[House Hearing, 108 Congress]
[From the U.S. Government Publishing Office]



 
      HEALTH INFORMATICS: WHAT IS THE PRESCRIPTION FOR SUCCESS IN 
     INTERGOVERNMENTAL INFORMATION SHARING AND EMERGENCY RESPONSE?

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

                                HEARING

                               before the

                SUBCOMMITTEE ON TECHNOLOGY, INFORMATION
                POLICY, INTERGOVERNMENTAL RELATIONS AND
                               THE CENSUS

                                 of the

                              COMMITTEE ON
                           GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED EIGHTH CONGRESS

                             SECOND SESSION

                               __________

                             JULY 14, 2004

                               __________

                           Serial No. 108-256

                               __________

       Printed for the use of the Committee on Government Reform


  Available via the World Wide Web: http://www.gpo.gov/congress/house
                      http://www.house.gov/reform







                 U.S. GOVERNMENT PRINTING OFFICE

98-120                 WASHINGTON : 2005
_________________________________________________________________
For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866)512-1800; 
DC area (202) 512-1800 Fax: (202) 512-2250 Mail: Stop SSOP, 
Washington, DC 20402-0001





                     COMMITTEE ON GOVERNMENT REFORM

                     TOM DAVIS, Virginia, Chairman
DAN BURTON, Indiana                  HENRY A. WAXMAN, California
CHRISTOPHER SHAYS, Connecticut       TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida         MAJOR R. OWENS, New York
JOHN M. McHUGH, New York             EDOLPHUS TOWNS, New York
JOHN L. MICA, Florida                PAUL E. KANJORSKI, Pennsylvania
MARK E. SOUDER, Indiana              CAROLYN B. MALONEY, New York
STEVEN C. LaTOURETTE, Ohio           ELIJAH E. CUMMINGS, Maryland
DOUG OSE, California                 DENNIS J. KUCINICH, Ohio
RON LEWIS, Kentucky                  DANNY K. DAVIS, Illinois
JO ANN DAVIS, Virginia               JOHN F. TIERNEY, Massachusetts
TODD RUSSELL PLATTS, Pennsylvania    WM. LACY CLAY, Missouri
CHRIS CANNON, Utah                   DIANE E. WATSON, California
ADAM H. PUTNAM, Florida              STEPHEN F. LYNCH, Massachusetts
EDWARD L. SCHROCK, Virginia          CHRIS VAN HOLLEN, Maryland
JOHN J. DUNCAN, Jr., Tennessee       LINDA T. SANCHEZ, California
NATHAN DEAL, Georgia                 C.A. ``DUTCH'' RUPPERSBERGER, 
CANDICE S. MILLER, Michigan              Maryland
TIM MURPHY, Pennsylvania             ELEANOR HOLMES NORTON, District of 
MICHAEL R. TURNER, Ohio                  Columbia
JOHN R. CARTER, Texas                JIM COOPER, Tennessee
MARSHA BLACKBURN, Tennessee          BETTY McCOLLUM, Minnesota
PATRICK J. TIBERI, Ohio                          ------
KATHERINE HARRIS, Florida            BERNARD SANDERS, Vermont 
                                         (Independent)

                    Melissa Wojciak, Staff Director
       David Marin, Deputy Staff Director/Communications Director
                      Rob Borden, Parliamentarian
                       Teresa Austin, Chief Clerk
          Phil Barnett, Minority Chief of Staff/Chief Counsel

   Subcommittee on Technology, Information Policy, Intergovernmental 
                        Relations and the Census

                   ADAM H. PUTNAM, Florida, Chairman
CANDICE S. MILLER, Michigan          WM. LACY CLAY, Missouri
DOUG OSE, California                 STEPHEN F. LYNCH, Massachusetts
TIM MURPHY, Pennsylvania             ------ ------
MICHAEL R. TURNER, Ohio

                               Ex Officio

TOM DAVIS, Virginia                  HENRY A. WAXMAN, California
                        Bob Dix, Staff Director
         Dan Daly, Professional Staff Member and Deputy Counsel
                         Juliana French, Clerk
            Adam Bordes, Minority Professional Staff Member



