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68–062 2011

NOT WHAT THE DOCTOR ORDERED: BARRIERS 

TO HEALTH IT FOR SMALL MEDICAL PRACTICES 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH CARE AND 

TECHNOLOGY 

OF THE

COMMITTEE ON SMALL BUSINESS 

UNITED STATES 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED TWELFTH CONGRESS 

FIRST SESSION 

HEARING HELD 

JUNE 2, 2011 

Small Business Committee Document Number 112-019 

Available via the GPO Website: www.fdsys.gov 


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(II) 

HOUSE COMMITTEE ON SMALL BUSINESS 

SAM GRAVES, Missouri, Chairman 

ROSCOE BARTLETT, Maryland 

STEVE CHABOT, Ohio 

STEVE KING, Iowa 

MIKE COFFMAN, Colorado 

MICK MULVANEY, South Carolina 

SCOTT TIPTON, Colorado 

JEFF LANDRY, Louisiana 

JAIME HERRERA BEUTLER, Washington 

ALLEN WEST, Florida 

RENEE ELLMERS, North Carolina 

JOE WALSH, Illinois 

LOU BARLETTA, Pennsylvania 

RICHARD HANNA, New York 

NYDIA VELA ́ ZQUEZ, New York, Ranking Member 

KURT SCHRADER, Oregon 

MARK CRITZ, Pennsylvania 

JASON ALTMIRE, Pennsylvania 

YVETTE CLARKE, New York 

JUDY CHU, California 

DAVID CICILLINE, Rhode Island 

CEDRIC RICHMOND, Louisiana 

GARY PETERS, Michigan 

BILL OWENS, New York 

BILL KEATING, Massachusetts 

LORI SALLEY, Staff Director 

PAUL SASS, Deputy Staff Director 

BARRY PINELES, Chief Counsel 

MICHAEL DAY, Minority Staff Director 


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C O N T E N T S 

Opening Statements: 

Page 

Ellmers, Hon. Renee ......................................................................................... 1 

Richmond, Hon. Cedric .................................................................................... 2 

Herrera Beutler, Hon. Jaime ........................................................................... 3 

WITNESSES 

Farzad Mostashari, M.D., Sc.M., National Coordinator for Health Information 

Technology, U.S. Department of Health and Human Services, Washington, 

DC .......................................................................................................................... 5 

Ms. Karen Trudel, Acting Director, Office of E-Health Standards and Services, Centers for Medicare and Medicaid Services, Baltimore, MD ................. 7 

Sasha Kramer, M.D., Olympia, WA ....................................................................... 18 

Denise Elliott, D.P.M., Marrero, LA ...................................................................... 20 

Mr. Andrew Slavitt, Chief Executive Officer, OptumInsight, Eden Prairie, 

MN ......................................................................................................................... 23 

David L. Baumer, Ph.D., Professor of Law and Technology, North Carolina 

State University, Raleigh, NC ............................................................................ 25 

APPENDIX 

Prepared Statements: 

Farzad Mostashari, M.D., Sc.M., National Coordinator for Health Information Technology, U.S. Department of Health and Human Services, 

Washington, DC ............................................................................................ 32 

Ms. Karen Trudel, Acting Director, Office of E-Health Standards and 

Services, Centers for Medicare and Medicaid Services, Baltimore, MD .. 50 

Sasha Kramer, M.D., Olympia, WA ................................................................ 64 

Denise Elliott, D.P.M., Marrero, LA ............................................................... 69 

Mr. Andrew Slavitt, Chief Executive Officer, OptumInsight, Eden Prairie, 

MN ................................................................................................................. 76 

David L. Baumer, Ph.D., Professor of Law and Technology, North Carolina State University, Raleigh, NC .............................................................. 85 

Questions for the Record: 

Ellmers, Hon. Renee for Ms. Karen Trudel .................................................... 92 

Ellmers, Hon. Renee for Dr. Farzad Mostashari ........................................... 105 

Statements for the Record: 

The Computer Technology Industry Association ........................................... 118 

The National Partnership for Women & Families ......................................... 123 

Additional Materials for the Record: 

‘‘E-Prescribing Penalty Could Hit Up to 109,000 Clinicians’’ By: Robert 

Lowes, Medscape Medical News .................................................................. 126 


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(1) 

HEARING: NOT WHAT THE DOCTOR ORDERED: BARRIERS TO HEALTH IT FOR 

SMALL MEDICAL PRACTICES 

THURSDAY, JUNE 2, 2011 

HOUSE OF REPRESENTATIVES

COMMITTEE ON SMALL BUSINESS, 

SUBCOMMITTEE ON HEALTHCARE AND TECHNOLOGY

Washington, DC. 

The Subcommittee met, pursuant to call, at 10 a.m., in room 

2360, Rayburn House Office Building. Hon. Renee Ellmers (chairwoman of the Subcommittee) presiding. 

Present: Representatives Ellmers, Herrera Beutler, Tipton, 

Hanna, Richmond, Altmire. 

Chairwoman ELLMERS. We will go ahead and get started. Thank 

you, Mr. Richmond, our ranking member. And we have today with 

us Congresswoman Herrera Beutler from Washington, who is on 

our Subcommittee. 

This is the Subcommittee on Health and Technology of the House 

Committee on Small Business. And the title of our Subcommittee 

hearing is Not What the Doctor Ordered: Barriers to Health IT for 

Small Medical Practices. 

Good morning to everyone. I call the hearing to order. 

This is a very important issue for our health care providers and 

health care across our country. 

Health information technology is the computerized management 

of health information. It has the potential to improve health care 

delivery, decrease medical errors, increase clinical and administrative efficiency, and reduce paperwork. Studies have shown that 

adoption of health IT is becoming more common, but the transition 

is a slow one. In 2010, the Centers of Disease Control and Prevention found that only 25 percent of office-based physicians had fully 

functional electronic health records or EHR. And 10 percent had a 

basic EHR system. Studies have shown that there is a digital divide on health IT between large and small medical practices. A 

study of eastern North Carolina confirmed the existence of the digital divide and found that the smaller medical practices is, the less 

likely to be using the EHR. 

As a registered nurse and the wife of a surgeon who has health 

IT, I understand that a modern efficiency and well-equipped office 

is critical to the practice of medicine. Health IT offers promise to 

all medical professionals; however, financial, legal, and technology 

barriers prevent many, particularly small practices, from moving 

forward on EHRs. This issue is critical because almost 60 percent 


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of office-based physicians work in practice with fewer than 10 doctors. In fact, the small practice is said to be the best indicator of 

the success of EHRs because it is likely to be the last to widely 

adopt the technology. 

Since 2009, many physicians have received Medicare incentive 

payments for e-prescribing part D medications. Beginning this 

year, doctors are eligible for Medicare and Medicaid incentives 

under a separate program if they demonstrate meaningful use of 

electronic health records. I am particularly concerned that physicians may not be aware that they must report e-prescribing activity 

this year to avoid e-prescribing penalties that will begin next year. 

There are other challenges, too. As more personal information is 

available electronically, patients must feel confident that their 

medical information is secure and their privacy is protected. And 

physicians need to be assured that the information that they transfer is not changed or misused. 

We look forward to hearing from today’s witnesses about how 

these barriers can be addressed. I now yield to our Ranking Member Richmond for his opening statement. [The information follows:] 

Mr. RICHMOND. Thank you, Madam Chairwoman. And I want to 

thank our panelists and our guests that are here today to discuss 

this very important issue, specially as we try across this country 

very diligently to improve our health outcomes and to make sure 

that we provide the best medical care that we can do—that we can 

possibly do. And that means effectively using our information technology to do that. 

So today’s hearing will offer an opportunity to examine ways that 

we can improve the implementation of health information technology. Health IT has the potential to advance health care quality 

while reducing costs, but right now many small health care providers simply cannot afford it. We have seen the benefits recent 

technology can bring to our daily lives in a variety of ways. It is 

now time for our health care system to catch up with the benefits 

of health IT that are numerous and wide-reaching for all sizes of 

medical practices. 

Those fortunate enough to have access to this technology already 

know how it decreases health care costs, improves patient safety, 

and reduces the practice of defensive medicine. These system-wide 

benefits ultimately to an increased access to affordable health care. 

Since Hurricanes Katrina and Rita, when physicians struggle to 

provide adequate care because they lacked access to patients’ 

health IT, it has been a key concern for my state, which is Louisiana, and our health care industry. I am proud to say Louisiana 

has been focused on creating a health information exchange since 

2007 and was among the first states to offer incentive patients to 

Medicaid providers this year. We have made upgrading our health 

IT infrastructure a priority and I am honored to have Dr. Elliott, 

a solo practitioner from my district here today to share her experiences. 

From a business perspective, fully functional electronic health 

records have the potential to improve a practice’s net profit by over 

$80,000 during a five-year period. In addition, effective health IT 

can increase the doctor’s time with the patients and improve administrative efficiency by reducing paperwork. Such benefits make 


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a clear case as to why health IT is needed to assist small practitioners who strive to provide the best care to their patients. However, right now there are inadequate incentives for health care providers to adopt many of these technologies. With 80 percent of the 

nation’s patient care delivered by small practices, it is important 

to understand why most of them do not use health IT. Small practices face a number of unique challenges, including financial barriers and complex regulations. Besides upfront costs exceeding 

$40,000 to implement the technology, small practices face additional design costs, practice disruption, and a lack of certified products. As a result, a significant gap exists in health IT adoption between large and small practices. 

I will just—I will insert the whole statement for the record but 

I just want to say and comment our Chairwoman Ellmers and add 

to the audience that I think that this is where Congress works 

best, when we acknowledge that we know what we know and we 

know what we do not know. And those things that we do not know 

we look to the people who do it on a daily basis and the people who 

have the on-the-ground expertise. So we look forward to hearing 

the testimony today because it will be your testimony, your suggestions, and your input that guides the way that we work towards 

solving this issue in a bipartisan way because the issue is too important not to get it done. It saves lives, reduces costs, and all of 

those things that I know we are all committed to doing on both 

sides of the aisle across every walk of life. 

So thank you to the Chairwoman and thank you to the panelists. 

[The information follows:] 

Chairwoman ELLMERS. Thank you, Mr. Richmond for your comments. And I cannot agree more on what you stated. 

I now would like to ask Ms. Herrera Beutler for her opening comments. 

Ms. HERRERA BEUTLER. I will keep it brief. I want to share a 

story. I had a young nurse, a young woman in my district in Clark 

County come and visit with me a month or two ago. And she was 

there to talk about electronic medical records, personal health 

records, or e-records for hospitals or small practices or solo practices. And her story was compelling. 

