U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Printing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2104 Mail: Stop IDCC, Washington, DC 20402–0001

45–627 PDF 2008

TOO MANY COOKS? COORDINATING FEDERAL

AND STATE HEALTH IT

HEARING

BEFORE THE

SUBCOMMITTEE ON GOVERNMENT MANAGEMENT,

ORGANIZATION, AND PROCUREMENT

OF THE

COMMITTEE ON OVERSIGHT

AND GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED TENTH CONGRESS

FIRST SESSION

NOVEMBER 1, 2007

Serial No. 110–99

Printed for the use of the Committee on Oversight and Government Reform

(

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

http://www.oversight.house.gov

(II)

COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM

HENRY A. WAXMAN, California, Chairman

TOM LANTOS, California

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

CAROLYN B. MALONEY, New York

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

BRIAN HIGGINS, New York

JOHN A. YARMUTH, Kentucky

BRUCE L. BRALEY, Iowa

ELEANOR HOLMES NORTON, District of

Columbia

BETTY MCCOLLUM, Minnesota

JIM COOPER, Tennessee

CHRIS VAN HOLLEN, Maryland

PAUL W. HODES, New Hampshire

CHRISTOPHER S. MURPHY, Connecticut

JOHN P. SARBANES, Maryland

PETER WELCH, Vermont

TOM DAVIS, Virginia

DAN BURTON, Indiana

CHRISTOPHER SHAYS, Connecticut

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

MARK E. SOUDER, Indiana

TODD RUSSELL PLATTS, Pennsylvania

CHRIS CANNON, Utah

JOHN J. DUNCAN, JR., Tennessee

MICHAEL R. TURNER, Ohio

DARRELL E. ISSA, California

KENNY MARCHANT, Texas

LYNN A. WESTMORELAND, Georgia

PATRICK T. MCHENRY, North Carolina

VIRGINIA FOXX, North Carolina

BRIAN P. BILBRAY, California

BILL SALI, Idaho

JIM JORDAN, Ohio

PHIL SCHILIRO, Chief of Staff

PHIL BARNETT, Staff Director

EARLEY GREEN, Chief Clerk

DAVID MARIN, Minority Staff Director

SUBCOMMITTEE ON GOVERNMENT MANAGEMENT, ORGANIZATION, AND PROCUREMENT

EDOLPHUS TOWNS, New York, Chairman

PAUL E. KANJORSKI, Pennsylvania

CHRISTOPHER S. MURPHY, Connecticut

PETER WELCH, Vermont

CAROLYN B. MALONEY, New York

BRIAN P. BILBRAY, California

TODD RUSSELL PLATTS, Pennsylvania,

JOHN J. DUNCAN, JR., Tennessee

MICHAEL MCCARTHY, Staff Director

(III)

C O N T E N T S

Page

Hearing held on November 1, 2007 ........................................................................ 1

Statement of:

Kolodner, Robert M., M.D., National Coordinator for Health Information

Technology, Department of Health and Human Services; Cheryl

Austein Casnoff, Associate Administrator, Office of Health Information

Technology, Health Resources Services Administration; and Carolyn

M. Clancy, M.D., Director, Agency for Healthcare Research and Quality ................................................................................................................... 9

Austein Casnoff, Cheryl ............................................................................ 26

Clancy, Carolyn M. .................................................................................... 37

Kolodner, Robert M. .................................................................................. 9

Marchibroda, Janet M., CEO, Ehealth Initiative; Dr. Winston Price,

Chair, Health IT and Transparency Advisory Board, State of Georgia;

Lori Evans, deputy commissioner for health IT transformation, State

of New York; Dr. Farzad Mostashari, assistant commissioner, Department of Health and Mental Hygiene, city of New York; and Dr. Neil

Calman, president, Institute for Urban Family Health ............................ 61

Calman, Neil .............................................................................................. 128

Evans, Lori ................................................................................................. 98

Marchibroda, Janet M. .............................................................................. 61

Mostashari, Farzad ................................................................................... 115

Price, Winston ........................................................................................... 75

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

Austein Casnoff, Cheryl, Associate Administrator, Office of Health Information Technology, Health Resources Services Administration, prepared statement of ........................................................................................ 28

Calman, Dr. Neil, president, Institute for Urban Family Health, prepared

statement of ................................................................................................... 131

Clancy, Carolyn M., M.D., Director, Agency for Healthcare Research and

Quality, prepared statement of .................................................................... 40

Evans, Lori, deputy commissioner for health IT transformation, State

of New York, prepared statement of ........................................................... 101

Kolodner, Robert M., M.D., National Coordinator for Health Information

Technology, Department of Health and Human Services, prepared

statement of ................................................................................................... 12

Marchibroda, Janet M., CEO, Ehealth Initiative, prepared statement of ... 64

Mostashari, Dr. Farzad, assistant commissioner, Department of Health

and Mental Hygiene, city of New York, prepared statement of ................ 118

Price, Dr. Winston, Chair, Health IT and Transparency Advisory Board,

State of Georgia, prepared statement of ..................................................... 78

Towns, Hon. Edolphus, a Representative in Congress from the State

of New York, prepared statement of ........................................................... 3

(1)

TOO MANY COOKS? COORDINATING FEDERAL

AND STATE HEALTH IT

THURSDAY, NOVEMBER 1, 2007

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON GOVERNMENT MANAGEMENT, ORGANIZATION, AND PROCUREMENT, COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM, Washington, DC.

The subcommittee met, pursuant to notice, at 3:10 p.m., in room

2154, Rayburn House Office Building, Hon. Edolphus Towns (chairman of the subcommittee) presiding.

Present: Representatives Towns, Christensen, Clay and Bilbray.

Staff present: Michael McCarthy, staff director; Rick Blake, professional staff member; Cecelia Morton, clerk; Charles Phillips, minority counsel; and Benjamin Chance, minority clerk.

Mr. TOWNS. The subcommittee will come to order.

I want to welcome everyone here today to what I consider to be

an extremely important hearing. Our Nation is on the verge of a

revolution in health services delivery through health information

technology, or health IT. This revolution, the transition from paper

to electronic health records, can reduce medical errors, can enhance

the security and privacy of medical records, and can enhance the

quality of care for medically underserved communities.

I am concerned about how we are currently managing our health

IT initiatives. I am concerned that we are developing top-down solutions and not fully connecting them to the reduction of health

disparities in the communities that need them the most. I am worried that the programs that State and local governments have

started will ultimately be bypassed by a one-sized Federal solution.

But I am also concerned that there is too much duplication of effort

and expense as different States start different programs.

I know that Dr. Kolodner and his team have been hard at work,

with not enough resources, I might add, in terms of developing this

health information highway. I just want to make sure that the people from my community, Brooklyn to communities all over the

country, don’t get left behind and that our State and local and community initiatives are not discarded.

I know that encouraging innovation from our local officials is a

policy that Ranking Member Bilbray shares, so I would like our

very knowledgeable expert witnesses to tell us how to reconcile national standards that we will ultimately need with existing State,

local and community health initiatives.

For those of you who know me, I have worked in a bipartisan

fashion regardless of who is in the majority. That’s why I hope,

2

today, we can find some solutions that address everybody’s concerns so that we can move forward together. I am going to announce a new House caucus within the next few days, the Health

IT Empowerment Caucus, that will focus on doing just that. We

plan to work with the administration and the 21st Century Caucus

and local and private sector groups to develop inclusive language,

programs and grant opportunities that connect health IT with the

reduction of health disparities.

In this regard, I would like to welcome other Members who have

been active on these issues. I would like to thank Congresswoman

and Dr. Donna Christian-Christensen for her work as a leader of

the Congressional Black Caucus’ Health Braintrust. I know that

you have taken a leadership role in working on the reduction of

health disparities and I am proud to be an original cosponsor of

H.R. 3014, the Health Equity and Accountability Act of 2007.

I would also like to thank Congressman Clay of St. Louis, MO,

for his efforts. He especially worked last year on the Electronic

Health Information Technology Act of 2006.

I ask unanimous consent that these Members be allowed to participate in today’s hearing. Without objection, so ordered.

I would also like to welcome those seated in the audience who

have worked long and hard to connect health IT with the reduction

of health disparities. I know that you have waited for some time

for the formal acknowledgment of your efforts, and I hope that you

will work with us and the House Health IT Empowerment Caucus

to make this happen.

[The prepared statement of Hon. Edolphus Towns follows:]

3

4

5

Mr. TOWNS. I yield now, of course, to Congresswoman and Doctor

Donna Christian-Christensen for her remarks.

Mrs. CHRISTENSEN. Thank you, Chairman Towns and Congressman Clay. I want to thank you for holding this important hearing

today on health information technology, and I want to thank you

for the opportunity to be able to provide some comments.

Before I get into the body of my testimony, Mr. Chairman, I

wanted to just thank you for your leadership and for your commitment to HIT and for your further commitment to ensuring that the

issue of health disparities is addressed in it and through it. You

have been at the forefront of successfully amending HIT legislation

to ensure that the issues and concerns of minorities have been addressed, and it’s been successful at least in this House.

I am here representing the Congressional Black Caucus’ Health

Braintrust, which has as its chief mission the elimination of health

disparities in African Americans as well as in other people of color

and the poor and rural populations. Just to single out the African

American community, the data shows that we have higher rates of

death and disability for almost every disease, from heart disease

and cancer to HIV and AIDS. Our infant mortality is more than

twice that of the white population, and the life expectancy of the

African American male is the lowest of all population groups.

There are many causes for this. Among them are high rates of

poverty and social determinants that follow from it, the lack of insurance, the lack of providers who come from the same cultural

and racial background, discrimination in health care services, the

high-risk lifestyles that are fueled by poverty and discrimination,

and a lack of sufficient political will to change it.

Health information technology has the great potential to improve

the health of Americans and to raise our country above that 37th

WHO rating, the lowest of all industrialized countries, many of

which are far ahead of us on health information technology. HIT

reduces errors by eliminating the illegible notes like the ones I

used to write, by reducing medication interactions and by providing

relevant and timely information. It also improves practice through

protocols and decision support for providers, and it can empower

patients through accurate and consumer-friendly health information.

The potential of HIT to improve health as well as to reduce costs

is great but not without deliberate action by this Congress. Without

that, it will fall short of the good that could be done. It’s imperative

that this committee and Congress pass provisions and funding to

ensure that HIT reaches all Americans, especially the most vulnerable populations and their providers. It is important because of the

extreme burden of disease that these populations bear, and it’s important for their providers. Doctors treating vulnerable populations

are largely at the mercy of Medicare and Medicaid, and so they receive the lowest reimbursements for the heroic work that they do.

Therefore, these patients and providers will require more help from

the Federal Government to ensure that the benefits of HIT are equitably available to them.

Reports show that 98,000 deaths occur annually from medical errors, and reports also show that they occur more frequently in minority populations. So we in the Congressional Black Caucus, as

6

well as in the Tri-Caucus, clearly have a stake in making sure that

health information technology is accessible to every community.

In the Federal Government’s efforts to fund health IT, there has

been very little focus on reducing health disparities, and we’ve seen

the consequences of not having health IT advancements in all communities through the natural disasters like Hurricane Katrina. The

victims then were largely those to whom this testimony is focused

and who need an extra effort to be reached, minorities and the

poor.

I would like to just highlight briefly a Tri-Caucus-sponsored bill

that takes a comprehensive approach to health disparity elimination; and it also includes HIT provisions that you, Congressman

Towns, amended into H.R. 4157 as one of its key provisions. That’s

the Health Equity and Accountability Act of 2007, which was introduced this year by Congresswoman Hilda Solis.

Under H.R. 3014, in addition to providing that our communities

have access to the programs that improve health care delivery,

using language lifted directly from your amendments, Congressman Towns, emphasis is placed on, ‘‘ensuring that health information technology and personal electronic health records become a

component in the efforts to measure, reduce and ultimately eliminate racial and ethnic as well as geographic health disparities.’’

The bill also has provisions to increase racial and ethnic minority

providers, to bolster data collection and to bolster accountability in

Federal agencies that have health and health care oversight. It’s a

much-needed bill, but it’s a bill that we will need your support to

pass.

A 2005 Minority Health Disparities Report coming out of the Office of Minority Health stated, ‘‘Life expectancy and overall health

have improved in recent years for large numbers of Americans due

to an increased focus on preventative medicine’’—and I don’t know

where that was’’—and by making new advances in medical technology.’’

