I think there would be a lot more input from providers to see if HHS is moving in the right direction.

Dr. PETTIT. Do you have time for one more comment.

Mr. REICHERT. Yes. Go ahead.

Dr. PETTIT. I think I’ve been criticized as being an idealist at

times, but when you think about how you spend your energy and

what you’re working towards, you want to make sure you’re working towards something that is really going to change the way we

do things. And to avoid all this redundancy, I still believe you have

to work towards a unified—and that doesn’t mean a single, but a

unified collection of information about a single person, that is accessible and controllable by them.

I think an analogy in this case might help. Because our world is

changing and we—let’s say, for example, you go to a class reunion

and you take pictures with your digital camera. And now you’ve got

a picture of each of your 150 classmates and you have given them

your e-mail address. And you go back home and you get e-mails

from all of your friends, saying, ‘‘Hey, could you send me that picture that you took?’’ Instead, how about if I have—we have sort of

a shared workspace. You’ve probably dealt with some of those

shares—Ofoto, Shutterfly, Snapfish—all of these different services,

where you can post your photos and then you’re out of the loop and

they can get what they want when they want, and you don’t have

to respond all the time.

So I think shared workspace is kind of analogous to a shared

chart. I mean, right now in this hospital, we use a shared chart.

If you’re—every inpatient here has a single chart, and if you want

to know what the pulmonologist thinks or the cardiologist thinks

or the home health person thinks, you read the chart, because

it’s—you have this singular sort of point of contact. And so we don’t

have that in the outpatient setting.

I think that there’s absolutely a place for the work that both of

these gentleman do. I mean, there’s always going to be a need for

encryption and sending information in a safe, unidentifiable way.

And some of the—some of the models that are being promoted, the

(unintelligible) models, include that sort of point-to-point contact—

I think the Markel model, for example.

Anyway, I could—I’m sort of going off. But I just want to say I

think there’s room for all of us in this workspace. I mean, there’s

so much to be done and there’s room for all of our work.

Mr. REICHERT. Thank you. Dr. Jeffrey was going to respond to

this question, and Mr. Wu has another follow-up question or two,

and then we’ll conclude.

Dr. JEFFREY. A quick answer to the first part of the question,

which is, basically, ‘‘is better the enemy of good enough,’’ on that.

One of the purposes of Secretary Leavitt’s setting up the American Health Information Community, which was actually to get the

representatives from the community, including not—it’s not just

87

government, but private sector at all phases of the health care industry, in there to help set the priorities, to help identify some of

these issues. And so I think that’s a very important mechanism by

which people in this room and others can interface and make sure

that we’re getting a good enough solution and not waiting for perfection. So I applaud Health and Human Services for that.

In terms of what is NIST doing specifically, since the September

’05, so now just about six months into the memorandum of the

agreement. We’re working on several specific issues that have been

identified as potential impediments. And one of them has been

mentioned already, that physicians can’t electronically share information, and it’s both internally and externally across that. And so

that’s where all of the usual things that NIST does—the standards,

the conformance, harmonization between different standard setting

organizations—so that you don’t have to worry about which one

your vendor picked, so that all the vendors will work together.

Those are important areas that we’re working on, and that’s something that’s sort of our bread and butter.

The second is something that we haven’t yet mentioned yet

today, which is the issue on medical terminologies. There are inconsistencies and ambiguities in the way that some of the medical

terminologies are recorded, and that’s actually a very hard problem

in getting that consistency. So it’s, essentially, not just a thesaurus

and a dictionary equivalent, but it’s functionally getting the equivalent.

And you don’t want all of the—again, in terms of training, you

don’t want every clinician to have to be forced to a very specific set

of terms. And so one of the things that we’re working on is a program to automatically identify ambiguities, cross-correlations, and

the like, that would eventually be able to band into that. And, obviously, we talked a lot about securing privacy. And we’re supporting

Dr. Brailer in a lot of the programs that he’s put together and the

contractors that he’s put forward to ensure that a lot of the security and privacy features are being incorporated in the validation

of those.

