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Opening Statement of U.S. Senator John Ensign (R-NV)
Good morning. Welcome to today’s Subcommittee hearing on health information technology. This hearing will examine the enormous potential of information technology to reduce medical errors, improve quality of care, and lower healthcare costs. Fragmented, disorganized, and inaccessible clinical information adversely affects the quality of health care and compromises patient safety. The Institute of Medicine estimates that as many as 98,000 Americans die each year from medical errors in hospitals. Many more Americans die or have permanent disability because of inappropriate treatments or mistreatments. Furthermore, studies have found that as much as $300 billion is spent each year on health care that does not improve patient outcomes – treatment that is unnecessary or ineffective.
Health information technology, which is used to collect and store clinical, administrative, and financial health information electronically, is a major part of the solution to this problem. Technologies such as electronic health records and bar coding of prescription drugs have been proposed as a means to lower healthcare costs and reduce medical errors. We need to explore these areas. We are constantly working on new ways to enhance and improve the field of medicine in the 21st Century. But efficient, quality patient care is often compromised because physicians and nurses still communicate vital information through handwritten notes. Medical orders and prescriptions are handwritten, and far too often, they are misunderstood or not followed in accordance with the physician’s instructions. And, patients often have multiple providers. In addition to seeing their internist, patients often schedule appointments with cardiologists, endocrinologists, rheumatologists, and other healthcare professionals.
In this outdated paper-based system, a patient's medical information is scattered across medical records kept by numerous caregivers in many different locations. As a result, all of the patient's medical information is often unavailable at the time of care. This is completely unacceptable.
I believe we need to begin transforming health care through information technology. The development and adoption of interoperable electronic health records is an important step that can be taken to improve quality of care and reduce costs.
An electronic record is never lost or misfiled. It is always exactly where it should be, even if you aren't. This means that an electronic record may be accessed from any point in the healthcare system.
So, if you’re happening to be traveling in my home state of Nevada and you get sick or get in an accident, a physician can instantly obtain medical information such as allergies, medications, and prior diagnoses to determine how best to treat you.
Electronic health records can also help ensure that physicians have the information they need to make appropriate clinical decisions. Because of the rapid growth of medical information and new treatment methods, physicians must accumulate a large volume of new knowledge in a short time. Information overload is, in general, an occupational dilemma that has been complicated by wide variability in treatment methods and patient care across geographic regions.
Best practices serve as a guideline for prevention or treatment of a certain disease or condition. They consist of quality-improving strategies which bring together the best external evidence and other knowledge necessary for informed decision-making about a specific healthcare problem. These guidelines can be easily incorporated into health information technology.
Clearly, health information technology has the potential to revolutionize the U.S. healthcare system. If properly implemented, health information technology will reduce duplication, and cut down administrative costs such as transcription and billing. In addition, this technology will reduce medical errors and potentially reduce medical liability insurance premiums for physicians and other healthcare professionals. I am eager to hear about the current state of health information technology in both the public and private sectors. It is my hope that this hearing will help us understand what we need to do to create a more affordable, efficient, and high-quality healthcare system in terms of patient care and safety. I look forward to the expert testimony of our distinguished panel of leaders in various federal agencies and the industry.
With that, I want to thank everyone for attending and participating in today’s hearing. I will now recognize the distinguished Ranking Member from Massachusetts, Senator Kerry, for any opening statement he might wish to make.
Witness Panel 1
The Honorable Michael EnziUnited States SenatorWyoming
Witness Panel 2
Dr. David BrailerNational Coordinator for Health Information TechnologyU.S. Department of Health and Human Services
Dr. Hratch G. SemerjianActing DirectorNational Institute of Standards and Technology
Dr. Hratch G. Semerjian
National Institute of Standards and Technology Technology
Administration U.S. Department of Commerce
Subcommittee on Technology, Innovation, and Competitiveness
Committee on Commerce, Science & Transportation
United States Senate
“Health Information Technology”
June 30, 2005 Introduction Chairman Ensign and Members of the Committee, I am Hratch Semerjian, acting Director of the National Institute of Standards and Technology (NIST), part of the Technology Administration of the Department of Commerce. I am pleased to be offered the opportunity to add to this discussion regarding health information technology. I will focus my testimony on the role that timely and reliable measurement and consensus based standards can play in increasing the accuracy, privacy, security, and reliability of health information to meet the President’s mandate to make our country’s premier healthcare system safer, more affordable, and more accessible through the utilization of information technology (IT). A cultural transformation of our nation’s $1.9 trillion national healthcare system can reverse troubling statistics such as 44,000-98,000 Americans dying each year from inpatient medical errors ; Americans are being injured or are dying each year from adverse drug events ; and a significant annual expenditure on treatments that may not improve health, may be redundant, or may be inappropriate. As a result of the President’s initiative, the nation will have a healthcare revolution that will connect IT systems for payment, prescriptions, and patient care. In order for this model to succeed, it will require interoperable IT standards and clinical diagnostic tools that are technically sound, robustly specified, and traceable to national standards and reference materials. These standards and measurements go directly to the heart of NIST’s core metrology mission. Several years ago, NIST recognized the growing importance of critical measurements and standards needed to advance the healthcare industry, and improve the quality and cost-effectiveness of health care delivery systems. Accordingly, NIST established a cross-disciplinary effort to address these needs. While a good portion of NIST healthcare portfolio makes a priority of providing the healthcare community with standards and diagnostic tools, our involvement is actually much broader. NIST has a long and effective history in working with health-related organizations to improve our nation’s healthcare system. In fiscal year 2005, NIST health related projects encompassed many areas of the healthcare sector, including screening and prevention, diagnostics, treatments, dentistry, quality assurance, bioimaging, systems biology, and clinical informatics. Recognizing the importance of this area and NIST’s crucial responsibilities, President Bush has requested an additional $7.2 million for this area for fiscal year 2006. In all aspects of this Strategic Focus Area in healthcare related activities, NIST recognizes the importance of directly addressing the needs of the doctors, clinics, and patients. NIST’s experience in managing the Baldrige National Quality Program, which promotes performance excellence among U.S. manufacturers, service companies, educational institutions, and health care providers, is another way in which NIST stays connected with health-related organizations. A large number of healthcare providers now are using or beginning to learn more about the Baldrige Quality Program as a framework for performance excellence within their organizations. The ways in which organizations manage and protect critical, electronic healthcare information and use IT systems to improve their performance is a major aspect of the Baldrige Health Care Criteria. Dealing with this sector and its senior leaders closely has provided NIST special insight into how these organizations operate and their special needs. NIST is committed to supporting the Department of Health and Human Services (HHS) in the implementation of the President’s Health IT initiative. Commerce Secretary Gutierrez and NIST stand ready to be helpful in ensuring the success of the President’s initiative. Secretary Leavitt is aware of NIST’s capabilities and we look forward to his guidance as to how we can best utilize our resources to assist the initiative. As you know the President has set a goal of widespread adoption of electronic health records within 10 years so that health information will follow patients throughout their care in a seamless and secure manner. To achieve this goal, NIST and the Department of Health and Human Services have developed strategic partnership that leverages each Department's core expertise and resources to facilitate science and technology innovation to improve human health and the U.S. economy. This agreement to work together on the key actions that will enable us to achieve the President’s goal, which the HHS witnesses will discuss in more detail, builds upon already-existing and successful collaborations between NIST and HHS in cancer research and treatment, standards for medical devices, and a host of other areas. To assist HHS in the first phase of NHIN development, NIST will: · Assist in evaluating responses to the Request For Proposals (RFP) recently issued by HHS; · Provide technical expertise for Nationwide Health Information Network (NHIN) architecture; · Assist in Standards Harmonization; · Develop Performance and Conformance Metrics for NHIN; · Assist in the development of procedures for certifying conformance; · Provide guidance for Security Specifically, HHS is soliciting proposals for a series of government contracts that will help advance health IT adoption. To support this effort in the near term, NIST has been asked to participate in the review and evaluation of responses to the Request For Proposals and will work in a technical advisory capacity to the contractors selected, as requested by the HHS National Coordinator for Health IT. To support the long-term vision of a NHIN where clinicians, laboratories, pharmacies, and patients have secure access to key medical information, NIST will continue its research with standards and emerging technologies, and provide testbeds for technology evaluation and standards harmonization for the NHIN. NIST is uniquely situated to contribute significantly to the advancement of this plan. NIST draws upon the expertise that exists in many of its programs. NIST’s scientific measurement laboratories respond to the measurement, standards and technology needs of US industry, Government, and academia. NIST’s industrial programs seek to further US technology development, as well as help ensure the growth of US small manufacturers, and have developed rigorous review and evaluation procedures for responses to open solicitations. As the lead federal agency for measurements and standards, NIST has a long and successful history of collaborating with industry sectors to respond to their needs and is poised to be successful in a strong collaboration with both industry and government partners in the development of widespread interoperability of healthcare applications. It bears repeating that in all aspects our healthcare related activities, NIST recognizes the importance of directly addressing the needs of the doctors, clinics, and patients In the remainder of my testimony, I will provide details on NIST’s track record in evaluating technical proposals and in IT standards harmonization, certification, accreditation, and measurement science to support the rigorous testing that is required for the development of the NHIN. The real value of a health IT system will only be achieved if such systems are interoperable and electronic connectivity is achieved, so that clinicians have key information, related to past patient experiences, laboratory results, and prescriptions, when and where it is needed – at the point of care. The development of such a health IT system will depend upon interoperability standards and clinical