Her father, who was a constituent of mine, would bike every day 

up and down a certain—perfect physical health. He was between 

55 and 60, I believe. Tremendous. And he had had—I do not know 

if it was a palpitation. He had a problem. They took him to the ER. 

And she was a nurse. She went with her mom and she said we 

think there is something here. She said I think there is a specific 

issue here. And they ran the tests and they waited and the tests 

came back negative. They said you are fine. So they sent him 

home. And I think within—I think it was two weeks. It was a 

shorter period of time. He had it happen again and he died. And, 

you know, she was devastated. The family was devastated. And she 

said about—a short period of time after that she received a call 

from the hospital that said we are so sorry. We lost the paper 

record. And it actually was not negative. And went on to explain 

it was a problem with the paper. It was a problem with losing the 

paper. 


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And it is so hard to sit there and have someone—you hear about 

it. You hear this is partially why we need to upgrade and we need 

to get there. And here is someone who works in the medical profession and she was looking at me saying do everything you can to 

speed the implementation of electronic medical records for many 

reasons. 

We talked about Katrina. I have Lewis County in my district. We 

have—Kent has severe flooding, which wipes out homes. Floods 

eight feet plus of the bottom and up to second story homes. And 

when that happens, these are older communities, their medical 

records could be—I do not know. Their immunizations could be 

stuffed somewhere in a file. And what happens? We lose patient 

records. And it is imperative. 

I served here on the Hill as a health policy aid before elected office, before going home and then coming back here. And this was 

a bubbling issue, you know, in the last decade. This has been something Washington State has worked towards, a state partnership 

along with the federal efforts in a very bipartisan way because we 

recognize we have to get there. 

The challenges are costs and implementation. I have a doctor 

from southwest Washington who is going to share a little bit about 

her experience, but the reality is we are trying to find out what we 

do not know, to Mr. Richmond’s point, and figure out how we can 

speed this along. Because paper is—as someone who represents a 

timber industry, I like using paper in a lot of areas. Let me put 

that on the board. But when it comes to this issue we need to make 

sure that we are entering the 21st century. 

So with that I yield back. I look forward to our testimony. 

Chairwoman ELLMERS. Thank you. And I will just start off by a 

little housekeeping. As far as the light system, you will have five 

minutes to deliver your testimony. I will be lenient if you go over 

because I value so much your input. And the light will start out 

as green. When you have one minute remaining the light will turn 

yellow. Finally, it will turn red. And then that basically ends your 

five-minute period of time. And I ask you to try to stay to that, but 

again, we will be lenient today for the purposes of this Subcommittee. 

STATEMENTS OF FARZAD MOSTASHARI, M.D., NATIONAL COORDINATOR FOR HEALTH INFORMATION TECHNOLOGY, U.S. 

DEPARTMENT OF HEALTH AND HUMAN SERVICES; KAREN 

TRUDEL, ACTING DIRECTOR, OFFICE OF E-HEALTH STANDARDS AND SERVICES, CENTERS FOR MEDICARE AND MEDICAID SERVICES; SASHA KRAMER, M.D.; DENISE ELLIOTT, 

M.D.; ANDREW SLAVITT, CEO, OPTUMINSIGHT; DAVID L. 

BAUMER, PH.D., PROFESSOR OF LAW AND TECHNOLOGY, 

NORTH CAROLINA STATE UNIVERSITY 

Chairwoman ELLMERS. With that, I would like to introduce our 

first panelist, Dr. Farzad Mostashari. He is the national coordinator of health information technology with the U.S. Department 

of Health and Human Services. Dr. Mostashari became the national coordinator in July 2009. Previously, he served in the New 

York Department of Health and as Assistant Commissioner for the 

Primary Care Information Project, where he facilitated the adopVerDate Mar 15 2010 01:21 Sep 21, 2011 Jkt 068062 PO 00000 Frm 00008 Fmt 6633 Sfmt 6602 E:\HR\OC\A062.XXX A062

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tion of health information technology by providers in underserved 

communities. Dr. Mostashari did his graduate training at the Harvard School of Public Health and Yale Medical School, and his internal medicine residency at Massachusetts General Hospital. 

Thank you so much for being here today, and again, you have 

five minutes. 

STATEMENT OF FARZAD MOSTASHARI 

Mr. MOSTASHARI. Good morning, Chairwoman Ellmers, Ranking 

Member Richmond, distinguished members of the Subcommittee. I 

am Dr. Farzad Mostashari, the national coordinator for health information technology at the Department of Health and Human 

Services. Thank you for giving me the opportunity to appear before 

you today to talk about what the Office of the National Coordinator 

is doing to support the deployment and meaningful use of electronic health records, especially among smaller physician practices. 

I know from personal experience, both the importance and the 

challenges of using better information to improve individual and 

population health, especially in a small practice setting. As the 

former head of the Primary Care Information Project in New York 

City, we reached out to practices that served Medicaid patients and 

signed agreements with providers in small practices and community health centers and hospital outpatient departments to establish electronic health records systems. 

Over half of small practices in the city’s three most underserved 

communities eventually signed up with the program. In a little 

over a year, more than 1,000 providers started live-use of EHR systems with a 99 percent implementation success rate. It was hard. 

The Office of the National Coordinator’s Core mission is to improve patient care, improve health outcomes, and make the health 

care system more efficient through the effective use of health IT. 

Much of ONC’s work is aligned in support of a Medicare and Medicaid meaningful use EHR incentive programs. These programs, 

which my colleague from CMS will talk about in more detail, provide financial incentives to eligible providers and hospitals that 

adopt and use electronic health records in a meaningful way to improve health and health care outcomes. This unprecedented public 

investment does not treat technology as an end to itself. Rather, it 

will result in concrete progress towards our policy objectives— 

measurable improvements in health and reduction in costs. 

I would be happy to talk about all the ways that ONC is supporting this transformation in health care, but in the interest of 

time today I will highlight some of our major initiatives. 

ONC is at the center of efforts to establish standards for EHR 

systems and let providers and the public know which EHR systems 

are meeting these standards. We currently have six authorized private sector certification bodies which have certified more than 700 

separate EHR products. This is indicative of the development of innovative EHR products that are less expensive and easier to implement for small practices than ever before. Of note, 60 percent of 

the vendors of these systems are small businesses with fewer than 

50 employees. 

Our Regional Extension Center program, inspired by the Agricultural Extension Center program, supports a network of 62 state 


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and local organizations that offer training, information, project 

management, and technical assistance to providers in order to ease 

and accelerate the adoption and meaningful use of EHR technology. 

Particularly by primary care providers, small practices, critical access hospitals and other underserved or underresourced providers. 

The Regional Extension Center program has enrolled more than 

70,000 providers, 94 percent of whom are primary care providers 

and about half are in individual or consortia of small practices. 

ONC’s Health Information Exchange program is helping build 

the infrastructure for sending and receiving electronic health information securely across the nation’s health care system with a focus 

of simple but secure technologies that can be used by all providers 

to improve coordination of care, whether they care for patients in 

small practices, urban clinics, or rural hospitals. 

These efforts have sparked a remarkable growth in the health IT 

industry as a whole, which has led to a strong demand for skilled 

works. To address this emerging shortage, ONC has supported 82 

community colleges in establishing health IT certificate programs 

where training can be completed in six months or less. So far, over 

2,400 students have graduated from the community college programs. Another 4,700 are currently enrolled, and we are on our 

way towards our target of graduating 10,000 students every year. 

Many of these graduates will end up helping small practices who 

often lack the resources for dedicated IT staff to successfully implement EHR systems. 

Finally, I want to point out that ONC, along with our partners 

at CMS, the Office of Civil Rights, and other federal agencies have 

taken a number of important steps towards making sure electronic 

health records remain private and secure. ONC has embedded privacy and security into all of our programs and policies. For example, the standards and certification criteria I spoke about require 

that EHRs have the capability of encrypting electronic health information, tracking who accesses each record, and limiting user access. Meaningful use requires that providers conduct a security risk 

assessment and mitigate any risks identified. Our Regional Extension Centers are providing technical assistance on protecting privacy and security and our new health IT training programs ensure 

that the future generation of technical workers are well grounded 

in privacy and security. 

Health information technology is indeed a critical foundation 

that supports efforts to modernize and transform our health care 

system. Now is the time to get down to the hard work of implementing and using health IT in a way that leads to better health 

care that is high quality, safe, coordinated, efficient, effective, and 

patient-centered. And I am proud of ONC’s role in achieving that 

goal. 

Thank you for giving me the opportunity to appear before you 

today. I look forward to answering any questions you might have. 

[The statement of Mr. Mostashari follows:] 

Chairwoman ELLMERS. Thank you, Dr. Mostashari. 

I would now like to introduce our second panelist today, Karen 

Trudel. Ms. Trudel is acting director of the Office of E-Health 

Standards and Services for the Centers of Medicare and Medicaid 

Services in Baltimore, Maryland. The Office of E-Health Standards 


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and Services coordinates implementation of the comprehensive ehealth strategy for CMS. Ms. Trudel also has responsibility for enforcement of Health Insurance Portability and Accountability Act 

standards and oversees the areas of personal health records and 

electronic prescribing. 

Welcome to you. And you have five minutes for your testimony. 

STATEMENT OF KAREN TRUDEL 

Ms. TRUDEL. Thank you, Chairwoman Ellmers, Ranking Member 

Richmond, and members of the Subcommittee. Thank you for the 

invitation to discuss CMS’s implementation of the Electronic 

Health Record (EHR) Incentives program created by the Recovery 

Act and specifically the impact of this implementation on small and 

solo providers. 

The widespread adoption of certified EHR technology used in a 

meaningful way is one piece of a broader health information technology infrastructure needed to modernize our nation’s health care 

system. As we have worked to implement the EHR incentive program, we have sought to strike a balance between setting program 

requirements high enough to move providers expeditiously towards 

this goal but not so high that providers choose not to participate 

in this voluntary initiative. 

The Medicare and Medicaid incentive programs provide incentive 

payments for eligible professionals and hospitals that demonstrate 

meaningful use of EHR technology. The Medicaid incentive program also provides incentive payments to providers in their first 

year of participation if they adopt, implement, and upgrade EHR 

technology. Eligible professionals can receive up to $44,000 over 

five years from the Medicare program, or up to $63,750 or six years 

through the Medicaid program. The hospital incentive payments 

for Medicare and Medicaid are calculated with a formula that begins with a base amount of $2 million with an added amount based 

on the number of discharges. 