However, not all Americans are benefiting equally. There are

continuing disparities in the burden of illness and death experienced by African Americans, Hispanic Americans, Asian Americans, Pacific Islanders, and American Indian/Alaska Natives as

compared to the U.S. population as a whole.

The expansion of health information technology is vital for our

communities, and it will require efforts from the Federal, State and

local government levels as well as from the university and private

sectors. And, it will require an investment, but it’s an investment

that will pay and will reduce future costs through better health.

I am proud to say that my alma mater of George Washington

University is a longtime leader in health information technology

and that my district, the Virgin Islands, has also begun its own

HIT initiative, but it is the Federal Government, through its programs and in having the responsibility for more than 115 million

Americans, that must be placed in the lead. So we need to continue

to work with you, Congressman Towns, and others to ensure that

we can get meaningful HIT legislation signed into law, which will

improve health care, reduce costs and eliminate health disparities.

It’s necessary for the health of all of us and for the economic health

and continued competitiveness and strength of our Nation.

7

So thank you again for the opportunity to make comments, and

I look forward to hearing from your witnesses.

Mr. TOWNS. Thank you very much for your statement. I also

thank you for your involvement in this issue.

At this time, I would like to yield to Congressman Clay from St.

Louis.

Mr. CLAY. Thank you, Mr. Chairman.

Let me begin by thanking you and your staff for your leadership

on this important issue.

I firmly believe that the Federal Government must take the lead

in the development and adaptation of a nationwide Health Information Network that can improve the quality of care provided to

all citizens.

During the 109th Congress, I introduced H.R. 4832, the Electronic Health Information Technology Act of 2006. H.R. 4832

sought to codify the current Office of the National Coordinator for

Health Information Technology at HHS. In addition, the bill

partnered with the private sector by providing grants and incorporating a direct loan program that would offer key economic assistance for institutions seeking to expand their electronic health

record capability.

Mr. Chairman, our effective pursuit of health IT standards will

dramatically reduce the significant health care disparities that Dr.

Christensen mentioned are facing many minority and rural populations. I look forward to today’s testimony and in working with

you on this issue.

I yield back.

Mr. TOWNS. Thank you. Thank you for your involvement as well.

At this time, I would like to yield to the ranking member of the

committee, Congressman Bilbray from California.

Mr. BILBRAY. Thank you, Mr. Chairman.

Mr. Chairman, let me just say that I appreciate your holding this

hearing.

As I have stated before, in my previous life, I was the chairman

of San Diego County, an area of 3 million people and we provided

the health care safety net for the working class people of that region; and health data assessment and information were critical

components there.

Also in my previous life, when I served 6 years here in the House

before the voters gave me a 5-year sabbatical, I was actually working on a telecommunications bill and the big issue of how much

Federal standards should be imposed, how much flexibility has to

be encouraged is a legitimate argument in every one of these discussions.

A good example was the fact that if we did not have a minimum

standard, we would never be able to get to the issue that you and

I had a hearing about last week. It was about making sure that

all drivers’ licenses in the United States are held to a minimum

standard, something the 9/11 Commission wanted to do. There, the

DMVs came forward and asked us, as a Federal agency, to create

a minimum standard so that we had uniformity there, at least with

the standard, even though we had a State-by-State application of

those standards.

8

On the other side, when we were working with telecommunications, we were saying we want to have a network—which is important—that the Federal Government leads on, but we didn’t

want the Federal Government to set a standard for it. You know,

if we’d set a standard for computers back when they came out,

none of us would ever have seen Windows. It wouldn’t have been

legal to have Windows. So just think about how far we’ve been able

to go because the Government wasn’t in the way, blocking it.

So, as they say, politics is the art of the possible. Contrary to

what the college professors say, it is not a science. It’s still an art.

You still have to finesse it, and you still have to have that delicate

touch of trying to respond to reality.

So I hope as we discuss this today, we look at that balance between the ability for information to be transmitted and read but

still the ability for systems to be able to be upgraded with innovation improvement being allowed in the process. Because I’ll tell you

one thing as somebody who has been in government since I was 24

years old—I was a city council member—so often we legislate our

way into dead ends, and some of the greatest challenges we have

with technology in America is not to get the technology online but

get it legally to go online. So I hope we look at this with the innovation of let’s just have just enough guidance to make the system

work but keep enough flexibility to where innovation and improvement can go on there.

I think all of us agree that there were a lot of people scared

when we busted up the monopoly of Ma Bell, but I don’t think any

of us are really pining for the days when we had rotary phones and

our kids couldn’t walk around the house with a cordless phone, and

so I hope that we look at it that way. We learn from our successes

of the past and from our mistakes of the past and, hopefully, this

panel will help set that foundation to make sure that the consumer

will be served, the ‘‘consumer’’ being the patient who needs to have

this information made available.

I would just like to close by saying, I serve on the Veterans’ Committee, Mr. Chairman, and we are looking at this issue from the

veteran’s point of view, and I would strongly urge that we work

with my old friend Bob Filner—and I say ‘‘old friend’’ because we’ve

been working together since the 1970’s—at maybe using the Veterans’ Committee as a stalking horse here and the Federal Government should get its medical records in order and straight as we

move forward in talking about a minimum standard for the rest of

the country.

I yield back, Mr. Chairman.

Mr. TOWNS. Thank you very much. I look forward to working

with you in every way to try and see if we can move this forward.

At this time, we will ask our first panel to come forward.

Will you continue to stand? It’s a longstanding tradition that we

swear our witnesses in.

[Witnesses sworn.]

Mr. TOWNS. Let the record reflect that all three answered in the

affirmative.

Let me introduce our first panel, the three leaders in the area

of health IT. We are delighted to have you.

9

Dr. Robert Kolodner is the National Coordinator for Health IT,

reporting to the Secretary of Health and Human Services. He has

served in a number of executive positions in Health IT, including

that of Chief Health Informatics Officer in the Department of Veterans Affairs; and, of course, he is responsible for the development

of the VA’s electronic health records system.

Of course, Cheryl Casnoff manages the Office of Health Information Technology for the Health Resources Services Administration.

She oversees the awards of $40 million in new telehealth and

health IT grants. She previously directed the State Children’s

Health Insurance Program at HHS.

Welcome.

Dr. Carolyn Clancy is the Director of the Agency for Healthcare

Research and Quality, one of the Nation’s most important health

research agencies. Dr. Clancy is one of the Nation’s leading authorities on health quality and access to care, and she has served

in a number of senior academic positions.

Your entire statements will be included in the record. So, if I

could, I’ll ask each of you to summarize within 5 minutes, which

will allow us an opportunity to raise questions.

So, Dr. Kolodner, why don’t you start?

STATEMENTS OF ROBERT M. KOLODNER, M.D., NATIONAL COORDINATOR FOR HEALTH INFORMATION TECHNOLOGY, DEPARTMENT OF HEALTH AND HUMAN SERVICES; CHERYL

AUSTEIN CASNOFF, ASSOCIATE ADMINISTRATOR, OFFICE

OF HEALTH INFORMATION TECHNOLOGY, HEALTH RESOURCES SERVICES ADMINISTRATION; AND CAROLYN M.

CLANCY, M.D., DIRECTOR, AGENCY FOR HEALTHCARE RESEARCH AND QUALITY

STATEMENT OF ROBERT M. KOLODNER, M.D.

Dr. KOLODNER. Thank you.

Good afternoon, Chairman Towns, Ranking Member Bilbray and

members of the subcommittee.

I am Dr. Robert Kolodner, as you heard, and I am pleased to testify before you today on the administration’s vision for interoperable health IT and how we are working with agencies and stakeholders to meet the needs of our Nation’s medically underserved.

Three years ago, President Bush established the position of the

National Coordinator, reporting to the Secretary of HHS, in order

to provide leadership and strategic guidance to advance the national health IT agenda in America with the goal that most Americans have access to electronic health records by 2014.

From my 29 years of experience as a physician and as an administrator at VA, I know that information technology is absolutely

necessary to be able to improve quality of care, to reduce medical

errors, to increase efficiency, and to provide better information to

patients and clinicians.

HHS is aggressively working to address the five critical components necessary to achieve widespread use of health IT across the

Nation. These are a collaborative decisionmaking process, a secure

Nationwide Health Information Network, health IT standards with

a certification process to confirm they are incorporated into health

10

IT products, the adoption and use of interoperable health IT products and solutions, and clear, strong privacy and security and other

health IT policies.

The first critical component, a collaborative decisionmaking process, had been served initially by the American Health Information

Community [AHIC], which was chartered in 2005 as a time-limited

Federal advisory committee to make recommendations to the Secretary of HHS on ways to accelerate the development and adoption

of health IT. We are now transitioning this collaborative function

to an independent public-private partnership based in the private

sector with the Federal Government continuing as an active member and participant. We have taken specific steps to ensure the involvement of consumers, including medically underserved populations, as we transition to the AHIC successor.

The second critical component is the Nationwide Health Information Network to allow health information to be appropriately available in a secure and reliable manner anywhere in the United

States. In fiscal years 2006 and 2007, the ONC led a project that

confirmed the feasibility of exchanging electronic health information nationwide. In September 2007, we funded multi-stakeholder

health information exchanges [HIEs], in nine communities across

the country to work together to identify and implement the best solutions for exchanging health information. These nine HIEs will include safety net providers in their communities.

The third critical component is the identification of health IT

standards and the incorporation of them into health IT products

and services. This activity has been extremely successful. Since

May 2006, 93 ambulatory electronic health record products, accounting for 75 percent of those in use in this country, have been

certified by CCHIT as meeting their functionality, interoperability

and security criteria. The first certified inpatient EHRs will be announced very soon.

The adoption and use of interoperable health IT products and

services is the fourth critical component. Today, only about 10 percent of all doctors and hospitals in the United States use EHRs

that have even a minimum set of functionality. We have been

working across the Federal Government as well as with the private

sector to remove barriers and to promote the use of EHRs by

health care providers. Actions have included regulatory changes to

allow hospitals to donate EHRs to physician practices in collaboration with HRSA regarding their grants to safety net providers. This

week, Secretary Leavitt announced a 5-year CMS demonstration

project designed to learn how we can most effectively promote EHR

adoption by physicians in small to mid-sized practices where the

current adoption rate is even lower, being under 5 percent.

The fifth critical component relates to Federal and State health

IT policies, including privacy and security policies. HHS is carefully

exploring options to address these issues. As part of this activity,

ONC and AHRQ have worked collaboratively to bring together a

broad range of grassroot stakeholders in 34 States and territories

to assess current variations in State-level privacy and security

practices and develop State-based solutions and implementation

plans. In at least 11 of these States, there have been specific representation for medically underserved populations who participate

11

in the working groups and steering committees. ONC is also working with the National Governors Association to address cross-State

health IT issues and challenges to interoperability.

In summary, the widespread use of health IT is a fundamental

change that must occur in order to improve the quality and efficiency of health care and to enable consumers to manage their

health and to promote individual and population health. Moreover,

the use of health IT has the potential to help decrease significantly

disparities in health care quality. We are pleased that over the

past 3 years there has been substantial progress in coordinating

multiple Federal and State health IT initiatives to ensure that all

populations get benefit from advancements in health IT.

Mr. Chairman, thank you for the opportunity to appear before

you today.

Mr. TOWNS. Thank you very much.

[The prepared statement of Dr. Kolodner follows:]

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

Mr. TOWNS. Ms. Casnoff.

STATEMENT OF CHERYL AUSTEIN CASNOFF

Ms. AUSTEIN CASNOFF. Good afternoon, Mr. Chairman and members of the subcommittee. Thank you for the opportunity to meet

with you today on behalf of the Health Resources and Services Administration [HRSA], to discuss the health information technology

programs we administer. I appreciate your support and awareness

of the importance of health information technology in underserved

communities.

Consistent with the President’s goal of the adoption of electronic

health records for most Americans by 2014, HRSA has a number

of grant programs already in place to assist safety net providers in

accomplishing this important goal. HRSA promotes the adoption

and effective use of HIT, including telehealth, to meet the needs of

people who are uninsured, underserved and/or have special needs.

HRSA also provides technical assistance to health centers and to

other HRSA grantees in adopting model practices and technologies,

in promoting grantee HIT advances and innovations as models and

in ensuring that HRSA HIT policy and programs are coordinated

with those of other U.S. Department of Health and Human Services’ components and those of other Federal programs.