diagnostic tools that are technically sound, robustly specified, and traceable to national standards and reference materials. It is critical that all systems be secure and reliable. Sometimes, it is literally a matter of life and death. Based on many decades of expertise in information technology, clinical measurements and decision support, NIST will contribute to both the short-term and long-term goals of establishing a National Health Information Network. NIST Experience in Evaluating Responses to RFPs NIST has valuable experience reviewing requests for proposals in several of its programs, including the Advanced Technology Program’s Information Infrastructure for Healthcare. NIST evaluates each submission against specific criteria, locating appropriate reviewers for technology areas represented, formulating Source Evaluation Boards as decision-making bodies, maintaining confidentiality of proprietary information, securely moving large number of documents and maintaining complete and accurate records, providing each submission full consideration and fair treatment, and providing unsuccessful candidates in-depth debriefings. A recent National Academy of Sciences report applauds NIST for its effectiveness and efficiency in this effort. Those capabilities will assist HHS in making very important health information technology awards. Secondly, NIST researchers have specific technical and business expertise that would add value to the review and evaluation of the submissions to the current RFP’s. This expertise spans broad areas of healthcare informatics and includes, but is not limited to: architectures, networks, interoperability, security and privacy, electronic health records, automation of clinical notes, expert alert systems, decision support systems, telemedicine, virtual reality training modules and simulation of minimally invasive surgery. NIST Technical Expertise for NHIN Architecture NIST works with industry, government, and academia to establish consensus-based standards, develop associated test metrics to ensure that implementations or devices perform according to the defined standard, and establish comprehensive certification capabilities for the IT industry. NIST has for many years been focused on developing metrics for the information technology industry. We develop tests and diagnostic tools for building robust, interoperable, commercial solutions. Applying such tools early in the life cycle process helps industry determine whether its products conform to the standard, and ultimately, will interoperate with other products. In addition, the development and use of these metrology tools fosters thorough review of the standard, which will, in turn, aid in resolving errors and ambiguities. The integration of information technology into the health industry has the potential to reduce medical costs by as much as 20 percent, a significant savings in an annual healthcare bill that was 14.9% of the GDP $1.6 trillion - in 2002 , estimated to be 1.9 trillion in 2005 and projected to rise to 3.6 trillion by 2014 . a) Standards Harmonization As the U.S. National Measurement Institute, NIST is frequently looked to for research and measurements that provide the technical underpinning for standards, ranging from materials test methods to standards for building performance, and for a range of technologies, from information and communications technologies to nano- and bio-technologies. As a matter of policy, NIST encourages and supports participation of researchers in standards developing activities related to the mission of the Institute. More than a quarter of NIST’s technical staff – 363 employees - participate in standards developing activities of 90 organizations. These include U.S. private sector standardization bodies, industry consortia, and international organizations. The NIST staff hold 1183 committee memberships, and chair 142 standards committees. In the information technology area, 40 NIST researchers have taken leadership roles and served with distinction in 80 national and international standards committees promoting the interests of many essential U.S. industries. Participation varies across a number of core information technology disciplines, including advancing and securing Internet and wireless networks, data exchange, data imaging, security and privacy, biometrics, and usability and accessibility of IT systems. In the area of telemedicine, NIST has worked in conjunction with the American Telemedicine Association to define standards and guidelines that enable the development and advancement of telemedicine. ATA and NIST have conducted a series of workshops to identify standards needed to provide ocular care through telecommunications technology. In the health IT arena, the NIST staff participates in the following key IT standards-related efforts: · ANSI Healthcare Informatics Standards Board (HISB) · ASTM International – Operating Room of the Future · Markle Foundation’s Connecting for Health · American Telemedicine Association (ATA) · Federal Health Architecture/Consolidated Health Informatics (FHA/CHI) · Medical Device Communications, Wireless Networks (IEEE) · Healthcare Information and Management Systems Society/ Integrating the Healthcare Enterprise (HIMSS/IHE) · Health Level 7 (HL7) In accordance with the National Technology Transfer and Advancement Act of 1995 (Public Law 104-113) and Administration policies, NIST supports the development of voluntary industry standards both nationally and internationally as the preferred source of standards to be used by the Federal government. NIST collaborates with national and international standards committees, users, industry groups, consortia, and research and trade organizations, to get needed standards developed. NIST will work with HHS to develop a strategy to promote such voluntary consensus standards, or Federal Information Processing Standards for use in the federal sector. As part of this process towards standardization of federal health information, NIST will begin to formalize the first set of data standards agreed upon in the Federal Health Architecture/Consolidated Health Informatics Initiative, through the development of appropriate Federal Information Processing Standards and guidance to federal agencies through NIST Special Publications. This will help the federal government to achieve a greater level of interoperability of federal health data. b) Performance and Conformance Metrics for the NHIN NIST works with industry to establish credible, cost-effective metrics to demonstrate software interoperability and conformance to particular standards. These metrics often form the basis or criteria upon which certifications are based. Typical NIST metrics include models, simulations, reference implementations, test suites, and testbeds. Specific activities in support of health information technology include: HIMSS/IHE: A key problem today in the realization of Electronic Health Records for the patient’s continuity of care is the inability to share patient records across disparate enterprises. To address this problem, NIST is collaborating with industry to develop standardized approaches to sharing electronic clinical documents across healthcare organizations and providers. NIST staff have built reference implementations and developed validation tools to demonstrate the feasibility and correctness of implementations, and worked with implementers to create integrated solutions based on these approaches. In particular, NIST is collaborating with the ‘Integrating the Healthcare Enterprise’ (IHE) project sponsored by the Radiological Society of North America, Healthcare Information and Management Systems Society (HIMSS) and the American College of Cardiology. The goal is to develop an approach called: Cross-Enterprise Document Sharing (XDS). This standards-based approach provides a mechanism to access a patient’s multi-faceted clinical information, regardless of where it is physically located, while maintaining local control and ownership of that information and without compromising the privacy and security of the patient’s clinical history. HL7: Health Level 7 is a standards development organization that provides standards for the exchange, management and integration of data that support clinical patient care and the management, delivery and evaluation of healthcare services. NIST is collaborating with HL 7 in defining standard functionality and conformance criteria for EHR systems. These criteria form the basis for EHR certification efforts and will help ensure that HL7 messaging and EHR systems' conformance can be defined and measured at an appropriate level. NIST is also developing a conformance-testing tool that automatically generates test messages for HL7 Version 2 message specifications. IEEE Medical Device Information: In a typical intensive care unit (ICU), a patient may be connected to one or more vital-sign monitors and receive medicine or other fluids through multiple infusion pumps. More acutely-ill patients may also be supported by devices such as ventilators, defibrillators or hemodialysis machines. Each of these medical devices has the ability to capture volumes of data, available multiple times per second. NIST is collaborating with the IEEE Medical Device Communications working group in developing conformance tests and associated tools to provide the medical device industry with the necessary tools to ensure that critical devices properly implement the medical device standards. Operating Room of the Future: It is estimated that 10-20% of hospital errors occur in the perioperative environment (before, during, and after surgery). Technology can play a major role in increasing the overall patient safety in such situations through the development of the operating room of the future (ORF). The ORF will consist of a network of interoperable plug and play medical devices, where the utilization of advanced technologies, such as robot-assisted surgery, sensor fusion, virtual reality, workflow integration, and surgical informatics, will result in a higher quality of healthcare by considerably increasing patient safety. NIST is working with the Center for the Integration of Medicine and Information Technology (CIMIT) in the development of an architectural framework for medical device integration, development of clinical requirements for device plug-and-play standards, identification of current interfaces, and development, testing and simulation of interfaces. Clinical Informatics: Building on past experience in information modeling and research to support interchange standards for the manufacturing industry, NIST is preparing a comprehensive report of all clinical information-oriented standards, their development organizations, their scope and the vocabularies/ontologies they employ. NIST will use the report as the basis for developing a plan for applying NIST’s experience to assist in clinical information-oriented standards development and closer harmonization. Improved Internet Protocols: The Internet Engineering Task Force (IETF) is a large open international community of network designers, operators, vendors, and researchers concerned with the evolution of the Internet architecture and the smooth operation of the Internet. NIST is actively participating in IETF efforts in the areas of: IP security, key management, Internet Protocol version 6, integrated services and resource reservation, IP switching, advanced routing and mobile ad hoc networks. NIST leads the IETF effort to develop and deploy a secure Internet naming and routing infrastructure. NIST metrics are used within this premier organization to expedite the development and deployment of standardized Internet infrastructure protection technologies. A secure infrastructure is an absolute first step in developing a National Health Information Network that can assure the confidentiality of electronic patient records. WPAN’s for Health Information: NIST is assisting industry in the development of a universal and interoperable wireless interface for medical equipment, expediting the development of standards for wireless technologies, and promoting their use in the healthcare environment. In close collaboration with the Institute of Electrical and Electronics Engineers (IEEE) and the U.S. Food and Drug Administration, NIST developed theoretical and simulation models for two candidate Wireless Personal Area Network (WPAN) technologies including the Bluetooth and the IEEE 802.15.4 specifications. NIST evaluated their performance for several realistic healthcare scenarios and contributed our results to the appropriate IEEE working group. NIST contributions will constitute the basis of standard requirements on the use of wireless communications for medical devices. c) Certification NIST has an established history of developing procedures for certifying conformance to consensus-based standards. Conformity assessment activities form a vital link between standards, which define necessary characteristics or requirements for software products, and