Providers must register to participate in the programs and attest 

that they have either adopted, implemented or upgraded certified 

EHR technology or that they have meaningfully used that technology during a 90-day reporting period. We recognize that for 

some providers, particularly small and solo practices, moving to 

adoption and meaningful use of EHRs is a huge shift from current 

practice. For that reason, CMS has taken an escalator approach to 

meaningful use envisioning three separate stages that demand increasingly vigorous requirements. 

We are currently in the first stage, which focuses on using EHRs 

to collect clinical data, electronic prescribing, initial steps toward 

patient engagement, and, as Dr. Mostashari mentioned, ensuring 

privacy and security of patient information. We originally proposed 

25 meaningful use criteria for eligible professionals and 24 for hospitals. The provider community commented that meeting all those 

criteria would be difficult and they requested flexibility. We responded by separating the criteria into a core set that all providers 

must meet. And those are 15 for eligible professionals and 14 for 

hospitals. And a menu set with providers being able to select five 

of the remaining 10 criteria to implement. 


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Less than a year after publishing the final rule, CMS is already 

providing incentive payments to providers. Since January 1, 2011, 

more than 42,600 eligible professionals and hospitals have registered for either the Medicare or the Medicaid EHR incentive program via a web-based application. The same application is used for 

Medicare providers to attest to their meaningful use of the EHRs. 

States are developing their own out-of-station mechanisms and 

data is exchanged bi-directionally with CMS and the States. Providers were first able to begin to attest to meaningful use beginning April 18th of this year, and 485 providers did so successfully 

in the first month of the program. The first Medicare payments totaling $75.9 million went out to meaningful users on May 19th. 

CMS is encouraged that States across the country have already 

shown strong enthusiasm for the EHR incentive program. States 

began launching their programs in January. Fifteen states have 

launched to date and two more are set to come online next week. 

Further, the majority of states have indicated to us they will 

launch by the end of calendar year 2011. And as of May 4th, over 

$83 million in Medicaid incentive payments have been made. 

CMS strives to increase awareness and participation in the incentive programs by offering a variety of information and tools that 

providers can use to learn about and successfully participate in the 

programs. We use a variety of mechanisms to engage providers, including social media, national provider calls, and webinars. We 

have developed a special website containing guides that explain the 

meaningful use requirements, user guides for the web-based system, and many other products. Our strategy focuses on making 

free, high quality information available through mechanisms that 

are accessible to busy providers. 

The administration has made the adoption of meaningful use of 

EHR technology a high priority. Our stage one rule lays the 

groundwork for establishing a robust national health infrastructure 

that supports the adoption of EHRs and PHRs and will help providers practice safer and more productive medicine. We look forward to working with Congress, our many stakeholder partners, 

and our colleagues at ONC to ensure that the implementation of 

the EHR incentive program fosters an expanded use of health information technology, broadens the information exchange infrastructure, and promotes the adoption of electronic health records as 

intended by Congress. 

I am happy to answer any questions you might have. Thank you. 

[The statement of Ms. Trudel follows:] 

Chairwoman ELLMERS. Thank you so much. I am going to ask a 

few questions and then I will yield to Mr. Richmond, our ranking 

member. And we will go from there. 

My first question is for you, Ms. Trudel. The meaningful use, you 

touched on it in your opening statement. Can you once again reiterate what it is and how it is that physicians and hospitals are adhering to it? Because that is obviously the proof that they have to 

provide. 

Ms. TRUDEL. Right. Exactly. I will walk through some of the core 

requirements for meaningful use, and I think that will give you a 

good idea of where we are trying to go with that. A number of the 

core requirements focus around capturing data in the electronic 


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health record so that it can be used over and over for clinical reasons. Some of those include capturing a list of current and active 

problems, medication lists, vital signs, allergies, smoking status, 

demographics. So those are the things that we are capturing in the 

EHR. Then there are some things that are action-oriented, like 

computerized provider order entry and electronic prescribing. And 

of course, the privacy and security requirements. 

Chairwoman ELLMERS. What would happen if a physician did not 

actually—what would happen if they were not able to provide that 

information to you? 

Ms. TRUDEL. For this first year, and again this is a voluntary 

program, the provider can register for the program and then has 

the entire year through to February of 2012, to report that they 

have meaningfully used for a 90-day period of their choosing. So 

they can decide what that period is. They track these requirements, 

make sure that they have met them, and at that point they would 

sign on and say I am a meaningful user. If they do not do that in 

the first year, they can choose to wait until the next year to start 

out and it does not have any effect on the total payment that they 

could receive. 

Chairwoman ELLMERS. So there are no penalties assessed for the 

first year? 

Ms. TRUDEL. Absolutely. The penalties do not take effect until 

2015. 

Chairwoman ELLMERS. 2015. And that would not reflect retroactively at all? 

Ms. TRUDEL. No. 

Chairwoman ELLMERS. Okay. I do want to clarify one thing and 

I hope you can do this for me. You mentioned the incentives in 

Medicare and Medicaid but you cannot get incentives for both. You 

basically have to—correct me if I am wrong, but the physician 

would have to choose which one he would—he or she would like. 

Ms. TRUDEL. Right. The eligible professionals must select one or 

the other. Hospitals, on the other hand, including critical access 

hospitals, can participate in both programs. 

Chairwoman ELLMERS. Okay. So hospitals can participate in 

both but physicians cannot. Thank you. 

Dr. Mostashari, I have a question about funding that was provided with the American Recovery and Reinvestment Act for HIT. 

Our records show that $2 billion was provided for this. How has 

that been utilized? And has all of it been utilized? Or is there other 

monies out there? How are we going to apply that? 

Mr. MOSTASHARI. Thank you. Yes. ARRA provided for $2 billion 

for the national coordinator to help establish the infrastructure 

that would permit providers to achieve meaningful use of electronic 

health records as well as increasing the privacy and security of 

such systems. We have obligated $1.97 billion of the $2 billion. The 

largest single chunk goes towards the Regional Extension Center 

program. Some $720 million to establish those assistance—technical assistance and project management facilities for small practices and critical access hospitals and so forth. There is approximately $560 or so million that went to state and state-designated 

entities for information exchange purposes. We have $265 million 

that went to beacon communities. These are 17 communities, kind 


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of our crown jewels. And I promise the fact that on this panel— 

have beacon communities in your states is completely accidental. 

And these are really the crown jewels that are showing how information technology can work. 

Chairwoman ELLMERS. Oh, so when you say beacon, is that, your 

field test? 

Mr. MOSTASHARI. These are communities that were ahead of the 

curve, whether it is in Piedmont, North Carolina; whether it is 

Crescent City; the inland Northwest beacon community or Grand 

Junction, Colorado which are putting it all together. They have 

higher rates of electronic health record adoption than other parts 

of the country. They also have governance mechanisms and leadership to use those—the technologies, the redesign of physician practices, the performance monitoring and feedback, and really bringing all the tools to bear to show how health information technology 

and its meaningful use can show demonstrable and near-term impact on cost and quality of health care. 

Chairwoman ELLMERS. Thank you so much. I yield now to Mr. 

Richmond, our ranking member. 

Mr. RICHMOND. Thank you. I will direct this question actually to 

both witnesses. And I can only think back to my life, and especially 

my childhood when we talk about motivating me to do one or two 

things. It was either the carrot or the stick. And in thinking of that 

I guess my question would be for many physicians. Medicare and 

Medicaid reimbursements are already low. The penalties that could 

further diminish these payment rates for practices that do not 

transition to electronic health records. And what I am afraid of is, 

especially in Louisiana, where we see more physicians denying to 

see Medicaid and Medicare patients. And as HHS and CMS examine how these penalties may ultimately affect access to health care. 

Ms. TRUDEL. I would start by pointing out that there are no penalties in the Medicaid program at all. The payment adjustments 

are related to the Medicare program solely. However, you make a 

good point and I think that the balance in the legislation was that 

there was a carrot and stick approach but I would venture to say 

that when you add the incentive programs together with what 

ONC has done to help to assist providers, especially small and solo 

providers, to move toward electronic health records, the carrot is a 

lot larger than the stick. 

Mr. MOSTASHARI. And I would add that our goal is to have as few 

providers, eligible professionals and hospitals that would incur the 

payment adjustments as possible. We want to help everybody succeed in this program. We really want and are doing everything we 

can to make it so that we not only have an ambitious program but 

one that is achievable and that we provide the supports and whatever else is needed to help every provider succeed on this track. 

And I think you do need both the incentives and the penalties to 

get to this transformation, but you also need the supports around 

it to help people succeed. 

Chairwoman ELLMERS. Mr. Richmond, will you yield? I have a 

question about the penalties versus the incentives. Is there a time 

limit on the incentives? I know the penalties start in 2015 but do 

the incentives continue on or does that stop at 2015? 


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Ms. TRUDEL. For Medicare purposes, the incentives extend for a five-year period. And they start with a maximum of $18,000 per 

year per provider and are scaled down to $2,000 per year per provider. For Medicaid, the incentive period goes on for six years and 

it is frontloaded with a first year incentive of $21,250. 

Chairwoman ELLMERS. And the penalties? Starting in 2015, does 

that extend on? 

Ms. TRUDEL. Right. No penalties for the Medicaid side, as I said. 

And for Medicare, they phase in, again, with a one percent penalty 

in 2015, moving to a two percent in 2016, and then between three 

and five extending indefinitely after that. 

Chairwoman ELLMERS. So there are penalties indefinitely? 

Ms. TRUDEL. Exactly. 

Chairwoman ELLMERS. Okay, thank you. And I thank Mr. Richmond. 

Mr. RICHMOND. And this question would be for Dr. Mostashari. 

The question is based on the idea, and I want to commend you all 

for a very open and competitive certification process and market. 

The concern is whether the deal in accreditation has burdened 

small providers. And if it is true, especially for those in need of 

practice compatible EHRs, did you all consider the potential impact 

of the delays when developing the certification program? 

Mr. MOSTASHARI. It was quite a concern. A little bit of background on this. Prior to the passage of HITECH there was only a 

single accreditation body. There was the Certification Commission 

for Health Information Technology. And the legislation—the 

HITECH legislation asked us to take another look at that. And the 

reason was because there were some who were concerned about 

having only a single point and not having options or choice and a 

competitive marketplace around that process. 

So we were required to take a look at that, and our federal advisory committees recommended to us that we, in fact, change that. 

And we opened it up and have more competition in the accreditation process. There was a risk, however, that you point out in this 

switchover that there would be a time where we would not have 

sufficient products certified or the pipeline for getting a product 

certified could hinder the ability of providers to meet meaningful 

use. And so we created a temporary program that could go into 

place quickly and a permanent program. The temporary program, 

indeed, went into effect very quickly and I think we have not heard 

much in the way of concerns about the certification program. And 

that is a good thing because it is working. We have now six accredited testing and certification bodies instead of where we had one. 