HRSA is working with many different stakeholders. Collaboration and coordination is key to the successful implementation of

HIT. At HRSA, I’d like to give a few examples of how we’re doing

this.

We are working with internal and external partners to make

sure the medically underserved and the safety net providers are a

part of every component of the HIT agenda. Reducing health disparities is a key goal of our agency. To this end, we have formed

a coordinating group with the Office of Minority Health specifically

to address the potential of HIT to reduce health disparities. We are

translating and customizing priorities of the National Coordinator’s

Office and standards for our grantees. We serve on several coordinating committees to help ensure that the medically underserved

will benefit from the promises of HIT. We participated in AHRQ’s

ambulatory safety and quality grant application review process as

well as in their contract for Medicaid HIT technical assistance. We

are working closely with CMS and with State Medicaid agencies

that receive Medicaid transformation grants, and we are linking

our grantees to these opportunities.

At this point, I would especially like to thank Dr. Kolodner for

all of his support and the support of the National Coordinator’s Office in recognizing the special goals of our agency to provide quality

care to vulnerable populations. He has worked with us to establish

a new grant program, and he took the time personally to visit some

of our health center sites.

HRSA’s Office of Health Information Technology was formed in

December 2005, as the principal advisor to the HRSA Administrator in developing in an agency-wide HIT strategy. OHIT, as

we’re called, was specifically created to promote the adoption and

effective use of HIT in the safety net community. Our office awards

planning and implementation grants for telehealth, electronic

health records and other HIT innovations, while encouraging marVerDate 11-MAY-2000 09:46 Jan 09, 2009 Jkt 000000 PO 00000 Frm 00030 Fmt 6633 Sfmt 6633 C:\DOCS\45627.TXT KATIE PsN: KATIE
27

ket-based solutions and while encouraging providers to incorporate

HIT as a normal cost of doing business. Our office also provides

leadership and representation for HRSA grantees with other Federal and State policymakers, researchers and other stakeholders.

For fiscal year 2007, we funded four new types of grants targeted specifically to health centers for a total of $33 million. These grants

were based on specific comments that we received from the safety

net community about how we could best support HIT in that community.

Implementing HIT innovations and transforming health care

through HIT is a huge undertaking that should not be underestimated. Some of the barriers that safety net providers face are the

scarcity of funding, expert staff and resources, sorting through the

flood of information on HIT, selecting software, hardware, appropriate tools, partners, and vendors and, perhaps most significantly,

using HIT to achieve real change in clinical practice operations’

staff and duties.

HRSA is continually looking for ways to overcome these barriers

for our grantees. We have compiled and shared lessons from grantees with others and have provided technical assistance.

In partnership with AHRQ, we have established an HIT community specifically for HRSA grantees. It serves as a virtual community for health centers, our health center networks and State primary care associations, as well as other grantees, to collaborate

around the adoption of technologies that are promoting patient

safety and high-quality care. This portal creates a central hub for

communication across geographic areas, and it allows our grantees

to talk about and to gain information about HIT advances.

We have also developed a toolbox, which is a compilation of HIT

planning, implementation and evaluation resources, to support our

grantees, and it will be expanded to include rural health, maternal

and child health, HIV/AIDS, and telehealth. We will be releasing

that shortly.

In conclusion, the Department of Health and Human Services

has identified furthering the use of HIT as a key priority. This

focus supports the President’s goal of the adoption of electronic

health records for most Americans by 2014. We are diligently working with our grantees and with our partners in ONC, in CMS, in

AHRQ, and other Federal and State public and private organizations to meet this important goal. We are very proud of our efforts

and progress to date.

Thank you for giving me the opportunity to come here today to

update you on the progress of our agency in the area of HIT and

for your dedication and interest in underserved communities. I will

be very happy to answer your questions.

Mr. TOWNS. Thank you very much.

[The prepared statement of Ms. Austein Casnoff follows:]

28

29

30

31

32

33

34

35

36

37

Mr. TOWNS. Dr. Clancy.

STATEMENT OF CAROLYN M. CLANCY, M.D.

Dr. CLANCY. Good afternoon, Mr. Chairman and members of the

subcommittee. I am Dr. Carolyn Clancy, the Director of the Agency

for Healthcare Research and Quality [AHRQ], a component of the

Department of Health and Human Services. I, too, would like to

thank you for the opportunity to discuss the role that health IT can

play in improving the quality of health care for underserved populations across the Nation.

It is an understatement to say that health care quality in this

country is nowhere near as good as it could or should be and we

also have wide racial, socioeconomic and geographic inequities in

health care and how it’s delivered.

So, according to research from RAND, partially funded by AHRQ,

Americans have a little bit better than a 50 percent chance of receiving the recommended care they need when they go to a doctor’s

office and serious problems with health care quality exists in all

areas of health care. These problems are pretty pervasive across

communities.

It actually doesn’t matter where you live, we have quality challenges. In fact, according to data from our annual congressionally

mandated National Healthcare Quality Report and our National

Healthcare Disparities Report, health care quality improved just

3.1 percent in 2006, the same rate of improvement as the previous

2 years. At that rate, it will take us about 20 years to close the

gap between best possible care, and care that’s routinely provided.

From these reports, we know that we have wide racial, ethnic,

economic, and geographic disparities in health care. For example,

rural Americans are more likely to be elderly, poor—in fair or poor

health—and to have chronic illnesses. They are less likely to receive recommended preventative care and report, on average, fewer

visits to health care providers. Unfortunately, we don’t have data

specific to urban underserved Americans.

So the good news here is that we’re working to resolve these

quality problems, and we are making some progress. The bad news

here is that the pace is slow, and we could move a whole lot faster.

So the big question then is: How do we accelerate the change

that we need? How do we engage all stakeholders so that we can

make sure that everyone, every American in this country, receives

the highest quality and safest health care possible?

Well, first, we have to recognize, as Secretary Mike Leavitt often

says, ‘‘We don’t have a health care system. We have a health care

sector that’s rapidly growing and is increasingly fragmented.’’

Health IT becomes a critical connector for the multiple parts of this

system that, today, are not very nicely connected.

It is very important to note, though, that health IT is not a

magic bullet. It alone will not transform the health care system,

but it’s impossible to envision how the transformation could occur

without the capacities that it brings. So AHRQ’s health IT initiative includes more than $166 million in grants and contracts to 41

States to support and to stimulate investment in health IT with a

particular focus on rural and underserved areas. Through this iniVerDate 11-MAY-2000 09:46 Jan 09, 2009 Jkt 000000 PO 00000 Frm 00041 Fmt 6633 Sfmt 6633 C:\DOCS\45627.TXT KATIE PsN: KATIE
38

tiative, we are working to ensure that the promise and potential

of health IT is available to all Americans.

More than 50 percent of our health IT funding has targeted rural

populations. So, from 2004 to 2006, the amount spent for rural

health IT projects totaled $75 million. Under our more recently

funded ambulatory safety and quality initiative, we’re spending

$6.5 million for health IT grants targeting priority populations, out

of a total of $21 million in these grants in fiscal year 2007.

Mr. Chairman, we recently awarded one such grant to the New

York City Department of Health and Mental Hygiene to enable the

meaningful measurement of the quality of care with a focus on

public health priority issues, disadvantaged populations and small

office practices.

We are very pleased to be collaborating with Dr. Kolodner’s office

on the funding of a report to review and analyze the best clinical

evidence on the use of health IT by the underserved, elderly and

disabled. We believe the findings from this analysis will give us

critical information that we need to ensure that these populations

reap the benefits of health IT. We have also just recently funded

a $3 million contract to provide technical assistance to up to 20

States on the best use of health IT to improve the quality of health

care for Medicaid and SCHIP beneficiaries.

Technical assistance is critical to the successful adoption and implementation of health IT and we take this so seriously that, from

the outset, we have created a national resource center for health

IT. This resource center leverages our investments by offering help

where it’s needed most in real-world clinical settings that may feel

ill-equipped, as my colleague described, to meet the implementation

challenge. So, by way of example, this resource center has assisted

States in their initiating Statewide clinical data-sharing and these

include New York, Wyoming, Montana, Maryland, Georgia, and

others. As my colleague noted, the resource provides a Web portal

with capabilities to convene practitioners, to encourage collaboration and to disseminate best practices.

Through our collaboration with HRSA, we have a special portal

for the Nation’s community health centers. We’ve also supported

providers in the Medicare health IT initiative and the Indian

Health Service, and we’ve seen some dramatic improvements in

care in the IHS.

So, Mr. Chairman, I’d like to conclude by offering just a few brief

observations on our work to date.

First, health IT alone cannot improve our health care system unless it is integrated and embedded in the very fabric of how we provide care.

Second, for most health care settings, health IT is not likely to

be an out-of-the-box solution. Effective use of health IT has to be

linked with a very careful examination of how care is delivered and

so that the power of health IT can be harnessed to enhance the effectiveness and the efficiency of care.

Third, accelerating the pace of adoption and implementation requires the sharing of both knowledge and experience through opportunities for voluntary peer-to-peer learning. It’s a fairly local

phenomenon.

39

Finally, the development of interoperable health IT can accelerate the pace of innovation and the speed with which patients will

benefit from new medical breakthroughs.

So I’d like to thank you for the opportunity to be here today. I

am confident that, in working together, we can ensure that all

Americans receive high-quality, safe health care services.

[The prepared statement of Dr. Clancy follows:]

40

41

42

43

44

45

46

47

48

49

50

Mr. TOWNS. Thank you.

Let me first thank all three of you for your testimony. Again, I

apologize for our lateness. There were votes on the floor and, you

know, you have to vote around here. You know, if you don’t vote,

they talk about you so that delayed us. So I wanted to just sort of

apologize for that.

Let me begin with some questions. You know, I’m concerned that

the communities that need health care, better health care, are generally the communities that will probably last be connected. I

mean, these are the communities that will sort of be left out.

What can we do to try and make certain that the communities

that have been neglected for so long are not neglected this time

around? What can we do to prevent that from happening?

Ms. AUSTEIN CASNOFF. Well, certainly that is the population that

we target, and those are the providers who we work with. Obviously, the majority of the patients we serve are uninsured. Over

two-thirds are minority populations, so HRSA’s mission is very

much geared toward addressing the needs and in providing the

highest quality care to those populations.

We do believe, as my peers today have talked about and as I’ve

talked about, that HIT is a very powerful tool to help move that

agenda forward; and I think you will hear as well from the next

panel some very specific examples, including one of our grantees

who is moving that forward and who is using HIT to accelerate the

pace of quality care in those kinds of communities. That’s specifically what our grants are targeted to do.

Mr. TOWNS. Any other comments?

Dr. KOLODNER. Mr. Chairman, as you know, we do have this national awareness of the need to move forward in health IT. And,

really, there have been fairly early efforts to move forward, and

there have been attempts to do this over the last 15 years. I would

say that the activities that have occurred in the last 3 years, actually, have made more progress than in the decade or two before

that.

What we need to do, as I’d mentioned, is to make sure that in

every aspect that we’re looking at, whether that’s the electronic

health record or the funding for resources there or the network and

how it is addressed or privacy and security policies and in understanding that there are difficult cultural biases and preferences,

that we need to take into account, to make sure, that as we do each

of these activities that we involve the community, that we involve

those who are members of the medically underserved communities

or those who are taking care of them.

Mr. TOWNS. Do you want to add anything, Dr. Clancy?

Dr. CLANCY. The only thing I’d add is, when I think about some

of the really dramatic successes we’ve seen, they include a number

of underserved communities; and I think our collective challenge in

working together and with you is to make sure that we can scale

this up as rapidly as possible. It is absolutely not a given that we

have to have a digital divide and that we can’t bring everyone

along together.

So, in New York City, you know, the Health and Hospitals Corp.

has been using a registry for the past few years, which is the specific application or functionality of an electronic health record to

51

track people with diabetes; and it makes a big difference. You can’t

do that on paper.

So that’s the kind of advance that I think we can insist on and

will continue to do so.

Mr. TOWNS. How about establishing an HIT empowerment zone,

a health empowerment zone?

You know, I’m looking at these empowerment zones around the

country and in other areas that have really done some remarkable

things. You know, I was in Harlem just recently, a place that was

just written off. They now have an empowerment zone there, and

it’s the place to be now. You know, people are fighting to get in

there, and they’re saying that the empowerment zone really made

the difference.