the performance of the products themselves. Conformity assessment procedures provide a means of ensuring that the products, services, or systems produced or operated have the required characteristics, and that these characteristics are consistent from product to product, service to service, or system to system. Conformity assessment includes: sampling and testing; inspection; certification; management system assessment and registration; accreditation of the competence of those activities and recognition of an accreditation program's capability. NIST has been in the certification business since its inception in 1901 and is well positioned to provide technical guidance in the development of a technical certification regimen, including specific certification metrics, software to perform comprehensive certification tests, and certification procedures. d) Security For many years, NIST has made great contributions to help secure our nation’s sensitive information and information systems. Our work has paralleled the evolution of IT systems, initially focused principally on mainframe computers, now encompassing today’s wide gamut of information technology devices. Our important responsibilities were re-affirmed by Congress with passage of the Federal Information Security Management Act (FISMA) of 2002 and the Cyber Security Research and Development Act of 2002. Beyond our role to serve the Federal Agencies under FISMA, our FIP standards and guidelines are often voluntarily used by U.S. industry, global industry, and foreign governments as sources of information and direction for securing information systems. Our research also contributes to securing the nation’s critical infrastructure systems. Moreover, NIST has an active role in both national and international standards organizations in promoting the interests of security and U.S. industry. Current areas that are applicable to the NHIN include: · Security Management and Guidance; · Cryptographic Standards and Applications; · Security Testing; · Security Research/ Emerging Technologies Recent activities specifically related to health IT include: Guidance for Understanding the HIPAA Security Rule: The Security Rule issued under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) directs certain health care entities, known as “covered entities,” to comply with standards for keeping certain health information that is in secure electronic form. NIST has published a document, An Introductory Resource Guide for Implementing the HIPAA Security Rule that summarizes and clarifies the HIPPA Security Rule requirements for federal agencies that are covered entities. It also directs readers to other NIST publications that can be useful in implementing the Security Rule. Healthcare Accreditation Guidance: NIST in conjunction with URAC (not an acronym) and the Workgroup of Electronic Data Interchange (WEDI) sponsors the NIST/URAC/WEDI Health Care Security Workgroup. The group promotes the implementation of a uniform approach to security practices and assessments by developing white papers, crosswalks (of regulations and standards), and educational programs. The group brings together stakeholders from the public and private sectors to facilitate communication and consensus on best practices for information security in healthcare. Ultimately, these best practices will be integrated into accreditation criteria used by hospitals and other healthcare facilities. The group draws heavily upon information technology security standards and guidelines developed by NIST. Clinical Decision Support In addition to our contributions to building a NHIN, NIST is developing measurements and technologies that can be used in providing advanced clinical decision support. Doctors rely on diagnostic tests to optimize patient care. Many of these tests owe their high accuracy to a variety of NIST standards, measurements, and calibrations. These measurements are essential for patient care and the most efficient use of available health care funds. NIST is contributing to increased efficiency in health care delivery by ensuring that the measurement quality assurance tools – reference measurement methods, certified reference materials and calibrations – are available and well integrated in the NHIN. Some examples of NIST work include: · In Vitro Diagnostic Medical Device Measurements; · Standard Reference Materials for Clinical Diagnostic Markers; · Joint Committee on Traceability in Laboratory Medicine; · Gene Expression Analysis; · Point-of-Care Testing; and · Analytical Information Exchange Conclusion As the Committee can see by the few examples I have cited, NIST has a very diverse portfolio of activities supporting our nation’s health information technology effort. With its long experience as well as a diverse array of expertise, NIST is able to the Department of Health and Human Services in achieving the President’s goal and respond meeting both the short-term and long-term needs of the Nationwide Health Information Network. Once again thank you for inviting me to testify about NIST’s activities and I would be happy to answer any questions you may have.
Dr. Carolyn ClancyDirector of the Agency for the Healthcare Research and QualityU.S. Department of Health and Human Services
Dr. Robert M. KolodnerActing Chief Informatics OfficerVeterans Health Administration
Robert M. Kolodner, MD
Acting Veterans Health Administration Chief Health
Department of Veterans Affairs
Committee on Science, Commerce, and Transportation
Subcommittee on Technology, Innovation, and Competitiveness
Unites States Senate
June 30, 2005
Good Morning, Mr. Chairman and Members of the Subcommittee. Thank you for inviting me here today to discuss our work in the field of health information technology. One year ago, Dr. Jonathan B. Perlin, MD, PhD, MSHA, FACP, Under Secretary for Health, Department of Veterans Affairs, appeared before the House Committee on Veterans’ Affairs, Subcommittee on Oversight and Investigations to discuss the importance of electronic health records and the role of the Department of Veterans Affairs (VA) in the development, use, and sharing of this valuable technology. President Bush had just outlined an ambitious plan to ensure that most Americans have electronic health records within 10 years. The President noted a range of benefits possible with the expanded use of information technology, including reduced costs; improved health care quality; reduced frequency of medical errors; advancements in the delivery of appropriate, evidence-based medical care; greater coordination of care among different providers; and increased privacy and security protections for personal health information. A lot has happened in the field of health information technology in the year since the President’s call to action announced at the VA Maryland Health Care System in April 2004, and discussions about the potential of electronic health records have become part of the national conversation. I have included, for the record, a brochure that highlights President Bush’s April visit to the Baltimore VA Medical Center. Today I’d like to talk about VA’s leadership in the field of health information technology, and tell you about our next generation health information system, known as HealtheVet. I’d also like to highlight our work in three areas that I think are pivotal to the broader, successful adoption of electronic health records: data standardization, interoperability, and privacy. A History of Innovation With one of the most comprehensive electronic health record (EHR) systems in use today, VA is a recognized leader in the development and use of EHRs and other information technology tools. VA’s work in health information technology goes back almost 30 years, when VA created the Decentralized Hospital Computer Program (DHCP), one of the first automated health information systems ever developed to support multiple sites and cover the full range of health care settings. VA has continued to lead the health care community in the development of new health IT tools, building on the foundation of DHCP to create the VistA system in use today – a suite of over 100 applications which support the day-to-day clinical, financial, and administrative functions of the Veterans Health Administration (VHA). These applications form the foundation of VistA – the Veterans Health Information Systems and Technology Architecture, the automated health information system used throughout VHA. Many VistA enhancements were designed to support the transformation of the VA health system over the past decade, as VA shifted its emphasis from inpatient care to outpatient care, and introduced performance measures and performance-based accountability throughout its health care system. In the mid-1990’s, VHA embarked on an ambitious effort to improve the coordination of care by providing integrated access to these applications through implementation of an electronic health record, known as the Computerized Patient Record System or CPRS. CPRS provides a graphical user interface, or GUI, to the information captured in VistA. With CPRS, providers can access patient information at the point of care – across multiple sites and clinical disciplines. CPRS provides a single interface through which providers can update a patient’s medical history, place a variety of orders, and review test results and drug prescriptions. The system has been implemented at all VA medical centers and at VA outpatient clinics, long-term care facilities, and domiciliaries – 1,300 sites of care throughout VHA. The Benefits of Electronic Health Records Electronic health records, or EHRs, are appealing for a number of reasons, including convenience, availability, and portability. The most compelling reason to use information technology in health care is that it helps us provide better, safer, more consistent care to all patients. The President referred to an oft-cited 1999 report in which the Institute of Medicine (IOM) estimated that between 44,000 and 98,000 Americans die each year due to medical errors. Many more die or suffer permanent disabilities because of inappropriate or missed treatments in ambulatory care settings. IOM cited the development of an electronic health record as essential for reducing these numbers and improving the safety of health care. In its 2002 publication Leadership by Example, IOM noted that “[c]omputerized order entry and electronic medical records have been found to result in measurably improved health care and better outcomes for patients.” How can EHRs improve patient safety and quality of care? First, with an EHR, all relevant information is available to clinicians when they need it, where they need it – and it’s legible. A provider can quickly review information from previous visits, have ready access to clinical guidelines, and survey research results to find the latest treatments and medications. All of this information is available wherever patients are seen – in acute settings, clinics, examining rooms, nursing stations, and offices. Many of us see different doctors for different medical conditions. How many of these physicians have access to all of the information that has been collected over the course of these visits? In VHA, patient records from multiple sites and different providers can be viewed at the same time at the point of care. This is simply not possible with paper records. In addition to making medical records more accessible, EHRs can help clinicians better document the reasons a patient sought care and the treatment that was provided. Given the time constraints they face, many physicians resort to writing brief, sometimes cryptic notes in a patient’s chart, and then write more complete documentation when they have time. EHRs enable clinicians to document care quickly and thoroughly, and can provide reminders based on the specific medical conditions and test results that have been documented. CPRS, for example, allows clinicians to enter progress notes, diagnoses, and treatments for each encounter, as well as discharge summaries for hospitalizations. Clinicians can easily order lab tests, medications, diets, radiology tests, and procedures electronically; record a patient’s allergies or adverse reactions to medications; or request and track consults with other providers. Even if we could transfer paper records quickly and reliably from one provider to another, and make sure that the information in records was complete, many hard-copy patient records simply contain too much information for a clinician to sift through effectively. There is always the possibility that something crucial could be missed. When health information is stored electronically, however, we can make use of software tools to analyze that information in real-time. We can target relevant information quickly, compare results, and use built-in order checks and reminders to support clinical decision-making. These capabilities promote safer, more complete, more systematic care. Consider the benefits we have seen in VHA in the area