Mr. REICHERT. Mr. Wu.

HIPAA

Mr. WU. Thank you very much, Dr. Jeffrey.

I just wanted to assure our previous commentator that the issues

of privacy and security are not at all ignored by those of us in Congress, or I doubt that they are ignored by anyone on this panel.

I did want to follow up on that, because—besides the incident

that we all know about here in the Portland Metro Area about loss

of records, Consumer Reports this month also ran an article on

some of the hazards of electronic health records. And Consumer Reports was actually quite critical of HIPAA for being inadequately

protective of patient records, primarily because of the potential for

sending health care information to health care affiliates.

You all have talked about changing the Stark Law, doing a couple of other things. I’d be very interested in your views on the concerns about HIPAA, any potential loopholes.

My understanding is that HIPAA is actually much less protective

of American patients than, say, European law is, European privacy.

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At least that’s been the assertion. I’d be interested in your comments about consumer and patient protection and privacy.

Mr. MACHUCA. Well, I would start by—make sure everybody understands that paper is not the stalwart of security and everybody

let’s just stay on paper because it’s secure, kidding themselves

every time something goes in a fax machine.

Mr. WU. Well, the thing is that it’s inconvenient to look in all

those files.

Mr. MACHUCA. Right.

Mr. WU. And the inconvenience is—it’s like inefficiency in the

Federal Government, it guarantees our liberties.

Mr. MACHUCA. And that’s true as long as the paper stays in the

chart.

Mr. WU. That’s right.

Mr. MACHUCA. But the moment it gets in a fax machine, you

have no idea what’s at the other end.

Mr. WU. That’s right.

Mr. MACHUCA. And that—And let me say also for the record, and

I don’t have a precise number of this, but we have, in a little bit

over three years, tens of thousands of clinicians sending secure

electronic e-mail—which, actually, Providence doesn’t get enough

credit for this.

They were the first provider to provide secure, encrypted e-mail,

in the Greater Northwest, which is now followed by everybody, and

I echo your point.

But in millions and millions of e-mails—and we don’t have a precise count—we have yet to have a single incidence of any kind of

a problem along those lines. So we take this issue very, very seriously, but we reject the notion that people should be afraid and use

privacy and security as the reason to not implement technology.

That—I think it’s going away, but it has been resonant in the early

days. And so I think the technology is absolutely there to ensure,

far beyond paper and far beyond anything we have, with very low

cost means, absolute privacy and security, provided, of course, that

there’s the will in the organization to implement it.

I’ll say one more thing on this topic. Sometimes we trip over the

pedestrian to look at the big thing with the shiny lights. I got the

call from your staff about testifying, and we had our meeting. And

immediately, within hours, I had two e-mails from your staff, one

with a full charter of the hearing and another one with an attached

Power Point of the work between NIST, ONC, and the other organizations. I had that on my desktop. I took off, I started preparing.

I left for San Diego. I came back on Thursday of last week. On my

regular mail was the letter inviting me to the hearing, with the

charter—no presentation on what NIST is doing.

So had I gone to—had I lived in that system, where I reject the

use of e-mail for business productive use, I would have prepared—

I would start preparing for this hearing on Friday of this week,

probably ruined my weekend, and it would have been an entirely

different situation, than the context and the information being

readily available.

And when you asked—I think you asked a very, very profound

question. I don’t think we’ve really given you a sharp, crisp answer.

If you wanted to hang on to one thing that could modernize the

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system tomorrow and make a quantum leap—not solve all the

problems that we have, but do the quantum leap—look at the physician use of e-mail in the routine part of their practice. And that,

in and of itself, as every other industry would suggest, and as your

own, I would bet, experience in your daily work flow would suggest,

could move that step forward. That first little baby step would give

you a tremendous amount of benefit. So I would leave that as my

comment on that.