So when I look at areas that have all of these health disparities,

what about the possibility of creating an empowerment zone to deal

with the health issues in these areas? Because the traditional fashion—you know, for some reason, they have just not gotten service,

and so I just think that if we continue down the road—and you

mentioned in terms of 20 years. See, those communities might be

40 years; they might be no years, you know. So I’m just wondering,

what is your reaction to a possible empowerment zone that would

take this information and would come in and would make certain

that they get everything and get it first and then move forward?

Dr. CLANCY. Well, I guess, Mr. Chairman, I’m not exactly sure

what an ‘‘empowerment zone’’ is. We’d like to followup with you on

that.

Let me say that I think one terrific aspect of the work that Dr.

Kolodner’s office has launched, particularly in the Nationwide

Health Information Network, is the potential to connect public

health with clinical care. We know that we’ve seen as a result of

reporting on quality of care that we are starting to see improvements overall and a reduction in disparities for those activities that

take place in a clinician’s practice—so were the right tests ordered?—and so forth.

Where we’re seeing slower improvements are in those areas that

require chronic, ongoing care to achieve, for example, the optimal

control of diabetes, the control of risk factors for heart disease and

so forth. We believe that in order to actually advance those areas

of quality, we are going to need good connections between clinicians’ practices and resources in the community, and I think health

IT could be very powerful there. And I think that’s one of the potential, powerful applications of the Nationwide Health Information

Network; it’s that kind of connectivity that you need.

Mr. TOWNS. Right.

Dr. Kolodner, is there a written policy office that ties the implementation of health IT and grants to the reduction of health disparities? Is there a written policy?

Dr. KOLODNER. There is not a specific written policy.

What we have done is, as I’ve mentioned, in each of the activities

that we’ve undertaken, we have specifically written in language.

For example, on the grant contract agreement that we put out for

the AHIC successor, we specifically wrote that a consumer sector

would need to address the needs of healthy populations as well as

those of vulnerable, disadvantaged and chronically ill populations.

52

In the NHIN network contracts that we put out, when we put

out the first contract language, we said that to be considered as an

eligible health information exchange the applicants would need to

include different types of provider organizations, two of which must

include independent physician practices and safety net providers.

So, while we don’t have a single specific policy written in the office that says what we’re going to do, we actually have been embedding it in all of the activities that we’ve undertaken.

Mr. TOWNS. You know, let me ask, is there any coordination of

these programs? I’m just concerned about that. I mean, do agencies

talk to each other about what’s going on and about what needs to

go on?

You know, I was just listening to the comments made earlier by

Dr. Christensen when she was talking about it in terms of disparities and in terms of the numbers. Are the agencies talking to each

other as we move forward?

Dr. KOLODNER. Yes. Actually, if you had asked me that question

3 or 4 years ago, I think you would have found kind of spotty collaboration. What we have, in fact, been doing, especially in the last

few years, is increasing that.

I think one of the reasons that you might have a question about

that is we probably haven’t done as good a job of communicating

the activities that we have been doing, but we have, for example,

a Health IT Policy Council that is across the Federal agencies and

departments, and we have a Federal health architecture group that

involves 26 different agencies and departments. So we actually do

have collaboration going on, and we connect the appropriate levels

and the appropriate types of people in each of the departments and

agencies. And, as I’ve mentioned, not only across the Federal sector

but also with our activities with AHRQ and with others, we’re actually facilitating collaboration across the States and between the

Federal and the State entities.

So we are doing our very best. There are a lot of things that are

going on. I’m sure there’s opportunity for improvement, but I think

we actually have been doing a great deal of the collaboration in the

last couple of years.

Ms. AUSTEIN CASNOFF. If I may, collaboration is absolutely key

to what we do. We spend a very large part of our energy in working

with other agencies and in finding partners to help the safety net

providers.

For example, next week, we’re having our first-ever HRSA-HIT

grantee meeting with over 600 attendees—the title is Success

through Collaboration and we are very pleased that AHRQ is represented there—the National Coordinator, every Federal agency as

well as public and private sector organizations.

So we believe it is absolutely critical to not only HRSA’s activities but particularly to our grantees, and we are trying to educate

our grantees about collaboration with potentially nontraditional

partners as well, working with States, working with the Governors

and their legislatures, working with their Medicaid agencies. So we

absolutely emphasize that as critical to the movement of HIT in

the safety net community.

Mr. TOWNS. At this time, I yield to the ranking member, Congressman Bilbray.

53

Mr. BILBRAY. Thank you.

Dr. Clancy, you made a reference that 50 percent of your funds

are going to rural, 50 percent.

Dr. CLANCY. Yes.

Mr. BILBRAY. Off the top of your head, generally, what would

that be in comparison to the general population? 10 percent?

Dr. CLANCY. Do you mean what proportion of the U.S. population

is rural?

Mr. BILBRAY. Yes.

Dr. CLANCY. About 25 percent.

Mr. BILBRAY. You know, I grew up in a working class neighborhood where, without the Navy hospital, you had the clinic, and

that’s about it; you had the neighborhood. With the underserved

community, it was so easy for us to use race and to use ethnic

background, but, overall, the common denominator in my neighborhood was that we were working class people who were below the

average income. That’s pretty consistent. The economic status is

the largest determining factor with the underserved. Is that fair to

say?

Dr. CLANCY. What I can tell you is, from our annual report on

health care disparities, we see big gaps associated with individuals’

race and ethnicity, and we also see very large gaps for poor compared to high-income Americans.

Mr. BILBRAY. But don’t those ethnic groups tend to fall into the

same category as the ethnic? I mean, I find it hard to believe that

a lot of our Californians who live in Hollywood and who happen to

be African American are not going to be falling into the underserved population in their neighborhoods. You know, the poor tend

to be underserved no matter who you are. Do we move up into the

middle class and upper middle class where the minorities are getting hit pretty hard with it?

Dr. CLANCY. Both race or ethnicity and income turn out to be important and independent predictors of getting even poorer quality

of care than everyone else. They are, as you note, often closely associated, but they are independent. So there are members of racial

and ethnic minorities who have done much better, in terms of income, who still experience disparities.

Mr. BILBRAY. But the community base tends to be served, generally, substandardly in both areas?

Dr. CLANCY. Yes.

Mr. BILBRAY. The VA had a success story with Hurricane

Katrina in recovering the records. Why were you able to be so

much more effective at recovering records than the private sector

in New Orleans?

Be careful. You’ve got to remember that my wife is from New Orleans, so I lived through that. We had a house hit by Katrina.

Dr. KOLODNER. For about 20 years, the VA started investing in

health IT, and it was an effort that was led by the frontline clinicians, not just a top-down type of process. So the issue of top-down/

bottom-up, for example, is something I do not see as an either/or.

It has to be at both ends. Leadership has to say that we want to

do it, but the real innovation and creativity and motivation is going

to come from the frontline commissions. So the VA had, over that

54

period of time, been able to put in an information system that was

extensively used.

In many places, such as New Orleans, it was essentially

paperless. When the power went out in New Orleans and the veterans were trapped in the VA hospital, they did have emergency

power, and the electronic health record actually continued to run

up until the time that the last person was evacuated. And they

were able to take that information and within 24 hours have it

loaded so that wherever those people went, their information was

there and available. And I think that’s the kind of experience that

confirms the value of having the information electronically and the

tremendous improvement in the continuity of care not only in crises, but in other times as well, and improving the quality of care

that electronic health records allow.

Mr. BILBRAY. Doctor, the private sector for decades now has been

trying to get away from paper records and trying to go to electronic, and they haven’t been doing it because of some lofty vision

of fairness. They’ve basically been doing it because they feel it’s

cost-effective.

Is that fair enough to say that we should be able to implement

an IT system that, in the long run, will be more cost-effective than

maintaining the paper structure we have today?

Dr. KOLODNER. Yes, I think that would be very fair.

Mr. BILBRAY. The question will be then, where are we going with

the VA? Can the VA lead the Federal family by setting an example

for the rest of the Nation and lead through example rather than

through mandate?

Dr. KOLODNER. Well, we are working—with the collaboration I

mentioned, we actually have the VA, the Department of Defense

and the Human Health Service all at the table and helping with

the national health IT agenda, both connecting into the Nationwide

Health Information Network as well as at the table, advancing the

standards and embracing the standards themselves.

I think one of the things that those agencies have had as an advantage is that there’s a perfect alignment between the funding

and the incorporation of health IT. Right now, one of the challenges

we have is, with the disparate funding mechanisms we have and

with some of the perverse incentives there, that what we are working to do is to get not only solutions in place, but we are working

to align those adoption incentives so that we can move forward.

Mr. BILBRAY. You know, sadly, so often those who would be the

best served are the most scared of new technology. I mean, the real

scare tactics out there are people being scared of new technology

being used. It astonishes me the people who will talk about and be

worried about privacy, and then they’ll have a cell phone on their

hip or in their purse and they’ll have a credit card in their wallet.

Any one of us who uses either one of those devices can be extensively tracked even when the phone is turned off.

I always like making my constituents feel really comfortable with

that.

What are we doing about security with the IT issue? Any one of

you can answer that, but I know the VA has been pounded on this

for a while.

55

Dr. KOLODNER. The VA has been pounded on it. Although, if you

look at the instances, the electronic health record that is used for

the delivery of care isn’t where the breaches have occurred. We

know, as we roll out the national health IT agenda, that the security and the privacy of that information is absolutely fundamental.

I would not put my information on a system that’s not secure and

that’s not honoring the privacy in the way that I might want it. So

we’re building that into the foundation.

As to the certification of the products—of the electronic health

records—for example, security is one key factor for that certification criteria. With the Nationwide Health Information Network,

the security is a key part, and what we actually have done in the

trial implementations of the nine contracts that we’ve just let is

we’ve built in consumer choice as a requirement for participating,

where the individuals get to say whether or not they want their information to flow over the network at all or how they might want

it to flow.

So we believe that those are critical capabilities. We are still

learning how to balance those and how to make sure that we honor

those without actually causing an increased chance of giving them

bad care. So those are the kinds of things that we need to pursue.

Mr. BILBRAY. But isn’t it true that with cooperation and with the

biometric confirmation that IT has the potential, if done properly,

to substantially increase the security and privacy with documentation as opposed to the existing system where you have clerks going

through it and you have paper needing to be shredded and that

kind of issue?

Dr. KOLODNER. When done properly, health IT actually is much,

much better than the paper record.

Mr. BILBRAY. Ladies, do you have any comments to either one of

those issues?

Dr. CLANCY. I agree.

Mr. BILBRAY. Thank you very much.

I yield back, Mr. Chairman.

Mr. TOWNS. Thank you very much, Congressman Bilbray.

Congresswoman Christensen.

Mrs. CHRISTENSEN. Thank you, Mr. Chairman. I thank you and

the ranking member for allowing us to join you in this hearing.

I would just like to say, on the health empowerment zones, I

know Dr. Clancy has heard me talk about them, the part of H.R.

3014 that have been part of our minority health bill going back two

Congresses. I think it’s a very good concept, and it goes beyond

what you may know as REACH, the REACH Program, to allow

communities to have priority access for programs at any agency

that can help them meet their health care goals. So, in 3014, you’ll

see a little of what a ‘‘health empowerment zone’’ is.

Dr. Clancy, I guess I’ll start with you. We’ve been working together for a long time, so you probably can anticipate my first

question, which is, are any grants going to territories or are they

precluded from having some of these grants, the $166 million worth

of grants that are going to 41 States?

Dr. CLANCY. I was just checking with my experts here who are

closer to the actual detail. We do have a collaboration with Puerto

56

Rico. This was part of the collaboration we did with ONC, which

looked at information security and privacy policies and actually——

Mrs. CHRISTENSEN. The territories are eligible and can apply

competitively?

Dr. CLANCY. Yes. Yes.

Mrs. CHRISTENSEN. With regard to community health centers,

how many community health centers do we have in the country?

Ms. AUSTEIN CASNOFF. I believe there are over 1,000.

Mrs. CHRISTENSEN. Was that ‘‘18’’ number for community health

centers that have gotten grants? Are those all that have gotten—

I can go back to your testimony, Dr. Casnoff: Eighteen health centers were awarded high-impact EHR grants in 2007.