of medication ordering. When orders for medications are handwritten or given verbally, errors and mistakes inevitably occur. However, when physicians use computerized order-entry systems to enter medication orders electronically, errors caused by illegible handwriting or misinterpretation of dosages, strengths, or medication names are virtually eliminated. CPRS includes automated checks for drug-drug or drug-allergy interactions, alerting the prescribing physician when potentially dangerous combinations occur. Currently, 94% of all VHA medication orders are entered by the ordering provider directly into VistA using CPRS. Information technology can also serve to reduce the number of errors that occur when medications are given to a patient. VHA’s Bar Code Medication Administration system (BCMA) is designed to ensure that each patient receives the correct medication, in the correct dose, at the correct time. In addition, the system reduces reliance on human short-term memory by providing real-time access to medication order information at the patient’s bedside. BCMA provides visual alerts – prior to administration of a medication – if the correct conditions are not met. For example, alerts signal the nurse when the software detects a wrong patient, wrong time, wrong medication, wrong dose, or no active medication order. These alerts require the nurse to review and correct the reason for the alert before actually administering the drug to the patient. Changes in medication orders are communicated instantaneously to the nurse administering medications, eliminating the dependence on verbal or handwritten communication to convey these order changes. Time delays are avoided, and administration accuracy is improved. BCMA also provides a system of reports to remind clinical staff when medications need to be administered or have been overlooked, or when the effectiveness of administered doses should be assessed. The system also alerts staff to potential allergies, adverse reactions, and special instructions concerning a medication order, and order changes that require action. The VistA Imaging system is another application which has extended the capabilities of VistA and CPRS. VistA Imaging stores medical images such as x-rays, pathology slides, scanned documents, cardiology exam results, wound photos, and endoscopies directly into the patient record as soon as they become available, providing clinicians with additional information essential for diagnosis and treatment. I have used VA’s electronic health record system for years. As a doctor – and as a patient – I am very enthusiastic about the benefits of this technology. I don’t think I can fully do the system justice by talking about it. I’d like to show you how it works. <
> The Importance of Standards The richness of VA’s EHR is evident, in terms of both clinical features and health data. Imagine the benefits of sharing this data – appropriately and securely – among VA’s health delivery partners, so that relevant health information would be available regardless of where a veteran sought care. As we move towards this goal, we need to make sure that we share not only data, but meaning. And to do this, we need health data standards. Virtually all clinical documents created by VA providers are stored in the EHR, and data from commercial medical devices can be transmitted automatically directly into a patient’s health record. To give you a sense of the magnitude of EHR use in VA, let me give you some round numbers: As of March 2005, VA’s VistA systems contained 658 million progress notes, discharge summaries, and other clinical documents; 1.35 billion orders, and 300 million images. More than 550 thousand new clinical documents, 910 thousand orders, and 475 thousand images are added each workday – a wealth of information for the clinician. And yet, with an electronic health record – as with a paper record – more information isn’t always better if we can’t use it. How can we be sure we can take full advantage of the voluminous information we collect in the EHR? The key is data standardization. There’s an old joke in the standards field: “The great thing about standards is that there are so many to choose from.” For nearly every kind of clinical data – from diseases, procedures, and immunizations, to drugs, lab results, and digital images – there are multiple sets of standards to choose from. For example, there are at least 12 separate systems for naming medications, and the ingredients, dosages, and routes of administration associated with them. It is often necessary to use a combination of data standards to transmit a single message from one system to another. Even health care organizations committed to using standards have a difficult time figuring out which standards to use. Consolidated Health Informatics (CHI) is an eGov initiative involving Federal agencies with responsibility for health-related activities. CHI participants evaluate and choose health data and communication standards to be incorporated into their future health IT systems. VA was instrumental in the formation of CHI, and works closely with the Department of Defense (DoD) and the Department of Health and Human Services (HHS) to help foster the federal adoption of the agreed-upon standards as part of a joint strategy for developing federal interoperability of electronic health information. To date, CHI has endorsed 20 communications and data standards in areas such as laboratory, radiology, pharmacy, encounters, diagnoses, nursing information, and drug information standards developed through a collaboration between VA and HHS. Within VA, we have established a formal program to coordinate the adoption, implementation, and verification of health data standards across all sites of care. We also work with external Standards Development Organizations (SDOs) to augment and refine available standards to ensure that they meet health care delivery needs in VA and elsewhere. The work involved in adopting and implementing data standards is deliberative and difficult. It requires collaboration among clinicians, health information professionals, developers, and business process experts. Yet, the use of data standards can have a very real effect on a patient’s care. When VA developed its first EHR, the technological environment in VA hospitals – as in other hospitals at the time – was very different from the environment today. There was not a computer on every desk. There were no graphical user interfaces, only text-based displays on “dumb terminals.” There were no multi-color screens, no Windows, no pull-down menus. No one had a mouse. When you wanted to enter data in an electronic health record, you didn’t point-and-click, you typed. For example, when a clinician wanted to document a patient’s allergy to penicillin, he typed the word “penicillin” in the allergy section of the patient’s electronic health record. To save time, many clinicians entered “PCN”, a common abbreviation for penicillin. As part of our data standardization effort, we went back and looked at the allergy data that had been collected over the years. We found that “penicillin” and “PCN” had been typed in more than 75,000 times. We also found thousands of entries in which penicillin had been misspelled. Not only is it a waste of time to type the same information over and over, it introduces a potential patient-safety issue. Let me give you an example. Suppose a veteran comes in for a check-up and tells the physician that he is allergic to sulfa drugs. The physician enters this information in the patient’s record under allergies, but because he is typing quickly, he inadvertently misspells the word ‘sulfa’. Suppose that on a subsequent visit, another clinician orders Sulfamethoprim, which is a type of sulfa drug. When a clinician orders a medication, CPRS checks the patient’s record to see if the patient is allergic to the medication. Although the system checks for common misspellings, it can’t predict every possible misspelling of every medication. In this case, CPRS might not alert the second physician that he had ordered a drug the patient was allergic to, simply because the word “sulfa” was misspelled when it was entered by the first physician. By eliminating misspellings and establishing a standard vocabulary across sites, we will ensure that medication order checks work as intended, and that the EHR supports patient safety and clinical decision-making to the fullest extent. Data Standards and Interoperability The use of electronic health records and other information technology tools in a single medical office can improve health care quality, reduce medical errors, improve efficiency, and reduce costs for the patients treated there. However, as the President noted a year ago, the full benefits of IT will be realized when we have a coordinated, national infrastructure to accelerate the broader adoption of health information technology. The problems created by a lack of standardized data are magnified when interacting with other organizations. Even seemingly straightforward information can be misconstrued when it is interpreted by different organizations. Consider two simple terms: yes and no. In many computer systems, the number ‘1’ is used to indicate ‘yes’, and the number ‘2’ is used to indicate ‘no’. In some systems, it is reversed: ‘1’ means ‘no’, and ‘2’ means ‘yes’. Some systems use ‘0’ and ‘1’, instead of ‘1’ and ‘2’. In still other systems, ‘Y’ is used to indicate ‘yes’, and ‘N’ is used to indicate ‘no’. Sometimes lower-case ‘y’ and ‘n’ are used. Sometimes, ‘yes’ is actually stored as ‘y-e-s’, and ‘no as ‘n-o’. In VA, we found 30 different combinations of codes for ‘yes’ and ‘no’, stored in nearly 4,000 different data fields. We can standardize our representation of ‘yes’ and ‘no’ within VA computer systems, but unless our healthcare partners employ the same standards to exchange data with us, we cannot be sure that we are conveying the intended meaning of the data we are exchanging. The Office of the National Coordinator for Health Information Technology (ONCHIT) recognizes the importance of data and communications standards in developing a comprehensive network of interoperable health information systems across the public and private sectors. Without data standards, we might be able to exchange health information, as we do now when we copy and send paper records, but we won’t be able to use it as effectively to deliver safer, higher-quality care using clinical alerts and reminders. True interoperability between providers simply cannot be achieved without data standardization. VHA has a long history of participation in standards development organizations. As a health care provider and early adopter of health IT on a large scale, VHA frequently identifies areas for standards development and works with other public- and private-sector organizations to develop consensus-based solutions. HHS Secretary Mike Leavitt recently announced the formation of the American Health Information Community. ONCHIT has released a Request for Proposal calling for standards harmonization. This effort will foster a more cohesive, integrated approach to standards development, replacing the existing fragmented, inefficient approach in which standards are developed topic-by-topic. VHA supports these HHS activities and looks forward to participating, along with other Federal partners, in these activities as they develop. Our data standardization efforts at VA have already improved our ability to share information with other agencies. I’d like to highlight our work with the Department of Defense. In April 2002, VA and DoD adopted a joint strategy to develop interoperable electronic health records by 2005. This cross-cutting initiative, known as the VA/DoD Joint Electronic Health Records Interoperability (JEHRI) Plan - HealthePeople (Federal), is based on the common adoption of standards, the development of interoperable data repositories, and joint or collaborative development of software applications to build a replicable model of data exchange technologies. The progress made by VA and DoD has served as a catalyst to move the health care industry toward the use of interoperable health information technologies that have the potential to improve health care delivery, increase patient safety, and support the provision of care in times of crisis. Through collaborative efforts, VA and DoD will be better positioned to evaluate health problems among service members, veterans, and shared beneficiary patients; to address short- and long-term post-deployment health questions; and to document any changes in health status that may be relevant for determining disability. VistA-Office EHR As a physician, I have seen first-hand the benefits of electronic health records in VA: immediate access to information, elimination of duplicate orders, increased patient safety, improved information-sharing, more advanced tracking and reporting tools, and reduced costs. VHA is now working with the Centers for Medicare and Medicaid Services (CMS) to make the benefits of electronic health records available to providers in rural and underserved areas, as directed by President Bush in Executive Order 13335 issued in April 2004. CMS is sponsoring the development of VistA-Office EHR, an enhanced version of VA’s VistA and CPRS designed specifically for use in non-VA clinics and physician offices. With the targeted release of VistA-Office EHR in August 2005, CMS hopes to stimulate the broader adoption and effective use of electronic health records by making a robust, flexible EHR product available in the public domain. The HealtheVet Program The spirit of innovation that inspired the development of VistA, CPRS, BCMA, and VistA Imaging has led VA to the next step in the evolution of health care IT – HealtheVet. HealtheVet-VistA is VA’s next-generation health information system, designed to support more personalized care for our veterans, more sophisticated clinical tools for our doctors and nurses, and more advanced communication with our health care partners. HealtheVet builds on decades of VA expertise in health care IT to support the strategic goals of the department, meet interagency obligations, take advantage of new developments in technology to address weaknesses in the current system, and most importantly, improve the safety and quality of health care for veterans. VA has been recognized by IOM and the mainstream press as having one of the most sophisticated EHR systems in the world. VistA and CPRS are in the public domain and have served as models for healthcare organizations in the public and the private sectors alike. VistA has been adopted for use by the District of Columbia Department of Health, and state veterans homes in Oklahoma. A number of other countries have either implemented VistA or expressed an interest in acquiring the technology. VA’s DHCP system was modified for use in DoD and DHCP, and VistA is used in modified form by the Indian Health Service. By the late-1990’s, the three largest federal systems providing direct health care were using derivatives of VA’s EHR, although only VA was using the current and more robust version including CPRS. Under the HealtheVet-VistA program, VA will incrementally enhance and supplement the current functional capabilities of VistA and will provide increased flexibility, more sophisticated analytical tools, and support for seamless data sharing among providers both within and outside VA. Like VistA, software developed under the HealtheVet program will be available in the public domain. Federal agencies, small medical practices, and EHR system vendors will all benefit from the advances made through HealtheVet-VistA. Given the success of VistA, some people have asked why we are changing it. The short answer is “to benefit the veteran”. VA health IT systems have been forged and tested in the real world of health care. I can think of no other successful organization, with a history of innovation and a world-class system, that would simply rest on its laurels. One reason there is so much interest in VistA is that it has never been a static system. The health care environment of today is not the health care environment of ten years ago. Nor is the VistA system today the VistA system of ten years ago – or even of one year ago. VA has continued to refine and enhance VistA since its introduction to reflect advances in clinical practice, the availability of new commercial products, the changing VA health care model, new Congressional mandates (such as those related to current combat engagements), and new federal laws (such as the Health Insurance Portability and Accountability Act and cyber security requirements). We have to make these types of changes all the time – that’s the nature of health care. The current VistA system has served us well through decades of transformation in health care. But VA has outgrown its facility-centric architecture, and the system has simply become too expensive to maintain. HealtheVet-VistA will give us a more flexible architecture so that we can support integrated ambulatory care and home-base health care, maintain continuity of operations in the event of a disaster, and improve response time by increasing system capacity and communications speed. HealtheVet-VistA will also allow us to strengthen privacy and security protections through use of features such as role-based access. We will be able to limit access to information based on the user’s identity, location, job function, or legal authority, for example. We will strengthen our ability to track exactly who looks at the information, at what time, and for how long. An estimated 40% of veterans we treat at VA each year also receive care from non-VA physicians. VA is working with DoD, ONCHIT, and other partner organizations to develop a longitudinal health record that will incorporate information from DoD, VA, and private-sector health providers from whom the veteran has sought care. Throughout these collaborative projects, safeguards have been implemented to ensure that the privacy of individuals is protected in accordance with the various confidentiality statutes and regulations governing health records, including the Privacy Act, the HIPAA Privacy Rule, and several agency-specific authorities. As we work toward greater data exchange and true interoperability with our health care partners, privacy and security of medical information will be a top priority. Personal Health Records and My HealtheVet I’d like to highlight another key component of the HealtheVet initiative: the My HealtheVet personal health record system, designed specifically to meet the needs of veterans. Personal health records are an adjunct to the electronic health records used in a clinical setting, providing patients a secure means of maintaining copies of their medical records and other personal health information they deem important. Information in a personal health record is the property of the patient; it is the patient who controls what information is stored and what information is accessible by others. Personal health records enable patients to consolidate information from multiple providers without having to track down, compile, and carry around copies of paper records. By simplifying the collection and maintenance of health information, personal health records encourage patients to become more involved in the health care decisions that affect them. The VHA My HealtheVet project was conceived as a way to help veterans manage their personal health data. My HealtheVet is a secure, web-based personal health record system designed to provide veterans key parts of their VHA health record as well as enabling them to enter, view, and update additional personal health information. Patients who take over-the-counter medications or herbs, or who monitor their own blood pressure, blood glucose, or weight, for example, can enter this information in their personal health records. They can enter readings such as cholesterol and pain, and can track results over time. My HealtheVet includes the Medlineplus.gov library of information on medical conditions, medications, health news, and preventive health from the National Institutes of Health and other authoritative sources. Veterans can use the system to explore health topics, research diseases and conditions, learn about veteran-specific conditions, understand medication and treatment options, assess and improve their wellness, view seasonal health reminders, and more. The implications of My HealtheVet are far-reaching. Clinicians will be able to communicate and collaborate with veterans much more easily. With My HealtheVet, veterans are able to consolidate and monitor their own health records and share this information with non-VA clinicians and others involved in their care. Patients who take a more active role in their health care have been found to have improved clinical outcomes and treatment adherence, as well as increased satisfaction with their care. The first version of My HealtheVet was released on Veterans Day 2003, and more than 50,000 veterans are now registered to use the system. The My HealtheVet user community is growing, with over 300 new registrants joining each day. By the end of this summer, veterans who receive their health care at VA will be able to use My HealtheVet to refill prescriptions online. By this time next year, veterans receiving care at VA medical centers will be able to request and maintain copies of key portions of their health records electronically through My HealtheVet and to grant authority to view that information to family members, veterans' service officers, and VA and non-VA clinicians involved in their care. This would allow a relative to provide support and care – even at a distance – by being better informed about the veteran’s health and medical status. Subsequent releases will provide additional capabilities, enabling veterans to view upcoming appointments and see co-payment balances. Summary For decades, VA has developed innovative IT solutions to support health care for veterans. Over the past several years, VA has worked with federal, state, and industry partners to broaden the use of information technology in health care. We have continued to enhance the capabilities of the EHR while protecting the privacy of our veteran population and maintaining the integrity of our systems. These efforts have laid the groundwork for the President’s health IT initiative. The team of VHA developers, clinicians, and administrators who designed VistA changed the practice of medicine in VA by creating IT tools such as these to support the interaction between providers in VA and their patients, increase patient safety, and improve reporting and tracking of clinical and administrative data. VA is now involved with public- and private-sector partners in the development of a new national model for the use of IT in health care, featuring more sophisticated clinical decision support tools, increased data sharing among health care providers, and the availability of affordable EHR technology to providers large and small. When he announced his plan to transform health care through the use of information technology, the President noted our country’s long and distinguished history of innovation – as well as our failure to use health information technology consistently as an integral part of medical care in America. We still have a long way to go in optimizing our use of information technology in health care; yet, we are not starting from scratch. Electronic health records, personal health records, data and communication standards, and sophisticated analytical tools – the building blocks of a comprehensive, national health information infrastructure – have already been implemented in some communities and settings and are maturing quickly. Our challenge is to create a technology infrastructure that will revolutionize health care without interfering with the human interaction between physicians and patients that is at the core of the art of medicine. The President recognized America’s medical professionals and the skill they have shown in providing high-quality health care despite our reliance on an outdated, paper-based system. At VA, we know that the support of clinicians is essential to the successful implementation of electronic health records and new IT tools. Clinicians, while often the greatest proponents of health information technology, can also be the greatest critics. At VA, physicians, nurses, and other providers are actively involved in defining requirements and business rules for systems, prioritizing enhancements, and conducting end-user testing. This involvement improves system usability, increases user acceptance, minimizes disruption during upgrades, and most importantly, enables us to tailor systems to the needs of the health care community. Throughout VA, the electronic health record is no longer a novelty – it is accepted as a standard tool in the provision of health care. For 20 years, VA has been an innovator in health care IT. We are now at the brink of a new era in health care, in which a new national model for the use of IT will support the development of more sophisticated clinical decision support tools, increased data sharing among health care providers, and the broader availability of affordable EHR technology to providers large and small. As VA refines and expands its use of information technology, we look forward to sharing our systems and expertise with our partners throughout the health care community to support the President’s plan for transforming health care – and the health of our veterans. Mr. Chairman, this completes my statement. I will now be happy to answer any questions that you or other members of the Subcommittee have.
Witness Panel 3
Ms. Karen IgnagniPresident & CEOAmerica's Health Insurance Plans
Ms. Susan BostromSenior Vice PresidentCisco Systems, Inc.
Testimony of Susan L. Bostrom
Senior Vice President
Internet Business Solutions Group
and Worldwide Government Affairs
Cisco Systems, Inc.
