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[Senate Hearing 114-703]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 114-703

         ACHIEVING THE PROMISE OF HEALTH INFORMATION TECHNOLOGY

=======================================================================

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                                   ON

    EXAMINING ACHIEVING THE PROMISE OF HEALTH INFORMATION TECHNOLOGY

                               __________

                            OCTOBER 1, 2015

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

      Available via the World Wide Web: http://www.gpo.gov/fdsys/

                                   ______
		 
                     U.S. GOVERNMENT PUBLISHING OFFICE 
		 
31-167                    WASHINGTON : 2017                 

          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                  LAMAR ALEXANDER, Tennessee, Chairman

MICHAEL B. ENZI, Wyoming             PATTY MURRAY, Washington
RICHARD BURR, North Carolina         BARBARA A. MIKULSKI, Maryland
JOHNNY ISAKSON, Georgia              BERNARD SANDERS (I), Vermont
RAND PAUL, Kentucky                  ROBERT P. CASEY, JR., Pennsylvania
SUSAN COLLINS, Maine                 AL FRANKEN, Minnesota
LISA MURKOWSKI, Alaska               MICHAEL F. BENNET, Colorado
MARK KIRK, Illinois                  SHELDON WHITEHOUSE, Rhode Island
TIM SCOTT, South Carolina            TAMMY BALDWIN, Wisconsin
ORRIN G. HATCH, Utah                 CHRISTOPHER S. MURPHY, Connecticut
PAT ROBERTS, Kansas                  ELIZABETH WARREN, Massachusetts
BILL CASSIDY, M.D., Louisiana
                        
               David P. Cleary, Republican Staff Director
                  Evan Schatz, Minority Staff Director
              John Righter, Minority Deputy Staff Director

                                  (ii)

  

                            C O N T E N T S

                               __________

                               STATEMENTS

                       THURSDAY, OCTOBER 1, 2015

                                                                   Page

                           Committee Members

Alexander, Hon. Lamar, Chairman, Committee on Health, Education, 
  Labor and Pensions,............................................     1
Murray, Hon. Patty, a U.S. Senator from the State of Washington, 
  opening statement..............................................     4
Burr, Hon. Richard, a U.S. Senator from the State of North 
  Carolina.......................................................    21
Casey, Hon. Robert P., Jr., a U.S. Senator from the State of 
  Pennsylvania...................................................    23
Cassidy, Hon. Bill, a U.S. Senator from the State of Louisiana...    25
Franken, Hon. Al, a U.S. Senator from the State of Minnesota.....    27
Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin..    29
Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode 
  Island.........................................................    31
Warren, Hon. Elizabeth, a U.S. Senator from the State of 
  Massachusetts..................................................    33

                               Witnesses

DeSalvo, Karen, M.D., MPH, MSc, National Coordinator for Health 
  Information Technology, Department of Health and Human 
  Services, U.S. Department of Health and Human Services, New 
  Orleans, LA....................................................     6
    Prepared statement...........................................     8
Conway, Patrick M.D., MSc, Acting Principal Deputy Administrator, 
  Deputy Administrator for Innovation and Quality, Centers for 
  Medicare and Medicaid Services Chief Medical Officer, Centers 
  for Medicare and Medicaid, College Station, TX.................    11
    Prepared statement...........................................    13

                                 (iii)

  

 
         ACHIEVING THE PROMISE OF HEALTH INFORMATION TECHNOLOGY

                              ----------                              

                       THURSDAY, OCTOBER 1, 2015

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:01 a.m., in 
room SD-430, Dirksen Senate Office Building, Hon. Lamar 
Alexander, chairman of the committee, presiding.
    Present: Senators Alexander, Burr, Cassidy, Murray, Casey, 
Franken, Bennet, Whitehouse, Baldwin, and Warren.

                 Opening Statement of Senator Alexander

    The Chairman. Good morning. The Committee on Health, 
Education, Labor, and Pensions will please come to order.
    This is our sixth hearing in this Congress on health 
information technology and the government's electronic health 
records program. Senator Murray and I will each have an opening 
statement, and then we'll introduce our panel of witnesses. 
After our witnesses' testimony, Senators will have about 5 
minutes of questions.
    This is a wrap-up session. We've really been working 
together, the committee staff on the Democratic and Republican 
side, and we've worked with the Administration to see if, 
jointly, we could improve electronic health record systems.
    Senator Murray and I were just talking a little earlier. I 
don't want anybody to think that the committee's goal on either 
the Republican or the Democratic side is not to move forward on 
electronic healthcare records. We don't want to stop them. We 
want to get them right, although we might have different 
opinions about how to get it right. I think I can speak for 
Democrats as well as Republicans on that.
    Over the last 5 years, the taxpayers have spent about $30 
billion to encourage doctors and hospitals to adopt electronic 
health records systems. The whole purpose of this is to benefit 
patients so that they and their healthcare providers have 
quicker and better access to their health histories, and their 
doctors, hospitals and pharmacists can provide them with better 
care. Making electronic health records succeed is essential to 
the biomedical research and innovation legislation that we hope 
to mark up and finish this year and have ready for the full 
Senate to work on.
    No. 1, it's especially critical to President Obama's 
Precision Medicine Initiative to assemble 1 million genomes and 
allow doctors to take advantage of that genomic information to 
prescribe the right medications in the right quantity at the 
right time. It doesn't make any sense to go to all this trouble 
to gather the information if you can't use it effectively.
    No. 2, getting electronic health records is also important 
to the shared goal between the Administration and Congress 
adopted in recent legislation--the doc-fix legislation, we call 
it--to change the way the Medicare program pays doctors so that 
Medicare is paying providers based on the quality rather than 
the quantity of care they give patients.
    Under the new Merit-Based Incentive Payment System, 25 
percent of the score that determines a provider's penalty or 
bonus payment will be based on participation in meaningful use 
and how well they comply with the regulations involving 
electronic health records. You're not going to be very 
successful with a merit-based system if electronic health 
records aren't working.
    We're now entering a period where the government is 
penalizing doctors and hospitals if they do not adopt 
electronic health records systems instead of giving them money 
as an incentive. Stage 1 of Meaningful Use has been a success. 
Stage 2 is not a success. Only 12 percent of doctors and 40 
percent of hospitals have been able to attest to Stage 2.
    The Administration has revised its rules for Stage 2. Most 
people believe it would be a big help to adopt that final rule 
immediately. I have urged those rules for Stage 2 be adopted 
immediately. I have also asked the government to make the rules 
final for Stage 3, to require doctors and hospitals to create 
electronic health records, no sooner than January 1 of 2017, 
and that the Stage 3 requirements be phased in at a rate that 
reflects how successfully the program is being implemented.
    Patients need an interoperable system that enables doctors 
and hospitals to share their records, but they need time to do 
it right. There are no reasons I've found not to do it on the 
schedule I've just suggested: Stage 2 now, Stage 3 in a year.
    There are five reasons--and I won't go into detail about 
them, but I'm going to mention each one--to do it according to 
the schedule I've suggested. One is only 12 percent of doctors 
and 40 percent of hospitals have attested to Stage 2. Rushing 
out Stage 3 seems premature.
    No. 2, I've mentioned that within the merit-based payment 
system for doctors, 25 percent of the penalties or incentives 
depend upon attesting to meaningful use. It's important that 
meaningful use be right. Just this week, the Administration 
began the process to develop regulations for its value-based 
payment system. It makes sense for the final stage of 
electronic health records to be developed at the same time you 
develop your merit-based payment system records.
    No. 3, several of the leading medical institutions in the 
country--and I won't name them--have recommended that we take 
more time on Stage 3. One of those, one of the finest, said it 
was literally terrified of Stage 3. That's no way to have a 
success.
    No. 4, the Government Accountability Office this week 
issued a report saying that complying with the meaningful use 
program is taking so much time that it's actually preventing 
work on interoperability.
    And, finally, we're working on legislation which we hope 
that the full Senate and Congress will adopt next year. We'll 
finish, we hope, in this committee this year and adopt it next 
year with our 21st Century Cures. We want to do in our 
legislation what the Administration can't do administratively. 
It would make sense to me to do that together.
    We're working on physician documentation; giving patients 
better access to their own records; encouraging the entire 
health team. We're working on things essential to 
interoperability; data blocking; certification; improving 
standards; security and privacy of patient records. All of 
those things help make electronic health records a better 
system.
    I visited the Budget Director the other day and gave this 
advice:

          ``When I was young and playing the piano, I used to 
        like to play fast, and my piano teacher would say to 
        me, `Lamar, play the music a little slower than you can 
        play it, and you're more likely to get it right when 
        you have a recital.' ''

    Well, my advice to the Administration on this is similar. 
You could go ahead with Stage 3, but I would suggest you go a 
little slower than you need to go and make sure you don't make 
a mistake.
    Senator Thune, chairman of the Commerce Committee, and I 
wrote a letter to the Administration suggesting the schedule 
I've just described. A bipartisan group of 96 Republicans and 
20 Democrats in the House did the same. I've got four letters 
I'd ask consent to put in the record reflecting that advice 
also from doctors and hospitals and others.
    [The information referred to may be found in Additional 
Material.]
    The Chairman. I want to make sure what I'm about to say 
isn't misunderstood, and I'll conclude and go to Senator 
Murray. We have an opportunity in Congress to carefully review 
whatever decision the Administration makes about how we 
proceed. One way we can do that is through the innovation 
legislation we're working on. Another way is through the 
congressional review process if we don't like the rule.
    I hope one of the lessons from the Affordable Care Act is 
that it's better to move ahead with consensus if you can get 
consensus. You can get consensus here. Republicans and 
Democrats want electronic health records to succeed for the 
benefit of the patients of this country and because it's 
critical to at least two of the Administration's major 
initiatives, precision medicine and merit-based payment.
    Why not move ahead on a schedule that adopts Stage 2 now 
and Stage 3 in a year and use the time between now and then to 
develop support and build on consensus and get doctors, 
hospitals and vendors to buy into what you're doing and go out 
of office at the end of the next year with a big success 
instead of a big problem? The big problem would be if you 
prematurely announce the rule and the people who don't like it 
try to repeal it from the day you do it.
    Senator Murray.

                  Opening Statement of Senator Murray

    Senator Murray. Well, thank you very much, Mr. Chairman.
    Dr. DeSalvo and Dr. Conway, thank you so much for taking 
the time to be here and for all you do to help improve the 
health and well-being of families across our country.
    I also want to thank all of our colleagues who are joining 
us today and for the bipartisan commitment all of you have 
shown to improving our Nation's health IT infrastructure.
    This is the sixth and final hearing in a series intended to 
explore ways that Congress can help improve health IT for 
patients and providers. Over the course of this conversation, 
we've heard striking examples that show how important 
electronic medical records are to providing patients with the 
care they need.
    Whether it's understanding a loved one's full medical 
history or being able to look up your own healthcare 
information online or using a patient's medical record to catch 
a dangerous interaction between medicines, it is very clear 
that a strong health IT infrastructure is a critical part of 
building a healthcare system that works for patients and 
families and puts their needs first.
    Hospitals and providers have made great strides over the 
last few years when it comes to adopting health IT. Today, 
almost 83 percent of physicians use some form of electronic 
health record s. That is compared to just 18 percent in 2001. 
The HITECH Act that passed in 2009 was a big part of that 
transformation, and I am very grateful for the work that so 
many doctors and hospitals have done to bring our healthcare 
system into the 21st century and improve the value and quality 
of care patients receive.
    There is certainly more to do, and I'm pleased that over 
the last few months, this committee has explored ways to build 
on this progress in a bipartisan way. I've been very focused on 
a few areas in particular.
    I believe that we need to prioritize standards so that, 
increasingly, systems developed by different vendors and used 
by different doctors are actually able to speak to each other. 
In the same way that an email sent from a gmail account makes 
sense when it's opened in Yahoo, data in one EHR system should 
be structured so that it makes sense in others.
    Other industries have been able to converge around common 
standards for exchanging digital information. It is important 
that healthcare organizations continue to adopt a standardized 
approach to sharing and using electronic health information. 
These standards would not only support important research but 
they would also cut down on the amount of time providers spend 
on administrative tasks and allow them to focus resources on 
providing care.
    We also need to continue supporting the development of a 
network of networks so that providers have many options for 
trustworthy information sharing and they don't have to reinvent 
the wheel every time they need to exchange information with a 
new facility. Put simply, this is like making sure that someone 
with a Verizon plan can call someone with a Sprint plan.
    Many organizations are working hard on this already. They 
are developing networks that allow information to be shared 
between patients' different health care providers.
    One great example is in my home State of Washington, the 
Everett Clinic. They have set up an infrastructure to share 
information with 121 different providers, helping to make sure 
a doctor has as much information as possible on hand about her 
patient's health. This is an effort Senator Baldwin is 
especially interested in, and I really appreciate her work on 
it.
    We should also look for ways to make it easier for 
providers to shop for electronic records systems and vote with 
their feet when one isn't working or when an organization is, 
as we've discussed in the committee, unnecessarily withholding 
data. I know that Senators Whitehouse and Cassidy have been 
very focused on this last challenge and on ensuring that 
providers can speak up about technology that isn't getting the 
job done, and I think that's very important.
    Security is another critical challenge. As electronic 
health record s become more integral to our healthcare system, 
we need to prioritize developing technology and best practices 
that can stand up to the realities of today's cybersecurity 
threats.
    Finally, one area that I think is absolutely critical is 
patient engagement. If you can easily look up and download your 
bank statement, you should be able to do the same with your 
medical history. For far too many patients, these experiences 
are very different.
    In our last hearing on EHRs, I told a story I'd heard about 
a woman looking up results of a pregnancy test in her medical 
records and finding her hormone levels listed instead of a 
simple yes, you are, or no, you're not. We've heard many other 
stories about patients seeking their medical records and being 
given massive binders, unreadable PDFs, and stacks of CDs. In 
the 21st century, we can and must do a lot better than that. 
I'm very hopeful we can do more to ensure electronic health 
record s are accessible to patients so that they are able to 
stay engaged in their care.
    I want to close with some news I got recently from 
Washington State. A doctor at Swedish Medical Center in Seattle 
wrote to my office about how electronic health records have 
changed the way her office works. She said that while their EHR 
system is far from perfect, it is alerting patients to come in 
for important preventive healthcare services, like cancer 
screenings.
    She said that since the summer, they have identified two 
breast cancers, two colon cancers, and one cervical carcinoma 
that otherwise may not have been detected. The doctor wrote me 
and said,

          ``There are five people in our clinic that would have 
        gone undiagnosed and possibly died that now have caught 
        the disease early and will hopefully see a long, happy 
        life.''