Dr. CHIN. I would just say that it’s a very, very complex area.

You know, Kaiser Permanente does take privacy very seriously and

we do monitor access to the medical record, and we’ve had to let

people go in some cases because of breaches of privacy. So we do

take it very seriously.

But it is a very complex question, and I think the only solution

to this would be to give individuals control over their medical information and somehow say, ‘‘Okay. You can see this, you can’t see

this; you can see this, you can’t see this.’’ And one of the reasons

why there is this issue with privacy in the United States is precisely because of payment mechanisms: In order for payers to pay,

they need to know what they’re paying for; and because of that,

there are issues where payers can see information that otherwise

would be private in other organizations. And that’s one of the key

reasons why there is this issue with HIPAA and the lack of security around HIPAA.

Dr. PETTIT. You bring up a very good point about—and someone

had mentioned to me last week at HIMSS about how people are

compelled to share their information, whether they really want to

or not; because if they don’t, they don’t get services. And it’s like

we all have done on the Internet, where you sign that EULA, the

end-user’s licensing agreement, that you don’t want to sign because

you can’t read it, but you scroll through it and you hit ‘‘agree,’’ even

though you have no idea what you just signed. And there are some

analogies to that in health care. Because you come into the emergency department and you sign because you want service or—and

if you want a health plan to cover you, you sign what you need to

sign. But I really do believe that the American public has no idea

how many people see their information; and I think when they do

find out, that there’s going to be some change.

Mr. REICHERT. Now they all know.

Mr. URALI. I tend to take privacy and security very seriously. In

fact, we came up with a tag line, ‘‘Trust is Earned,’’ to indicate that

we take it very seriously, and through our actions we will show

that we will honor the trust of the public in how we approach it.

It fundamentally boils down to a central principle we have,

which is the part of the network that we make it available is only

accessible to the clinicians; and so right there, we are restricting

access to information, even in the community setting. And then we

give hundred percent opt-out capability for any patient that has

not consented. So I can say I don’t want to be part of the network,

and hence none of my data will be electronically shared.

The problem with having patients decide which piece of information that they want to share or which piece they don’t want to

share is that they can make very serious mistakes. None of us are

experts at health care. We’ve talked to literally hundreds of docVerDate 11-MAY-2000 14:54 Jun 23, 2006 Jkt 026205 PO 00000 Frm 00093 Fmt 6633 Sfmt 6601 C:\WORKD\ETS06\022306\26205 SCIENCE1 PsN: SCIENCE1
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tors, and they say a certain psychiatric condition may be important

even for treating the foot. And it’s not something that I can personally understand, but we’ve had those types of conversations. So

having nonsophisticated patients making decisions as to which

medication information they will share, or which problem they will

share, and who’s the physician—that is going to build a very complicated system.

I think we’re all looking for simple systems that work. If you

think about your banking system, the ATM card, you know, how

simpler could it get? I just get a card, I can go into a machine, put

it in, I put a four-digit PIN code and I can get my money out. That

is a simple system. That system works. Of course we can’t use the

banking standards for health care data. We have to come up with

a lot more security and privacy solutions; but at the same time, we

can make it so difficult that the system doesn’t actually work.

Mr. REICHERT. Go ahead.

Mr. URALI. So in our model, the first step we took is restrict data

access to only clinicians. We saw some survey that said more than

95 percent of patients trust their primary care provider and their

doctors, you know, to do the right things in terms of protecting

their privacy.

Mr. REICHERT. The Chair will recognize Mr. Wu for the final

question.

Mr. WU. Mr. Chairman, I think that, given the tremendous forbearance and attention of both—well, all of our guests and panelists here, I’m going to forego this last question, because there are—

there’s never a last question; there’s just so many more to ask.

I’ll just take a moment to thank—Mr. Reichert, you, and I always

get the honor of being the talking face and being in front of the

microphone; but there are many, many people who work very hard

to make these things happen, and work behind the scenes.