The cost of certification has come down. The speed of certification 

has gone up. We hear from vendors that the quality of service they 

are receiving has increased, and we now have more certified products than ever before. So in this case, it was a concern but I think 

with the right policies and with the right implementation we have 

managed to address that well. 

Mr. RICHMOND. Good. And then my last question directed at both 

of you or both of you feel free to answer or not answer. But the 

last question is just in today’s age with so many concerns with security and privacy—I also sit on Homeland Security so I am very 

aware of the fact that everyday there are thousands of people that 


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wake up trying to hack into either the .gov world or the .com world. 

And we have to be concerned about that. 

And what I am asking about now are complaints that especially 

for small practitioners that there is little guidance on how to safeguard to ensure HIPAA compliance. And what can we do, what can 

you all do to help those small practitioners overcome that fear? 

And after that I will yield back, Chairman. 

Mr. MOSTASHARI. Absolutely. And maybe after my colleague from 

CMS can speak about that. 

Safeguarding privacy and security is a shared responsibility. And 

the practices, not just in terms of their professional responsibilities, 

not only in terms of patient expectations, but also under the law 

have a responsibility to safeguard the patient information that has 

been entrusted to them. And the Office of Civil Rights has the ability to investigate any complaints and can levy substantial fines as 

they have done against some hospitals and health plans recently. 

But we need to, as you say, support providers, particularly the 

smaller practices in being able to do this. We are working with the 

extension center program to provide that technical assistance, to 

provide that checklist, that easy to understand, easy to use checklist. Some templates and best practices are on how to do the appropriate way, whether it is physical security, administrative security, 

clinical security settings, configurations and so forth in the small 

practice setting. And that information is available not only to providers who work with the extension centers, but to any provider. 

We are also working to make it easier on the technology side 

through our research and development programs. We have a consortium of academic medical centers who are at researchers’ institutions who are working to develop the next generation of technologies to make it the easy thing to do, the secure thing to do. 

And to make it almost a default and to bake into the products the 

ability to encrypt automatically, for example, and to safeguard patient privacy. 

But as you point out, it is a—we can just remain ever vigilant. 

This is a daily war where the folks of the other side are constantly 

looking for new opportunities, new vulnerabilities, and new technologies. And we have to, on our side, be ever vigilant as well. 

Chairwoman ELLMERS. Well, thank you, Mr. Richmond. And I 

now yield to Ms. Herrera Beutler, for her questions. 

Ms. HERRERA BEUTLER. I will make it brief. Thank you, Madam 

Chair. 

A couple of things you mentioned, Ms. Trudel, that kind of 

sparked my interest, with regard to penalties, did I understand you 

right when you were saying that for hospitals versus, you know, 

group practices there were different—I know they went into effect 

on different implementation dates and I know Medicaid is withheld 

from the penalty side. Did I hear you say that hospitals are exempt? At the very beginning, what did—— 

Ms. TRUDEL. No, hospitals and eligible professionals are both 

subject to the same penalty at the same time. 

Ms. HERRERA BEUTLER. Okay. Okay. And in terms of small group 

or solo practitioners, I mean, a hospital system is going to have a 

lot more wherewithal to implement any HER, period—a small 

group practitioner or a solo provider in a rural area, who is not a 


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critical access hospital. Right? I know we have brought that up— 

is going to have a hard time making this investment, particularly 

if they are the only family physician or OB in a region. And I have 

met some of those doctors. Are you taking extra precaution and 

care and assistance? Because I heard you talk about a lot of—the 

goal is to assist—with some of those in recognizing—especially if 

we are talking about a family doc—it is an aging population. Right? 

Not very many people are going back into this practice and that 

is a whole other issue. But some of them I have met have said do 

you know what? I can run my practice. I have figured this out. I 

have enough problems with med-mal and everything else. Do not 

bring this my way. How are you overcoming that in a non, you 

know, penalty way? 

Ms. TRUDEL. First, I would like to talk a little bit about the outreach that we have been doing which is very much geared toward 

reaching exactly those kinds of providers. 

As an example, our 10 regional offices over the past nine months 

have conducted over 400 events, more than half of which were targeted specifically to, or included, significant quantities of small and 

rural physicians to try to explain to them what the program is, 

what the advantages are of it, how to take advantage of it, and 

what some of the other tools and resources, including the Regional 

Extension Centers, are available to them so at least they have the 

ability to fully and completely assess the opportunity and make a 

decision as to whether or not they want to take advantage of it. 

Ms. HERRERA BEUTLER. What kind of feedback, and this is a 

question I will ask of the next panel as well because they are the 

docs doing this, what kind of feedback have you had from them? 

What kind of uptake—positive or negative? 

Ms. TRUDEL. We are actually getting good uptake. We have been 

doing some trending over the period of the last year and we are 

getting a sense that many, a large percentage, I would say over 70 

percent of the physician practices that we are talking to, actually 

have exhibited some interest and are thinking about it. 

Ms. HERRERA BEUTLER. So when they have problems, right, with 

a company that was certified by one of the six, you know, certification agencies, what is their recourse? 

Mr. MOSTASHARI. Let me talk about the supports that we are offering. Dr. Brull was one of the first providers to get their payments for meaningful use last week, and she spoke about working 

with the Regional Extension Center in Kansas where she is a family practitioner in a small practice. And she talked about how when 

she first saw the—started adopting the systems and saw the list 

of requirements, that she was daunted by that. But that the Extension Center helped give her an understanding of what is really behind the meaningful use, practical steps on how to achieve it, help 

with project management. And she gave one example about saying 

there were quality measures around colonoscopies. And she 

thought she was doing a pretty good job with colonoscopies that 

can be lifesaving if they identify cancers early on and they can be 

removed. And she said when she actually had the information to 

look within her data she was only doing it about 40 percent of the 

time. And she was really upset. But then the technology helped her 

make a list of all the patients, reach out to them, have reminders 


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in the system. Those are all part of meaningful use. And she reported that she was not satisfied yet but things were better; she 

was at 84 percent now. And she said I would never go back to 

being on paper. 

So I think what we have in our favor is that providers, even 

though the road is hard, providers like Chairwoman Ellmers husband, who has gone through the hard work, would never go back 

to using paper-based systems. And it is rewarding because it is in 

line with what they want to do as physicians and nurses. 

Ms. HERRERA BEUTLER. And really quickly, if they have not just 

a bump in filling out the paperwork or jumping through the hoop 

or meeting the quality measure, if they have a real substantive 

problem—— 

Mr. MOSTASHARI. Yes. 

Ms. HERRERA BEUTLER [continuing]. Or IT provider, I mean, do 

they have recourse? 

Mr. MOSTASHARI. Yes. The Regional Extension Centers—let me 

give the example. Georgia and Massachusetts Regional Extension 

Centers are working with banks to help their providers get loans 

for the hardware and software. Very practical, addressing a real 

need that they have. The Extension Center in L.A. are doing 

project management, helping them do every phrase of project management of going from implementation to meaningful use and are 

working directly with the vendors to identify problems and mitigate them when they have it. Ohio REC has developed a comprehensive needs assessment that goes through and helps the practices identify what are some of the weak points and gaps and barriers and working with the provideri to address any issues before 

they go live, rather than trying to fix things afterwards. 

So those are all examples of practical ways that the extension 

centers all across America are working with the 70,000 providers 

to help them address any problems they might have and move forward productively. 

Chairwoman ELLMERS. Thank you. And I now yield to Mr. Altmire for his questions. 

Mr. ALTMIRE. Dr. Mostashari, I represent an area in western 

Pennsylvania that has some rural areas, it has some very highly 

developed health care systems, as well as smaller providers like 

you are talking about today. But what I hear all the time is that 

the certification process is still very cumbersome, the additional 

certifying entities that were there. And for folks who have failed 

certification, if a provider fails certification, does HHS encourage 

the certifying bodies to share why the certification failed, to recommend improvements that could be made the next time? 

Mr. MOSTASHARI. the certification process, the way it works is 

that a vendor of a system, a company that manufacturers the software, would go to the accredited testing and certifying body and 

they would seek certification of their product. So that process we 

have heard relatively few complaints about. There is, as I mentioned, more competition in that area that has reduced the costs. 

It has increased the timeliness and the level of service that the 

vendors are achieving. And as a result, we now have more products 

certified by a whole range of vendors than ever before. So providers 

have—now, the health care providers who purchased these sysVerDate Mar 15 2010 01:21 Sep 21, 2011 Jkt 068062 PO 00000 Frm 00018 Fmt 6633 Sfmt 6602 E:\HR\OC\A062.XXX A062

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tems, they do not themselves need to go to get certified for the 

product. They can purchase the system that has already been certified. 

There are, particularly for the larger health systems who have 

self-developed their own systems, we have created an opportunity 

for them in the regulation to get self-certified, to say I do not want 

to buy a product that is commercial, off-the-shelf; I want to be selfcertified. And for that purpose we do have a program that would 

allow them to be self-certified. We have not heard much in the way 

of—I mean, the standards that they have to meet are the same as 

the standards that a vendor would have to meet and it is a rigorous process. They have to show that the products have the same 

security as a commercially-developed product, the same level of 

interoperability as a commercially-developed product, and that can 

be a challenge. But many of the organizations who have developed 

their own products are very capable and we have not heard too 

much in the way of concerns about that. 

Mr. ALTMIRE. And that is where I was going to go actually. How 

do you distinguish—how does HHS distinguish between a large, 

very advanced on the health IT side, provider that has already 

spent in some cases hundreds of millions of dollars to upgrade their 

IT to become compliant, to go through the certification process, and 

then contrast that with the money that is available, the incentives, 

the meaningful use regulations, to a much smaller provider, maybe 

out in a rural area that does not have anywhere near the resources, but we all want to go in the same direction. You do not 

want to end up with a VA DOD circumstance where they are incompatible, they cannot communicate with each other, you want to 

all make sure, especially in a region but eventually for the country, 

we have an interoperable IT system. So how do you navigate those 

two very different situations? 

Mr. MOSTASHARI. That is exactly right. And I think that is why 

the certification is so important because it says that no matter 

what system you are using, whether it is self-developed, whether 

it is the biggest vendor in the country or the small vendor in the 

country, they all have to meet certain requirements around interoperability. But they all have to have the codes that map to a same 

set of codes that if I get a piece of information from one vendor to 

another vendor, it can be understood across the systems, that they 

can produce the same sort of messages when they are reporting to 

public health, for example. On the quality measures, producing 

those. So the certification process really is our most important tool 

in ensuring the interoperability between vendor systems, large or 

small. 