    This really reinforces the importance of the bipartisan 
work this committee is doing to strengthen our healthcare 
information infrastructure and improve our healthcare system 
for patients like these and their families. We've come a long 
way. We've got a lot more to do.
    I'm looking forward to working with you, Mr. Chairman, on a 
bipartisan effort on this.
    Dr. DeSalvo and Dr. Conway, thank you again for being here 
and sharing your expertise with us.
    The Chairman. Thank you, Senator Murray.
    I want to thank Senator Murray, as we have been working all 
year in a bipartisan way on this. Our hearings have been 
bipartisan. Our working groups have been bipartisan.
    Our hope is that Senator Murray and I will be able to 
present a bipartisan starting point for our medical innovation 
legislation to the committee for its consideration that would 
include whatever we need to do about electronic health records 
that the Administration can't do by Executive order, that can 
then be ready for the Senate, passed and be combined next year 
with the House 21st Century Cures and enacted. That's the 
schedule that we hope to go on, and we're making very good 
progress.
    We have two witnesses today from the Department of Health 
and Human Services. The purpose of the hearing really is to 
wrap up the work we've been doing within our bipartisan working 
groups and with the Administration to try to identify five or 
six steps that we could take to improve the electronic records 
system.
    First, we'll hear from Dr. Karen DeSalvo. She is the 
National Coordinator for Health Information Technology and 
Acting Assistant Secretary for Health for the Department of 
Health and Human Services. As National Coordinator, she has 
spent a lot of time on this issue and worked well with the 
committee, and we thank her for that. She's been nominated by 
the President to be the Assistant Secretary for Health, and her 
nomination has been cleared by this committee already.
    Our second witness is Dr. Patrick Conway. He is the Deputy 
Administrator for Innovation and Quality and Chief Medical 
Officer at the Centers for Medicare and Medicaid Services. He 
leads the Center for Clinical Standards and Quality, which is 
responsible for all quality measures and standards of Medicare 
and Medicaid providers. He is also the Principal Administrator 
for the Electronic Health Record Incentive Program, commonly 
referred to as meaningful use.
    Dr. DeSalvo and Dr. Conway, thank you for coming. If you 
would summarize your remarks in about 5 minutes, there are 
several Senators here who would like to have a conversation 
with you about electronic health records.
    Dr. DeSalvo.

     STATEMENT OF KAREN DeSALVO, M.D., MPH, MSc, NATIONAL 
 COORDINATOR FOR HEALTH INFORMATION TECHNOLOGY, DEPARTMENT OF 
HEALTH AND HUMAN SERVICES, U.S. DEPARTMENT OF HEALTH AND HUMAN 
                   SERVICES, NEW ORLEANS, LA