My question really is, since these are so central to the delivery

of health care in underserved communities, is there a long-term

plan to have all of them hooked up to HIT, all of them electronically, to have all of their medical activities electronic?

Ms. AUSTEIN CASNOFF. Well, we are still exploring how to get to

complete coverage for all of the health centers. Obviously, they

need to be part of the broader movement toward electronic records.

What we are doing is, in a sense, we are seeding; we are demonstrating; we are getting started and are helping each of our networks’ grantees move to more and more health centers. So we are

continuing to expand the number of health centers that are getting

HIT support, and we believe very strongly they need to do it together and not necessarily as individual health centers. So we

think they can learn from each other, benefit, reduce the risk of

purchasing. Each of our grants requires these networks to take on

new health centers and not continue to fund the same ones, so we

are moving in that direction.

Mrs. CHRISTENSEN. As the different agencies under Health and

Human Services collaborate, do you try to make sure that—because

HRSA has grants and Dr. Clancy’s agency has grants and there are

other grants in the department, do you try to coordinate so that

they are fairly spread across the country, so that one State isn’t

getting one from the agency for health care quality and research

grants and also getting yours? Are you spreading it around in your

collaboration?

Dr. KOLODNER. Many of the grants and contracts are a competitive process; and so, depending on whether it’s a contract or a

grant, we may be actually locked into what the ranking of the applicant is. But we do, in fact, sit down and look at where those different activities are occurring so that we can get as broad a spectrum as possible.

Mrs. CHRISTENSEN. Well, our communities don’t necessarily have

a lot of grant-writing expertise. I wonder how you accommodate for

communities that have high need but don’t really get the high

grades on the grant applications.

Ms. AUSTEIN CASNOFF. That was a very large priority of Dr.

Duke’s, the Administrator of HRSA, which was to make sure those

communities that, in a sense, were left behind in the grant process

received grants. So there was a whole special competition this year

for those areas that have never received a health center grant before, and we also work very closely—we have something called

‘‘planning grants,’’ because we heard from the communities that

57

not everybody was ready to move into a more sophisticated HIT,

so we actually did a special competition of relatively small grants

to get people started. We certainly recognize that not everyone is

at the same point.

Mrs. CHRISTENSEN. Dr. Kolodner, you said in your testimony that

the agency has taken specific steps to include medically underserved populations as you transition to the AHIC successor. Could

you tell us something about the steps that you’ve been taking?

Dr. KOLODNER. OK. That’s what I mentioned a little bit earlier.

The process that we’re doing right now is—we actually put out

a cooperative agreement type of grant. The applicants sent in their

applications by the end of September, and we are in the process of

selecting, but the messaging that we sent out to anybody who was

considering that application was, as I mentioned, the need to take

into account and to include a broad spectrum of consumers, including those who are from the vulnerable populations.

In addition, because it’s a cooperative agreement, we will be

working with the awardee to make sure that they, in fact, have at

the table, as part of the participating group, members from a variety of rural, underserved and medically vulnerable populations.

Mrs. CHRISTENSEN. Go ahead.

Ms. AUSTEIN CASNOFF. I was just going to add that any time

there is a public notice as Dr. Kolodner is referring to, we get that

out specifically to our HRSA grantees to make sure that they’re

aware of these public comment opportunities and to offer them the

opportunity to make sure that they do respond.

Dr. CLANCY. One other point. I’m sorry. When you were asking

about how we try to create a coherent portfolio and to make sure

that we’re reaching out, one of the ways that we do that—as a matter of fiscal responsibility, there are very specific checks and balances—for example, to make sure that we’re not funding the same

person in four different agencies to do the same work. In addition

to that, you heard Cheryl say that she served as a reviewer for our

grants. We also use set-aside mechanisms.

So, this year, in a portfolio of $21 million of grants that we were

going to make, we said we are going to set aside a few million dollars. Actually, we ended up investing more in underserved communities. We had about twice as much as we had set aside, which I

thought was actually a very good sign. So there is a fair amount

of outreach. I think we could do more, but we are working very

hard.

Mrs. CHRISTENSEN. Just as I’m going through—I’ll hold on any

other questions I might have for right now.

I wanted to just point out that some of you are familiar with the

minority AIDS initiative and the fact that when funds were to be

targeted to indigenous communities and faith-based groups, a lot of

other groups came in and started to change the board around. They

hired a new executive director and presented themselves as minority organizations.

So as you reach out to make sure that minorities are sitting at

the table, I just want to make sure that you’re aware of that and

that you try to get organizations or groups that are really from the

community.

Mr. TOWNS. Thank you very much.

58

Congressman Clay.

Mr. CLAY. Thank you, Mr. Chairman.

Let me start off with some questions for the entire panel.

Is there any consideration given to reducing health disparities in

either your grant deliverables or your grant strategy? And this is

along the same line of questioning as Dr. Christensen. In other

words, what health-policy objectives are you attempting to meet, in

terms of your agencies’ overall goals?

Ms. AUSTEIN CASNOFF. If I may begin, we actually asked anyone

applying for money this year to have a baseline set of core quality

measures. HRSA’s moving toward a consistent set of measures, and

we have built some of those specifically into our grants. And then

we will be monitoring; they will be required to report on those as

well.

So we absolutely are committed to quality measurement, because, again, HIT is not the end. It’s improving the quality of care

in a very quantitative, measurable way.

Mr. CLAY. OK.

Dr. Clancy.

Dr. CLANCY. Because we have the opportunity, which I would

like to thank you all for, to report annually to all of you on both

quality and disparities in care, what that means is that, for the

first time in this country, we actually have a consistent set of

metrics, and we can report our progress in terms of how we are

doing.

And for each group, in some areas we are doing better, in other

areas we’re about the same, and in some areas we’re doing worse.

We use that very specifically to frame a lot of priorities for our initiatives.

So, by way of example, our recent disparities report found some

pretty glaring problems for Hispanic elders. So that has resulted in

a collaboration with the Administration on Aging specifically targeting preventative services for Hispanic elders, because the rates

were so strikingly different.

So we’ve got the framework to be able to do that, and my colleagues will tell you that we’re not shy about sharing these results.

Mr. CLAY. Very good.

Anything to add, Doctor?

Dr. KOLODNER. Well, the activity of our office is actually fairly

small, in terms of the grant. It’s really trying to get the infrastructure in place. But, as I’ve mentioned, it is important that we make

sure that infrastructure be informed by the needs of all of the communities. And we have done the very best that we know how to get

that input and to make sure that those communities are involved.

We will continue to work in that direction.

Mr. CLAY. Thank you for that.

Another panel-wide question: The implementation of health IT

can be expensive, in terms of large-scale enterprise-type solutions.

Have you looked into smaller-scale technologies like smart cards,

cellular phones, to interconnect community health facilities?

Ms. AUSTEIN CASNOFF. One of the things we heard from our community, again, when we put out a Federal Register notice, was it

was not just about electronic health records, as you say, so we created something called the innovations grant. And we had, in a

59

sense, low-hanging fruit and heavy lifting. And it was just as you

said, for our health centers serving the populations in need, what

best serves their needs?

And you will hear on the next panel from one of the recipients

of that, about how personal health records or kiosks or e-prescribing or linking oral health or mental health to medical records. So

it is not always the biggest solution. Sometimes it is those intermediate solutions or building on something that is already in place.

So that’s absolutely a priority for our awards.

Dr. CLANCY. I mean, I’m sure you’re aware that in the health

care industry, generally, there is a lot of innovation going on, in

terms of using cell phones and other technologies to reach people

for disease management and other interventions. We have funded

a fair amount of work in this area.

In addition to that, we now have a clearinghouse where people

can share these innovations. And we are reaching out very broadly

so that people know about this, so they know about potential promising practices that will help them.

So it is not the full enterprise solution or paper, you know, that

there is steps on the way.

Mr. CLAY. Doctor.

Dr. KOLODNER. Well, the idea of having standards is that it actually breaks you free of a particular technology solution so that,

really, innovation can occur. And by making sure that the standards are there and not proprietary but are really open, I think it

fosters a tremendous amount of creativity and movement forward

for just the type of opportunities you are talking about.

Mr. CLAY. Thank you.

Mr. Chairman, is the clock malfunctioning? That 5 minutes went

awfully quick. Oh, it’s 3 minutes. I’m sorry.

Mr. TOWNS. Yes, yes, but if you need another half a minute, I’d

be delighted to give it to you.

Mr. CLAY. Thank you. I’m touched.

Just real quickly from all of you, are you using small or disadvantaged business vendors to supply your grantees with any

technological capability?

Ms. AUSTEIN CASNOFF. Well, we award grants to our health-center networks, and then they have to follow proper procedures to do

competitive purchasing. We do not get involved at all in their selection of products. But they do have to follow Government rules in

terms of competitive purchasing.

Mr. CLAY. But you do monitor who they award the contracts to?

Ms. AUSTEIN CASNOFF. Correct.

Mr. CLAY. And do you know if they use small or disadvantagedowned business?

Ms. AUSTEIN CASNOFF. I am not aware of that, but we can certainly get that information for you.

Mr. CLAY. Would you provide this committee with that, please?

Ms. AUSTEIN CASNOFF. Sure. OK.

Mr. CLAY. Thank you. I yield back.

Mr. TOWNS. Yeah, on that note, let me just say that—do other

agencies outside of HHS have health IT grants?

Dr. KOLODNER. I think the grants to the communities—USDA

has some grants. I don’t know that their communities—they do

60

have grants for electronic health records. FCC has some things; in

fact, they have a grant program that I think they will be announcing the results of shortly, that are medical broadband connectivity

to rural and underserved areas. And that is not just rural, but also

inner-cities.

There are others that do have related technologies but not usually for the kinds of health IT that HHS entities fund.

Mr. TOWNS. All right. How can we get a list of these grants? Is

there any way that we can—I will definitely be delighted to hold

the record open to get it—a list of all of these grants, because I

think the question raised by my colleague from Missouri, in reference to minority vendors, you know, I think that is something

that we need to really look into.

Dr. KOLODNER. I think we have a partial list. I can go see whether we can refresh that and get that back to you.

Mr. TOWNS. I appreciate that. Thank you so much.

Any other questions?

Let me thank all three of you for your testimony. I really feel

that this is a very important issue. I think that this is a way that

we can address some of the concerns that are out there. And I appreciate your honesty and the fact that there is a disparity in a

major kind of way, and we feel that through this process, maybe

we can correct some of these things. But in order to do it, you will

have to be flexible and to make certain that the areas that are not

served are served. And I think that’s key. You know, we don’t want

to leave them out again.

So thank you so much for coming. I look forward to working with

you in the days and months ahead.

And you will hear more about this empowerment zone. You

know, we think that has a lot of potential; we think that will help

us with the disparities. And, of course, we will be working on it.

And I want to thank Dr. Christensen for her efforts in this area.

I want to thank Congressman Clay and my colleague, Congressman Bilbray.

And I say about this committee, you know, in the Congress, we

have a lot of people that do not work together and do not work in

a bipartisan way. But I tell you now, this committee is a bipartisan

committee, and we work together.

Thank you so much.

Mr. BILBRAY. Because we fear the chairman; that’s why. [Laughter.]

Mr. TOWNS. Thank you so much.

[Witnesses sworn.]

Mr. TOWNS. Let the record reflect that all five have answered in

the affirmative.

So I want to start with you, Ms. Marchibroda, and then sort of

just move right down the line.

61

STATEMENTS OF JANET M. MARCHIBRODA, CEO, EHEALTH

INITIATIVE; DR. WINSTON PRICE, CHAIR, HEALTH IT AND

TRANSPARENCY ADVISORY BOARD, STATE OF GEORGIA;

LORI EVANS, DEPUTY COMMISSIONER FOR HEALTH IT

TRANSFORMATION, STATE OF NEW YORK; DR. FARZAD

MOSTASHARI, ASSISTANT COMMISSIONER, DEPARTMENT OF

HEALTH AND MENTAL HYGIENE, CITY OF NEW YORK; AND

DR. NEIL CALMAN, PRESIDENT, INSTITUTE FOR URBAN FAMILY HEALTH

STATEMENT OF JANET MARCHIBRODA

Ms. MARCHIBRODA. Good afternoon, Chairman Towns, Ranking

Member Bilbray, honorable subcommittee members, Dr.

Christensen, distinguished panelists and guests.