And first and foremost, I want to thank Marshall Jeffrey from

our office, who has taken the lead in organizing this field hearing

today.

From the Science Committee staff, the majority side, Jamie

Brown has really done heroic work. And supervising Jamie’s work

is Olwen Huxley. On the minority staff, Mike Quear. Thank you,

all, for making the long trip from Washington, D.C. and our

Science Committee.

Staffers Stella Ma, who has also worked very, very hard on this,

along with Dan Whelan and John Wykoff of our district staff. And

I’d also like to recognize Kevin from the NIST congressional liaison

office, who was so helpful with information about Dr. Jeffrey.

Ralph Hall’s Legislative Director who has joined us from Texas and

Washington, D.C., and Chairman—Mr. Chairman, I believe that

your district director is also here today.

Mr. REICHERT. My deputy district director, Sue Foy.

Mr. WU. And I want to thank you all for attending. And I thank

the staff for their very, very hard work to bring this together. As

we all know, for every person who’s in front of the microphones,

there are probably five or ten people who are behind the microphones or behind the camera, making the system work.

And with that, Mr. Chairman, I yield back to you for a closing.

Mr. REICHERT. Thank you, Mr. Wu.

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Well, it’s been a pleasure being here this afternoon. We have a

little bit of a drive back now to Seattle, and I’m also on the Transportation Committee, and so we’ll have a chance to have firsthand

experience with the commute between Portland and Seattle, which

I’ve experienced in the past. Today will be special.

I just, too, want to echo the words shared by Mr. Wu.

All of you in the audience, thank you so much for everything that

you do. And the panelists, thank you for being here. I know it’s not

just appearing for two or two and a half hours, responding to questions and giving testimony, but there is preparation time. And, fortunately, you were fully informed with the e-mail service and better able to prepare.

One of the things that I think that a forum like this provides,

certainly for those of us who can’t—some who can’t travel back and

forth to Washington, D.C., and attend a forum like this, you kind

of get a flavor for what it’s like back in D.C. and how business is

sort of conducted. It can be a little bit awkward and formal, I’m

discovering. But it also, I think, more importantly, provides an opportunity for all of us to visit, person to person, to have a discussion, to interact with each other on a personal level and to hear

from people who are involved every day in trying to solve our

health care IT problems.

And so, you know, when you talk about e-mail and you talk

about IT and you talk about the changing world that we’re living

in, you know, a year ago, I used to reach and I would have my

badge. Now I have a—this is, yeah, I’m stuck with this Blackberry,

but——

Mr. WU. It will respond to all functions.

Mr. REICHERT. Right. I think it has a ‘‘beam me up’’ button on

it.

Mr. WU. Right.

Mr. REICHERT. The point I want to make here is that—and Dr.

Pettit, you know, I appreciate your comments on the personal

issue. Because doctors can look at a record, you can read the

record—and I was wondering, and somebody did mention, I think—

Doctor, I think you mentioned the inconsistency of recording data

and information. And so as you read data and information, as you

read e-mails and you don’t know what you’re signing and the data

is inconsistent, there is this importance for us to interact as human

beings; we can never let that go. And so I just want to leave us

with that thought. We all have that access to e-mails and technology; but, please, never hesitate to pick up the telephone or walk

down the hallway and knock on someone’s door and have a little

visit with someone.

So there’s a closing statement I need to read. Before we bring the

hearing to a close, again I want to thank everyone for being here.

This has been highly educational, and our witnesses have given

this committee a lot to consider about the potential role of information technology in the health care industry.

And if there is no objection, the record will remain open for additional statements from other Members and for answers to any follow-up questions the Committee may ask of the witnesses.

Without objection, so ordered. The hearing is now adjourned.

Thank you.

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[Whereupon, at 2:32 p.m., the Subcommittee was adjourned.]

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