                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on July 14, 2004....................................     1
Statement of:
    Foldy, Dr. Seth, M.D., former Chair, Information Technology 
      Committee, National Association of County and City Health 
      Officials [NACCHO], former health commissioner, city of 
      Milwaukee, associate clinical professor, family and 
      community medicine, Medical College of Wisconsin; Richard 
      S. Weisman, coordinator, Weapons of Mass Destruction 
      Response Program, Jackson Memorial Medical Center, 
      director, Florida Poison Information Center/Miami, research 
      associate professor, pediatrics, UM/Jackson Memorial 
      Hospital; and Gordon Aoyagi, fire administrator, Montgomery 
      County Fire and Rescue Service.............................   115
    Gingrich, Hon. Newt, former Speaker of the U.S. House of 
      Representatives, the Gingrich Group; Karen S. Evans, 
      Administrator of e-Government and Information Technology, 
      Office of Management and Budget; David A. Powner, Director, 
      Information Technology Management Issues, U.S. Government 
      Accountability Office; and Dr. Claire V. Broome, M.D., 
      Senior Advisor to the Director for Integrated Health 
      Information Systems, Centers for Disease Control and 
      Prevention, U.S. Department of Health and Human Services...    13
Letters, statements, etc., submitted for the record by:
    Aoyagi, Gordon, fire administrator, Montgomery County Fire 
      and Rescue Service, prepared statement of..................   133
    Broome, Dr. Claire V., M.D., Senior Advisor to the Director 
      for Integrated Health Information Systems, Centers for 
      Disease Control and Prevention, U.S. Department of Health 
      and Human Services, prepared statement of..................    86
    Clay, Hon. Wm. Lacy, a Representative in Congress from the 
      State of Missouri, prepared statement of...................     8
    Evans, Karen S., Administrator of e-Government and 
      Information Technology, Office of Management and Budget:
    Information concerning high level deliverables...............   110
        Prepared statement of....................................    62
    Foldy, Dr. Seth, M.D., former Chair, Information Technology 
      Committee, National Association of County and City Health 
      Officials [NACCHO], former health commissioner, city of 
      Milwaukee, associate clinical professor, family and 
      community medicine, Medical College of Wisconsin, prepared 
      statement of...............................................   118
    Gingrich, Hon. Newt, former Speaker of the U.S. House of 
      Representatives, the Gingrich Group, prepared statement of.    18
    Murphy, Hon. Tim, a Representative in Congress from the State 
      of Pennsylvania, prepared statement of.....................    12
    Powner, David A., Director, Information Technology Management 
      Issues, U.S. Government Accountability Office, prepared 
      statement of...............................................    70
    Putnam, Hon. Adam H., a Representative in Congress from the 
      State of Florida, prepared statement of....................     4
    Weisman, Richard S., coordinator, Weapons of Mass Destruction 
      Response Program, Jackson Memorial Medical Center, 
      director, Florida Poison Information Center/Miami, research 
      associate professor, pediatrics, UM/Jackson Memorial 
      Hospital, prepared statement of............................   127


      HEALTH INFORMATICS: WHAT IS THE PRESCRIPTION FOR SUCCESS IN 
     INTERGOVERNMENTAL INFORMATION SHARING AND EMERGENCY RESPONSE?