My name is Janet Marchibroda, and I am the chief executive officer of the eHealth Initiative. It is an honor to offer my testimony

before you today on Federal, State and local efforts to transform

health and health care using health information technology.

Chairman Towns, I greatly appreciate your invitation to address

this subcommittee, and I commend you for your leadership in furthering the use of health IT to improve health outcomes, enhance

access to care for medically underserved communities, and reduce

health disparities. We at the eHealth Initiative look forward to

working with you and the Health IT Empowerment Caucus.

The eHealth Initiative [eHI], is a nonprofit independent organization whose mission is to improve the quality, safety and efficiency of health care using information and information technology.

We are a diverse group representing every sector of health care,

both nationally and locally. We serve as a key bridge between national policy and local initiatives through our work in States and

communities, and actually helped 20 States in our country develop

road maps for using health IT and are working with a number of

regions to drive sustainability of health information exchange.

As my written testimony indicates, concerns about quality, safety

and disparities in care and rising health care costs have driven the

Federal Government and national and local leaders alike to look for

solutions to these challenges.

Because of the highly fragmented nature of our health care system, clinicians often don’t have the information they need to better

serve patients, those that are responsible for population health also

don’t have that information, and then, most importantly, patients

can’t easily engage in their own health and health care, view their

own health records or choose to share their health information

across clinicians who treat them.

And so, a lot is going on at the Federal level—that is in my written testimony—as well as the State level, and it’s very interesting.

A number of States are now moving forward with great vigor

around moving the health IT agenda. While there was no legislation prior to 2005, actually in 2005 and 2006, 38 States introduced

121 bills related to health IT, and 36 were passed in half of our

country’s States.

Since January 1 of this year, 217 bills have been introduced

across all 50 States in the United States related to health IT, and

62

also Governors are playing a significant role, with 20 Executive orders having been issued.

In addition, if we go one more level down, there are a number

of community-based initiatives—and we counted 165 back in

2006—that are bringing multiple stakeholders together to mobilize

data to improve health care quality and safety.

But, despite all of this activity, adoption has been slow for a

number of reasons. There is a lack of standards adoption that

would enable interoperability. There is a misalignment of incentives that often drives volume and fragmentation as opposed to

sharing information. There are some concerns about privacy and

confidentiality, and not to mention the significant workflow issues

within the small physician practice.

We put together, working with 200 organizations from every sector of health care, the ‘‘eHealth Initiative Blueprint: Building Consensus for Common Action,’’ which is a shared vision and a set of

common principles, strategies and actions for improving health

through information technology.

We were able to achieve consensus on a number of issues, but

there were two areas where more work, more dialog is needed. We

got to consensus on principles, but in the areas around policies for

information-sharing, and specifically financing, more work is needed, and a public-private sector dialog and partnership will be needed in order to move that work forward.

You asked us, top-down or bottom-up? Are there too many cooks

in the kitchen? And which approach will work best? We believe

that leadership needs to come from both but needs to be coordinated.

Clearly, a need for Federal leadership for moving this agenda,

particularly around adopting standards for interoperability, getting

harmonization in adopting, providing guidance on policies related

to information-sharing, and then, of course, stimulating the private-sector investment by providing necessary seed funding and

aligning incentives.

At the same time, much work is also needed at the State and

local level, and we are actually not going to get there just with the

top-down approach. And I will be very brief, as we watch the time.

We did some research, and we released it back in June 2007.

And what did it tell us? It said there are no incentives for sharing

information, or actually disincentives across the country for doctors

and hospitals and plans to share information, given our current

payment system. So those that have been successful have been able

to do so because they’ve built social capital, a radius of trust among

folks that don’t ordinarily work together, in order to move that forward. And you’ve got to do that locally, where health care is delivered. And you really need it in order to address those difficult policies for information-sharing. How do we address the privacy issues?

The other thing is just logistical. If you look, and our survey

shows, that the clinical data that you need to exchange to deliver

health care, most of it, a lot of it, resides locally, within the doctor’s

office, within the hospital, within local pharmacies. So, as a result,

the Nationwide Health Information Network will need to be built

from the ground up, but also linked with national networks, because there are many actors working at the national level.

63

So, in closing, some suggested actions for national and Federal

leadership.

First thing, we need to drive standards adoption. We need to harmonize and drive adoption for interoperability. And this is critical.

The Federal Government has made significant progress in the area

of standards so far. We believe that the transition of the AHIC over

the next several months will support the continuation of this work.

We believe that this transition, however, will require an independent convener that engages every sector of health care in an inclusive, transparent and balanced process that is designed to listen,

engage, synthesize and deliver a common path forward.

Second, the Federal Government should continue to lead and expand upon its efforts to develop a framework for privacy and security, leveraging things like the HISPC as well as the FACA committee under AHIC 1.0. We need to focus on aligning incentives, of

course, and that is a complicated problem that we’ll need to address, and a public-private sector dialog is needed.

But we think, in addition, much progress can be made today

through a public-private partnership that can provide guidance on

and stimulate shared action for how the field might move forward

on some short-term actions or business cases for the use of information, whether it is around quality, drug safety or consumer access for information.

The Federal Government is playing a leadership role in addressing disparities, but opportunities exist for more leadership in this

area. Health IT offers great promise for helping clinicians deliver

equitable care through evidence-based decision support, chronic

care management tools and population health functions.

But targeted resources must be provided to those clinicians who

serve minority and other underserved communities to ensure they

are not left behind in the drive to accelerate health IT adoption.

The Federal Government can play a strong role in ensuring that

the providers have the resources they need, whether it’s grants,

loans or hands-on help, to support this process.

In addition, the Federal Government——

Mr. TOWNS. If you could sum up. Yeah, the lighting is not working.

Ms. MARCHIBRODA. OK. Should I stop?

Mr. TOWNS. Sum up. Just sum up.

Ms. MARCHIBRODA. OK, I’ll sum up.

So around the areas of disparities, there are a number of areas

that need more Federal involvement in order to move this work forward.

Finally, and we heard earlier, providing technical assistance is

very important and particularly States and communities, as you

deal with sustainability, we need to focus on that area.

Thank you for the opportunity, and I look forward to answering

any questions you may have.

[The prepared statement of Ms. Marchibroda follows:]

64

65

66

67

68

69

70

71

72

73

74

75

M. TOWNS. Thank you very much.

Dr. Price.

STATEMENT OF WINSTON PRICE

Dr. PRICE. Thank you very much, and I hope you’re using the

same hearing timing technology.

Mr. Chairman, members of this committee, Members of the

House of Representatives, ladies and gentlemen, good afternoon.

I am Dr. Winston Price, a board-certified pediatrician working

both in New York and Georgia. I am also a past president of the

National Medical Association and the current chair of the Georgia

Health Information Technology and Transparency Board. On behalf

of the NMA and the Georgia HIT Board, I would like to thank you

for the privilege of testifying before you at this time on this vital

subject.

Mr. Towns and your staff deserves special mention in light of

your role in the preparation of this important hearing.

Throughout the 112-year history of the National Medical Association, we have been a leading voice in the struggle toward eliminating health disparities that affect not only our members but also the

millions of minority patients that we serve. As we embrace the innovations of the 21st century, we remain committed to the notion

that all Americans should have access to health care of the highest

quality. It is in this context that I have framed my remarks.

As the Nation addresses this subject, we must ask ourselves, are

vulnerable populations at the crossroads of a health care evolution,

or are they in someone’s cross-hairs during a health care revolution?

I think we can all agree that health care has evolved. The United

States leads the world in health care innovation, as noted, for example, by the many Nobel Prizes Americans continue to win in

medicine. The whole world seems to want to come to American hospitals, especially our teaching hospitals, for cutting-edge treatments and cures. Our pharmacy industry is the world’s most innovative and profitable.

But be that as it may, our health outcomes do not speak to that

same degree of advantages. Unfortunately—and you’ve heard from

the honorable Dr. Christensen, so I won’t belabor that issue

again—but America’s vulnerable populations do not display the

same high quality that we see in terms of the innovations that bespeak our health care system.

So is it a revolution? Well, many of us are now convinced that

America’s health care is in need of a revolution. If health care

innovators are the leading revolutionaries, then the concerns of the

Nation’s underserved populations must be their vox populi that informs their manifesto.

Our strategy for ensuring that this revolution efficiently addresses the needs of all Americans is that we must understand the

heavy weight as impacted by each of the following five factors and

I will be very brief with those.

Standards: And you heard the description about the importance

of standards in moving this health care HIT agenda forward.

Electronic health records: And you will hear from the other members of this panel, so I won’t go into detail about that. But let me

76

emphasize the fact that electronic health records is a key component of this HIT initiative. We have lessons learned from Katrina,

but I want you to not lose sight of the more than a half-million

children in foster care who suffer from a perennial Katrina every

day. These unfortunate individuals, similarly like the individuals

in Katrina, are separated from their family historians who could

fill in the health care history gaps and they, many of them, received fragmented, episodic and oftentimes substandard care without the benefit of available and continuous medical record.

Let me delve into pay-for-performance, very briefly, as the third

category. Now, many facets of determining the return on investment for HIT is centering around the fact that it’s going to improve

the quality of health care for Americans. But I must impress upon

you the fact that these initiatives, while well-intended under the

guise of improving quality, aim many times to position themselves

in such a way to redefine methodologies for physician reimbursement. We must ask ourselves, how will pay-for-performance affect

physicians’ practice patterns as they relate to sicker minority

groups? And given the sicker caseload of minority physicians, how

will pay-for-performance affect the viability of these physicians?

Now, we certainly believe that health disparity speaks for itself,

but we know that the main reason for minority physicians not getting involved with health information technology is the fact of

funding. Indeed, the Medical Records Institute’s survey in 2006, reported that the top two reasons for not engaging in health information technology was lack of adequate funding and lack of support

by the medical staff.

Process and outcomes is certainly important, as well.

And because time is up, I’m going to summarize in the last 30

seconds that we have between Brooklyn folks.

And that is, in Georgia, where I chair the Health Information

Technology Transparency Board, we recognize the importance of

addressing a number of the issues that we talked about earlier. We

have instituted a $1 million demonstration pilot project that we

targeted specifically to rural communities and some of the issues

that you raised earlier, in terms of making sure that minority vendors are involved in the engagement in those particular grants, are

things that we look at very consciously.

And, recently, we were awarded a $3.9 million grant from CMS

to look at the development of a transparency Web site. A transparency Web site to bring the quality and cost to the consumer are

two of the cornerstones of Secretary Leavitt’s initiatives to make

sure we move that health care agenda.

So I’m just going to tell you the broad categories. I promise I’m

only going to read the categories of the AMA recommendations to

move this forward: bridge the digital divide; amend the charter of

the American Health Information Community to make sure that

there is adequate representation by the minority community; create

HIT empowerment zones, something that you’ve been discussing already; implement a Medicare and Medicaid demonstration project

to identify payment methodologies that encourage participation and

make sure the underserved communities are part of the mix; and,

last, to coordinate the Federal data-collection process.

77

Mr. Chair, I want to thank you for the opportunity to speak with

you on this particularly important topic and we stand ready, at the

National Medical Association, to assist you in your movement forward. And I commend you on the selection of your committee members.

Thank you.

[The prepared statement of Dr. Price follows:]

78

79

80

81

82

83

84

85

86

87

88

89

90

91

92

93

94

95

96

97

98

Mr. TOWNS. Thank you very much, Dr. Price.

Ms. Evans.

STATEMENT OF LORI EVANS

Ms. EVANS. Good afternoon, Mr. Chairman, Ranking Member

Bilbray, Dr. Christensen. Thank you very much for inviting me

here today.

My name is Lori Evans. I am deputy commissioner at the New

York State Department of Health, responsible for our new Office of

Health Information Technology Transformation. I also had the fortune of helping launch the first national health IT office with Dr.

David Braylor, so I am especially excited about the topic of the

hearing today.

And I’m also thrilled to have two co-cooks with me, Doctors

Mostashari and Calman, who you will be hearing from as well.

In New York, we are currently investing approximately $150 million in health information technology to support our progress in improving health care quality, affordability and outcomes for all New

Yorkers.

The most important aspects of health IT is not software and computers; it is clinicians being able to make better treatment decisions and coordinating care more effectively. It’s about nurses and

pharmacists delivering safer therapies, and consumers and patients

making better choices from different health care options. It’s the

way people connect together across a fragmented delivery system,

from community health centers to physician offices, hospitals to

skilled nursing facilities, and even to the consumer’s home. It’s the

way information is retrieved and used to realize value from health

information technology.