    Dr. DeSalvo. Good morning, Chairman Alexander and Ranking 
Member Murray and distinguished committee members. I'd like to 
start by thanking you all for your ongoing interest in 
continuing the country's progress toward health information 
technology and seeing that we create an open, connected 
community of health.
    I do appreciate the opportunity to appear here today and 
discuss with you the current State of health IT in our Nation 
and how we can work together to see that these systems realize 
their full potential now and in the future so that health 
information is available to the right person, at the right 
place, at the right time in a private and secure manner. I do 
firmly believe that we have common ground and shared goals.
    Under my leadership, the Office of the National Coordinator 
for Health IT has been working urgently to ensure that we 
realize a return on investment for electronic health records. 
Our urgency mirrors your own and hundreds of doctors, consumers 
and stakeholders with whom I have spoken during my tenure as 
National Coordinator and my own personal experience practicing 
medicine in the community.
    We have, indeed, achieved a tremendous success in advancing 
the digitization of the healthcare experience for Americans. 
Nearly three-quarters of doctors and more than 90 percent of 
hospitals use electronic health records, and providers do want 
this progress to continue.
    Our work is only beginning. We continue to work 
collaboratively to see that health IT matures and becomes a 
more seamless support for doctors and the health system as it 
seeks to provide individuals with the kind of safe, person-
centered care that we're all working toward.
    As Congress has recognized, the availability of usable 
electronic health information through a more connected and 
interoperable health system is a major priority. I have made it 
ONC's priority since I started my tenure a year and a half ago.
    Within months of becoming National Coordinator, we released 
a vision document for interoperability and followed up shortly 
thereafter with a draft nationwide interoperability road map, 
which we have used to establish a dialog with the health IT 
community. In the road map, we describe what needs to be 
achieved when and by whom to reach the goal of the open, 
connected community of health IT so that we can support better 
care and efforts like precision medicine.
    We have identified that we need to move forward with a set 
of shared interoperability standards, to establish an 
environment of trust, and to create the right business 
environment that will allow data to flow. We have been working 
with our Federal and private sector partners since the release 
of the draft road map but have not waited for the final version 
which will come out in the coming weeks.
    Here are some examples of actions that we have taken in the 
near term to see that we can advance interoperability. We have 
set exact and explicit technology standards. We have promoted 
the use of APIs, which are doorways to the data. We are 
building an economic case for sharing data through the 
Secretary's delivery system reform effort. We are exposing and 
discouraging health information blocking.
    We have been coordinating with our Federal partners to 
enhance education around HIPAA and privacy, and we have 
proposed in our certification program to push more 
transparency, more competition in the marketplace to encourage 
innovation in areas like usability and to help providers know 
what systems they are purchasing. We've been working to 
increase awareness of the hardship exemption for providers who 
might want to switch products and for those who want to stay 
with the products they have, offering technical assistance on 
the front lines.
    We believe that in addition to the actions we can take as 
an administration, the private sector needs to continue to 
contribute. They can help us make more progress now by agreeing 
to make publicly available APIs to allow consumers to have 
access and control of their data and share it where they like. 
We can agree to not knowingly or unreasonably engage in health 
information blocking, and they can agree to a set of federally 
recognized national interoperability standards for technology 
and policy.
    In addition to the steps taken by the Administration in the 
near term and in the days to come and our partners in the 
private sector, we understand that the committee may be 
interested in ways to increase interoperability. We think this 
can be achieved by establishing a governance approach for how 
technology is used in practice, improving transparency in the 
market, and prohibiting information blocking.
    A governance mechanism would ensure that those 
participating in the exchange and interoperability of health 
information can be held accountable, including, for example, 
vendors and providers. Improving transparency in the 
marketplace by outlining basic expectations would improve 
interoperability and exchange of information, making purchasing 
decisions easier if doctors and hospitals had a better sense of 
the cost, limitations, and other performance characteristics of 
their products.
    Last, by promoting and prohibiting information blocking and 
associated business practices under programs recognized by the 
National Coordinator, we would prevent unnecessary impediments 
to data flow and interoperability of health IT. Any actions in 
this area should balance the need for not only health 
information availability, but patient safety and the interests 
of the business practices at hand.
    Thank you to the members of the committee for this 
opportunity to discuss health information technology, which is, 
we agree, a critical underpinning of the better health system, 
where we have better care, smarter spending, and a healthier 
population. I do look forward to a continued partnership so 
that, together, we can achieve our shared goals, and I'm happy 
to answer any questions.
    [The prepared statement of Dr. DeSalvo follows:]
         Prepared Statement of Karen B. DeSalvo, M.D., MPH, MSc
    Chairman Alexander, Ranking Member Murray, and distinguished 
committee members, thank you for the opportunity to appear today. My 
name is Dr. Karen DeSalvo and I am the National Coordinator for Health 
Information Technology. Thank you for the invitation to be here to 
discuss the current state of health information technology in our 
Nation and how we can work together to help these systems realize their 
full potential now and in the future.
    The Office of the National Coordinator for Health Information 
Technology (ONC) was established by Executive Order in 2004 and charged 
with the mission of giving every American access to their electronic 
health information when and where they need it most. In 2009, ONC was 
statutorily established by the Health Information Technology for 
Economic and Clinical Health Act (HITECH), enacted as part of the 
American Reinvestment and Recovery Act (ARRA). HITECH also provided the 
resources and infrastructure needed to stimulate the rapid, nationwide 
adoption and use of health IT, especially electronic health records 
(EHRs). In the 6 years since the HITECH Act was enacted, we have seen 
dramatic advancement in the use and adoption of health IT. The 
proportion of U.S. physicians using EHRs increased from 18 percent to 
78 percent between 2001 and 2013,\1\ and 94 percent of hospitals now 
report use of certified EHRs.\2\ The combined efforts of initiatives 
like the Regional Extension Centers, the ONC Health IT Certification 
Program, use of standard terminologies, and the CMS Medicare and 
Medicaid EHR Incentives Programs have brought us past a tipping point 
in the use of health IT. Today, we are firmly on the path to a digital 
health care system; but, there is still much work to do.
---------------------------------------------------------------------------
    \1\ http://www.cdc.gov/nchs/data/databriefs/db143.htm.
    \2\ http://healthit.gov/sites/default/files/data-brief/
2014HospitalAdoptionDataBrief.pdf.
---------------------------------------------------------------------------
    Prior to becoming the National Coordinator in January 2014, I 
worked in a variety of settings, which provided me with keen insight 
into and experience working with health IT systems. My previous 
positions include serving as the Health Commissioner for the city of 
New Orleans, a Senior Health Policy Advisor to the Mayor of New 
Orleans, and a professor of medicine and vice dean for community 
affairs at Tulane University School of Medicine. In addition, I have 
practiced internal medicine for close to a quarter century. In all of 
these positions, I have established, purchased, utilized, implemented, 
and studied health IT systems. I not only understand the importance of 
health IT to improving the overall health care in this Nation, but I 
also understand firsthand the numerous complications and frustrations 
that we have faced, and continue to face along the way. I came to ONC 
to build on the incredible progress we have made since 2009, and to 
move us forward into a new and exciting era of health IT. Thus far, I 
have focused my energy and attention on what I believe is a fundamental 
piece of the puzzle to moving us forward, and that is a ubiquitous, 
safe, and secure interoperable health IT infrastructure.
    Since I became the National Coordinator, ONC has been working 
intensely to harness the health care industry's energy and consumer 
demands for interoperability to drive improvement in health--we feel 
the strong sense of urgency and have acted on it quickly. The Nation 
asked for a clear strategy to get to interoperability and a learning 
health system, and we delivered that plan in ``Connecting Health and 
Care for the Nation: A Shared Nationwide Interoperability Roadmap Draft 
Version 1.0.'' We received broad feedback and have heard agreement from 
critical stakeholders like developers, consumers, providers, 
technologists, and others that this plan is the right path forward, and 
that they would like to work with us to advance interoperability. The 
Roadmap explains that, in order to meet stakeholders' specific 
interoperability needs as quickly, securely, and safely as possible, we 
must: (1) buildupon the current infrastructure; (2) ensure that 
applicable standards are consistently used; (3) foster an environment 
of trust where individuals can access their data in a private and 
secure manner; and (4) incent, through consumer demand and delivery-
system reform, enduring, self-sustaining interoperable movement and use 
of electronic health information.
    We anticipate releasing in the very near future the final 
streamlined Version 1.0 of the Roadmap, which will focus primarily on 
impactful, near-term actions we all can take by the end of 2017 to 
improve interoperability. These actions are detailed in three areas in 
the Roadmap. First, ``Drivers,'' which are mechanisms that can propel a 
supportive payment and regulatory environment that relies on and 
deepens interoperability. Second, ``Policy and Technical Components,'' 
which are essential items stakeholders need to implement to enable 
interoperability, such as shared standards and expectations around 
privacy and security. Third, ``Outcomes,'' which serve as metrics by 
which stakeholders will measure our collective progress on implementing 
the Roadmap.
    We are also working across the Department on ways to increase 
interoperability. As part of the Department's Delivery System Reform 
initiative, HHS is using a variety of policies and programs to achieve 
a vision of information sharing and interoperability. A key component 
of the Delivery System Reform initiative is expanding the use of 
alternative payment models that reward quality over quantity and 
linking fee-for-service payments to quality and value. Electronic 
sharing of health information is an important element of how care is 
delivered under these models. ONC activities are focused on the 
Delivery System Reform goal to improve the way information is shared 
among providers to create a better, smarter, and healthier system. ONC 
is working closely with CMS on certifying that health IT products 
adhere to interoperability standards, providing support to stakeholders 
focused on sharing health information, and working with other agencies 
across HHS to reinforce the use of health information interoperability 
and adoption of health IT through a variety of policies and programs.
    Achieving interoperability to meet stakeholder needs now, and 
throughout the next few years, can help us to realize our vision of a 
learning health system--one that delivers high-quality care, lower 
costs, a healthy population, and engaged people. It is clear we must 
move beyond electronic health record adoption and focus on liberating 
health data, so critical information is available when and where it 
matters most to transform individual, community, and population health 
and care.
    In our pursuit of achieving a learning health system, we are also 
continuing our work with our other Federal partners. As you know, we 
recently issued the Federal Health IT Strategic Plan 2015-20. This 
Plan, developed in partnership with over 35 Federal entities, 
demonstrates the extensive interest across the Federal Government to 
digitize the health experience for all individuals and facilitate 
progress toward a learning health system that can improve health and 
care. The Plan has been designed to support important changes already 
occurring in the health landscape, such as the Precision Medicine 
Initiative and the Department of Defense's Military Health System's 
acquisition of a new health IT system, as well as longer-range changes, 
such as FDA's Sentinel program. The Plan's long-term vision of a 
learning health system relies on the use of technology and health 
information from a multitude of sources for a multitude of purposes, 
and working with our Federal partners, with the Congress, and other 
stakeholders, our strategies will evolve to ensure we can meet this 
vision for the Nation. In addition, we will continue our collaboration 
with the Office for Civil Rights, and the Food and Drug Administration, 
both within HHS, and with the Federal Trade Commission to improve 
security in health IT and consumer understanding of security risks.
    We also understand that advancing health IT requires engagement 
beyond the government, which is why we have continued our ongoing 
collaborative work with not only this committee, but also outside 
stakeholders, patients, hospitals, and providers to name a few. For 
example, ONC is currently working with the National Quality Forum (NQF) 
to develop multi-stakeholder consensus around health IT safety 
measurement priorities, create an organizing framework for health IT 
safety measures, and identify potential health IT safety measures and 
current gaps in health IT safety measures. In 2014, we participated in 
a series of ``Learning What Works'' listening sessions in five cities 
across the country with the Robert Wood Johnson Foundation to hear from 
local leaders, residents, and professionals from a wide range of 
sectors on what information is important to them and how they might use 
it to help people lead healthier lives and improve health in their 
communities. ONC participated in these listening sessions and heard 
feedback about the importance of trust, data access, and how 
individuals and communities want to use data to improve overall health.
    In addition, last year, Health Level Seven International (HL7) 
launched an initiative to accelerate the development and adoption of 
HL7's Fast Healthcare Interoperability Resources (FHIR), with support 
from 11 organizations, including EHR vendors like Epic and Cerner and 
health systems like Mayo Clinic and Intermountain Healthcare. Following 
the JASON Report,\3\ our Federal advisory committees urged the Office 
of the National Coordinator to focus on an approach involving public 
application programming interfaces (APIs) and FHIR, which you see in 
our proposed 2015 Edition certification rule and is also addressed in 
CMS's proposed rule for Stage 3. I'm optimistic because I am seeing 
more collaborations like these from the private sector. For example, 
the Argonauts Project, which is a coalition of industry vendors and 
providers, is collaborating in an unprecedented fashion. They are 
accelerating the maturation of FHIR, to see that we have a safe, but 
highly usable new technology that stands to transform the health IT 
ecosystem.
---------------------------------------------------------------------------
    \3\ JASON. (2013). A Robust Health Data Infrastructure. Washington, 
DC: MITRE for Agency for Healthcare Research and Quality.
---------------------------------------------------------------------------
    Through this ongoing work, as a Department, we have concluded that 
to achieve a learning health system, we must buildupon the current 
health information infrastructure and work together to focus on three 
key areas. We have prioritized and intend to focus on: (1) ensuring 
that electronic health information is appropriately available, easily 
transferable, and readily usable by the patient, provider, payer, 
scientist, and others; (2) improving the safety and usability of health 
information technology and allowing the market to function in a way to 
incentivize necessary improvements; and (3) simplifying program 
requirements to lower administrative burden and create a clear link 
between program participation and outcomes. We believe this work will 
support providers as they adopt and use health IT and work to deliver 
better care for patients. While ONC will support efforts on all three 
fronts, we plan to focus our attention most acutely on addressing the 
first two.
    It is imperative to a functioning health information technology 
infrastructure to have data available to the right person, at the right 
place, at the right time. ONC can make a big impact in this area by 
promoting interoperability, addressing information blocking, and by 
empowering providers to engage patients. In 2012, ONC took on the 
responsibility for spreading the Blue Button initiative nationwide. 
This work was done in collaboration with the Department of Veterans 
Affairs, the White House, and a host of other public and private sector 
leaders. Patients can securely access their health data from multiple 
sources and then choose to download that data to their computer, thumb 
drive or smartphone without using any special software, or choose to 
share that data with individuals they trust--whether it's their other 
physicians or family members. To date, there are more than 600 member 
organizations participating in the Blue Button initiative. Meanwhile 
our actions over the next year will focus on continuing to build the 
economic case for interoperability, including increasing incentives and 
improving the regulatory and business environments; coordinating with 
health information technology stakeholders to coalesce around a shared 
set of technical standards; exposing and discouraging health 
information blocking; and ensuring the implementation of robust privacy 
and security protections.
    We recognize that the current marketplace does not always function 
in a way that promotes a learning health system. ONC is committed to 
supporting providers as they use health IT for more advanced 
applications and encourage the private sector to address this 
challenge. For example, we proposed the 2015 Edition rule with the goal 
of improving transparency for certified health IT systems. We believe 
we can help by driving secure, safe and usable products while also 
continuing to offer technical assistance to providers. Through the 2015 
Edition proposed rule, we also are continuing to help make the business 
case that investments in health IT tools that support better care 
coordination and population health management offer an important way to 
drive continued innovation as vendors seek to meet the needs of 
providers moving toward value-based care.
    In addition to taking steps administratively within these important 
spaces, we understand that the committee may be interested in ways to 
make technology more usable by (1) establishing a governance mechanism 
for how technology is used in practice; (2) improving transparency in 
the market; and (3) prohibiting information blocking. For example, a 
governance mechanism would ensure that those participating in the 
exchange and interoperability of health information, including, for 
example, health IT vendors, can be held accountable. Defining and 
outlining basic expectations would improve interoperability and the 
exchange of information. Moreover, providers would be able to make more 
informed purchasing decisions if they had a better sense of the costs, 
capabilities, limitations, and other performance characteristics of 
certified health IT. And, last, prohibiting information blocking and 
associated business practices by providers, suppliers, and vendors of 
health IT certified under programs recognized by the National 
Coordinator would prevent unnecessary impediments to the use of health 
IT for the interoperable exchange of electronic health information. Of 
course, any action in this area should balance the need for 
availability of electronic health information with the need to promote 
patient safety, maintain the privacy and security of electronic health 
information, and protect the legitimate economic interests and 
incentives of providers, developers, and other market participants.
    We share the goal of making this technology more usable, and should 
the Congress choose to legislate in this area, these actions could 
further help health IT reach its full potential. With that in mind, ONC 
is committed to moving forward by promoting the use of health IT to 
encourage information exchange, not only across the Department and 
Governmentwide, but also with outside stakeholders, including the 
Congress. We realize everyone has a role to play in moving health IT 
systems forward and look forward to the challenge ahead of us.
    Thank you again for inviting me today.

    The Chairman. Thank you, Dr. DeSalvo.
    Dr. Conway.

STATEMENT OF PATRICK CONWAY, M.D., MSc, ACTING PRINCIPAL DEPUTY 
ADMINISTRATOR, DEPUTY ADMINISTRATOR FOR INNOVATION AND QUALITY, 
   CENTERS FOR MEDICARE AND MEDICAID SERVICES CHIEF MEDICAL 
OFFICER, CENTERS FOR MEDICARE AND MEDICAID, COLLEGE STATION, TX