Subcommittee on Technology, Innovation and Competitiveness
Hearing on Health Information Technology
June 30, 2005 Thank you, Chairman Ensign, for inviting me to testify today. I would also like to thank Ranking Member Kerry and the other Senators on the Subcommittee for holding and participating in this important hearing on Health Information Technology. My name is Sue Bostrom, Senior Vice President of the Internet Business Solutions Group (IBSG) and Worldwide Government Affairs at Cisco Systems, Inc. I also have the privilege of sitting on the board of directors at Stanford Hospital and Varian Medical Systems, a manufacturer of radiation equipment for cancer treatment. These positions have given me the opportunity to witness first-hand the challenges facing major sectors of the healthcare industry – providers, payers, pharmaceutical and medical device firms, and government agencies. My goal here today is to share with you what we’ve learned through Cisco’s customers and in our own practice in the area of improving healthcare quality, increasing productivity and driving down costs through technology. There is one overwhelming challenge faced by all sectors – the spiraling cost of health care. As you well know, healthcare spending in the US has topped $1.6 trillion a year and will reach $2.5 trillion by 2010—that’s more than 15 percent of the Gross Domestic Product. Meanwhile, healthcare insurance premiums are rising at four to five times the rate of growth in wages and inflation. Much of these rising costs can be attributed to underlying demographic trends and advances in medical care. The healthcare industry is being asked to offer ever-more sophisticated and expensive treatments for an aging population. Another major cost driver is the enormous amount of ongoing paperwork, waste, and re-work. For instance, of the 30-billion individual healthcare communications in the United States, more than 90% of them are sent by fax, surface mail, or telephone. A full 30% of the cost of healthcare can be attributed to these poor healthcare practices. In fact, this industry ranks among the bottom five industries in terms of contribution to U.S. productivity, according to a Harvard University study. If we look at other industries, we see a direct correlation between productivity gains and investment in Information Technology (IT) capital and solutions. These industries, on average, invest about $8,000 per year per employee in IT. In comparison, the healthcare industry invests only $1,100 per worker. But saving money is only one part of the equation. Information Technology can also help reduce medical errors and save thousands of lives each year. Estimates vary, but experts believe between 44,000 and 98,000 people die in the United States each year from preventable medical errors. The greatest impact on cost, productivity, and quality can be driven at those points where patients receive care—in the physician’s office and in the hospital. If healthcare organizations widely adopted just one Information Technology solution -- Electronic Health Records (EHR) – the industry could save close to $78 billion annually. Taking a quick look at the IT trends in healthcare, we find that deployment of technology has been relatively slow, with implementation of each wave of new applications taking decades rather than the 5 to 10 years it takes in other IT-oriented industries. The first applications implemented in the late 1980s to early 1990’s were departmental applications – lab automation, pictorial archiving systems, human resources systems, and patient admitting applications – all solutions designed to make specific departments in a healthcare provider more efficient. The next two waves of applications in healthcare have been broader, including both enterprise solutions -- such as electronic health record systems, clinical decision support systems – and inter-enterprise applications that cross institutional boundaries, such as remote patient monitoring, and automated payment programs that link providers with payors. Despite the proven value of these applications in specific institutions, less than 5% of healthcare organizations have deployed electronic health records, 10% computerized physician order entry systems (CPOEs), less than 3 percent have adopted Clinical Decision Support and less than 1 percent have instituted support for Tele-Specialty – specifically electronic Intensive Care Units (eICU). The most challenging roadblocks to adoption overall are: a lack of precise interoperable standards, a misalignment of financial incentives across the industry, and, finally, the inherent reluctance to change – especially when human life could be on the line. Like many enterprises, we have found at Cisco that IT can play a significant role in improving the quality of care while driving down costs. Cisco Systems provides healthcare benefits for more than 65,000 employees and dependents worldwide. Looking to expand the use of technology to improve the healthcare provided to our employees and dependents, Cisco is now focused on promoting the more rapid adoption of electronic health records, electronic prescribing and secure physician-patient messaging, and will be adopting a pay for performance program in 2006 that supports these objectives with key physician groups serving Cisco employees and dependents. The advantages of e-prescribing alone are significant, given that 50 percent of calls to physician offices are for prescription issues, and the average physician writes 30 prescriptions a day. The potential impact of e-prescribing includes an increase of 27 percent generic prescribing, a reduction in adverse drug prescribing of 15 percent, and an average per physician savings of $28,000 per year based on existing studies. Cisco has also had the privilege of participating in a number of IT healthcare deployments that clearly demonstrate the significant role Information Technology (IT) plays in improving healthcare quality, reducing costs, and enhancing industry productivity. For example, we helped a community healthcare center in Florida deploy an electronic health records solution, which has cut lab turnaround time by 89 percent and is saving the center over $2 million annually. In Virginia and North Carolina we assisted a healthcare delivery network in establishing a Picture Archive and Communications system (PACs) -- that delivers radiology reports to doctors in minutes instead of days. And in the Mountain West, we helped a regional medical center set up a Computerized Physician Order Entry system (CPOEs), which reduced antibiotic-related adverse drug events by 70 percent. I offer these examples to illustrate that health Information Technology is working to fix the major problems facing the healthcare industry today. Imagine if Electronic Health Records (EHR), Picture Archive and Communication system (PACs) and Physician Computer Order Entry system (CPOE) could be implemented worldwide? Tens of thousands of lives could be spared and billions of dollars saved. Indeed, study after study demonstrate the impressive impact healthcare IT solutions have on rising costs and quality of care. With broad adoption of proven technology solutions, the industry could save over $200 billion annually, enough to bring healthcare costs in line with the current rate of inflation or cover all the uninsured according to a variety of studies and presentations from Center for Information Technology Leadership (CITL), and American Health Quality Association (March 2004). It’s clear that the next revolution in healthcare will use information to drive patient-centric, safe, and efficient care. A fitting term for this model is “Connected Health.” What is Connected Health? · Connected Health is the power of technology -- not simply to automate old tasks -- but to facilitate richer and better health care interactions between patients, physicians, and insurers. · Connected Health is the power of technology to place information at the point of care, empowering both providers and patients to make better, more informed decisions. · Connected Health is the power of technology to connect doctors with hospitals, hospitals with pharmacies, pharmacies with insurers, insurers with patients, and finally, patients with doctors so that no one is stranded on their own island of information. Changing the way information is handled may not seem like a development to rival antibiotics or X-rays, but it has the potential to be every bit as revolutionary. So what’s the hold up? Why is healthcare among the five lowest ranking industries in Information Technology spending per employee? For one, the industry has historically underinvested in IT, partly because healthcare spending is decoupled from healthcare funding. And clearly complexity plays a part. Connected Health systems require significant investment, standards, metrics, effective change management and, above all, a top-down commitment to transformation. Healthcare organizations can get started by looking at their greatest needs, studying what other institutions have done, and strategically deploying first-strike applications with proven impact. The challenge is great, but the stakes are higher. . Healthcare Information Technology has proven its efficacy. All that’s needed now is the willpower and resources to deliver the solution nationwide. Thank you again, Mr. Chairman, Ranking Member Kerry, and other members on the Subcommittee for inviting me here today. I am happy to answer any questions.
Dr. Peter BaschMedical Director for e-HealthMedStar Health
Ms. Pamela PureExecutive Vice PresidentMcKesson Corporation
President, McKesson Provider Technologies,
Executive Vice President, McKesson Corporation
Before the Subcommittee on Technology, Innovation, and Competitiveness
Of the Committee on Commerce, Science, and Transportation
United States Senate
June 30, 2005
My name is Pamela Pure, and I am the Executive Vice President of McKesson Corporation and President of McKesson Provider Technologies, the company’s health information technology business. I thank Chairman Ensign, Ranking Member Kerry, and the members of the subcommittee for the opportunity to submit testimony on behalf of McKesson. McKesson strongly supports the goal of improving healthcare quality by using healthcare information technology (IT) to reduce medical errors and lower costs. For more than 170 years, McKesson has led the industry in the wholesale delivery of medicines and healthcare products. Today a Fortune 15 corporation, McKesson delivers vital pharmaceuticals, medical supplies, and healthcare IT solutions that touch the lives of more than 100 million patients each day in every healthcare setting. As the world’s largest healthcare services company with a customer base that includes more than 200,000 physicians, 25,000 retail pharmacies, 5,000 hospitals and 600 payers, McKesson is well positioned to help transform the healthcare system. As the largest provider of automation and information technology in the healthcare industry, we deliver innovative technologies at each point in the healthcare system to reduce medication errors, lower costs, and improve the quality and efficiency of healthcare. We are dedicated to making healthcare safer, a goal that requires a deep understanding of healthcare delivery processes and a clear focus on what is required by key stakeholders such as physicians, nurses, pharmacists and patients. My colleagues and peers know that for me this is not a job; it is a passion. After 20 years of advocating the use of technology and witnessing firsthand the benefits and challenges associated with its implementation, I am delighted to have this opportunity to share my insights with the Congress. McKesson fully supports the President’s goal that every American should have an electronic health record (EHR) in 10 years. To meet this bold vision, McKesson believes that the federal government should pursue a two-pronged strategy to spur the adoption of automation and healthcare IT. First, we need broad deployment today of high-impact technologies that provide unquestionable benefits in the delivery of healthcare. Second, on a parallel track, we need to develop the standards and promote the interoperability of systems that are essential for medical information to be shared among healthcare providers, patients, and public health agencies in a safe, secure manner. At McKesson, we know that technology itself is not the inhibitor of change in the healthcare system. The technology is available and working. It is intolerable that people die every day from medication errors that could be prevented with bar-code technology, the same technology that is used in every major retail outlet in this country. We conduct sophisticated banking and other business transactions electronically across continents; yet most physicians in the United States still rely on their memories for complex medical information, and write orders using pen and paper. While deployment of healthcare IT is growing, less than 20 percent of hospitals in the United States today use bar-codes to verify the administration of patient medications, and fewer than 10 percent of physicians in hospitals enter patient prescriptions and medical orders electronically. The numbers are only slightly better outside the hospital: only about 25 percent of large physician offices enter their prescriptions electronically. The number drops considerably for small physician practices. Three Areas Where High-value, High-impact Technologies Already Make a Difference We can and must make the healthcare system safer and more efficient by accelerating the use of technology in all hospitals and physicians’ offices in the United States. There are three areas where high-value, high-impact technologies already make a significant difference: 1. Bar-code technology. Medications should be packaged in unit-doses labeled with bar codes and scanned at the bedside before they are given to patients. Today, on average, there are 27 steps in the medication use process that involve many decisions, multiple handoffs and various people, ranging from the physician who prescribes the order to the pharmacy staff to the nurse who ultimately administers the medication to the patient. Healthcare IT and automation can reduce the handoffs and eliminate, on average, 40 percent of the steps with dramatically improved accuracy, efficiency and safety. In a group of 75 hospitals that use McKesson’s bedside bar-coding technology, 400,000 “alerts” are triggered weekly to nurses or other healthcare professionals to advise them that the wrong medication or incorrect dosage is about to be administered. As a result of these on-line warnings, we estimate that these hospitals prevent 56,000 errors each week; a staggering statistic! Hospitals that deploy bar-code scanning technology report dramatic error reduction in medication administration, as high as 90 percent. 