                              ----------                              


                        WEDNESDAY, JULY 14, 2004

                  House of Representatives,
   Subcommittee on Technology, Information Policy, 
        Intergovernmental Relations and the Census,
                            Committee on Government Reform,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 2:35 p.m., in 
room 2154, Rayburn House Office Building, Hon. Adam Putnam 
(chairman of the subcommittee) presiding.
    Present: Representatives Putnam, Murphy, Miller, and Clay.
    Staff present: Bob Dix, staff director; John Hambel, senior 
counsel; Dan Daly and Shannon Weinberg, professional staff 
members and deputy counsels; Juliana French, clerk; Felipe 
Colon, fellow; Erik Glavich, legislative assistant; Adam 
Bordes, minority professional staff member; and Jean Gosa, 
minority assistant clerk.
    Mr. Putnam. A quorum being present, this hearing of the 
Subcommittee on Technology, Information Policy, 
Intergovernmental Relations and the Census will come to order.
    Good afternoon and welcome to the subcommittee's hearing 
entitled, ``Health Informatics: What is the Prescription for 
Success in Intergovernmental Information Sharing and Emergency 
Response?''
    The purpose of this oversight hearing is to examine the 
progress and impediments to the development and implementation 
of an efficient, secure, and reliable health information 
sharing network related to public health issues and emergency 
response: at the clinical care delivery, public health and 
consumer health levels, as well as among and between various 
government entities. At this hearing, the subcommittee will 
explore the role and status of technology in contributing to 
the success of those efforts. The subcommittee will also review 
the progress and results of the Federal Government's efforts in 
Consolidated Health Informatics e-government initiative. 
Further, the subcommittee will explore efforts to develop 
standards for the collection and use of health information to 
facilitate information sharing, as well as privacy protections 
that are related to the collection and use of such data.
    Today's hearing is an opportunity to examine the efforts 
underway in the advancement of information technology in the 
healthcare industry. The industry also provides an opportunity 
to examine the cross-agency coordination in the collection, 
consolidation, maintenance, and sharing of healthcare data, as 
well as across public and private sectors.
    This hearing is the second in a series this week that 
focuses on intergovernmental information sharing and the use of 
technology to facilitate capabilities. Yesterday the 
subcommittee examined the issue in the context of the linkage 
between law enforcement and homeland security, and the need for 
timely, reliable, and secure information sharing between 
various Federal agencies, as well as State and local 
government.
    Our Nation benefits from great advances in information 
technology. Such technologies have introduced multimillion 
dollar diagnostic instruments, a vast facilities 
infrastructure, and highly trained providers. However, our 
healthcare system has not leveraged information technology in 
healthcare record keeping. As Secretary Thompson remarked, 
``The most remarkable feature of this 21st century medicine is 
that we hold it together with 19th century paperwork.''
    The resolution of this problem is a high priority for the 
President. Earlier this year, the President further accelerated 
this work, calling for electronic health records to be 
available to most Americans within the next decade. His vision 
is to develop a nationwide health information technology 
infrastructure that ensures appropriate information is 
available at the time and place of care, resulting in improved 
healthcare quality, fewer medical errors, and a reduction in 
healthcare costs. In April, the President signed an Executive 
order that laid out the first steps in pursuing this goal with 
the establishment of a National Coordinator for Health 
Information Technology within the Department of Health and 
Human Services. The purpose behind the creation of this sub-
cabinet level position was to drive health information 
technology adoption in the health system and to centralize 
leadership in the Federal Government in pursuit of this 
objective.
    To achieve the important goals of coordination across the 
sectors of the U.S. healthcare system, the challenge of the 
development and implementation of standards and 
interoperability must be addressed. In many cases, data is 
collected using a format and vocabulary that suits the 
individual data collector, without consideration for the 
possibility of subsequent data sharing. The date is thus 
useless to others because the data was not collected in a 
standardized format using standardized vocabulary, and is not 
interoperable with data sets other healthcare providers may 
hold. This results in wasteful redundancy and a reduced ability 
to perform critical healthcare functions.
    The consensus across the healthcare industry is that the 
time is right to establish universal clinical vocabulary and 
messaging standards to enable technology development which 
better supports exchange in a secure environment. Leaders in 
the healthcare industry have communicated how important the 
Federal Government's leadership role is in adoption of those 
standards. As the Government is involved in providing and 
paying for healthcare--it is the largest third-party purchaser 
of healthcare--the standards used by Federal agencies 
significantly influence the decisions on standards made by the 
rest of the healthcare marketplace.
    Through the administration CHI initiative, numerous 
agencies and departments have endorsed 20 sets of standards 
thus far. About 20 department and/or agencies, including Health 
and Human Services, Veterans Administration, Department of 
Defense, Social Security, GSA, and NIST, are active in the CHI 
governance process. It is through this process that all Federal 
agencies will incorporate the adopted standards into their 
individual agency health data enterprise architecture, which is 
used to build all new systems or modify existing ones. CHI also 
conducts outreach to the private sector through the National 
Committee on Vital and Health Statistics.
    Beyond improving healthcare delivery and controlling rising 
healthcare costs, improved information sharing will provide the 
tools necessary to respond to a bioemergency event, whether 
terrorist-related or naturally occurring. It is through the 
development, adoption, and implementation of standards in data 
collection and transfer, as well as the installation of health 
IT systems in the clinical care and public health sectors, that 
the U.S. healthcare system will be better equipped to share 
information with clinicians, public health officials, and 
emergency response personnel in the event of a public health 
emergency. With better information sharing comes faster 
identification, containment, and response to any health-related 
emergency or disaster management situation such as bioterror, a 
SARS-like epidemic, or floods, hurricanes, wildfires, or other 
natural disasters.
    We are eager to hear about the current state of information 
technology and sharing in the healthcare industry, and what we 
can do to move forward in creating a more efficient healthcare 
system not only in terms of patient care, but in terms of 
improving our response and handling of any bioemergency that 
threatens the public health at large. I eagerly look forward to 
the expert testimony of our distinguished panel of leaders from 
throughout the Federal Government and the private sector today.
    [The prepared statement of Hon. Adam H. Putnam follows:]
    [GRAPHIC] [TIFF OMITTED] 98120.001
    