    Dr. Conway. Chairman Alexander, Ranking Member Murray, and 
members of the committee, thank you for the opportunity to 
discuss the work of the Centers for Medicare and Medicaid 
Services related to health information technology.
    When I started practicing medicine, I remember trying to 
read hand-scrawled consult notes, struggling to find an x-ray 
in the basement of the hospital, and going to the lab to track 
down lab results for patients. It was not an effective system.
    I practice as an attending physician on weekends in a 
hospital with a electronic health record, or EHR, networked 
with other hospitals across the region. With the click of a 
button, I can pull up lab results, x-rays, or consult notes. I 
can even show the radiologic image to a worried family on the 
computer screen and explain the treatment.
    When I was at Cincinnati Children's Hospital, I led 
efforts, using our EHRs, to measure quality across the system. 
We used EHRs as an essential tool to measure and improve care 
and patient outcomes.
    Health IT is an important catalyst for improving care 
delivery and can help prepare providers to be successful under 
alternative payment models. Earlier this year, Secretary 
Burwell announced measurable goals and a timeline to move the 
Medicare program and the health system at large toward paying 
providers based on quality rather than the quantity of care 
they deliver.
    In April, Congress passed the Medicare Access and CHIP 
Reauthorization Act, or MACRA, which aligns with and supports 
the Secretary's goals by requiring implementation of a new 
value-based payment system for physicians and other clinicians 
in Medicare. We would like to thank those on the committee who 
supported MACRA and have helped continue our efforts to 
accelerate delivery system reform.
    CMS has worked to advance the use of EHRs as an investment 
to ensure we can realize the benefits of value-based payment 
systems established by MACRA and other initiatives. We are 
focused on implementing MACRA in a manner that allows 
physicians and other clinicians to succeed in improving their 
practice and, most importantly, in delivering high-quality 
coordinated care to all people.
    CMS will also work to implement provisions in MACRA that 
address information blocking by requiring providers to 
demonstrate they have not acted to limit or restrict 
interoperability of certified EHR technology.
    Under alternative payment models, it is essential for 
providers to communicate across care settings, reduce 
duplication, and engage patients. The effective use of health 
IT can help providers achieve those aims. For example, health 
IT can help a patient transition safely from the hospital to 
home by enabling inpatient and ambulatory providers to quickly 
and easily share information.
    The Medicare and Medicaid EHR incentive programs provide 
incentive payments to eligible professionals, hospitals, and 
critical access hospitals in order to encourage the adoption of 
health IT to improve care for beneficiaries. Participation in 
the program remains strong. As of July 2015, more than 474,000 
healthcare providers had received payment for participating in 
either the Medicare or Medicaid incentive program. That 
represents over 70 percent of eligible professionals and over 
95 percent of eligible hospitals.
    CMS is working to simplify program expectations and give 
providers needed flexibility while advancing important 
capabilities such as effective health information exchange and 
population health management that are essential to better care 
and lower costs. Many of the proposed objectives and measures 
for Stage 3 are focused on interoperability. For example, we 
have proposed to encourage providers to make available their 
EHR's application program interfaces, or APIs.
    APIs are like road maps for computer software. Opening them 
up allows programmers to design applications that help patients 
view and share their health information where and when they 
need to. In fact, the majority of the proposed measures in 
Stage 3 require interoperability and information exchange, 
which is a significant increase from Stage 1 and 2.
    In addition, CMS identified redundancies, duplication, and 
incidences of measures that were topped out. Based on that 
analysis, we proposed the Stage 3 rule focused on an aligned 
set of only eight objectives and measures, down from 20 in 
Stage 2.
    We have also proposed to give eligible professionals 
options within several objectives, allowing providers 
flexibility to concentrate on factors of health IT 
implementation that are most applicable to their practice. 
Furthermore, CMS has proposed to modify Stage 1 and 2 
requirements to reduce complexity, lessen providers' reporting 
burdens, and shorten the EHR reporting period in 2015 to 90 
days to accommodate these changes.
    In totality, these proposed changes put an end to the 
stages of so-called meaningful use and move us forward to MACRA 
and comprehensive quality and value programs for physicians, 
clinicians, and hospitals. Our primary goal is to ensure 
beneficiaries and providers can realize all the benefits of EHR 
systems to support high-quality, value-based care.
    We will continue our work with ONC, providers, Congress, 
and others to improve the interoperability, make health IT more 
user-friendly, and simplify program requirements as we work to 
transform the healthcare delivery system to achieve better 
care, smarter spending, and healthier people.
    I have read all three of my older children into the 
congressional record, and I am dedicated to a long-term, 
affordable, high-quality Medicare program for our new 2-month-
old daughter, Isabelle Ann Conway, who is now also in the 
congressional record.
    Thank you again for the opportunity to testify. I'd be 
happy to answer your questions.
    [The prepared statement of Dr. Conway follows:]
            Prepared Statement of Patrick Conway, M.D., MSc
    Chairman Alexander, Ranking Member Murray, and members of the 
committee, thank you for the opportunity to discuss our work at the 
Centers for Medicare & Medicaid Services (CMS) related to health 
information technology (health IT). CMS is committed to working with 
providers and stakeholders to harness the potential of health IT to 
improve the quality and reduce the cost of care--and, more broadly, 
transform our Nation's health care delivery system.
    As a result of the Medicare and Medicaid Electronic Health Record 
(EHR) Incentive Programs, adoption of electronic health records 
continues to increase among physicians, hospitals, and others serving 
Medicare and Medicaid beneficiaries. Higher EHR adoption has helped 
care providers evaluate patients' medical status, coordinate care, 
eliminate redundant procedures and provide high-quality care. The 
proportion of U.S. physicians using Electronic Health Records (EHRs) 
increased from 18 percent to 78 percent between 2001 and 2013, and 94 
percent of hospitals now report use of certified EHRs. EHRs also will 
help speed the adoption of key delivery-system reforms by making it 
easier for hospitals and doctors to better coordinate care and achieve 
improvements in quality.
    Earlier this year, Health and Human Services Secretary Burwell 
announced measurable goals and a timeline to move the Medicare program, 
and the health care system at large, toward paying providers based on 
the quality, rather than the quantity of care they give patients. Such 
incentives will help achieve the critical goal of improving care 
delivery and access to information. Encouraging the use of health IT is 
an important component of HHS efforts to transform the delivery system. 
It supports the health information exchange needed to improve 
communication and care coordination, promote patient safety, enhance 
clinical decisionmaking, track patient outcomes and support payment for 
care quality. Health IT helps provide the information needed to 
clinicians and patients at the point-of-care.
    On April 16, 2015, President Obama signed the Medicare Access and 
CHIP Reauthorization Act (MACRA),\1\ which supports the Secretary's 
goals by requiring the implementation of new payment systems for 
physicians and other practitioners in Medicare by 2019: the Merit-Based 
Incentive Payment System and Alternative Payment Models,. Together, 
these important steps to transform the way Medicare pays practitioners 
will promote a long-term business case for effective health IT adoption 
and, in turn, lead to better care and improved outcomes.
---------------------------------------------------------------------------
    \1\ PL 114-10 https://www.Congress.gov/114/plaws/publ10/PLAW-
114publ10.pdf.
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    Health IT is an important catalyst for improving care delivery, 
enabling providers to prepare for and be successful under new 
alternative payment models. Under new payment models, it is 
increasingly critical for providers to communicate effectively across 
care settings, quickly and easily share health information, reduce 
duplicative and unnecessary care, successfully manage high-risk 
populations and engage patients in their care by communicating and 
sharing test results electronically. Effective use of health IT can 
help providers achieve those aims: helping a patient transition safely 
from the hospital to the home by enabling inpatient and outpatient 
providers to quickly and easily share key information; helping patients 
communicate with providers through secure, electronic messaging; and 
helping providers identify and communicate with patients who are in 
need of followup care to address their chronic condition(s). 
Additionally, many providers now are using clinical and patient-
submitted data from health IT systems to track and improve population 
health.
    While the use of health IT can promote higher-quality care 
delivery, we also recognize that providers face costs when adopting and 
implementing new EHRs and other health IT systems, such as the up-front 
cost to purchase new technology and the indirect cost of the provider's 
time to incorporate that new technology into practice workflow. By 
aligning CMS programs and providing flexibility, we aim to ensure that 
providers focus their resources on delivering high-quality care for our 
beneficiaries.
    CMS is focused on efforts to simplify our program requirements to 
lower administrative requirements and create a clear link between 
program participation and better outcomes. These include providing 
provider flexibility in achieving meaningful use of certified EHR 
technology and aligning quality measures across payment programs. At 
the same time, CMS is supporting the ongoing efforts of the Office of 
the National Coordinator for Health IT (ONC) to make electronic health 
information more readily transferable and to promote more user-centric 
EHR systems. We believe this work will support providers as they adopt 
and use health IT and work to deliver better care for Medicare and 
Medicaid beneficiaries.
                        encouraging ehr adoption
    Since the passage of the American Recovery and Reinvestment Act of 
2009 (``Recovery Act''), CMS has been hard at work implementing 
financial incentives and technical assistance to encourage the 
widespread use of certified EHR technology to improve quality, safety 
and efficiency; reduce health disparities; engage patients and 
families; improve care coordination; improve population and public 
health; and maintain the privacy and security of patient health 
information.
    The Recovery Act established the Medicare and Medicaid EHR 
Incentive Programs, which provide incentive payments to eligible 
professionals, eligible hospitals, and critical access hospitals (CAHs) 
as they adopt, implement, upgrade or demonstrate meaningful use of 
certified EHR technology. To receive an EHR incentive payment under 
Medicare, providers must demonstrate that they are ``meaningfully 
using'' their certified EHR technology by meeting thresholds for a 
number of objectives and reporting clinical quality measures.
    States verify eligibility for the Medicaid EHR Incentive Program. 
Several additional types of health care providers are eligible for 
Medicaid EHR incentive payments, including nurse practitioners, 
certified nurse-midwives, dentists, and physician assistants who 
furnish services at a physician assistant-led federally qualified 
health center or rural health clinic. There also are patient-volume 
thresholds that providers must meet to be eligible for EHR incentive 
payments under Medicaid. Children's hospitals, however, are eligible 
for Medicaid incentive payments regardless of Medicaid patient volume. 
In their first year in the Medicaid EHR Incentive Program, Medicaid 
providers also have the option to receive incentive payments based on 
whether they adopt, implement or upgrade a certified EHR technology.
    The Medicare and Medicaid EHR Incentive Programs have progressed in 
stages, moving from basic data capture to advanced functionality of 
EHRs, including interoperability, patient engagement, clinical decision 
support, and quality measurement and then to increased health 
information exchange, interoperability and improved patient outcomes. 
This last phase, referred to as ``Stage 3,'' would make changes that 
are responsive to stakeholders asking for more time, flexibility and 
simplicity in the program.\2\
---------------------------------------------------------------------------
    \2\ Electronic Health Record Incentive Program--Stage 3 Notice of 
Proposed Rulemaking https://www.Federalregister.gov/articles/2015/03/
30/2015-06685/medicare-and-medicaid-programs-electronic-health-record-
incentive-program-stage-3.
---------------------------------------------------------------------------
    Participation in the Medicare and Medicaid EHR Incentive Programs 
remains strong. As of July 2015, more than 474,000 health care 
providers received payment for participating in either the Medicare or 
Medicaid Incentive Program. More than $20.9 billion in Medicare EHR 
Incentive Program payments were made between May 2011 and July 2015. In 
addition, more than $9.98 billion in Medicaid EHR Incentive Program 
payments were made between January 2011 (when the first set of States 
launched their programs) and July 2015.\3\ As of July 2015, over 
300,000 unique providers had received Medicare EHR Incentive Program 
payments under Stage 1 and over 50,000 providers had received payments 
under Stage 2.\4\
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    \3\ https://www.cms.gov/Regulations-and-Guidance/Legislation/
EHRIncentivePrograms/Down
loads/July2015_PaymentsbyStatebyProgramandProvider.pdf.
    \4\ Ibid.
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    reducing administrative requirements and increasing flexibility
    CMS is taking several steps to streamline Medicare and Medicaid EHR 
Incentive Program requirements and provide flexibility based on lessons 
learned from the initial years of operating the programs. For example, 
in March we proposed that Stage 3 will be optional in 2017,\5\ giving 
program participants and industry more time to implement changes, 
update workflows and adopt new technology.
---------------------------------------------------------------------------
    \5\ Electronic Health Record Incentive Program--Stage 3 Notice of 
Proposed Rulemaking https://www.Federalregister.gov/articles/2015/03/
30/2015-06685/medicare-and-medicaid-programs-electronic-health-record-
incentive-program-stage-3.
---------------------------------------------------------------------------
    CMS also aims to streamline and reduce overall reporting 
requirements. We analyzed the objectives and measures of the program to 
determine where measures are redundant, duplicative or have ``topped 
out.''.\6\ For Stage 3 specifically, based on this analysis, we 
proposed an aligned set of eight objectives and measures for eligible 
professionals and hospitals, down from 20\7\ in Stage 2.\8\ If 
finalized, we believe these changes will focus provider efforts on 
objectives that pertain to the advanced use of EHRs, such as using data 
to drive improvements in care coordination, care management and 
population health outcomes.
---------------------------------------------------------------------------
    \6\ ``Topped out'' is the term used to describe measures that have 
achieved widespread adoption at a high rate of performance and no 
longer represent a basis upon which provider performance may be 
differentiated. It is commonly used to justify removal of specific 
clinical quality measures from public and private sector quality 
reporting programs.
    \7\ Eligible Providers must achieve 20 Meaningful Use Objectives in 
Stage 2; Eligible Hospitals must achieve 19, see Stage 2 final rule 
here: http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-21050.pdf.
    \8\ Electronic Health Record Incentive Program--Stage 3 Notice of 
Proposed Rulemaking https://www.Federalregister.gov/articles/2015/03/
30/2015-06685/medicare-and-medicaid-programs-electronic-health-record-
incentive-program-stage-3.
---------------------------------------------------------------------------
    Providers have indicated to CMS that they need flexibility in 
implementing the objectives and measures of meaningful use in diverse 
clinical settings. As a result, we proposed to give eligible 
professionals measure options within several objectives to allow 
providers to report on measures most applicable to their practice.\9\ 
In addition, CMS proposed to focus objectives and measures on 
interoperability requirements, such as allowing the use of Application 
Program Interfaces and focusing on electronic exchange of health 
information between providers. In Stage 3, more than 60 percent of the 
proposed Meaningful Use measures require interoperability, up from 33 
percent in Stage 2.
---------------------------------------------------------------------------
    \9\ For example, providers must report the numerator and 
denominators for all three measures within the Health Information 
Exchange objective. However, providers are only required to achieve the 
thresholds for two measures to meet the objective. See Electronic 
Health Record Incentive Program--Stage 3 Notice of Proposed Rulemaking 
https://www.Federalregister.gov/articles/2015/03/30/2015-06685/
medicare-and-medicaid-programs-electronic-health-record-incentive-
program-stage-3.
---------------------------------------------------------------------------
    Finally, we are aligning clinical quality measure reporting 
requirements across payment programs to reduce reporting requirements 
and focus provider efforts on high-impact outcomes-based measures. 
Today, eligible professionals in the Medicare EHR Incentive Program 
that report quality measures to CMS electronically can receive credit 
in both the EHR Incentive Program and the Physician Quality Reporting 
System.\10\ These results also will be used in calculating eligible 
professionals' performance under the physician value modifier and 
future value-based purchasing initiatives. The CMS goal is to allow 
providers to report once for all applicable quality programs. We also 
are working to align CMS quality measures with those used by the 
private sector, concentrating provider efforts and lowering the 
reporting burden for those providers that submit data to both public 
and private payers. While we are removing ``topped-out'' and outdated 
measures, we are simultaneously working to fill measure gaps by 
developing measures for important health conditions and provider types 
where sufficient measures have yet to be created. Over time, these 
measures will be added to our quality programs, making them more 
relevant to certain specialties and better reflective of the latest 
evidence base.
---------------------------------------------------------------------------
    \10\ Electronic Health Record Incentive Programs Stage 2 Final 
Rules: http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-21050.pdf.
---------------------------------------------------------------------------
            health it and delivery system reform initiatives
    CMS is working hard to implement MACRA, which will promote the 
adoption of new payment and service delivery models. The law creates a 
value-based physician payment system (Merit-Based Incentive Payment 
Systems or MIPS), and the adoption and meaningful use of health IT will 
be one of the categories for determining how Medicare provider 
performance is assessed--and rewarded--under MIPS. MACRA also 
encourages participation in alternative payment models by requiring 
eligible professionals participating in such models to use certified 
EHR technology.
    Adopting health IT enables capabilities--like efficient 
communication across care settings, safe prescribing and managing 
overall population health--that are central to improving care and 
lowering costs. In addition to implementing MACRA, CMS is supporting 
the business case for EHR adoption through targeted initiatives that 
encourage health care providers to deliver high-quality, coordinated 
care at lower costs. These reforms enable us to pay based on value 
while promoting patient safety and better care coordination across the 
health care delivery system.
    CMS initiatives include Accountable Care Organizations (ACOs)--
groups of doctors and other health care providers that have agreed to 
work together to treat individual patients and better coordinate their 
care across care settings. They have the opportunity to share in 
savings generated from lowering the growth in health care costs while 
improving quality of care, including a measure that promotes use of EHR 
technology. Medicare ACOs have already demonstrated significant cost 
savings and improvements in quality. In 2014, 20 Pioneer and 333 Shared 
Savings Program ACOs generated more than $411 million in savings. 
Pioneer ACOs also showed improvements in 28 of 33 quality measures and 
experienced average improvements of 3.6 percent across all quality 
measures. Shared Savings Program ACOs that reported quality measures in 
2013 and 2014 improved on 27 of 33 quality measures.
    Another example is the Comprehensive Primary Care Initiative 
(CPC),\11\ which is a multi-payer partnership between Medicare, 
Medicaid, private health care payers and primary care practices in four 
States\12\ and three regions.\13\ CMS requires all participants in CPC 
to use ONC Certified EHR Technology. A few of the ways the practices 
use such certified technology include: (1) reporting their practice 
results for all electronic clinical quality measures; (2) risk-
stratifying their patient populations to focus on patients likely to 
benefit from active intensive care management; (3) ensuring patients 
can reach a member of their care team who has real-time access to their 
EHRs 24 hours a day; and (4) achieving meaningful use. Results from the 
first year suggest CPC, on average across seven regions, has generated 
nearly enough savings in Medicare health expenditures to offset care 
management fees paid by CMS, with hospital admissions decreasing by 2 
percent across all sites and emergency department visits decreasing by 
3 percent.
---------------------------------------------------------------------------
    \11\ http://innovation.cms.gov/initiatives/comprehensive-primary-
care-initiative/.
    \12\ Arkansas, Colorado, New Jersey and Oregon.
    \13\ New York's Capital District and Hudson Valley, Ohio and 
Kentucky's Cincinnati-Dayton region, and Oklahoma's Greater Tulsa 
region.
---------------------------------------------------------------------------
    Finally, CMS is testing bundled-payment models,\14\ which link 
payments for multiple services beneficiaries receive during a single 
episode of care, encouraging doctors, hospitals and other health care 
providers to work together on delivering coordinated care for patients. 
CMS recently proposed the Comprehensive Care for Joint Replacement 
initiative that would buildupon other bundled-payment models already 
being tested by the Centers for Medicare and Medicaid Innovation. 
Providers and suppliers in the proposed joint replacement initiative 
would be paid under the existing payment systems in the Medicare 
program for services provided during episodes of care for hip and knee 
replacements. Following the end of a model's performance year, actual 
episode spending for beneficiaries who receive certain joint-
replacement surgeries in a participant hospital would be compared to 
the Medicare episode price. Depending on the participant hospital's 
quality and episode spending performance, the hospital may receive an 
additional payment from Medicare or, beginning in the second year of 
the model, may need to repay Medicare for a portion of the episode 
spending. This proposed initiative, like other bundled-payment models, 
incentivizes the type of close collaboration among inpatient and 
outpatient providers and suppliers that is made easier with the 
effective use of health IT.
---------------------------------------------------------------------------
    \14\ http://innovation.cms.gov/initiatives/bundled-payments/.
---------------------------------------------------------------------------
    Although designed for different providers and care settings, all of 
these initiatives promote well-coordinated, high quality care and build 
the business case to adopt health IT systems that help providers manage 
population health and share information across care settings.
                               conclusion
    CMS will continue to support the adoption and effective 
implementation of health IT that supports better care and lower costs 
for Medicare and Medicaid beneficiaries. While health IT alone does not 
make care better, it is an essential ingredient to improvement of care 
and supporting providers as they transition from volume-based to value-
based payment models. Health IT moves us away from illegible notes and 
prescriptions, reams of paper charts, x-rays that cannot be found and 
lost faxed lab results toward a health system where relevant 
information is available for providers at the point of care and for 
patients when they need it at home or at the pharmacy. As a practicing 
physician, I have experienced the power of health IT to improve care 
and patient safety, and I also realize that we need to continue to 
improve the programs and products so they support clinicians and 
patients in achieving better outcomes.
    CMS's primary goal is to ensure that beneficiaries and providers 
can realize all of the benefits of EHR systems without unnecessary 
costs. Providers should be confident that their time and resources will 
be spent caring for patients rather than unnecessary or duplicative 
administrative requirements. CMS will continue our work with ONC to 
improve interoperability, make health IT more user-friendly, and 
streamline program requirements as we work to transform the health care 
delivery system and promote high-quality care.