Mr. ALTMIRE. so you do have an end in mind. You are not just 

allowing everyone in sort of a free-for-all manner to come up with 

their own systems and get certified, but you are saying we are not 

going to tell you how to do it. We are not going to tell you what 

direction to go and what is best for you, but in the end we want 

to have a system where everyday can communicate with each 

other. 

Mr. MOSTASHARI. That is exactly right. We have to balance between allowing innovation to flourish, not overspecifying to say 

that, you know, the box has to be this big and this wide and this 


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is how it has to look. Allowing innovation to flourish but saying 

there are some bottom-line outcomes that we are going to hold you 

to. Can you produce a message, an electronic message for interoperability that is specified exactly thus? Can you meet these functional requirements and ensure that we do have, not just a collection of systems that are deployed but actually systems that can 

work together to create the bigger public benefit. 

Mr. ALTMIRE. Thank you, Madam Chair. 

Chairwoman ELLMERS. Thank you. I now yield to Mr. Tipton for 

his questions. 

Mr. TIPTON. Thank you, Chairwoman Ellmers and Ranking 

Member Richmond, for convening this. Obviously, a very important 

issue for all of our areas. And Dr. Mostashari, I appreciate you 

bringing up Grand Junction on the western slope of Colorado, and 

we are seeing that extension actually in terms of the quality health 

care network going down through Montrose with the idea of extending it throughout the entire western slope of Colorado. 

I do have a couple of questions here in terms of just having an 

idea of really where we are at right now. What is the timeframe 

that it takes—weeks, months—to be able to get to the certification? 

For either of you. For doctor. Do you have any kind of averages? 

Mr. MOSTASHARI. So for a provider to adopt an electronic health 

record system, it depends upon—very much on the product they select and the assistance they have around project management. So 

there are some vendors who very effectively can get a provider 

from start to finish in a matter of weeks. There are others, particularly for larger, much longer lead time planning, implementation, 

and so forth, design and custom configuration that is needed to 

take place. Every provider makes a decision for themselves in 

terms of what is in their best interest. And our hope with the extension centers is to give them the best advice we can or the extension centers can about what it right for that provider, that group, 

that hospital, in terms of the system that they implement. 

It is a challenging process. I want to make no bones about the 

transformation of workflows and processes and the difficulties that 

many practices, particularly smaller practices, will face as they 

make this difficult transition. But it is a rewarding process and ultimately will be not only leading to improved patient care and coordinated care but actually will help those practices succeed financially over the long run. 

Mr. TIPTON. And if I missed this I apologize. But how many people—how many practices, if you have got an average, have signed 

up? And out of those, how many are solo practitioners? 

Ms. TRUDEL. I do not have any information about how many are 

solo practitioners. So far, since January we have had 42,600 health 

care providers register for either the Medicare or the Medicaid program. Almost all of those were physicians. And, at this point, we 

have had our first payment run. Let me just kind of tack onto the 

back of the how long it takes question. Once a provider has gotten 

to the point where they believe they can meet the meaningful use 

requirements, they then have a 90-day reporting period during 

which they must meet all of those requirements. As soon as they 

have done that, they can go online to a web system and attest to 


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that meaningful use and in a month or so they will have their incentive payment. 

Mr. TIPTON. This may be a question maybe for the next panel. 

But if you would like to maybe contribute into one of the big complaints that I hear consistently from a lot of our physicians gets 

down to the coding issue which Dr. Mostashari, you were talking 

about just a moment ago. When we are talking about, like, Medicaid, is there kind of a streamlining process between requirements 

at the state and federal level? Because that has been a real costdriver. I know, I believe in the state of Colorado we have a different from than the federal government has, you know, which is 

additional costs that the doctors actually have to be able to assume. 

Ms. TRUDEL. This has very much been foremost in our thoughts 

through the entire development and standing up of this program 

because there are both Medicare and Medicaid incentives. And in 

the case of hospitals, they can qualify for both. So, we have worked 

very closely with the states to make sure that the requirements for 

both, the meaningful use requirements, are essentially identical. 

The web-based system that we use for registration is the same for 

Medicare and Medicaid. The states will handle their own attestation and payments but we communicate with the state on an online 

basis so that we are comparing information and making sure that 

we have the right providers in the right programs. 

Mr. TIPTON. And Madam Chairwoman, this may take just a second more if you would allow the answer on it, but one of the other 

concerns that we have from the patient side is certainly the privacy 

issues. Are you comfortable that, you know, we are making the 

strides and then are going to have, I think, Dr. Mostashari had 

taken to it being ever vigilant in terms of making sure that we are 

going to be able to have the patient privacy which I think has been 

an obstacle for some physicians as well? 

Mr. MOSTASHARI. I think that we are making strides, important 

strides in that direction, everything from the laws and regulations 

that were passed through the HITECH Act that increased protections for patient privacy. They gave patients the right to see who 

has looked at their information and who their information has been 

divulged to, which I think is going to serve an important role in 

providing that assurance to patients. It provides for higher penalties, civil penalties for violations, consistent violations of HIPAA. 

It extends the range of HIPAA to business associates, that they 

must follow the same security requirements as the covered entities. 

There are, as we mentioned, protections that we put in place under 

the certification program, as well as through meaningful use that 

security be assessed and any gaps mitigated. We are working very 

hard to establish a governance mechanism for health information 

exchange entities. These are all pieces of this and I think we will 

see more and more of an impact on making sure that there is more 

of a sense of public understanding and public comfort, that their 

information is if anything, more secure in electronic format than in 

a paper-based world where you do not know where your record is 

oftentimes. Records can be lost as Ms. Beutler recounted where you 

do not know who has looked at your record, where there is no way 

of limiting access to certain parts of the record. For example, the 

front office who maybe do not need to know all your diagnoses. So 


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there are important protections, but we need to be ever vigilant 

and we need to do everything we can to ensure that we maintain 

the public trust. 

Mr. TIPTON. Thank you, sir. And I yield back. 

Chairwoman ELLMERS. Thank you. And I would like to thank our 

first panel for being here today and giving us your very important 

insight on the adoption of health IT for small medical practices. We 

will continue to watch all of this, and I want to work with you on 

helping to reduce the barriers that small medical practices encounter. 

And I would like to suggest, in regard to our second panel, if you 

both have staff here, if one of your staff members could remain and 

if you would identify those individuals to us. And again, thank you. 

We will now call the second panel to the table. 

Okay. I think we can go ahead and get started. And with that, 

I would like to say to our panel thank you very much for coming 

and sharing your comments and concerns with us on health IT. 

And I would like to yield to Ms. Herrera Beutler to introduce Dr. 

Sasha Kramer. 

Ms. HERRERA BEUTLER. Thank you, Madam Chair. 

It is my pleasure to introduce Dr. Kramer. Dr. Kramer is a resident of southwest Washington. She serves Olympia, which is the 

northern part of my district on I–5, if anybody wants to know 

where that is. We are in between Seattle and Portland, but we are 

neither Seattle or Portland. Serves in Olympia and the surrounding areas in the field of dermatology. After completing a residency at Geisinger Medical Center in Danville, Pennsylvania, Dr. 

Kramer moved to Olympia in 2005 where she now lives with her 

husband and two sons. In May of 2009, she opened her own practice and has been an asset to our community ever since. 

Dr. Kramer, thank you very much for coming today and we look 

forward to your testimony as we move forward. 

STATEMENT OF SASHA KRAMER, M.D. 

Ms. KRAMER. Good morning, Madam Chairwoman and distinguished members of the Committee, especially Congresswoman 

Herrera Beutler who represents my hometown of Olympia. As she 

said, Washington State. 

My name is Sasha Kramer. I am a board-certified dermatologist 

and I appreciate the opportunity to talk to you today about health 

information technology and the challenges that are facing physicians surrounding the selection, purchase, and implementation of 

electronic health records and their practices. 

So as Ms. Beutler mentioned, two years ago I opened my own 

practice in Olympia, where I currently employ two full-time and 

one part-time employee, and I see an average of 125 patients per 

week with 40 to 45 percent of my revenue coming from Medicare 

and Medicaid. Over two years ago I invested in an EHR system at 

a total cost of about $41,000. I did receive a $20,000 grant funded 

through the Washington Health Information Collaborative for 

Health Information Technology and paid for the remaining $21,000 

out of my business cash reserves. 

As a solo practitioner, I was solely responsible for the research, 

selection, and implementation process of the EHR vendor and sysVerDate Mar 15 2010 01:21 Sep 21, 2011 Jkt 068062 PO 00000 Frm 00022 Fmt 6633 Sfmt 6602 E:\HR\OC\A062.XXX A062

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tem. Initially, during system implementation my patient volume 

was dramatically reduced in order to accommodate the learning of 

the system by myself and the staff. It did take me about four weeks 

to return back to my normal patient schedule. However, two years 

later I am faced with the situation where I have to completely reinvest in a new system. Approximately one and a half years after I 

implemented my original system, my software vendor was acquired 

by another company that will not support my current network platform. Now I have no choice but to purchase a new system that will 

cost approximately $30,000 with $6,000 in annual charges. And 

aside from the financial investment, I once again have to take time 

away from my patients to implement and train my entire practice 

on this new system. 

Having said this, I fully support the use of health information 

technology. My practice and patients benefit from HIT in a number 

of ways, including improved patient safety, increased practice efficiency, and simplified claims processing. While I see these as benefits in my practice, there are significant barriers to full-scale adoption and implementation of HIT, including cost, regulatory barriers, 

and financial penalties and system integration. 

According to the American Medical Association, the average cost of an EHR system is estimated to be $30,000 per physician, with 

an average maintenance cost of between $3,000 and $15,000 per 

year. This is a significant barrier for a specialty like dermatology 

where over 40 percent of the practitioners are in private practice 

or solo practitioners and half of those are in rural areas. Physicians 

seeking investment capital are having issues finding a lender willing to provide them with an unsecured loan. Others may attempt 

to finance their HIT system purchase with the vendor, but small 

practices like mine have little or no leverage in negotiating the 

terms and rates because of a limited market share. 

My practice is a great example of the unpredictable marketplace as I will have invested over $53,000, which would have been 

$73,000 if it were not for the grant, in two different systems over 

just a three-year time period. 

In addition, there are regulatory burdens with financial penalties 

that could hurt the full-scale adoption of HIT. Dermatologists and 

other providers are struggling with the CMS meaningful use 

timeline. For early adopters who have a contract with a service 

provider to meet 2011 and 2012 requirements under phase one, 

there will be a very short window between the release of phase two 

requirements and the deadline for meeting them in 2013. Furthermore, physicians are facing financial penalties on their annual 

Medicare billables of seven percent by 2017 if they are not in compliance with the meaningful use criteria, the physician quality reporting system, and e-prescribing. This seven percent could be a 

practice’s entire profit margin and could make the difference between a practice staying open and a practice closing. Simply understanding and implementing all of these different programs is extremely difficult and often overwhelming, especially to a small 

practice. 