Reforming our health care system will require many things,

which are under way in New York such as universal coverage, such

as long-term care and hospital restructuring and many other

things and it must also include vastly improved availability in use

of health information. Our success in New York and our success

across the country will be defined by whether or not we use information to improve patient care and to reduce health care costs and

to support different ways of paying for health care in different models of delivering care, especially in our most underserved areas.

In my written testimony, I provided a high level of discussion of

our approach in New York related to the funds that we have the

good fortune of spending. And there are really three foundations

that we are trying to realize in New York, that we are trying to

set in New York. And one is the technical, one the clinical, and one

is organizational.

And the technical foundation is about enabling the technical

interoperability and transformation of today’s largely paper-based

system to an electronic interconnected system and being able to

measure and report on quality in population health information.

The clinical foundation is about clinical adoption to attract the

sufficient demands for health IT from clinicians and the supply of

it from the industry. So we ensure that the health IT tools increase

the likelihood of success and are able to deliver value to those that

are using them and to result in patient care improvements.

99

And the organizational foundation is also crucial. It’s about governance and public trust and how health care clinicians can use

health information technology to succeed in patient care improvements, and for them to know that there their issues will be resolved in a reasonable way.

The successful adoption of health information technology must

emerge from these three intertwined capabilities. For example,

interoperability is as much a function of trust as technology or clinical participation, and it is achieved through policy and governance.

Regional health information organizations become very important in this context. RHIOs working with other RHIOs, the Government and others, are about creating this collaborative, multi-stakeholder environment that assures effective interoperability and

quality in population health improvement.

Another critical component of the organizational foundation is an

organization called the New York eHealth Collaborative. That is a

public-private statewide partnership in New York that is helping

to drive a lot of our work there.

Turning to the role of health information technology in improving

health outcomes and decreasing health disparities, I think this

agenda really starts with access to care. But I think this is also

where access to insurance and access to information go hand-inglove, because simply having health insurance is no guarantee that

there will be access to the right high-quality care at the right time

by the right clinician.

This requires a health care system that is restructured to create

a patient-centered model that emphasizes primary and preventive

care. In New York, we believe these reforms start with the Medicaid program. This requires changing our reimbursement system

from a system that rewards volumes of services to a system that

recognizes quality and improved outcomes and encourages the delivery of preventive care. Creating this quality-based or outcomesbased reimbursement system will require the widespread adoption

of health information technology, and that is the foundation that

we are trying to lay through our grant program.

Integrating prevention and quality measurement enabled by

health information technology offers tremendous potential in addressing and eliminating health disparities caused by a lack of prevention and access to the most effective health interventions.

Regarding the interplay of Federal and State government—and

I wish our Federal colleagues were still here—I think the interplay

is crucial to advance the socially optimal level and type of health

information technology adoption we need in New York and across

the United States. We don’t have too many cooks. We have too few

cooks. We need a solidification in funding of a coordinated structure and process comprised of Federal and State leadership, as well

as the health care community. And I think the three panelists from

New York today really symbolize that quite nicely.

Mr. TOWNS. Could you sum up?

Ms. EVANS. Sum up.

In the Congress, you know, we think that the lack of funding has

been significant. And to just have as bit of fun with the analogy

today, I think we have been served a small plate of lima beans. We

need many cooks contributing to a well-defined meal plan with all

100

food groups and proper nutritional levels. This, with the proper

funding, will lead to a feast of health information that will feed the

Nation’s health reform efforts.

Thank you.

[The prepared statement of Ms. Evans follows:]

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

Mr. TOWNS. That is why we are having this hearing, trying to

get you a balanced diet.

Ms. EVANS. Thank you.

Mr. TOWNS. Dr. Mostashari.

STATEMENT OF FARZAD MOSTASHARI

Dr. MOSTASHARI. Good afternoon, Chairman Towns and Ranking

Member Bilbray. I am Dr. Farzad Mostashari. I am assistant commissioner in charge of the Primary Care Information Project at the

New York City Department of Health and Mental Hygiene.

We heard that our current health care system does not deliver

health efficacy, efficiency or equity. Our system is rife with redundant, unnecessary and sometimes harmful interventions, while evidence-based, life-preserving measures are delivered only about half

the time. Health disparities are not addressed, or even exacerbated

by unequal delivery of services.

We, at all levels of government, as purchasers of health care and

as guardians of the health and safety of the public, now have a responsibility and an opportunity to create a new landscape for

health care.

Extension of electronic health records and establishment of policy

and standards for health information exchange are critical building

blocks, but they are not sufficient. A recent study in the Archives

of Medicine found that patient encounters conducted with electronic medical records, as currently designed and implemented, had

the same low quality of chronic disease management and preventive care as those conducted with paper records.

This may seem paradoxical but should not come as a surprise.

Consumers, purchasers and payers do not have the information

needed to recognize and incentivize providers who deliver better

prevention. So our reimbursement system rewards providers who

deliver more services, not prevention. It therefore follows that the

health care IT market and physician office workflows are also not

oriented toward prevention in chronic disease management.

In order to break this logjam, we need to simultaneously support

a restructuring of health IT, office workflows and reimbursement

systems. Once established, these new structures will be mutually

reinforcing, and market forces can finally be aligned to deliver improved health and value.

We believe that we have created a local model for this

transforation through the New York City Primary Care Information Project. Anchored by a city commitment of $27 million and approximately 40 staff members, we are implementing electronic

health records for over half of all high-volume Medicaid providers

in the city; establishing standards-based data transmission between practices in laboratories, pharmacies, health plans and hospitals; integrating prevention into EHR software and practice

workflows and enabling pay-for-prevention. Let me briefly describe

each of these interdependent pieces.

We are assisting more than 1,500 New York City primary care

providers to adopt prevention-oriented EHR systems over the next

2 years. This includes all 29 of the city’s federally qualified health

center networks. This group alone comprises 648 providers and half

116

a million patients, 50 percent of whom are on Medicaid and 20 percent of whom are uninsured.

We are also focusing on Medicaid providers among solo and small

practices, which provide most of the primary care in this country

but don’t have the financial, technical and quality-improvement resources of larger practices and the lowest rates of EHR adoption.

Bringing interoperability and health information exchange to

this community of safety-net providers has required a great deal of

effort on our part. As the Institute of Medicine’s recent report describes, the absence of a strategic plan and the lack of clear decisionmaking processes have hindered national progress on interoperability. They also suggest process and a commitment to evaluation and updating of standards based on experience in the field.

In our experience in the field, these Federal efforts have had a

measurable impact in some areas, but well-established and agreedupon standards are still not widely implemented. The absence of

policy guidance has resulted in slow standards developments in

some priority areas and the risk of overly hasty standards-setting

in other areas, including quality reporting in biosurveillance.

The impact of the planned transformation of the American health

information community is unknown, but in our opinion, it is unlikely that an industry-led entity will be able to provide the credible policy leadership to this process, as has been done in New York

through the work of the State Department of Health and the New

York eHealth Collaborative.

The policy leadership requirement extends to EHR functionality

as well as interoperability. Several features critical for improving

prevention are not consistently or effectively implemented in products meeting Certification Commission for Health Information

Technology’s standards. These include structured data collection for

a minimal set of required clinical items, like smoking status; registry tools for examining entire patient panels and generating lists

of patients for recall or anticipatory care; automated clinical quality

measurement, including the ability to view and analyze health disparities in every measure; and real-time, bilateral connections to

the public health system for immunization and disease reporting.

Unfortunately, practices are also not structured to effectively deliver or monitor preventive care. As part of our community initiative, we are working with safety-net providers to maximize the productivity of support staff, the completeness of necessary documentation, improve patient satisfaction. In some cases, we need to

design new workflows.

We believe that interoperable EHRs with registry functions implemented by practices that focus on quality of care can finally

produce reliable metrics of actual clinical outcomes. And this platform can be the basis for pilot physician recognition and paper-prevention incentive programs.

In conclusion, although I would like to gratefully acknowledge

the support we have received from CDC and ARC for research and

evaluation, New York City’s Primary Care Information Project is

an example of a community-led project with local innovation and

resources.

Healing our health care system using interoperable health information technology will require the resources and energy of all of

117

us at the Federal, State and local levels. There is a need for a common policy framework at the national level, but we cannot afford

overly prescriptive or premature policies or standards that would

thwart State and local innovation and stifle local investments.

We, and other communities like ours, could realize a great public

benefit from Federal legislation that provided funding and a comprehensive policy framework for EHR extension, health information

exchange, and quality-based recognition incentive programs if such

legislation included an explicit and pervasive emphasis on prevention, a concern for disadvantaged communities, support for community-based projects as the action arm for these activities, and a

commitment to fund and support the rigorous evaluation and optimization of these initiatives.

Thank you for the opportunity to testify. I’ll be happy to answer

questions.

[The prepared statement of Dr. Mostashari follows:]

118

119

120

121

122

123

124

125

126

127

128

Mr. TOWNS. Thank you very much.

Dr. Calman.

STATEMENT OF NEIL S. CALMAN

Dr. CALMAN. Chairman Towns, thank you for inviting me to provide testimony on this very critical issue of health information

technology and health information exchange. I am going to focus

my remarks very specifically on issues related to the care of those

who are traditionally underserved by our current health care system: the poor, the uninsured, the homeless, new immigrants, people of color, folks whose primary language is other than English,

those who are covered by Medicaid, in many cases, and other vulnerable groups.

I am a family physician still practicing in the Bronx and Manhattan for the past 31 years. I am also president and cofounder of

the Institute for Family Health. We are a Reach community; we

are a federally qualified health center. We operate 29 practices in

New York City and up in the mid Hudson Valley. We were founded

in 1983 with the specific goal of serving the underserved.

We serve 75,000 patients at our sites; 67 percent are black or

Hispanic; 12 percent are uninsured; 40 percent receive Medicaid;

65 percent are below 200 percent of the Federal policy level; and

18 percent require services in a language other than English.

In 2006, we had a thousand patients served who were homeless

and more than 600 with HIV/AIDS.

The institute is similar to over a thousand other community

health centers in this country. What is different about us is that,

in 2002, we made the investment to become one of the first community health center networks to implement a fully integrated electronic medical record and practice management system throughout

our entire network.

This has allowed us to enhance our services, significantly improving patient care through improved record keeping, tracking

systems, alerts to providers at the point of care, visit summaries,

which we give to our patients after each visit, and a vast library

of health educational material that are available in multiple languages.

The motivation for this project, interestingly, came out of our

work with REACH and our work with over 40 diverse organizations including 20 faith-based organizations whom we work with to

try to eliminate racial disparities in diabetes and cardiovascular

disease. We were recently named a National Center of Excellence

in Health Disparities.

I want to give you four very specific examples of how health information technology works in this safety net.

First of all, alerts to providers, to our providers reminding them

to give pneumonia vaccine to patients over 65 brought the number

of vaccine dosages that we give a month from 23 to 395 a month.

An alert which asks nurses to ask a two question depression

screening questionnaire brought our rate of depression screening

from 4 percent to over 90 percent within 4 months of implementing

this technology.

Talking about recall systems, there was a recent study which

showed that 7 percent of all people taking a blood pressure mediVerDate 11-MAY-2000 09:46 Jan 09, 2009 Jkt 000000 PO 00000 Frm 00132 Fmt 6633 Sfmt 6633 C:\DOCS\45627.TXT KATIE PsN: KATIE
129

cine called ace inhibitors, if they take it in the first trimester of

pregnancy, will give birth to a baby with severe cardiac or respiratory birth defects. Within a day of the study being released, we

identified 225 people in our practice who were taking this medication, women of child bearing age, and reached out to every single

one of them to warn them that if they were going to become pregnant, that they needed to stop the medication.

These kinds of activities were completely unable to be done before the implementation of health information technology.

We also provide data to the New York City Department of

Health and Mental Hygiene every day on the symptoms and findings in our patients in the city.

This resulted in putting our information into their syndromic

surveillance system of identifying the onset of the flu epidemic in

2004, 13 days before the data from any of their other data sources.

There are dozens of other examples of how health information

technology and information exchange in service to our most vulnerable and needy populations is a worthwhile investment.

I would like to end with some very specific recommendations for

this as we move forward.