    The Chairman. Well, we welcome all four children into the 
congressional record.
    [Laughter.]
    We'll now begin a round of 5-minute questions. Let me 
repeat what I said earlier. At least, speaking for myself, I 
want to move forward, not backward, on electronic health 
records. There's no doubt in my mind that that's where we're 
headed.
    Dr. Conway, it is correct, isn't it, that the merit-based 
payment system, or moving to paying doctors for value, is a top 
priority of the Administration?
    Dr. Conway. Yes.
    The Chairman. I gather from Secretary Burwell that she is 
bound and determined to get that done in the next year. Am I 
correct about that?
    Dr. Conway. Yes, sir. Implementing the MACRA legislation 
and the merit-based incentive program and alternative payment 
models is an extremely high priority.
    The Chairman. It has broad support in Congress. You began 
the process of making regulations on that this week. Is that 
correct?
    Dr. Conway. We released a request for information to get 
public input and engagement on the rulemaking process.
    The Chairman. Right. When do you expect to have those 
regulations completed?
    Dr. Conway. We are aiming to put out those regulations next 
year, most likely in the late spring timeframe.
    The Chairman. Next spring. Isn't it true that 25 percent of 
the incentive payment or the penalty for doctors under your new 
payment system would depend upon how well they complied with 
meaningful use?
    Dr. Conway. Yes. The good news is that Congress, in passing 
the statute for MACRA, enabled significantly more flexibility 
in the EHR incentive portion or meaningful use. In the RFI, we 
asked questions around the issue of the so-called all-or-none 
phenomenon from providers in terms of meaningful use. We 
believe the MACRA statute provides us more flexibility for that 
25 percent in terms of how we consider successful use of 
electronic health records, and we want to thank Congress for 
that flexibility.
    The Chairman. The most important thing would be the better 
the electronic health record system is and the easier it is for 
doctors to comply with it, the more effective your new value-
based system will be. Right?
    Dr. Conway. We are committed in the value-based system for 
electronic health records----
    The Chairman. No, but is it right or wrong?
    Dr. Conway. Yes, sir. We are committed in the electronic 
health record systems that they be usable----
    The Chairman. A yes would be adequate. What I'm getting at 
is why wouldn't you want to develop the final rules for the 
electronic health record system at the same time you're 
developing your rules for your value-based system? Why would 
you go ahead with finalizing Stage 3 and then have to do what 
you did with Stage 2, which is then to say, ``OK. This is our 
final rule, but it's not very good, so we're going to spend the 
next 2 or 3 years changing it.''
    Why don't you go ahead and do Stage 2, which you're ready 
to do, and then you've got Stage 3 out there, and work with 
doctors and hospitals and vendors and make your changes before 
you make it final?
    Dr. Conway. We are committed to work with Congress, 
doctors, and other providers to improve the program over time. 
We're committed to work with you both on legislative and 
administrative options----
    The Chairman. That's not an answer. That's not an answer.
    Let me ask you, Dr. DeSalvo. If Proctor and Gamble was 
going to introduce a new soap or a new product, it surely 
wouldn't introduce it in the whole country to test it out. They 
would make sure it was right. If McDonald's was introducing a 
new sauce or gravy or hamburger, they would test it out.
    Most businesses would do things that way, and as a result, 
we have in our private sector things like ATMs that actually 
work all over the world. We have an amazing system for making 
airline reservations. That's the kind of system we'd like to 
have for our electronic health records.
    Why wouldn't it be a good idea to take my music teacher's 
advice and play it a little slower than you can play it and go 
ahead and do Stage 2 now? Only 12 percent of doctors can comply 
with Stage 2 the way it is now and only 40 percent of 
hospitals.
    Let them do that, and then say, ``We're going to do Stage 3 
in a year. Count on it. Between now and then, we're going to 
work with you on all these issues.'' How can we reduce 
physician documentation? What other things can we do to 
encourage interoperability? Get buy-in and broad support in 
Congress for it, and then have a big success in a year, rather 
than spend the whole year defending a rushed-up program.
    Dr. DeSalvo. Senator, as Dr. Conway shared, we do want to 
get this right, and that means that we've taken a lot of time 
to listen and receive feedback for ONC's rule, the 
certification rule. An example of where we did, of course, 
correction is, for example, last summer, we realized that some 
of the approaches to technology we were taking needed to be 
fixed so that interoperability would be better. We have been 
willing to make changes where it was necessary along the way.
    Similarly, with respect to flexibility, some year and a 
half ago, we worked with CMS on making adjustments so that if 
docs weren't ready to upgrade to a new product, if they needed 
more time to get used to their product and make it work better 
on the front lines, that flexibility rule has given them that 
additional time. Our track record reflects that we are willing 
to work with the private sector.
    We do understand firsthand what that's like to be in the 
clinical environment and working with our electronic health 
records. Our certification rule, as proposed, itself has some 
of the protections and advancements that I believe are shared 
interests with this committee--so better security, more access 
to data for consumers through these APIs, better opportunities 
to address blocking, and opportunities to advance the 
marketplace so that docs and others know what they're buying, 
to make more transparency.
    The proposals in our certification rule reflect the input 
and the guidance that we received through not just abstract 
conversation, but meaningful day-long conversations with docs 
and others to see how we could better serve them through this 
program.
    The Chairman. Thank you.
    Senator Murray.
    Senator Murray. Dr. DeSalvo, I'm really pleased to see the 
hard work your office has done to advance the interoperability 
of health IT. Time and time again, we've had witnesses before 
this committee that testified that systems need to be 
interoperable to unlock the full potential of electronic 
medical records.
    The interoperability road map that you developed with 
providers and developers includes some both short- and long-
term objectives for achieving interoperability. This committee 
has heard about how the lack of interoperability really impedes 
care coordination and quality improvement.
    Can you share with us what your plans are for working with 
healthcare providers and health IT companies to accelerate the 
adoption of common standards and business practices that are 
needed to improve interoperability?
    Dr. DeSalvo. Thank you, Senator Murray. It is our approach 
and our philosophy that to get to interoperability, we have to 
do this with the private sector and with consumers as our goal, 
them having control of their data. They're right at the center 
of this.
    All of our actions reflect their input and our cooperation 
with them to advance new technologies like something called 
FIRE--great name--a nice new way to have data be accessed in 
systems. That's the result of a collaboration between us and 
the private sector to see that that's moving along as quickly 
as possible, faster than we might be able to do it federally.
    More importantly, what it's going to do is give consumers 
an opportunity to be able to pull their data out of the record 
at their--Sunday evening, I'm filling out the immunization 
record for my kid's camp. I can go online and do that in a way 
that's not going to be quite as clunky as it might be today for 
some families.
    On the other hand, we see remarkable examples of how 
interoperability is already working, and we want to learn from 
those and buildupon it. Right here in DC, in Maryland, there 
are systems where you can do a Google type search to find a 
patient and understand their last visit to the ER and the 
information that's necessary for the care in that doctor's 
visit.
    New York, Nebraska--so many great examples of where this 
works. We've seen even within systems, like at Vanderbilt, 
they've been able to leverage what they've done with meaningful 
use around smoking and improve their smoking programs for the 
patients that are within their system.
    The excitement is that we know the private sector is using 
the technology to create solutions around quality and safety 
and better care and information flow. As people move through 
the care system, it's giving them more access to data. Our goal 
is to catalyze that to accelerate it, but at the same time make 
certain that we're being clear that we all need to move to some 
federally recognized national standards, that we have to have 
the right trust environment, and we need to push on these 
drivers to make sure that the system is working on behalf of 
the consumers.
    Senator Murray. Dr. Conway, there's a lot more work to do. 
Health IT really is supporting some improvements in the quality 
of care. Providence Health, which is in my home State, is using 
their electronic health record now to prevent a common form of 
hospital-acquired infection associated with catheters. Early 
results from that show their system is helping to implement 
clinical best practices that may eventually lead to shorter 
hospital stays, even reduce mortality.
    You noted in your testimony that Medicare and Medicaid are 
rapidly changing how they pay providers based on quality, value 
of care they deliver to patients. Reduced hospital-acquired 
infections is just one of the ways that these new models will 
help improve quality for patients.
    Can you talk a little bit to us about how critical health 
IT is to helping providers adjust to new models of care 
delivery?
    Dr. Conway. Yes, Senator Murray. Thank you for the 
question. First, on Providence, I know the system relatively 
well--just incredible work in patient safety, patient 
engagement. Thank you for sharing that example.
    Just a few other tangible examples to bring home the power 
of health information technology. One, in our Comprehensive 
Primary Care Initiative, a large focus is using electronic 
health records for advanced primary care and managing patients.
    A practice in rural Arkansas, using their electronic health 
record, measure their patient population and figure out who's 
not getting preventative screenings, which you mentioned 
bringing those patients in for prevention; using remote 
technology to interact with patients to prevent exacerbations 
of diseases like diabetes and congestive heart failure; using 
various tools connected to their EHR to really achieve those 
better health outcomes for the patient population they serve in 
a small rural practice.
    Another example in some of our accountable care 
organizations is using their electronic health record to track 
and coordinate care for patients across settings, across 
nursing homes, across primary care offices, et cetera, and 
really understanding what services that patients needed. And, 
last, true patient engagement, allowing patients access to 
their information to help manage their own care. It's a 
critical foundation to our delivery system reform efforts.
    Senator Murray. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Murray.
    Senator Burr.