In improving HIT adoption across dermatology, I urge the Committee to address three issues. Number one, provide sufficient financial and other resources so solo physicians are able to select 


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and implement HIT system. Number two, consider delaying the 

penalties associated with HIT adoption until such a time as a functional integrational system is in place. Short of that, consider 

grandfathering in some physicians and exempting them from financial penalties so that they are not pushed into early retirement 

which could further exacerbate the physician shortage in this country. And number three, if penalties are not delayed, provide a safe 

harbor for those early adopters of HIT to protect them from financial penalties related to the meaningful user requirement. They 

should not be punished for the failure of their EHR vendor to implement new criteria. 

In closing, I will absolutely continue to incorporate HIT because 

I see its benefits to my practice and patients, and I look forward 

to working with you. And thank you for the opportunity to testify 

before the Committee today. 

[The statement of Ms. Kramer follows:] 

Chairwoman ELLMERS. Thank you, Dr. Kramer. And now I will 

yield to Ranking Member Richmond, who is going to introduce his 

witness. 

Mr. RICHMOND. Thank you, Madam Chairwoman. 

It is now my pleasure and honor to introduce Dr. Denise Elliott, 

who is from Marrero, Louisiana, who practices in Marrero, Louisiana. She is a graduate of Loyola University and Barrett University of Podiatric Medicine. Dr. Elliott has served as an insurance 

advisor for the APMA and is board-certified by the American College of Podiatric Surgery. She has over a decade of experience as 

a medical specialist running her own practice. So with that I will 

welcome you, Dr. Elliott, and say that we look forward to hearing 

your testimony. 

STATEMENT OF DENISE ELLIOTT 

Ms. ELLIOTT. Chairwoman Ellmers, Ranking Member Richmond, 

and members of the Subcommittee. 

I welcome the opportunity to testify before you today on behalf 

of myself and the American Podiatric Medical Association. I commend the Subcommittee for its focus on the vital issue of how the 

implementation of health information technology and electronic 

health records under the Medicare program will impact small medical practices. 

I am Dr. Denise Lea Elliott and a member of the American 

Podiatric Medical Association and Doctor of Podiatry. Currently, I 

am a solo practitioner and the owner of the Foot and Ankle Center 

in Marrero, Louisiana. I know there are members of the Subcommittee who are quite familiar and supportive of the podiatric 

profession, but for those who may not know, today’s podiatrists are 

physicians and surgeons licensed in the state in which they practice podiatric medicine. We are qualified by education and training 

to diagnose and treat conditions affecting the foot, ankle, and related structures, and provide the majority of foot care services to 

the Medicare population. 

Podiatrists receive medical education and training comparable to 

medical doctors, including four years of undergraduate education, 

four years of graduate education at one of eight accredited podiatric 

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ing. Most podiatrists are board certified in podiatric orthopedics 

and medicine or in surgery. I have been board certified in surgery 

since 2007. 

More than 65 percent of the podiatrists in this country practice 

in one- or two-person groups, usually employing a very small support staff and enjoying modest annual revenues. Truly the definition of a small business. We face the same challenges confronted 

by all small businesses that must compete in marketplaces that do 

not always provide a level playing field. Podiatry practices and 

other small businesses can and do compete successfully against 

large businesses when the terms of that competition are fair. But 

success becomes difficult when the same demands are made upon 

large and small businesses with no consideration of the unique 

pressures placed on the small business. 

Congress is to be commended for recognizing the potential value 

of health information technology to improve patient care and 

produce efficiencies that reduce costs. Chronic diseases, such as diabetes, heart disease, and kidney failure have devastating effects 

on patients. Many of these ailments have significant effects on the 

lower extremities and the feet in particular. In efficiencies abound 

in the treatment of such disease that could be alleviated through 

communication and record sharing between family physicians, cardiologists, nephrologists, vascular surgeons, podiatrists and others. 

Giving doctors the ability to access information on the patients 

they care for in real-time has the potential to significantly improve 

the treatment and the lives of patients. 

At the same time, such communication and coordination should 

save the cost of duplicate tests, reduce emergency care, and hospitalization admissions, and decrease the practice of defensive medicine. The APMA fully supports this initiative that will help podiatrists provide better care for the patients they serve. However, Congress’ requirement that eligible providers implement electronic 

health care records for Medicare over the next five years places an 

undue financial burden on the majority of podiatrists that are 

small business owners. And while we are well aware of the incentive program to encourage practitioners such as myself to adopt an 

EMR program, it in no way begins to take into account the great 

expense that a solo practitioner will incur. I do not have access to 

the economies of scale that work in favor of larger practices, nor 

do I have the opportunity to participate in a hospital cost-sharing 

program. 

I have not yet implemented an electronic health record system in 

my office although I have explored and continue to explore the possibilities. In addition to the cost, I fear the effect it may have on 

my practice. Typical EMR implementation takes anywhere from six 

to eight months, and I anticipate that I will not be able to treat 

the same patient load during that period. To what extent will care 

be disrupted during the procurement and installation process? How 

long will it take to convert all my patient records? Will I be able 

to adapt to an EMR system? Will my staff? How long will it take? 

And while I certainly understand that an EMR system would benefit patients, will it ultimately benefit my practice? The worst thing 

that could happen for me and for my patients would be to lose my 


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practice because of the cost of implementing an EMR system that 

is supposed to help them. 

It has been daunting to try to figure out where to start with the 

almost 300 certified programs listed on the ONC health information technology product list. I am affiliated with West Jefferson 

Medical Center, a large hospital in Marrero, Louisiana, so I decided 

to initially look at a product that is utilized by this hospital. It 

seemed logical to me to put a system in my office that would work 

seamlessly with my hospital system and could potentially simplify 

my efforts in establishing electronic health records in my practice. 

But I was astounded at the cost. More than $14,000 in start-up 

costs just for the actual electronic health record software lease. The 

cost for additional hardware, computers, and servers that I would 

have to purchase could run an additional $15,000 to $20,000. What 

do I do about my film x-ray equipment? I have not yet tallied the 

cost to purchase a digital x-ray system that would be compatible 

with an EMR. All of this I might add, at a time when Medicare 

is decreasing my reimbursements for radiology services and for 

physicians. 

I am also evaluating other EMR options, but am consistently 

learning that the software purchased, installation, and training 

costs run approximately $25,000 to $30,000 per system, plus additional per doctor monthly fees of up to $600. In Washington, D.C., 

this may not seem like a big deal, but it certainly is in Marrero, 

Louisiana. The current Medicare incentive program offers $18,000 

this year or next year if I implement an EMR program and demonstrate meaningful use for 90 consecutive days, but it appears 

payments in subsequent years will be significantly delayed. At 

first, $44,000 over five years sounded like a great deal of money 

but I have learned that it will not begin to cover all the costs incurred over those five years to become fully compliant with what 

is hoped to be a fully certifiable, reliable, and interoperable system. 

EMR vendors are currently not certified beyond stage one of this 

three-stage meaningful use implementation plan. In fact, vendors 

have only temporary certification of their software programs. What 

happens if the vendor and product I choose is not certified for all 

three stages? If continuing certification is costly—— 

Chairwoman ELLMERS. Dr. Elliott—— 

Ms. ELLIOTT. Yes, ma’am. 

Chairwoman ELLMERS [continuing]. I am going to interrupt you 

there but I am going to ask the rest of your opening statement will 

be submitted for the record. And just in the constraints of time. 

And I apologize for that because you are obviously presenting some 

very vital information. So thank you. 

Ms. ELLIOTT. Thank you. 

[The statement of Ms. Elliott follows:] 

Chairwoman ELLMERS. I will now introduce our next witness, 

Andrew Slavitt. Mr. Slavitt is the chief executive officer of the 

OptimumInsight, one of the largest health information technology 

and consulting companies. 

He has held executive positions with several other health care 

companies. He also worked at McKinsey and Company and Goldman Sachs. Welcome. And you have five minutes and we will be 

lenient with you as well. 


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STATEMENT OF ANDREW SLAVITT 

Mr. SLAVITT. Thank you, Madam Chair, Ranking Member Richmond, members of the Subcommittee, for the opportunity to testify 

today on the barriers faced by small group physicians and single 

physician professionals in adopting and implementing health information technology. 

My name is Andy Slavitt. I am the CEO of OptumInsight, and 

we are one of the world’s largest health information technology 

companies with about 14,000 people worldwide. And we have 

worked with thousands of physicians to help them implement 

health information technology and help them overcome their greatest concerns—cost, uncertainty, and complexity. We have learned a 

lot about what works. Health doctors make the complex simple and 

you will see improvements in productivity and adoption. Resist the 

urge to support efforts even tied to financial incentives that do otherwise by adding complexity. It is not just technology adoption that 

is at stake; what is at stake is actually the very future of the solo 

practitioner in this country where costs, complexity, and uncertainty are driving consolidation into hospitals. 

So to be adopted, technology must meet the needs of supporting 

the physician and the patient in something beneficial to them. And 

it can. Consider how the example of how technology could help reduce unnecessary hospital admissions. A doctor may see 40 or so 

patients in a day. Data suggests that only a small handful of these 

patients will drive the majority of costs and potential hospitalizations if not treated. Without technology, every patient looks alike 

until the doctor walks into the exam room. As the doctor gives our 

orders for a prescription, lab tests, a dietary restriction, those that 

go unfollowed are more likely to end up with a patient needlessly 

hospitalized. Without technology to help, doctors do not know who 

is complying and who is not until the patient shows up in the hospital even then, data suggests that doctors only become aware of 

this about half the time, and without the technology to trigger a 

follow-up visit, the chances of a longer stay or readmission to up. 

All of these changes require less information technology than is 

used by an airline reservation clerk. In communities where this 

sort of technology adoption is occurring, like Grand Junction, Colorado, there is evidence that unnecessary hospitalizations, which 

cost us $30 billion annually, may be dramatically reduced. So I 

would urge us to focus on these basic things which simplify a physician’s life and add more productive time to their day before we 

focus on more abstract requirements. 

So what is it about technology that is creating these barriers? 

Physicians will point to several issues that have been brought up 

on this panel already—costs, legal uncertainty, and privacy regulations. But perhaps the greatest barrier is simpler than those. Productivity-enhancing capabilities that I describe are not today driving the purchase and design of this technology. Ironically, in a 

world where cloud computing, mobile technology, and social networking are creating low-cost access to a variety of capabilities for 

individuals and small businesses, the typical physician may tell 

you that the technology in their office or hospital has often become 

a contributor to regulatory burdens they face. 