2. Electronic prescriptions. We must eliminate paper prescriptions. Each year more than three million preventable adverse drug events occur in physicians’ offices or other out-patient care settings. Imagine a world where a patient’s list of current medications is available to the physician and the physician can order initial scripts or refill them online. All the medication names would be legible, and all orders checked for drug-drug interactions and allergies. Today, McKesson’s systems help to ensure safe prescriptions are written and filled 100,000 times each month, but, nationwide, 80 percent of prescriptions are still on paper, and many are illegible. 3. Secure Web-based access to patient information. We must equip physicians and clinicians with the information needed to make informed decisions about patient care. Today, most healthcare is delivered in a paper-based world. It is not uncommon for physicians to provide patients with advice, give directions to other staff and recommend treatment changes without any access to a patient’s chart. These blind encounters happen every day. Secure Web-based access to clinical patient information, such as laboratory results, the patient’s medical record and diagnostic images, enables physicians to find, within seconds, the information they need to make more informed decisions and initiate or adjust treatment. McKesson currently records 1.8 million logins each month to its Web-based physician portal, almost double compared to a year ago. Remote access via Web portal technology is in common use across many industries; yet, in healthcare, its deployment is only in the 50 – 60 percent range. Funding to support these focused initiatives can lead to dramatic progress very quickly. McKesson applauds the leadership shown and initiatives undertaken by the Congress and this Administration. Implementing these three forms of technology will build the required momentum and provider support for adoption of healthcare IT. Technology is Improving Healthcare Quality Today Healthcare technologies today save lives, reduce medical errors, improve the quality of care, and reduce overall health costs. The following healthcare organizations are just a few of our customers that have taken these important first steps to improve care for their patients: Concord Hospital, an affiliate of Capital Region Health Care (CRHC), Concord, NH: Concord was one of the first hospitals in the United States to introduce bedside bar-code scanning of medications in 1994, which reduced its already low medication error rate by 80 percent. This reduced error rate, which has been sustained for more than 10 years, has improved productivity and efficiency as well as increased clinician satisfaction and retention. Medical Associates Clinic, Dubuque, IA: Medical Associates is deploying an ambulatory electronic health record and e-prescribing system for more than 100 physicians and medical providers, which represent 30 specialties dispersed across 16 locations in three states. With the implementation still underway, physicians are already entering 26,000 e-prescriptions each month, and patient information is available electronically regardless of location. Nurses spend far less time on medication management; they have reduced the time spent on paper charting activities by 24 percent and they spend 16 percent more time with patients and their families. In addition to improved quality and better decision-making, this clinic projects an annualized net gain of $1.7 million with full system deployment. Regional West Medical Center, Scottsbluff, NE: A regional referral center covering more than 12,000 square miles in rural Nebraska, Regional West has used information technology to streamline the delivery of healthcare. Through secure Internet access, physicians and other clinicians can view a single electronic medical record for each patient, which includes diagnostic medical images, pharmacy data and laboratory results. A McKesson pharmacy robot dispenses bar-coded, unit-dose medication packets virtually error-free. Electronic patient charting at the bedside has cut nurses’ daily paperwork by nearly 1.5 hours, enabling them to spend more time caring for patients. The hospital has reduced its medication error rate by 30 percent to less than one percent. Before giving a medication, the nurse must capture a three-way bar-code match between his/her badge, the medication and the patient’s wristband to check the five “rights”: the right patient is receiving the right dose of the right medication at the right time via the right route. Mary Lanning Memorial Hospital, Hastings, NE: The largest employer in Hastings, Nebraska, Mary Lanning Memorial Hospital has served the healthcare needs of the surrounding community for the past 83 years. Although the hospital’s medication error rate was low, a single tragic event highlighted the need for standardized medication administration. Bedside bar-code scanning technology was implemented along with a pharmacy information system to reduce the risk of medication errors. Additionally, medications scanned at the bedside are compared to orders reviewed by pharmacists and screened for allergies, interactions and therapeutic duplications. Preliminary data has shown a 35 percent increase in the reporting of near-miss events related to wrong drug and wrong patient. Presbyterian Healthcare Services in Albuquerque, NM: Using McKesson’s bar-code technology solutions, Presbyterian reduced medication administration errors by 80 percent. Technology has also allowed pharmacists to be redeployed to critical care units to work directly with patients and physicians and enhance the quality of care. These innovative health systems and others across the country are saving lives and saving money. Physicians, nurses, and pharmacists now spend more time interacting with patients and less time performing administrative functions. More importantly, these organizations are creating a new baseline for patient care in the United States. While making healthcare safer through seamless, rapid and accurate information flow, they are also addressing one-third of healthcare’s overall costs: administrative paperwork, clinical errors, manual hand-offs and rework. Developing Standards and Promoting Interoperability McKesson fully supports efforts of Congress and the Administration to facilitate standards harmonization, encourage the formation of regional health information organizations and establish a National Health Information Network. Development of the requisite technology standards will allow the computer systems of doctors, hospitals, laboratories, pharmacists and payers to efficiently communicate and share information. We are honored to work with Dr. David Brailer and the Office of the National Coordinator for Health Information Technology as he moves to create a foundation for the transformation of our healthcare system. We are also pleased to be a member of the Commission for the Certification of Health Information Technology, a collaborative public-private partnership to develop standards and certify health information technology systems. We all remember the incremental steps that were taken by other industries as they moved towards connectivity and interoperability. First, they automated individually and then, collectively, they collaborated to connect the information. Consider the banking industry. A full decade elapsed between the early proliferation of bank-specific automatic teller machines (ATM) and the formation of “shared ATM networks” in the 1980s. Once the automation was complete, connectivity and interoperability occurred very quickly. In the interim, banks were able to realize the cost and efficiency savings of ATMs, and consumers, appreciating the convenience of ATMs, quickly adapted to this new banking system. Connectivity is a natural evolution of automation. We are confident the same evolution will happen in healthcare. Once our nation’s healthcare providers are fully automated, it will be possible to connect previously isolated healthcare systems. Understanding and Overcoming Barriers to Rapid Adoption of Health Technology The biggest obstacle to healthcare information technology adoption is securing the needed funding and resources. Today, physician practices and hospitals do not have access to the capital necessary to invest in their own technology or, on a larger scale, to fund connectivity. The federal government can play a key role in financing this healthcare transformation through creative funding arrangements. One option is through the creation of Government Sponsored Entities, which would provide indirect federal support through guaranteed loans for healthcare providers to purchase, adopt, and implement proven health technology solutions that are focused on error elimination and safety. Coupled with the pay-for-performance initiatives that reward providers for the quality of healthcare delivered rather than for services rendered, guaranteed loans or other financial incentives will spur technology adoption. A combination of financial and performance incentives would help mitigate the initial expense of technology implementation. The reduction in medication errors and improved efficiencies in delivering improved healthcare will also provide a return on investment for healthcare organizations, thereby enabling them to repay the loans. Conclusion McKesson believes our healthcare system must adopt and deploy proven technologies today that reduce medical errors in order to save lives, improve the quality of care, and reduce costs. These initial steps should include: 1. Implementation of bedside bar-coded medication administration systems across the United States. 2. Elimination of paper prescriptions through use of e-prescribing in physicians’ offices. 3. Secure, online, “anytime, anywhere” access for physicians to critical patient information. Automated information will enable our healthcare organizations to store and collect patient data, which will ultimately lead to a comprehensive electronic health record. Concurrently, we need to adopt the standards necessary to ensure interoperability among systems that will facilitate communication within our health system. If we execute these initiatives simultaneously, McKesson strongly believes that this Congress and this Administration will be able to deliver visible and measurable results with a lasting impact on the quality of healthcare for the American public. As a nation, we have both the will and the means to transform healthcare for the better. This will be a remarkable legacy, and one we should act on today. Mr. Chairman and members of the subcommittee, thank you for your interest in this important subject. I will be happy to answer any questions.
Dr. John GlaserSenior Vice President and Chief Information OfficerPartner HealthCare System, Inc.
John Glaser, PhD, Vice-President and Chief Information Officer,
Partners Healthcare, Boston, Massachusetts
Before the Subcommittee on Technology, Innovation and Competitiveness
Senate Committee on Commerce, Science and Transportation
Use of Information Technology to Improve the Quality of Patient Care.