                       Statement of Senator Burr

    Senator Burr. Dr. DeSalvo, welcome. Dr. Conway, welcome. 
I've got to be candid with you guys. I really do thank you for 
the job you do. I wouldn't do it. You're stuck in a 
bureaucratic structure that has no hope of succeeding. Let me 
explain why.
    Technology is changing at a pace that nobody in government 
envisioned ever would be this fast. I would only say this, that 
you're going to continually play a catch-up game, late to the 
party of change that the private sector makes because 
technology allows them to do it faster, cheaper, and better, 
and the whole of government is making no effort to structurally 
change to be able to respond to what your customers are doing 
day in and day out, or hoping to do, and that's to take 
advantage of that technological change.
    I've got three questions. They're jump balls. If one of you 
or both of you don't take them, I will assign them.
    [Laughter.]
    The first one is why is interoperability so difficult to 
achieve? Second, how do you define the term you use, a safe and 
secure information system? And, third--this will probably be 
yours, Dr. DeSalvo. You said in your testimony to us that you 
have implemented some things along the way since the April 
deadline of comments on the road map. Well, this is 5 months 
later, and the testimony says in the near future, we're going 
to see the road map. I sort of get the impression that we're 
like deer in the headlights.
    Five months is a significant technological shift in the 
marketplace. The information you heard 5 months ago may or may 
not be relevant today from a standpoint of what doctors shared 
with you, what hospitals shared with you, what their data has 
suggested that they ought to do.
    The question is, if the guidelines don't change, if there's 
not enough flexibility, how in the hell do we expect them to 
perform at the highest level of quality and execution, when 
it's, in fact, our regulations that stand in the way of doing 
it? The floor is yours.
    Dr. DeSalvo. Thank you, Senator. I actually really 
appreciate the questions, because I believe it reflects the way 
that we've been approaching this challenge as the Office of the 
National Coordinator. In the last year and a half since I've 
been National Coordinator, we have taken a shift and been 
working in a more open fashion with the technology private 
sector.
    For example, the interoperability standards advisory, which 
is an action that we have taken as a result of the road map we 
developed with the private sector, with the technology 
industry. It's sub-
regulatory so not regulatory, so that we can continue to 
iterate it and keep up the times, as you say. We are already on 
our second version in the last 6 months of putting out that 
document, and we'll have another turn of the crank in December 
as we are continuously getting feedback and making that better.
    An example of how we work directly with the private sector 
to help spur new technology and/or make sure that we're ready 
for them is FIRE, which I mentioned earlier. I'm sorry to get a 
little wonky, but it's the sort of new thing--that everybody is 
looking forward to making the system more internet-like and 
making data more available.
    We commissioned a report that we then handed to our 
advisory committee, who then pulled together a private sector 
team called the Argonaut, who have been working in concert to 
come up with this new technology that they have to mature. 
They've now matured it, and we are ready to receive on the 
other side as we're thinking about our certification program, 
or even as the DOD is thinking about how it's going to 
implement its records.
    We are continuously in conversation and trying to make 
certain that we're doing our work in as much of a sub-
regulatory fashion as possible so that we're giving guidance 
and setting guardrails but not getting in the way, because what 
we want to do is raise the floor. We want to get everybody on a 
set of shared standards that make sense, that are common, but 
not get in the way of innovation, because we really need to see 
the marketplace advance in such a way that it's going to meet 
the needs of the providers on the front lines.
    Dr. Conway. The only two brief things I'll add on 
interoperability--we have significantly reduced the total 
number of measures and requirements, tried to simplify the 
program and really focus on high-level requirements to not 
stifle innovation, and those that are left are--the vast 
majority are focused on interoperability.
    Second, on the new payment models, to give you another 
example, in our bundled payment initiative, where these 
providers are caring for an episode of care across settings--
they figure out, to your point--in the marketplace, they figure 
out how to share information, because it's critical to be 
successful in these alternative payment models. Those are two 
tangible examples.
    Senator Burr. I'll let you answer what your definition of 
safe and secure is, but let me just say this. It's amazing that 
they can figure it out, yet we can't figure out how to design a 
structure, because you're right. The private sector has total 
flexibility.
    I hope you understand. I'm not being critical. I'm 
expressing something that every member hears. The healthcare 
community comes to us and says, ``How are we going to do 
this?'' We're supposed to be the road map, and if the road map 
takes 7 months to do, after you've gotten all the input, 7 
months is an eternity to them.
    Do you want to address safe and secure for the information 
system?
    Dr. DeSalvo. Yes, sir. I'd like to just reemphasize that 
our milestones along the way of updating that road map is a 
reflection of the continuous conversation. It's not that we go 
in a room and then put out a new road map. We're continuously 
acting on it in partnership with the private sector.
    The privacy and security components, particularly security, 
are a major focus for us. We have been working with the 
Administration--wide efforts around cyber security, and we tend 
to follow NIST recommendations, NIST recommendations about 
making certain that the systems are secure and that 
authentication works, and have used our certification program 
to--every time--maturations, but are encouraging the private 
sector to keep moving and not to--they don't always have to 
wait for us. We really want to see them continuously update.
    Senator Burr. Thank you.
    Dr. DeSalvo. Thank you.
    The Chairman. Thank you, Senator Burr.
    Senator Casey.

                       Statement of Senator Casey

    Senator Casey. Thank you, Mr. Chairman.
    I want to thank you both for your testimony, also for your 
public service. This is hard to get right, and we've got a ways 
to go.
    I did note in Dr. Conway's testimony in the first page some 
numbers that I know others have mentioned but it bears 
repeating. The proportion of U.S. physicians using electronic 
health records increased from 18 percent to 78 percent between 
2001 and 2013, and 94 percent of hospitals now report using. 
There is progress, but I know we've got a whole host of 
problems to work through and to consider today.
    I wanted to focus on the question of flexibility as it 
relates to care settings and to really zero in on those care 
settings as they relate to children.
    Dr. Conway, we've all heard the expression for years that 
kids are not small adults. They have to be treated differently. 
They need different treatment regimens and approaches. Based 
upon the unique aspects of their care, are there ways that the 
electronic health records, both in terms of implementation and 
use, can be tailored to meet those specific needs? Can you 
speak to that in terms of the different settings that we have 
for children?
    Dr. Conway. Yes, Senator Casey. Thank you for that question 
and thanks for your dedication to child health. As a 
pediatrician, it means a lot.
    I'll speak to a few aspects. With the CHIP reauthorization 
act, it gave us the opportunity to work on an electronic health 
record format, but was a joint effort between the Agency for 
Healthcare Research and Quality, ONC, and CMS. Through that 
work, we're able to develop standards adjustments for 
pediatrics, things like weight-based dosing, which are critical 
for children but not as critical for adults.
    We've now tested that in several States. We've tested it 
with various vendors, and we're really working with the vendor 
community, with States, and with the pediatric community to 
make sure there are vendor products that meet their needs.
    I alluded to Cincinnati Children's. At that time, this 
didn't exist. I did the implementation prior to that work, and 
we had to modify an EHR that was largely based on adults to our 
system. Over time, we'd like that to not be the case, where 
pediatric practitioners and hospitals have the ability to 
utilize the EHRs that have already been modified in a way that 
they're useful in pediatrics.
    Senator Casey. Just an additional question, and I'm going 
to be out of time. One issue that's surfaced is with regard to 
minors, the varying confidentiality restrictions. Can you tell 
us more about how to strike that balance between facilitating 
the use of electronic records among adolescent patient 
populations and balancing that with ensuring confidentiality?
    Dr. Conway. Yes. I'll start, and Dr. DeSalvo may add more 
from the certification perspective. There are some of the same 
key principles from paper records that apply in an electronic 
environment. Then it's how do you adjust those in an electronic 
environment.
    I'll give you some tangible examples. We have worked with a 
network of pediatric specialists who are actually using their 
EHR and social networking to engage their patients in a much 
more real way, in this case, for inflammatory bowel disease, a 
chronic condition.
    That work has actually shown decreased hospitalizations, 
increased growth in better outcomes for patients. It's a 
critical example of not just using the EHR as a recordkeeping 
system, but how do you use that information to really engage 
patients, in this case, adolescents, in their own care and 
improving their care, including feeding data back into the 
electronic health record.
    Senator Casey. Dr. DeSalvo, anything on this question of 
confidentiality?
    Dr. DeSalvo. Just to add that today, across town, we're 
having an eConsumer Health Summit, where hundreds are in person 
and thousands online, of consumers who tell us not just 
themselves, but through their own data and others, that they 
have an expectation that providers are sharing their electronic 
health data on their behalf to improve their care and, in many 
cases, to improve the care of others like them with similar 
chronic diseases or other diseases.
    In general, consumers are expecting and wanting information 
to be shared with their consent. Getting that right is what 
really matters. It needs to be informed consent, and we need to 
be able to protect their data when they don't want it shared. 
Those are the kinds of efforts we're always engaged in. Thank 
you.
    Senator Casey. Thank you.
    The Chairman. Thank you, Senator Casey.
    Senator Franken.
    Senator Cassidy. We're not going to this side?
    The Chairman. I made a mistake. Excuse me.
    Senator Cassidy.