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Whether meaningful use standards are right or wrong is not the 

real issue. What is important is that today the end-users, doctors 

and patients, are further away from the actual product design because new product development is focused on satisfying those regulatory hurdles of a payer, CMS, rather than on simple innovations 

that improve productivity. 

The HITECH Act created important momentum. Approximately 

a third of office-based physicians are currently planning to achieve 

meaningful use of EHRs and apply for incentive payments this 

year. We need to consider that for the rest of the physician practices, the smaller ones, the temporary financial incentives will not 

be enough to compensate for productivity losses and private sector 

innovation is at work to demonstrate the power of technology 

where meaningful use is just the starting point. 

Our company, OptumInsight offers technology, for example, with 

no upfront costs or maintenance required, no purchase of servers, 

automating the coding process for billing and collecting from health 

plans, and most importantly, it is instantly updatable based on the 

needs of the user right from the cloud. The way the world is going, 

we believe technology should be free. Services should cost money; 

technology is becoming more and more a part of the fabric of our 

lives. 

Our written testimony offers five common sense recommendations for Congress. Allowing the requirements and regulations 

placed on physicians in the multitude of programs Congress oversees. Second, continue Federal investments in HIEs, which should 

be as essential to CMS as MMIS systems which pay Medicaid 

claims and administer benefits. Third, reduce uncertainty over the 

legal environment. Fourth, provide SBA loans, guarantees for small 

and solo practices and other clinicians not eligible for Medicaid 

meaningful use incentives. We understand this to be budget-neutral. Continue support for the Regional Extension Centers you 

heard about on the first panel, which are providing to be a strong 

tool to provide expertise to small practices which lack resources. 

In conclusion, I applaud the Subcommittee for focusing attention 

on this issue. Physicians who practice in small practices, who were 

once the cornerstone of health care in most communities, are already an endangered species. In the 10 years prior to 2007, the 

percentage of visits to physicians who are solo practitioners decreased 21 percent. The trend has only grown more severe since. 

Simplifying the environment for these practices and private sector 

innovation should be the goal, while supporting and improving 

upon the efforts that got underway with the HITECH Act. 

Thank you for the opportunity to testify. 

[The statement of Mr. Slavitt follows:] 

Chairwoman ELLMERS. Thank you, Mr. Slavitt, for your testimony, your opening statement. 

I am going to introduce Dr. Baumer now, our last witness. Dr. 

Baumer is a professor of law and technology at North Carolina 

State University, which I was just there about a week ago, in Raleigh, North Carolina. Dr. Baumer has written extensively on the 

security and privacy of electronic medical records as well as legal 

liability in the information age. He received his B.A. from Ohio 

University, his J.D. from University of Miami, and his Ph.D. from 


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the University of Virginia. Welcome, Dr. Baumer. And you have 

five minutes for your testimony. And I will be equally as lenient 

with you. 

STATEMENT OF DAVID L. BAUMER 

Mr. BAUMER. Thank you very much. It is a pleasure to be here. 

Actually, it is a pleasure and an honor to address the House Subcommittee on Health Care and Technology with Congresswoman 

Renee Ellmers and Congressman Richmond. 

I am the head of the Business Management Department at 

NCSU. I have a Ph.D. in economics and a law degree. I have been 

a member of the bar for 31 years. And within the field of law and 

technology, I have examined security and privacy issues. My work 

has been published in economic, engineering, accounting and law 

reviews. But enough bragging. 

I delivered this speech to my wife and she said tell them what 

you are going to talk about and then get to it. So let me just say 

that I believe the written statement that I provide outside fills in 

a lot of the gaps relative to this PowerPoint presentation. 

However, my recommendations to get right to the point are that 

small health care firms should be provided with safe harbors in the 

form of EHR software that insulates them from suit by the Federal 

Trade Commission, by private class actions, and by State attorney 

generals. Secondly, currently there is no private right of action 

under HIPAA, nor should there be. Third, small health care providers should not have to be IT specialists aware of the latest techniques in combating identity thieves. And fourth, a step in the 

right direction and I am gratified to hear this discussion, is certified software under ARRA, which creates, I would hope, a due 

diligence defense if somehow a cyber break-in occurs. 

So finally, I would like to point out that removing legal uncertainty as we have see will not result in widespread adoption of 

EHR unless other obstacles are dealt with, including start-up costs 

and interoperability. However, going back to some of the work that 

I have done, we have—I have worked with people at Carnegie Mellon, Virginia Tech, Georgia Tech, examining FTC interventions on 

behalf of citizens’ privacy and security. And the FTC has done a 

very good job. They are dealing with some very clever people. But 

what we have found and what we have discussed in the FTC’s 

interventions is that the FTC standards for commercially reasonable security evolves from case to case. And that is because the IT 

technology continues to evolve. 

So encryption. People talk about encryption. Forty-point 

encryption is no longer state-of-the-art. It is now up to 130 and it 

could be higher. So these interventions by the FTC create uncertainty in my opinion, even among large firms, but certainly small 

firms are overwhelmed. 

In 2004, I wrote an article, co-wrote internet privacy law comparison between the United States and the European Union. It was 

apparent to me that E.U. protection of PII (personally identifying 

information) is much more extensive and effective than in the U.S. 

More recently, I co-authored an article, Privacy and Security in the 

Implementation of Health Information Technology: U.S. and E.U. 

Compared. Now, we start with the assumption that there will be 


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significant efficiency gains, but there could be some diminution in 

the privacy of medical records. Let me just provide you with some 

overall statistics. 

In some E.U. countries, 90 percent plus of their medical records 

are electronic. In the United States it is fewer than 50 percent. 

And it is also true that in economic parlance there are significant 

and positive network externalities associated with making all medical records electronic so that there is, excuse me, an economic justification for subsidizing startup costs. 

All right. I know I was supposed to confine my remarks to legal, 

but these things are interspersed. Let me just jump ahead and 

point out, for example, that HIPAA has over 15 exceptions in which 

medical information can be transmitted to third parties without patient consent. In the E.U., there are only three exceptions, which 

I would be glad to go into. 

Let me cite a couple quotes and then finish up. There was a recent article in November 2010 in the New England Journal of Medicine in which it was stated the question is whether EHRs will help 

providers defend against such claims, medical malpractice and 

medical liability, or leave them more vulnerable. The answer seems 

to be it will do both. I am sure that is reassuring to providers. 

Compliance with FTC and security protection standards necessitates firms to be cognizant of recent FTC actions which requires 

firms to possess substantial expertise in IT. And yet, in my opinion, 

security breaches are inevitable. An article written by my colleague, Professor Fay Cobb-Payton at NCSU—— 

[The statement of Mr. Baumer follows:] 

Chairwoman ELLMERS. I am sorry, Dr. Baumer, I am going to 

stop you there but your testimony will be submitted for the record. 

And I do appreciate that insight regarding all of the security issues 

that we face. 

And I would just further that by saying that you have highlighted an area that I think shows just some of the hurdles and 

barriers that we are up against, which is that technology keeps 

building upon itself so quickly and yet we are putting this on our 

physicians who are small business owners. And how can our physicians be able to incur that cost and stay up-to-date with the mandates of meaningful use as those evolve, the dollar signs. And I can 

speak to this on a personal level. In our practice, having had IT 

for probably going on about five years now, now in order for us to 

be compatible with meaningful use we are going to have to encounter about another $20,000. And that is for the meaningful use as 

it is applied now and not considering the possibilities of changes 

in the future. 

So thank you, Dr. Baumer. I do have a couple of questions and 

then I will be yielding to our ranking member. 

To Dr. Elliott, I know you have stated that you have not put into 

place your IT yet because of all of the costs that you know you are 

going to have to incur. One, being a podiatrist, what is the percentage of Medicare patients that you see? Or no, in relation to, I 

mean, if you could say how many patients you see a week and of 

that, if you have an idea of the percentage. 

Ms. ELLIOTT. I see an average of 30 to 40 patients a day, four 

days a week. So 120 to 150 patients. And about 15 percent is MediVerDate Mar 15 2010 01:21 Sep 21, 2011 Jkt 068062 PO 00000 Frm 00030 Fmt 6633 Sfmt 6602 E:\HR\OC\A062.XXX A062

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care. The majority of those Medicare patients are hospital-based 

patients, the patients with the end-stage renal disease, diabetics—— 

Chairwoman ELLMERS. Right. 

Ms. ELLIOTT [continuing]. Being called for wounds or amputations—— 

Chairwoman ELLMERS. Sure. 

Ms. ELLIOTT. [continuing]. Things along that line. The more severe type of foot conditions. 

Chairwoman ELLMERS. So I guess the question is, and of course 

this is completely your opinion, is it cost effective for you to incur 

the cost for health IT in relation to the possibility of future penalties that you may incur? Because as you have seen as of 2015, 

the penalities will increase and will be sustained. Can your practice take on that penalty if you do not implement the IT? 

Ms. ELLIOTT. My practice can because it is a small percentage of 

my practice. So that one percent then becomes two percent and 

three percent but it is only 15 percent of my practice. So if I was 

going to do a cost analysis and I had to outlay all of this money, 

for me it might be a better financial decision not to implement it. 

Chairwoman ELLMERS. Not to implement it at all. 

Ms. ELLIOTT. Correct. And my big fear is what my colleague here 

went through where you do spend all this money and in the future 

things change and you have to start over again. I already have 

11,000 patients. I have to convert all those records from paper to 

electronic. Now I have to go with a different company and I have 

to convert again. Those are all costs that are involved once you convert from one system to another system because it is not ready for 

the second phase or it has gotten booted out or bought out by a bigger company. So. 

Chairwoman ELLMERS. There again, the implementation and the 

changes in the technology world are really affecting us directly because, how can we comply with these issues? And that is one of our 

concerns. And I thank you for that. 

I will now yield to Ranking Member Richmond. 

Mr. RICHMOND. Dr. Elliott, I know that you did not get a chance 

to finish your testimony but I believe in the portion of your testimony that you did not get to talk about you talked about your concerns about meaningful use criteria. So I will ask you, consistent 

with what you said, that we have heard from providers who are 

concerned that they will not meet the ambitious definition of meaningful use goals required for stage one demonstration. And do you 

believe widespread adoption can be accomplished within CMS’s aggressive timeline? And are there unique challenges to specialists in 

this area? 