June 30, 2005
Mr. Chairman and Members of the Subcommittee: Good morning. My name is John Glaser. I am the Vice President and Chief Information Officer of Partners HealthCare. Partners HealthCare is an integrated system of medical care whose members include the Brigham and Women’s Hospital, the Massachusetts General Hospital, community hospitals, health centers, physician practices and visiting nurses. Over the course of a year, Partners physicians and nurses will deliver care in 4,000,000 outpatient visits and 160,000 admissions. I am also the President of the Board of the eHealth Initiative (eHI). The eHealth Initiative represents the multiple and diverse stakeholders in healthcare and health information -- consumer and patient groups, employers and purchasers, health plans, hospitals, laboratories, practicing clinicians, public health agencies, HIT suppliers and others-- dedicated to driving improvement in the quality, safety, and efficiency of healthcare through information and information technology. Implementation of Electronic Medical Records (EMRs) For the past 18 years, I have had the overall responsibility for the implementation of electronic health records (EHRs) at the Brigham and Women’s Hospital and then Partners HealthCare. During this time, we have implemented computerized provider order entry (CPOE) at Brigham and Women’s Hospital, the Massachusetts General Hospital, the Faulkner Hospital and the Dana Farber Cancer Institute. Physicians use CPOE to enter 30,000 clinical orders a day. Medical logic is applied to the order to ensure, for example, that the requested medication is safe or the radiology procedure being ordered is appropriate. Implementation across all our community hospitals will be completed by the end of next year. Currently, we have 2,600 Partners physician users of our electronic medical record (EMR) and over the course of the next four years, we will add an additional 2,000 physicians. Our implementation efforts are currently focused on physicians in our community practices. We have applied telemedicine to offer specialist second opinions to patients around the country and the world. And we support the home monitoring of patients with chronic diseases and recent surgical patients. We provide technologies to enable patients to converse with their physician and access their medical record. Our base of 25,000 patients is growing at a rate of 7,000 new patients a year. More recently, we have begun to invest in the information technology necessary to help our physician researchers understand the genomic basis of disease. These systems help the researcher, for example, to determine why most asthma patients respond to steroid therapy, while 10 percent do not. In collaboration with regional providers and payers, we have recently begun to integrate our EHRs with those of other providers across the Commonwealth of Massachusetts. Health Information Technology and Patient Safety Based on our extensive experience, and those of others, there is no question that information technology, when thoughtfully applied, can be leveraged to effect significant improvements in the safety, quality and efficiency of the care that we deliver. Studies of CPOE with decision support, at the Brigham and Women’s Hospital, show that medication errors were reduced by 80 percent and serious medication errors were reduced by 55 percent Additional studies of CPOE show decreases in the time spent by patients in the hospital, significant reductions in inappropriate antibiotic use, increased appropriateness of medication and radiology procedure orders and significantly faster notification of physicians regarding alarming patient test results. Electronic medical record reminders resulted in a 30% increase in diabetic patients and 25% increase in patients with coronary artery disease receiving recommended care. Our electronic medical records medication ordering system provides guidance to the physician and has led to 15 percent of all orders being changed to lower cost, but equally effective medications. Remote monitoring of elderly patients with congestive heart failure not only leads to earlier detection of possible deterioration in heart function, but also results in a 25 percent improvement in productivity for our visiting nurses. When data such as ours and others are extrapolated across the country, the Center for Information Technology Leadership, a healthcare information technology analysis group at Partners, finds that the widespread implementation of interoperable EHRs would provide a national net savings of $78B per year (5 percent of the nation’s total healthcare costs) by avoiding medical errors, reducing unnecessary care and improving administrative efficiency. Such systems are projected to eliminate 2,000,000 adverse drug events per year across the nation. Challenges of Health Information Technology While offering significant gains, the implementation of these systems and the achievement of improvements in patient care are very complex and difficult undertakings. Physicians and nurses must learn new ways of doing their work. Hospital and physician practice workflow must change. At times, performing a task using a computer takes longer than using paper. For providers already facing extreme demands on their time, these changes and time commitments can be overwhelming. Healthcare providers confront a complex financial decision when they seek to invest in these applications. While they are committed to the mission of delivering the best possible patient care, these systems represent significant capital commitments. With a reimbursement system that very often does not reward them for improving quality or support them in making these investments, their precarious financial positions and limited resources prevents them from pursuing these systems. For example, an EMR can have a five-year cost of $100,000 per physician. This cost can pose an insurmountable barrier for a physician who is facing decreasing Medicare reimbursement. Assuming that physicians and hospitals can overcome the difficult changes in clinical practice and can find the necessary funds, the majority of them have little experience with the acquisition and implementation of EHRs. They want to proceed but they don’t know how and they are rightfully concerned with making significant mistakes. This is particularly true for the small physician practice and small community hospital. At Partners we confront these challenges every day. And every hospital, physician practice, health center and visiting nurse agency in the country confronts these challenges. Community Health Information Exchange To these challenges, we are beginning to add a new dimension of complexity: the formation of regional and national networks to integrate EHRs across providers. There is no question that interoperable EHRs are a necessary step in our efforts to improve patient care. But there is also no question that there is very little experience with how to organize communities, develop the necessary information technologies, identify strategies for addressing complex issues such as privacy and mechanisms to ensure the ongoing financial stability of these efforts. This complexity is compounded by the bewildering array of standards that are often inconsistent, hindering our ability to efficiently connect our systems. There is much that provider, payers, employers, and patients can do to address these challenges and further the thoughtful adoption of EHRs. Partners Healthcare is an example of an organization that is committed to improving care through the use of information technology. We spend over $50M annually to acquire, implement and support EHRs. (This investment is in stark contrast to the $150M annual budget of the Office of the National Coordinator for Health Information Technology. A budget that, while well intentioned, is clearly insufficient to move the nation towards the widespread adoption of interoperable electronic health records). Partners is not alone. Many provider organizations are making significant investments in EHRs. Across the country, the healthcare community and its stakeholders are coming together in national and regional forums to discuss the industry’s collective efforts, learn from each other and jointly develop analyses, guides and positions. The eHealth Initiative The eHealth Initiative is supporting these efforts through its formation of working groups of physicians, employers/purchasers and community collaboratives whose members come together to address the mutual challenges. The eHI, national meeting, Connecting Communities for Better Health (CCBH), held one month ago, was attended by representatives of over 100 communities that have begun to implement local interoperability. The Parallel Pathways Framework of eHI has been hailed as an important guide to the industry as it seeks to integrate financial incentives, quality reporting, EHR adoption and community-based interoperability. Federal Leadership And while, the healthcare industry and those who have a stake in the industry’s efforts to improve care, must lead and are leading these efforts, the Federal government must play a critical role in supporting this work. A very significant national hurdle is the mis-alignment of financial incentives for EHR adoption. The provider must bear 100 percent of the costs of these systems and yet studies suggest that 89 percent of the economic benefit flows to groups and organizations other than the provider. Improvements in the safety of patient care will benefit the employer, payer and patient but there is little economic benefit to the provider. Hence the provider is confronting an investment that, while improving the care that they deliver, has a high likelihood of leading to an economic loss for the practice. At Partners, we have begun to address this problem through very constructive discussions with local payers that have led to modest reimbursement to physicians who adopt an EHR by the end of 2006. The Federal government is the country’s largest employer and payer. The Federal Government can alter its Medicare reimbursement approaches and the provider arrangements for its employees such that improvements in care and investments in necessary information technology will be financially rewarded. The inconsistency, and at times dearth, of necessary data and data exchange standards hinders our ability to create the necessary interoperability between EHRs and our ability to report on the quality and cost of the care that we deliver. The Federal Government can use its powers of convening and persuasion to help the industry resolve these problems. And the Government can insist that the federal health sector adopts and implements standards. A community hospital or small physician group in Massachusetts that wants to invest in information technology can turn to me and my staff for assistance. However, if you are small physician practice or a small community hospital, there may be no one who can provide this assistance. Mechanisms are needed to bring information technology support to those providers who do not have the benefit of an information technology staff. The Federal Government can leverage its resources to help establish and sustain needed support mechanisms. The current Doctors Office Quality Information Technology program (DOQ-IT) is an example. The Federal government should consider changes in the Stark and Anti-Fraud laws to enable organizations such as Partners to extend its EHRs and its implementation expertise to physician practices and share the costs with the physician. Partners is an active member of MA SHARE and the Massachusetts eHealth Collaborative efforts to provide Commonwealth-wide interoperability of EHRs. And at the eHealth Initiative, we see over 100 comparable efforts across the country. These efforts need to be nurtured and they invariable need access to seed funds. While they should strive to be financially self-sustaining within a couple of years, the availability of federally sponsored grants and loans will be a critical contributor to these early efforts. While we at Partners have been implementing EHRs for many years, there is still much that we do not know about their impact on patient care. New technologies and innovations bring new opportunities, but studies are needed to help the industry understand the potential contributions of these opportunities. We know even less about the value of regional and statewide interoperable EHRs. The Federal Government, in particularly AHRQ, has been a major supporter of research on the value and impact of information technology in medical care. These studies provide very important insight for all of our efforts and should continue. The Federal Government has extraordinary leadership leverage. Both elected and appointed officials can use this role to convene the industry, to encourage its participants to resolve problems, to use speeches and appearances to continuously stress the need for interoperable EHRs and to respond, as needed, to industry problems by crafting appropriate legislation. This role is not a transient one; rather it will be needed for years to come. The industry does listen. Conclusion I know that many of the recommendations described above are being analyzed and several are in the process of being put in place. And I know that I will have undoubtedly failed to appreciate the complexity and nuances of carrying out these recommendations. However, I live the reality of implementing EHRs every day and I see the reality of my colleagues across the country. From those perspectives I believe that I can see what is needed. All of us, and those who we love, seek healthcare. I won’t recite the now well-known numbers that illustrate the litany of problems that afflict our healthcare system. I do know that I want my kids and my eventual grand kids to have a healthcare system that has made major strides in safety, appropriateness and efficiency. And I have committed my professional life to helping to create that system through the application of information technology. Providers, payers, employers and patients must shoulder most of the burden to improve healthcare. And they are willing to do so. I am often struck, during conversations with health care leadership across the country, by the depth of their commitment and that they will continue their EHR efforts, even if the Federal response is minimal. However, the federal government actions or inactions will have a very significant impact on the pace of change, the degree to which we avoid mis-steps and our eventual success. Thank you for the opportunity to testify. I welcome the opportunity to respond to your questions.