    [GRAPHIC] [TIFF OMITTED] 98120.002
    
    [GRAPHIC] [TIFF OMITTED] 98120.003
    
    Mr. Putnam. And we do apologize for the delay in beginning 
the hearing, as it is the rush to the August recess and votes 
have interrupted. But I believe that we do have a clean block 
of time for this hearing. We do very much appreciate your 
patience and understanding, and at this time I will yield to 
the distinguished ranking member from Missouri, Mr. Clay, for 
his opening remarks.
    Mr. Clay. Thank you, Mr. Chairman, and especially for 
calling today's hearing on ways we can improve the use of 
information technology in our healthcare delivery system. Since 
our subcommittee has not spent much time addressing these 
topics, I hope our witnesses will be thorough in their 
responses and in outlining their positions on all topics.
    Although our citizens are living longer and healthier 
lives, the state of our Nation's public health remains fragile, 
not only from long-term public health crises such as HIV and 
AIDS, but the emergency of new threats such as SARS or 
antibiotic resistant strains of previously identified viruses. 
These problems are compounded by demographic disparities in 
access to quality healthcare, an increasing population of 
uninsured citizens, and costs for services that continue to 
outpace the annual rate of inflation.
    All of these problems, however, can be partially addressed 
through the use of information technology in healthcare. 
Information technology has a positive impact on nearly all 
components of a national public health infrastructure. More, 
its intangible measures, including: the improved response of an 
agency to a public health crisis; significant reductions in the 
number of medical errors among patients annually, thus reducing 
the cost and resources necessary for positive outcomes among 
patients and the improvement of patient care through technology 
advances.
    If we continue our pursuit of utilizing IT throughout our 
healthcare delivery system, we are sure to experience shorter 
hospital stays, improved management of chronic disease, and a 
reduction in the number of needless tests and examinations 
administered over time. This cannot be accomplished, however, 
until geographic and economic boundaries are remedied to ensure 
that our public health infrastructure has the necessary 
resources for implementing such a system and there remains a 
vibrant IT research and development component throughout the 
public and private sector.
    This concludes my remarks, Mr. Chairman, and I ask that 
they be included in the record.
    Mr. Putnam. Without objection, all Members' opening 
statements will be included in the record.
    [The prepared statement of Hon. Wm. Lacy Clay follows:]
    [GRAPHIC] [TIFF OMITTED] 98120.004
    