Ms. ELLIOTT. I think that most of the subsystems out there are 

designed for your primary are physicians. So as far as the specialists, I think it is a little more challenging. I think you have to go 

with a smaller company that is going to cater to my specialty, 

which will not necessarily integrate as well with the larger hospitals. Then there is interface fees. If you want to try to connect 

with a smaller company to a larger company. So I think it will be 

a challenge. I would love to see more efforts being placed on the 


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specialist as far as the software vendors. I think it is possible from 

a timeline to put this in practice, to answer that question. 

Mr. RICHMOND. The other one, and this question would be for Dr. 

Elliott and Dr. Kramer. A lot of times, I guess, there are not clear 

instances of where reality and theory just do not meet. And when 

we talk about the incentive program, and I am curious especially 

for both of you as small practitioners where, Dr. Elliott, I think you 

said that you estimate spending $25,00 to $30,000 to implement, 

you may be reimbursed $18,000. And that is after a 90-day period 

of demonstrating use. Then four to eight week after that. Is that 

just a reasonable timeline or reasonable expectation to expect a 

small practitioner to be able to front that money and float all of 

the necessary bills and recoup it at the end? And at the end of that 

question, do you all have the access to capital to, if you do not have 

the money within your budget, are there lenders out there willing 

to lend you that money to get you through that hurdle? 

Ms. ELLIOTT. Do you want to go? I know the software companies 

I have looked at, some of them have invested in different loaning 

programs. So the individual vendors have partnered with banks or 

loaning institutions. But now you are taking on a loan. You are 

taking on a business loan. It would not be a desirable thing for me 

as a small business owner. So, of course, it would put a kink in 

your cash flow if you had to outlay all this money and then wait 

for the timeframe for it to come back to you. So. 

Ms. KRAMER. I think it is difficult for many practices. Most of the 

companies do give you a 12-month lease period where you divide 

the payments over a year. And so that makes it more manageable. 

But it is still a large amount of money at the beginning, which you 

basically just, as a small business owner, you are the last person 

to get paid. So you pay yourself last, you save money, and I mean, 

I would much rather do that than take out a business loan. 

Mr. RICHMOND. And my last question, what was the decrease in 

the number of patients you could visit while you went through your 

installation and your 90-day? 

Ms. KRAMER. It is very significant because it is not just me who 

has to learn how to use it but it is the front desk staff who has 

to register the patient, get the information in the system. The 

nurses have to enter the medications and allergies. So the first 

week I saw one patient an hour. And I normally see between four, 

six, seven patients an hour. So that is a huge—not only do you 

have to front the cash for the system but it is a big dip in your 

cash flow for the month or months. Usually it takes approximately 

six to nine months for a practice to get up and running fully with 

the system. So it took me about four to six weeks but the average, 

I believe, is six to nine months. 

Mr. RICHMOND. Wow. 

Ms. KRAMER. Yeah. 

Mr. RICHMOND. According to my quick math over here, I mean, 

that is almost a reduction from anywhere of 75 percent to 85 percent of the number of patients you can see, which reduces your income 75 to 85 percent during this time period. 

Ms. KRAMER. It is huge. 

Mr. RICHMOND. Thank you. 


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Ms. KRAMER. And I am looking at having to do it all over again 

and that is really concerning. And I also mentioned that, you know, 

a lot of practices, especially in my field, there is a huge wait period 

to see specialists. I am booked five to six months out and so that 

just puts me even another month behind. 

Mr. RICHMOND. Thank you so much. 

Ms. KRAMER. Thank you. 

Mr. RICHMOND. All of you. 

Chairwoman ELLMERS. Thank you. And I now yield to Ms. Herrera Beutler for her questions. 

Ms. HERRERA BEUTLER. Thank you. And Mr. Richmond kind of 

asked what I was thinking. How long is the recoup time? You 

know, exactly what you said. I was thinking you have to front the 

money upfront. You have to put the cash down and then you are 

not having the same revenue that you had in months previous. 

Ms. KRAMER. Correct. Yeah. 

Ms. HERRERA BEUTLER. So nine months? How long does it take 

you to break even? Did you break even up to this point and now 

you are having to look at another IT provider? 

Ms. KRAMER. Yeah. It probably takes, I would say, to increase 

productivity—I mean, in my mind there is no doubt that over the 

long term it will increase productivity. I mean, I have fewer staff 

and if I had paper charts I do not have someone that has to be 

pulling charts, etcetera. But I think it would probably take several 

years to turn a profit. I would think three, four, five, six years. 

Ms. HERRERA BEUTLER. So it is a long-term investment. 

Ms. KRAMER. Yes, it is. 

Ms. HERRERA BEUTLER. I was disappointed not to have our previous panel here. I did not know they were going to leave or I 

would have asked them to stay because I think it is incredibly important for them to hear. And I was trying to get at it a little bit 

what happens to the small and solo guys who run into a problem 

like this. There is no real hold harmless, I think, in a contract for 

you. 

Ms. KRAMER. Nothing—— 

Ms. HERRERA BEUTLER. Is there anything that even as you are 

negotiating with vendors, is that something that you can require? 

Or do you need—or are they just going to kind of laugh at that? 

Ms. KRAMER. Yeah, I asked and I asked, you know, the new vendors that I was interviewing and they said, yes, you know, our 

company is stable. But what does that really mean? 

Ms. HERRERA BEUTLER. Thank you for that. 

I wanted to also ask Dr. Baumer, I had a physician in my office 

a few weeks ago and they were talking to me. You kind of came 

at the security portion from the cyber attack side of it and you 

mentioned med-mal, but in terms of discoverability, I have had 

physicians say, look, once I put all this on line it is discoverable 

in a med-mal case. What is the case with paper records? And is 

that something you are hearing? Is it the same? 

Mr. BAUMER. I do not think that there is a difference between 

paper records in terms of discoverability and electronic records. 

Ms. HERRERA BEUTLER. You know what? Part of what he was 

saying was so you have this great new metrics, right, you put the 

information in and they can—then the computer can generate are 


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you looking at this? Are you looking at this? Are you looking at 

this? Well, a physician may be looking at certain criteria. It is 

probably not one of these one percent chance it is one of these other 

things, but if the computer brings it up there is a one percent 

chance and you did not go after it, is it expanding your liability exposure? 

Mr. BAUMER. Well, I think that is a very good question. I mean, 

if the computer puts out four or five scenarios, do you have a due 

diligence obligation to investigate each of these? And, you know, 

that problem, however, has been dealt with for some time. There 

is kind of recommended treatment and then physicians reject that 

and use their own judgment. So I am not sure that because we 

have electronic records that that is going to be a new source of liability. But as that New England Journal points out, we do not 

know. And there has not been, you know, hopefully in the long run, 

but people cannot hold their breath in the long run, that we will 

have a reduction in liability. I think that most of these providers 

are very concerned about lawsuits from people they do not even 

know about issues that they are not trained about, namely IT 

issues, which Mr. Slavitt might be able to talk about. 

Ms. HERRERA BEUTLER. Did you have a thought? 

Mr. SLAVITT. Yeah. I think there is a slight difference, Congressman, and that difference is that in a paper record it may say that 

a patient is taking certain medication. Now, an electronic system 

may say because this patient is taking this medication do not give 

them this treatment or there is going to be a bad interaction. And 

so I think the fear is that that creates a level of liability. Invisibility in the liability that did not exist before. So what we obviously 

need to do is encourage the development of—encourage people to 

learn and improve and not penalize people for improving. And to 

self-report and so forth. That type of environment, I think, you 

know, will balance the needs and interests of the patient with the, 

I think, very real concerns of a physician to make sure that they 

do not get penalized for effectively trying to advance the care they 

are delivering. 

Ms. HERRERA BEUTLER. Absolutely. Thank you. I yield back. 

Chairwoman ELLMERS. Thank you. And I now yield to Mr. 

Hanna. Mr. Hanna, you are fine? With that I will—— 

Mr. Slavitt, I did have a couple of questions along the same lines 

of what we were just discussing. With the incredible rate of innovation in technology and the changes and all of the concerns that you 

have brought up, and you did an excellent job of outlining some of 

the areas that we need to address, with that I just want you to 

elaborate a little bit more on the cost and the time that it does take 

for our physician offices to implement this. You know, many times 

the software company, the vendor will say, within three months 

you will be up and running and you are going to turn a profit. Realistically, and I know Dr. Kramer you had outlined, you know, six 

to nine months. And each office is certainly going to be different 

based on the number of employees that will be working with it, and 

the time that the physician can afford to devote to it. In your opinion, are those costs and time estimates underestimated? Because 

that was certainly our experience. 


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Mr. SLAVITT. Sure. It is a great question and I think Dr. Kramer’s story is really probably one of the most important cautionary 

tales for what can be avoided. And, you know, I think that to the 

extent that we think physicians and a large integrated delivery 

system and in Geisinger where you have come from, you have got 

to think of it very differently than small business, solo practitioners, who are very much—they are very much consumer professionals all at the same time. And they need to be treated differently. And so, you know, if you think about what companies like 

Intuit charge for practice software for a small business, for a small 

physician office where they have 75,000 physicians, it is very small. 

The training time is easy. It is a very intuitive set of applications. 

Likewise, you know, I do not think there is a great future in charging individuals $75,000 to install technology in their offices 

and maintain it. We all know that is not the direction things are 

going. If you are not happy with Google, you switch to Microsoft. 

And if you are not happy with Microsoft, just switch to Google. 

That is the environment that needs to be stimulated out of ONC 

here. And I think there is good news and I think the kind of questions that I think need to be asked when talking to vendors are 

how updatable? Can it be delivered through the cloud? Can you 

provide guarantees that I can reach meaningful use? Can you give 

me a money back guarantee on the loan if I do not reach meaningful uses? And the competition—the good news is that some of the 

competition that has been spurred are actually driving in that direction. It clearly has not gotten out to you, Dr. Kramer, but that 

is what needs to happen. 

Ms. ELLMERS. Thank you so much. And at that I will say thank 

you to our panel. This will conclude our hearing today. 

This Subcommittee will continue to closely follow and take into 

account all of your comments and concerns, and I certainly do appreciate your time. We will be sending a letter to CMS on the eprescribing incentive program proposed rule during the comment 

period that is now currently in effect. 

I ask unanimous consent that members have five legislative days 

to submit statements and supporting materials for the record. 

I have an article here that was just posted in Medscape Medical 

News and I will just briefly touch on it. Centers for Medicare and 

Medicaid Services, CMS, is proposing more exceptions to an electronic prescribing requirement that could penalize as many as 

109,000 physicians, nurse practitioners, and other prescribers who 

do not adopt the technology. The title of the article is E-Prescribing 

Penalty Could Hit up to 109,000 Clinicians. 

With that, this meeting is adjourned. [Whereupon, at 11:57 a.m., 

the Subcommittee hearing was adjourned.] 


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