We have to ensure that all legislation and funding that supports

the implementation of electronic health records targets the patients

at highest risk in our society. All of the developments must have

organized ways for community participation in planning and execution. This is something that, to date, has been sorely lacking.

We need to make sure that providers in the health care safety

net are included as primary targets for funding.

Two, we need to make sure that in health information exchange

networks that community health centers and other safety net providers are required to be participants in these networks and in

order to participate in them, they need electronic health records. So

you can’t participate in health information exchange if you don’t

have the core fundamentals of electronic health records in your system.

Three, we need to fund the integration of electronic health

records into systems like those run by the city department of

health so that we become part of a monitoring system that monitors the care of vulnerable populations, and that can only be done

if we aggregate our information and send it to our local health departments.

Four, we have to mandate that all electronic health record systems capture data on race, ethnicity, primary language because

otherwise we have no mechanism for determining whether people

being cared for in the big academic medical center in New York

City are being cared for the same irrespective of race or their insurance coverage.

Five, we have to encourage electronic health record vendors to

find mechanisms to help flag people who are eligible for clinical

trials. Underrepresented—minorities are vastly underrepresented

in clinical trials, and so the data that comes from those trials turns

out to be of very limited usefulness in treating those populations.

There are only a few more.

Six, we have to require that EHR certification requires that information that is produced by electronic health records for patient

130

consumption, such as health education materials, visit summaries,

portals that allow patients internet access, all have to be made

available in multiple languages and in a fourth grade literacy level.

We have to ensure that all rural areas and all public housing

projects are wired, that all rural areas deploy broadband technology and that broadband access is provided in all newly funded

public housing, and we need to set a date when all existing public

housing needs to have broadband technology; otherwise we are not

going to have access in those places.

Finally, we have to require input of communities of color in planning privacy and security requirements. Dr. Price mentioned this

before, but privacy and security mean different things in communities of color than they mean for the rest of our society.

There have been enough examples of abuses that people do not

trust when information is shared without adequate protections.

We have to provide resources for health information technology

in places where the most vulnerable patients are served in prison,

in our foster care agencies, in homeless health care sites, migrant

health care providers. We have to create a national system for specifically monitoring the impact of health information technology,

and I believe one of you asked, but every single grant program

should be required to report on the impact of the dollars that are

being spent on disparities in the communities that they serve.

I have provided the subcommittee a complete analysis of these

issues as well as detailed examples of how our institute has

achieved substantial success in some but not all of these areas. And

I make myself available to you as you explore this issue further to

work with the subcommittee or any Members of Congress who seek

to further understand and address the important issues of health

information technology in our most vulnerable communities.

Thank you.

[The prepared statement of Dr. Calman follows:]

131

132

133

134

135

136

137

138

139

140

141

142

143

144

145

Mr. TOWNS. Let me thank all five of you for your statements. I

really, really feel you were very helpful in terms of sharing.

Let me just move to you, Dr. Price.

Are there any issues that African American doctors may have

adopting this technology, and what can we do to facilitate them if

there are able to be helped? What can we do?

Dr. PRICE. Well, I think some of those points were raised by a

number of the speakers. Cost is the No. 1 issue in terms of implementation. I think that many of the programs that you heard about

from the Federal agencies have all of the right rhetoric and nice

touchy-feely sounds about getting into communities, but physicians

are facing decreasing reimbursement, increasing liability costs, and

the expense of health information technology is just not a priority

right now, even though they recognize the benefits, such as Doctor

Calman explained.

So I think the best things that can be done are similar to what

CMS just announced, getting the systems in as a basic course of

business for doing good medical care and in the territories as well

to make sure the Virgin Islands and Puerto Rico and Guam are

also covered.

Mr. TOWNS. Let me ask this question. I really should have dealt

with the Federal agencies on this.

This is an area that I am really concerned about.

You know, now we have physicians that are in private practice

and, of course, still single practice and you know, when they expire,

nobody comes into that practice. That is a thing of the past.

What happens with those records of those doctors that have been

practicing for 40, 45 years, have a room full of records that are now

there? What happens? Because in many instances, these are people

that have had, you know, serious kinds of operations and all kinds

of things, these records are going to be there and nobody wants to

be responsible, you know, for them in bringing them. So what do

we do with a case like that?

Dr. PRICE. There are technologically possible ways to integrate

that by scanning and digital archiving those records, but for the

most part, those records sit dormant in damp basements unbeknownst to anyone.

I think as we move forward—I think one of the key issues is that

the health care of the future is going to be improved as we get

more people to enter their data into electronic health records and

also as we improve the issue of personalized health records so individuals can carry their information with them.

Mr. TOWNS. Because in the old days, somebody would come buy

the practice.

Dr. PRICE. Someone would buy the practice but wouldn’t want to

decipher the scribbly notes that are on 3-by–5 index cards.

Mr. TOWNS. I yield to my colleague.

Ms. CHRISTENSEN. Thank you, Mr. Towns.

Thank you all for being here.

Dr. Calman, and maybe you said it in your testimony, if you did,

I missed it. Did you have problems getting your patients in the

health center and the community that you are serving to accept the

electronic medical records?

146

Dr. CALMAN. Actually, they love it. What we did when we set it

up, we based it on the focus groups that we had done with our

REACH colleagues, and what we found out was that trust was one

of the biggest issues that our community faced. So when we set it

up, we used that as sort of a framework for everything from how

we designed the exam rooms to how we designed the electronic

health records. I’ll give you two examples.

We put flat panel monitors in the exam room so the patients can

watch when the doctors are recording the visit on the screen. They

can also look at their health education materials, diagrams of different health education, things that the doctors can bring up when

they are seeing the patient.

We also created what is called an after-visit summary. So far

only available in English, but we are now working on ways to see

if we can translate it into other languages so that literally at the

end of a visit in our center, we hand a patient a copy of everything

that was written about them that day, including new lab reports,

new X-ray reports and even though people can’t necessarily read

this, there is something incredibly symbolic when you say to the

patient, there is nothing that I have about you, there is nothing

that I know about you that I don’t feel comfortable sharing with

you.

This was more of a transformation for our providers than it was

for the patients. The patients were anxious to get their information. The providers were initially reluctant to give it to them. But

now have basically complied.

Ms. CHRISTENSEN. Thank you. So the concerns we have that people are going to be afraid for their privacy and everybody knowing

their medical history, you were able to overcome this?

Dr. CALMAN. We have taken a slightly different approach in that

we believe that before we can share information about patients in

a network, whether it is a national network or a State-wide network, patients have to have access to that information themselves.

They need to know what is in their record before we go putting it

out on the airwaves, and I think that is critically important. So

that it will be years before we are all connected, but we have already, for the last 5 years, started to transform that process. And

hopefully by this fall—one of the grants we got from HRSA was a

grant to implement a patient portal into our electronic health

records.

So patients will be able to, either through the Internet or

through kiosks in our waiting room, look at their own records with

the help of an assistant who will teach them about that, and we

are looking at that as a way of both bridging their health literacy

issues but also their technology literacy issues as kind of a double

win.

Dr. PRICE. I know you are familiar with the discrimination that

disproportionately affected African American and Latinos when

health information was inadvertently shared, particularly in the

light of sickle cell disease and early on in the game with HIV.

I think we are going to need in the medical community to turn

back to the legislature to put some real teeth behind the inappropriate gathering of health information by hacking into health systems and sharing or using that information to discriminate. We

147

don’t need that kind of a negative throwback on some of the innovative projects that are going on, like Dr. Calman described, but

without those teeth, those things will happen. And they must be

dealt with appropriately for our community to have real trust and

not be concerned about Tuskegee coming back again.

Ms. CHRISTENSEN. While you’re at your mic, Dr. Price, do you

have any ideas, just in MNA membership, how many MNA physicians are using electronic medical records now?

The USA Today says under 35, 44 percent; 65 and older, 18; 55–

64, 18 and the rest somewhere in between that. Do you know—do

we have any idea?

Dr. PRICE. It is 35 percent of those who are in hospital based systems. It is probably closer to 10 percent for individual practitioners

and the ones that are using practices.

We are in the process of finalizing a survey that we are going

to do electronically and by fax of our entire membership to be able

to give you those numbers, so hopefully within the next couple of

months.

Ms. CHRISTENSEN. Do you think that it is possible to do pay-forperformance across the board without having electronic, you know,

electronic medical records in a fully network system?

Dr. PRICE. Absolutely not. Not effectively, and it is pay-for-performing for many of our physicians. We are concerned about the

methodology that is used. As many of you are well aware, if the

right data is not being used to set up the metrics for pay-for-performance, with a sicker population we suffer in any of those

schemas, in particularly if they use as a method of reimbursement.

Ms. CHRISTENSEN. Ms. Evans and Dr. Mostashari, I am sorry

that I had to step out and take a call during part of each of your

testimony. You may have talked about this before. But what specific outreach was made to ensure that providers in poor—your

poor communities in New York City were able to participate?

Dr. MOSTASHARI. I am very happy to answer that.

Our target population are Medicaid providers in New York City.

We also—so our first group of outreach was community health centers, and that was a group of community health centers, a consortium that we brought together of every single community health

center network in New York City. So that was the first kind of the

backbone of our safety net system that we worked with.

Then we started looking at the small providers, and we actually

have a program in Harlem, South Bronx and Central Brooklyn,

and we went to every single practice in Harlem, South Bronx and

central Brooklyn, every single one. We visited them, we talked to

them, we developed this brochure that talks about readiness for

adopting electronic health record system, protecting patient data,

the small practice economics, health information exchange; what

does it mean to the practice?

So we actually get more time with the providers than the pharmaceutical companies do.

And we are also, you know, continuing to put the word out there

to hospital affiliated providers, to the ethnic IPAs and others to say

this is exactly the—if you care for medically underserved populations, we want to sponsor you to get in the electronic health

record.

148

And I think an important point I want to add here, I am not sure

if I made that point clearly in my testimony was, you can’t support

people getting electronic health records by just giving them cash.

To effectively create a cocoon of services around EHR adoption and

quality improvement, we need boots on the ground. Mailing a check

from Washington isn’t going to do it, and that is what we have

built. That is what we found; we need to have in our community

and every community that the Federal Government wants to see

the entire EHR adoption really happen and really have gains for

prevention and gains for population health, we need that local

presence, that community network.

Ms. CHRISTENSEN. Thank you.

Mr. TOWNS. Let me ask you, one question to you, Ms.

Marchibroda.

I’m sure you know that people of color can be less trustful of the

Federal Government and of the Federal agencies and, of course,

technology, too. Since you are one of the primary health IT collaborators, how do you intend to address these concerns?

Ms. MARCHIBRODA. Chairman, getting to agreement on policies

for information-sharing is probably one of the most important

things that folks at the State and local levels engage in. What we

tell them and what they’re doing—and those who are successful are

having those hard conversations about building trust and what

policies will work for us, whether we’re in New Hampshire or in

Oklahoma City or in Los Angeles, around what rules or policies

will we put in place to protect privacy and confidentiality. What

are we comfortable with among us? How do patients and consumers feel about this?

There are a number of tools out there that are actually helping

State and regional leaders, including one delivered by Connecting

for Health with the Markle Foundation and with support by the

Robert Wood Johnson Foundation that is providing a toolkit, if you

will, for having those tough conversations.

But you can’t shortcut it. You can’t get to the technical aspects

of this, until you begin to have those tough conversations about

what policies will be put in place to build trust.

Mr. TOWNS. Let me thank all of you for your testimony, and, of

course, we really appreciate your sharing with us. And we are convinced we have a long way to go, no ifs, ands or buts about it.

Dr. Calman, I am really impressed with what you’re doing, and

I know it has not been easy because of the fact that, at times, the

support system has not really been in place or has been cooperative. But we really realize, in order to really deal with the health

care disparities that this is one thing that we need to try and fix

and try and fix it as soon as possible.

So you can be assured that we will be working on this side to

try and get the resources out and to try and highlight how important it is to move forward in this direction. And we’ll be recognizing

that there will be problems as we move forward, but in working together, I am sure we’ll be able to solve them.

Thank you again for your testimony.

The subcommittee stands adjourned.

[Whereupon, at 5:15 p.m., the subcommittee was adjourned.]

[Additional information submitted for the hearing record follows:]

149

150

151

152

153

154

155

156

157

158

159

160

161

162

163

164

165

166

167

Æ