                      Statement of Senator Cassidy

    Senator Cassidy. I was going to thank my chairman, but 
never mind.
    [Laughter.]
    I do want to thank the Chairman and the Ranking Member. 
Obviously, we've spent a lot of time on electronic medical 
records. As a physician, I know just how fundamental this is to 
how we're going forward. Thank you all for your kind of dogged 
determination to make sure we get this down. Thank you.
    I'd also like to announce today, as Senator Murray referred 
to, that Senator Whitehouse and I will introduce legislation 
this coming Tuesday to enhance interoperability. I think that 
Senator Whitehouse asked we share that with you all, and in the 
spirit of trust, we have shared it with you. Please don't 
backstab me. Senator Whitehouse and I thank you all for your 
partnership in this effort, and I look forward to working with 
him on that.
    Let me pick up something--both Senator Casey and Senator 
Alexander just said things that kind of triggered with me. 
Senator Alexander started off by saying why don't we get the 
meaningful use right. I'm going to speak not as a Senator. I'm 
going to speak as a physician colleague. You'll understand what 
I'm about to say.
    I had this kind of weird experience. I still see patients. 
I'm seeing a guy who had vomited blood the week before from 
varices. His belly is full of fluid. He's as orange as orange 
can be.
    As I'm trying to get his medicines right so he doesn't re-
bleed, talk to him about not drinking, get his ascites down to 
make sure that it's not infected, and get him down to a liver 
transplant unit, I'm supposed to take a minute of my precious 
time and ask him, ``Have you stopped smoking?'' The absurdity 
of that in this situation is evident even to those who don't 
know physicians.
    One of the suggestions that we have had in these hearings 
from a subspecialist is why don't we allow subspecialists to 
define what their meaningful use Stage 3 is? What a pediatric 
endocrinologist is going to ask is far different from an 
orthopedist.
    You've mentioned, Dr. Conway, that you're trying to make 
this more relevant. The ultimate in relevance is to allow the 
specialty societies to define, No. 1. And, No. 2, as Senator 
Alexander said, why don't we do that on the front end as 
opposed to kind of attaching it to the back? I hope you're 
about to tell me that, yes, you've already decided to do that.
    Dr. Conway. There's a couple of points to bring up, and 
thank you for the question, Senator. One, with the proposal for 
the modifications, it does lessen the number of measures and 
provides more flexibility, including flexibility to specialists 
in terms of what they focus on, in terms of care.
    Senator Cassidy. Does it allow the specialists to define 
for their own specialty that which should be meaningful?
    Dr. Conway. It does to a large degree, and then let me try 
to explain. In the clinical quality measure arena, for example, 
we have increasing of flexibility, and as we move to MACRA, an 
implementation of a merit-based incentive system, we're working 
closely with specialty societies so we have measures relevant 
to their practice and give them the flexibility so if we don't 
have sufficient measures relevant to their practice, they can 
report that. They can say, ``These measures are pertinent to my 
practice. I don't have''----
    Senator Cassidy. The impression I get of what you're 
saying, though, is as opposed to the specialty societies 
saying, ``Listen, this is what only 30 percent of our 
colleagues are doing, 100 percent should, and this is maximally 
relevant,'' it is rather CMS saying, or your office saying, 
``Listen, this is what we're going to have you do, and you have 
latitude within this as to what you do, but let us know if we 
didn't do it right.''
    It seems better to have them tell you whatever you should 
be doing and isn't. You see where I'm going with that?
    Dr. Conway. I do, sir. In terms of--to give another example 
where it is not us defining for the specialties, specialties 
can now use electronic health records and report via qualified 
clinical data registries to CMS. These are registries that are 
linked to the EHR, typically----
    Senator Cassidy. I get that, but that's not quite the 
question where I was. Are we going to allow specialty societies 
to define what meaningful use is? Just yes or no.
    Dr. Conway. Specialty societies are allowed to define 
within meaningful use the measures that are most applicable to 
their practice.
    Senator Cassidy. Not those which should be applied. There's 
a difference there, and I think the difference is critical. One 
is they're being told to select from a smorgasbord that we have 
decided is relevant. This is--no, let us tell you what is 
relevant, and that would make it most meaningful. I gather 
that's not what you've done. Let me just say as a practicing 
physician that that's what we've heard in our testimony, and 
that's what we should do.
    Let me ask--because I'm going to run out of time. The other 
thing we've heard is that absent a unique identifier, it's 
going to be very hard for the comatose patient being seen in 
New Orleans, who previously was seen at some hospital in 
Missoula--how does a doc in New Orleans figure out what the doc 
in Missoula ordered that would be relevant to the comatose 
patient now before her?
    I guess my question--and we've heard how unique identifiers 
is like the only way, really, to get there, unless the patient 
can volunteer. Civil libertarians obviously are concerned about 
unique identifiers, and yet you've just told us that in e-
health, there's an expectation that doctors are sharing 
records.
    Without going further into the kind of obstacles there, 
what do you think of a global entry type situation? I bypass 
the long lines at the airport because I've given all my 
personal data to TSA, who figured out that I'm an OK guy and 
then allows me to kind of go in with an expedited screening. 
This is voluntary, so the civil libertarians can't say, ``Well, 
heck, it's big brother.'' Any thoughts about that?
    Dr. DeSalvo. Senator, let me begin just by thanking you and 
your staff and Senator Whitehouse and his staff. You've been 
great partners as we've been talking about this technology work 
that you're doing. This whole committee has gotten so steeped 
in it. It's exciting for us at the Office of the National 
Coordinator.
    With respect to identifying the right patient, you and I 
experienced this after Katrina. Somebody is displaced to 
Missoula or wherever, and you want to make sure that that's the 
right Jim Smith, that you're giving the right drug or pulling 
up the right medication history for them.
    There are models that work in the field right now that have 
been, to Senator Burr's comment, developed by the private 
sector and get pretty close to matching well so that we can 
maximally reduce harm within the constraints of being able to 
match. Are you the right person? I'm going to a bunch of 
algorithms to make sure that we have that right. We have been 
working very----
    Senator Cassidy. That's different from a unique identifier.
    Dr. DeSalvo. It is. That is the technology in hand, and we 
have been accelerating that, working aggressively to work on 
getting to a place where we have been making recommendations 
that everybody is going to move to a more safe system. That's 
one pathway. Since it's what we have today, and with working in 
places like Maryland, DC, New York and Nebraska, we need to 
keep advancing that.
    There are private sector groups working on a unique 
identifier model, and we appreciate the work that they're 
continuing to do. We have partnered with them in some cases, 
just to be a part of the conversation so we can listen. It's 
possible that some may decide to go in that direction. In the 
meantime, we've certainly been making certain that everybody is 
being as aggressive as possible about getting the patient right 
so that we can reduce as much harm.
    Senator Cassidy. I yield back. Thank you.
    The Chairman. Thank you, Senator Cassidy, and thanks for 
your contribution to the certification bill and for bringing 
your medical experience to the committee. We appreciate that.
    Senator Franken.

                      Statement of Senator Franken

    Senator Franken. Thank you, Mr. Chairman. I am not a 
doctor, but I played one in a sketch.
    [Laughter.]
    I want to make sure I understand Dr. Cassidy's question, 
because he created a scenario in which someone was basically in 
an emergency situation. In an emergency situation--just let me 
make sure of this--don't you have some discretion as a 
physician to say, ``This is not the time I have to follow 
certain protocols in terms of electronic medical records.'' 
Also, aren't there--emergencies actually create--haven't we 
seen where in emergencies, electronic medical records are very, 
very beneficial because you can get records much faster?
    Dr. Conway. I'll start if it's OK, and Dr. DeSalvo may add 
more. No. 1, yes, in emergency situations, we would want 
physicians and clinicians to deliver the appropriate care. We 
would not in any way want to regulate that, and it is 
appropriate. I practice in a hospital medicine environment 
where there are emergencies. You deliver the appropriate care. 
Whether it's a paper-based or electronic environment, you can 
document it after the delivery of that appropriate care, and 
that's what we would want.
    No. 2, we actually do have examples. One patient, or the 
wife of a patient, spoke very eloquently at one of our events 
that the EHR prevented a safety event and literally saved her 
husband's life, because that information--he came in 
unconscious, not with information--had the ability for 
electronic health record information to be transferred. That 
was a life-saving event. I don't have specific data on how 
often that happens, but it can certainly occur, and we have 
instances where electronic health records have saved lives.
    Senator Franken. The Hennepin County Medical Center, when 
the bridge collapsed, used electronic medical records and found 
that they were extremely helpful in that situation.
    Dr. Conway. Yes.
    Senator Franken. I just wanted to understand something, 
unusual as that is in a hearing. I'm co-chair of the bipartisan 
Senate Rural Health Caucus, so I want to talk about rural and 
small practices. I've been meeting with providers and health 
systems in rural communities across Minnesota to learn about 
the challenges that they face.
    In previous hearings, I've talked about the resource 
constraints and sort of the asymmetrical bargaining power that 
tend to make it more difficult for rural providers to 
successfully adopt the EHR systems. They want to implement EHR 
systems and are striving, often struggling, to meet the 
meaningful use requirements.
    Dr. DeSalvo, my question is: What is the agency doing to 
help rural and small practice providers be successful? We've 
talked a lot about carrots and sticks, but what are the 
agency's plans for providing continued support and technical 
assistance throughout the process, this transformational 
process?
    Dr. DeSalvo. Thank you, Senator. We share a policy goal 
that no provider, no patient, no person should get left behind. 
That means we have to, in some cases, pay special attention to 
smaller practices, small hospitals, small group practices, and 
those in rural areas to see that they have the technical 
assistance and the supports they need.
    The Senator may be aware that our office, in partnership 
with HRSA and with USDA, over time has leveraged additional 
resources for broadband access, for additional technical 
assistance on the front lines. We did this with CMS in the 
meaningful use program. They were very successful early 
adopters, they being rural providers and critical access and 
small providers--keeping them in the program, but, more 
importantly, keeping them having a digitized care system so 
that information will flow and follow.
    Their constituency is important, and it's increasingly 
important to the VA and the DOD. I's a part of the work we're 
going to do going forward to see that soldiers and veterans 
have access to their information as they're moving through 
those systems.
    I had the experience of--it wasn't a rural, but it was 
close. It was a small 80-bed hospital that I was on the board 
of and led the development of our health IT purchase and 
started the implementation before I came to Federal Government, 
and it was--it's a challenge when you're that small. We had no 
IT shop. We were borrowing--parts of staff we were contracting 
out from nearby hospitals just to try to get the pieces back 
together.
    I know it acutely, because I was on a hospital board when I 
was commissioner, trying to build a hospital and get it 
rolling. It's in my mind every day about how we make sure that 
they don't get left behind in this really critically march 
forward, because the people that they serve deserve to have as 
much access to data and information as those in urban areas.
    Senator Franken. Well, I'm out of time. Let me just put a 
word in for rural broadband, because if we're talking about 
tackling electronic health records, rural providers need that 
broadband.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Franken.
    Senator Baldwin.

                      Statement of Senator Baldwin

    Senator Baldwin. Thank you, Mr. Chairman and Ranking 
Member.
    It's clear that we still have more work to do with 
interoperability. Recently, industry stakeholders have made 
really significant progress in coming together to solve some of 
the IT infrastructure problems. For one, a diverse group of 
stakeholders from providers to EHR vendors, even competitors, 
are developing a unifying agreement to connect the existing 
exchange networks. This could serve as a national structure to 
ensure that all of the networks can securely share patient 
records with each other.
    Just like we've heard with other examples--ATMs, et cetera, 
cell phone networks--it shouldn't matter what network your 
doctor belongs to. They should all be able to talk to one 
another.
    Dr. DeSalvo, much if not most of the work in this space has 
been done for us. How can we ensure that patients and providers 
and developers benefit from all this effort that is ongoing and 
has already been done? What can the ONC do to both leverage and 
implement the work of these public-private collaborations? 
Specifically, I'm looking at--you were talking about 
guardrails, but nudges versus mandates, leveraging.
    Dr. DeSalvo. Well, Senator, thank you for the question, and 
I'm so encouraged in the last year, especially, by the work the 
private sector is doing to come together to set some shared 
rules of the road, to agree on privacy and security and, 
increasingly, standards. That's the reason that efforts like 
our interoperability standards advisory--it's a document, but 
it's really a process. It's a way that we've been working with 
them to come up with a federally recognized list of national 
standards, many of which are developed in the private sector.
    This helps us, as the Federal partners who purchase and pay 
for and deliver care and make IT systems, also be on the same 
page with them so that we're using the same rules of the road 
and that we're using the same standards as we all move forward. 
We consider ourselves partners with them.
    At the end of the day, the guardrails are necessary in some 
cases because, unlike the private sector, I believe that we 
have the responsibility to protect everyone, no matter their 
geography, where they live, the color of their skin, the source 
of payment, the kind of provider that they have. If you think 
about rural America, making sure that all those connections are 
made and also that that data is available to consumers and for 
public good, public health preparedness and public health 
everyday.
    There are additional--outside of the healthcare sphere that 
some of the conversations have been occurring. It's important 
for us to remember that we have a responsibility to consumers 
and to the community beyond. I agree with you. I'm encouraged 
by their advancements. I want to see that continue going. I 
want to see that we're holding them accountable and that we're 
setting, the right guardrails, governance expectations, that 
the data is there for the consumer when and where it matters in 
disaster and every day.
    Senator Baldwin. Following on for both of you, Dr. DeSalvo 
and Dr. Conway, we have throughout these hearings identified a 
number of areas where we need to do better to realize the full 
benefits of health IT. In both of your testimonies, you outline 
a number of initiatives that each of your organizations are 
planning to further advance interoperability as well as 
enhancing patient engagement and reducing the burden that we've 
all been talking about that providers have shared.
    We, universally on this committee, are committed to these 
goals. I'm curious to know whether you believe that your 
agencies need specific new legislative authority to 
successfully achieve these goals, given the planning that 
you've outlined to us today.
    Dr. DeSalvo. Senator, we really do appreciate the 
partnership this committee has brought forward, this 
conversation into the public mind, and it's actually really 
helping to accelerate what's happening in the private sector. 
Thank you all for that.
    We are looking across the Administration at every 
opportunity we have as an administration to see that systems 
are more usable, that data blocking is not occurring, and that 
interoperability is happening in a consistent and equitable 
way. There may be some opportunities where the committee could 
help to give us more opportunities to approach governance, so 
setting rules of the road, business practices and 
implementations in the marketplace, in some cases around 
blocking and in some cases just around consistent data sharing.
    There may be additional opportunities for us to make the 
market more transparent, to be able to share business 
practices, costs, et cetera, of products so that docs and 
others know what they're buying. When they go shopping, it's 
more clear what they're getting and if the batteries are 
included, if you will. We have noted some of those. I have in 
my written testimony that was given, and I would really look 
forward to the opportunity to provide some ongoing technical 
assistance to the committee about that.
    Senator Baldwin. Dr. Conway.
    Dr. Conway. We would agree with Dr. DeSalvo on the issues 
noted around information blocking, oversight of certification, 
et cetera, and we're happy to work with the committee if 
there's other ideas that you would like technical assistance 
with.
    Senator Baldwin. I see that I have run out of time.
    The Chairman. Thank you, Senator Baldwin.
    Senator Whitehouse.

                    Statement of Senator Whitehouse

    Senator Whitehouse. Thanks very much, Chairman, and thank 
you for yours and Ranking Member Murray's continued initiative 
and effort in this area. It's going to be very productive for 
our committee.
    Thank you to Dr. DeSalvo, particularly, but both of you for 
your work and your leadership in this area. Thank you for the 
support you've given for my efforts with Senator Cassidy to try 
to improve the certification piece.
    If I take a step back from this, I see a need--if health 
information technology is going to be really effective--for 
there to be very good health information exchange. One of the 
ways very good health information exchange happens is through 
very good health information exchanges, like CurrentCare in 
Rhode Island, like the exchange up in Maine. There are a number 
of them.
    One of the continuing concerns and questions that I have is 
that meaningful use tees up an enormous amount of resources and 
directs them at supporting the purchase of health information 
equipment and kind of, in an indirect, like pool table bank 
shot type way, tries through the certification process and the 
standards to back encourage health information exchange. Having 
lived the life of Rhode Island's health information exchange of 
CurrentCare, I don't think that's adequate.
    I don't think that having these big national companies that 
are clawing at each other for market share and that in some 
cases appear to be engaged in some pretty unfortunate 
practices, like data blocking and hiding costs in the contract 
that doctors get clobbered with later--they're not, I don't 
see, incented in any way to focus on going to a particular 
location, like Rhode Island or Maine, and supporting the 
development of a really robust local exchange. A really robust 
local exchange is a really important piece of this equation.
    When you look at the amount of support--and, by the way, 
thank you for the support CurrentCare has gotten. They've won 
everything that's available out there. Even so, you put that up 
against the absolute avalanche of money that's going into 
meaningful use, and it seems very, very disproportionate.
    What can we do to further encourage and support the 
development of health information exchanges at a local level? I 
would carve out of that the exchange of information within 
either a hospital system or a corporate system or a particular 
company that provides a service in health information exchange, 
because that doesn't work. It's not good enough to get health 
information exchange within your hospital chain or within 
everybody who buys this particular product. That, in fact, is 
really adverse to the public interest.
    The place where you get across all those problems is when 
there's a public health information exchange. How do we make 
that work better? How do we tip the huge Mississippi River of 
money that's flowing into meaningful use so that a bigger 
trickle of a creek comes off of it for information exchange?
    Dr. DeSalvo. Senator, I wish I had 3 hours to talk about 
that with you. Let me be brief because I have about a minute 
and 37 seconds.
    Senator Whitehouse. It won't be these 3 hours, but I'm all 
in.
    Dr. DeSalvo. Rhode Island is a model example of how the 
investments that the Office of the National Coordinator made 
through the HITECH funding in local health information exchange 
can take off and be successful. There's one in every State, and 
some are more successful than others. It is a part of the 
fabric of how data is going to move. Senator Baldwin mentioned 
some of the private sector efforts, which are also part of that 
fabric.
    In the public interest, I agree, is for information to not 
stop at the artificial barriers between private sector network 
service providers and health information exchanges that may be 
run by the public sector or at the local level. That means that 
we need to see, first of all, that the artificial barriers of 
different standards don't exist, so we move to a shared set of 
standards so the data flow is easier.
    We have a set of rules of engagement, rules of the road, 
that will be agreed to, and there is an accountability 
mechanism. The Senator asked about additional opportunities 
that we might need to be able to get into the space that you're 
describing, the certification program, and other opportunities 
that the Office of National Coordinator has. We have been 
pushing that through our proposed rule, but there may be 
additional opportunities for us to see that the public's 
interest is met in that space.
    With respect to the business sustainability, what I want to 
see is that there is a sustainable business model that works 
for everybody in this country and is not a pay-to-play.
    Senator Whitehouse. My time is running out, but I really 
want to make this point. If you're really doing health 
information exchange through a public facility that brings in 
all comers and isn't picked off by a particular private sector 
company to emphasize its own business, if it's truly across the 
board, then, really, what you've done is develop a piece of 
infrastructure, a piece of safety, hardware, and I view it as 
akin to air traffic control at an airport.
    Dr. DeSalvo. Yes.
    Senator Whitehouse. We don't ask for our air traffic 
control system to have a sustainable business model. We know 
that it provides safety and supports the business models that 
are out there of the airlines. I really push back hard on the 
notion that a CurrentCare or the Maine information exchange or 
any of these need to show a sustainable business model. They 
don't. They support everybody else's sustainable business 
model.
    Dr. DeSalvo. We actually agree, sir.
    Senator Whitehouse. Great.
    Sorry to go over the time, Mr. Chairman, but I sometimes 
get a head of steam up on this.
    The Chairman. No, that's good. Thank you, Senator 
Whitehouse.
    Dr. DeSalvo. I'll catch you a little bit later and we can 
go over this.
    Senator Whitehouse. By the way, I think Dr. DeSalvo is 
terrific.
    The Chairman. Senator Warren.

                      Statement of Senator Warren

    Senator Warren. Thank you, Mr. Chairman.
    We all know that one way to get the cost of healthcare 
under control and to improve quality is to change the way that 
we buy care. Instead of charging for each test, for each 
procedure, for each followup visit, we need a better way to 
pay.
    Secretary Burwell has set the goal of transitioning 30 
percent of Medicare payments away from fee-for-service by the 
end of 2016. One alternative payment model is bundled payments, 
a lump sum payment that covers all the costs of a procedure and 
the followup care. For example, BayState Health in 
Massachusetts has been bundling payments for hip and knee 
replacements and the necessary followup care for years, and it 
has improved quality and saved an average of $2,700 per 
patient.
    The data are clear. Bundles can help us move toward better 
outcomes at lower costs, and it's good to see that CMS recently 
announced their intent to use bundled payments, like 
Baystate's, in 750 hospitals across the country, starting next 
year through the comprehensive care for joint replacement 
model.
    Dr. Conway, can you explain why interoperability, making 
sure that the electronic medical records can actually talk to 
each other, is important to facilitate alternative payment 
models like bundled payments?
    Dr. Conway. Senator Warren, thank you for the question. I'm 
familiar with some of the work of BayState. I was in 
Massachusetts last week and it's just tremendous work.
    On bundled payments, interoperability--thanks for your 
comments on the comprehensive joint model. We're very excited 
as well. We're getting comments on rulemaking now. I'm 
actually, this afternoon, talking to hundreds--and we actually 
have over 1,500 providers in our voluntary bundled model, and 
hip and knee replacement is actually the most common condition.
    Interoperability is a critical underpinning. The key to 
effective care, in these bundled payment arrangements, is to 
truly coordinate care for that patient for the entire episode.
    What we hear when we interact with providers in bundled 
payment is they're sharing information from the hospital to the 
physician group, to the post acute care provider, even home and 
remote monitoring technology. Some of them are very successful 
by getting patients in their home and then caring for them in 
their home, which is a lower cost setting and, generally, 
patients prefer.
    The interoperability piece is critical to the success of 
bundled payments. As you said, we believe bundled payments are 
a critical piece of the overall picture of alternative payment 
models and delivery systems.
    Senator Warren. Thank you. That's very helpful.
    This is the sixth hearing that this committee has held on 
health information technology, and one point that I think has 
come across in every single hearing is despite the success of 
Federal incentives in getting doctors and hospitals to 
implement electronic health records, most still can't exchange 
basic patient information.
    Dr. DeSalvo, the Office of the National Coordinator for 
Health IT is charged with advancing interoperability of 
healthcare technology, which, as Dr. Conway said, can help 
advance alternative payment models. Is the reverse also true? 
Do payment models that require cooperation across care settings 
help promote interoperability?
    Dr. DeSalvo. Senator, it is absolutely true that moving to 
a changed business environment, moving to alternative payment 
models, ones that reward value and population-based care, 
requires us to have a health IT infrastructure that works, that 
provides the data necessary to the docs and the hospitals and 
the other care team members and the consumer, to know what 
information is there so they're not doing redundant tests, and 
that they're able to save money, reduce harm, and improve the 
quality of care.
    These two concepts are so tightly linked. It is one of the 
reasons that the department's delivery system reform effort has 
been so tightly linked, that when we change the way we pay for 
care and deliver care--but it requires a new information model 
that we want to advance. System after system that's highly 
successful, whether it's in Massachusetts or--I was just at 
Intermountain yesterday. They can show you clearly that when 
they have better data, a better dashboard, they know where 
they're going, it helps them to reduce costs and improve 
quality.
    Senator Warren. Thank you. This is very helpful. I fully 
support CMS moving forward with the mandatory joint replacement 
model. The Congressional Budget Office estimates that 
widespread use of bundled payments could save our healthcare 
system $46.6 billion. We need to continue to build 
interoperable health IT infrastructure in order to realize 
those savings.
    That means setting common standards for transferring 
information and developing a way to accurately link medical 
records to patients. It also means creating incentives that 
encourage information sharing. Like Dr. DeSalvo and Dr. Conway 
have said today, alternative payment models are one way to 
create those incentives.
    Moving forward with these new models and improving 
interoperability go hand-in-hand, just as you've said, tightly 
linked. I hope that the Office of the National Coordinator, 
CMS, and this committee will continue to coordinate on these 
initiatives so we can move toward a healthcare system that 
gives us better outcomes at lower costs.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Warren.
    Senator Murray, any other thoughts?
    Senator Murray. I just want to thank both of our witnesses 
today for their incredible work on this. This has been a really 
important series of hearings.
    Mr. Chairman, we've heard a lot about how critical the role 
of information technology is in making sure that we have a 
strong healthcare system for patients, families, and everyone. 
I just want to thank you for this, and I look forward to 
working with you.
    The Chairman. Thank you.
    I want to thank the Senators here for their participation. 
This has been a pretty heavy focus on a target, but that's one 
way to get a result. Your active participation in this has made 
a difference.
    I want to thank Dr. DeSalvo and Dr. Conway for the work 
you've done with our staffs over the last several months. We've 
tried to identify five or six steps we can take to get an 
electronic health record system that had really gotten in the 
ditch back on track so that it helps patients and realizes all 
the promise that all of us have talked about.
    I hope that everyone listening understands that I believe 
it's unanimous on the committee--that's kind of a bold 
statement to make on a committee this diverse--that we all want 
to go forward. Nobody wants to go backward. We want our country 
to have a system of electronic health records, and we want to 
create an environment in which that can succeed.
    A couple of thoughts. A group of Senators met with a group 
of Nobel laureates earlier this week, and one of the Nobel 
laureates said something that fit into what Senator Whitehouse, 
Senator Burr, and others have said. She said that she thought 
it was likely that some disruptive technology would come along 
that we don't really anticipate and provide most of the answers 
for how we have an electronic health system that works the way 
we hope it will work. Maybe that's right. Maybe it's wrong.
    What we want to get is a system that works as well as our 
airline reservations, as our ATM cards, and we would guess that 
there will be some Google-like or Apple-like entrepreneur that 
will come in and provide some answers to that. I guess what 
we're saying is in our regulatory structure, we need to leave 
room for that, and you've said that you understand that. That's 
a very important thing. None of us are wise enough to guess how 
that will happen.
    Creating a platform which attracts applications and 
solutions is much better than trying to figure out what the 
applications or solutions are here. The government historically 
hasn't been that good at doing that. I hope that's a part of 
it, and I thought that was pretty good advice from the Nobel 
laureate.
    My final advice is my starting advice from my piano teacher 
who said, ``play it a little slower than you can play it, and 
you're less likely to make a mistake.'' You've got broad-based 
support for what you're doing, and recommendations have come 
from a number of us, not all of us, but a number of us that the 
wiser approach would be to adopt the Stage 2 rule now and get 
that percent of doctors up from 12 percent who comply with 
meaningful use and spend the next 12 months getting the 
meaningful use Stage 3 rule right and use the year to align it 
with the merit-based payment system rule that will be coming 
out this next year and with the legislation that will be coming 
out this next year.
    That is more likely, it seems to me, to help get it right 
for patients than to go ahead and rush something out and run 
the risk that you're going to have people in Congress try to 
overturn the rule and spend the next year arguing about that 
rather than working together to try to have a big success by 
the end of next year.
    I thank the Senators. I thank the witnesses. We look 
forward to the promise of an electronic health record system 
that works perfectly some day for the benefit of patients.
    The hearing is adjourned.
    [Whereupon, at 11:28 a.m., the hearing was adjourned.]

                                 [all]
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