    [GRAPHIC] [TIFF OMITTED] 98120.005
    
    Mr. Putnam. I would like to recognize the vice chair of the 
subcommittee, the gentlelady from Michigan, Ms. Miller.
    Ms. Miller. Thank you, Mr. Chairman. I will be very brief. 
We all certainly want to hear the testimony from our 
distinguished panelists here. And I appreciate your calling 
this hearing today, and certainly all of the panelists for 
appearing here today, especially noting the presence of the 
distinguished former Speaker of the House, Newt Gingrich, as 
well.
    The whole issue of healthcare, I think, and our ability to 
deliver it cost-effectively, cost-efficiently, all these kinds 
of things, is certainly one of the more larger challenges that 
our Nation faces, and I know every Member of Congress goes home 
to their districts and hears about these challenges all the 
time, and I think we are all very aware of many of the 
problems. I personally had the opportunity in a former life, it 
seems like, a former job that I had previously, serving as a 
trustee on the board of the second largest healthcare system in 
my State of Michigan, the St. John's Healthcare System, and I 
think I certainly profited much from that by just becoming more 
cognizant, aware of all of the problems that everybody is 
facing.
    You talk to the doctors and the doctors will tell you that 
they were actually determining which profession they would 
pursue based on medical malpractice, for instance. Perhaps they 
didn't want to be an OB-GYN anymore or a pediatrician or what 
have you. The issue of critical nursing shortages, which is 
particularly acute in Southeast Michigan, quite frankly. We 
have, I guess, the fortunate experience of being able to 
cannibalize our neighbor to the north of Canada. We have about 
20 percent of any of the nurses that are in any of our medical 
institutions are Canadian nurses.
    As well, you talk to the various hospitals, so many of them 
struggling with reimbursement rates, and their ability to 
collect, having a huge amount of the percentage of their 
receivables in a float, which a normal business would just not 
be able to withstand is very commonplace today throughout the 
industry.
    And, of course, we hear about the high accident rates in 
our hospital facilities or erroneously dispensing prescription 
drugs. In fact, in Michigan we are, just about as we speak, our 
State house and State senate is voting on a new piece of 
legislation that would require our doctors' signatures to be 
legible about prescription drugs because there have been all of 
these various incidents that had happened there.
    And, you know, I think sometimes you think, oh my gosh, 
there are all these problems, it is just so overwhelming. Well, 
the reality is that we are living longer, and we are living 
better, so how fantastic that we have an opportunity to have 
these problems, I suppose, and debate these different solutions 
to it. And I think it is a positive trend line that will 
absolutely continue. There is nothing more exciting than what 
is happening in the healthcare profession today, particularly 
when you think about the information highway and how we are 
utilizing technology. And I think it is for those of us that 
are in any level of government, quite frankly, but particularly 
at the Federal level, to make sure that we do not over-tax or 
over-regulate or over-something and stifle the creativity that 
is happening in the medical field and in healthcare.
    And I am very interested and desirous of working with the 
members of this panel and everybody in the healthcare industry 
to make sure that our brain trust continue to be very creative 
and flourish, and I thank you all for coming. I look forward to 
your testimony.
    Mr. Putnam. The gentleman from Pennsylvania, Mr. Murphy.
    Mr. Murphy. Thank you, Mr. Speaker, and welcome to the 
panel.
    Too often the matter of information sharing in the 
healthcare field is overlooked or ignored because of the 
development of a world-class system, and we face so many 
obstacles there. Private health systems are reluctant to move 
forward with electronic record systems because the costs, they 
say, are prohibitive. And there is no common technology used or 
recognized by all health systems.
    The use and transmission of electronic medical records 
poses innumerable privacy and security concerns which we have 
to deal with; however, we have to acknowledge this is an issue 
that cannot be ignored. Shockingly, of the over 3.7 billion 
prescriptions issued last year, there were 8.8 million 
instances of serious illness resulting from drug errors. 
Medication-related errors or adverse drug events are one of the 
most common types of medical errors and one of the greatest 
threats to patient safety. I believe the CDC estimated about 
7,000 U.S. deaths occur each year as a result of medication 
errors. On average, medication errors increase patient hospital 
stays by 2 to 5 days and increase medical bills by nearly 
$6,000 a person.
    Medication errors not only are harmful to patients, but are 
financially costly to healthcare providers. Resources that 
could be spent on direct services are instead diverted to 
counteract adverse drug events. Resources that could be used to 
improve healthcare end up going to pay for higher insurance 
premiums because of the problems that come after this with 
lawsuits.
    This issue goes beyond personal healthcare. How ready is 
our health system infrastructure for a widespread health 
epidemic at terrorists' hands? Even if only one life is lost 
due to the inability for community, State, and national health 
and emergency management systems to communicate in times of 
emergency, that is one life too many.
    The failure to use information technology in the healthcare 
field is unacceptable and must be addressed not tomorrow, but 
today. It is inexcusable and worrisome that this country is not 
leading the world in the widespread use of health information 
technology, and I fear that if this Congress does not do more 
to encourage a new road for our healthcare systems, future 
generations will question what we were waiting for.
    For that reason, Mr. Chairman, I applaud you in calling 
this hearing. It is extremely important, it is indeed one of 
making a difference in life or death. Thank you.
    [The prepared statement of Hon. Tim Murphy follows:]
    [GRAPHIC] [TIFF OMITTED] 98120.006
    
    Mr. Putnam. I thank all the Members for their opening 
statements. We will move to the administration of the oath. If 
the witnesses will please rise and raise your right hands.
    [Witnesses sworn.]
    Mr Putnam. Note for the record that the witnesses responded 
in the affirmative.
    We will move directly to testify, beginning with Dr. 
Gingrich. Dr. Newt Gingrich served the Sixth District of 
Georgia in the U.S. House of Representatives for more than 20 
years and served as Speaker of the House from 1995 to 1999. 
Since his time in Congress, Dr. Gingrich has become an 
outspoken advocate for a better system of health for all 
Americans. His leadership in the arena helped save Medicare 
from bankruptcy, prompted FDA reform to help the seriously ill, 
and initiated a new focus on research prevention and wellness. 
His contributions have been so great that the American Diabetes 
Association awarded him their highest non-medical award and the 
March of Dimes named him their 1995 Georgia Citizen of the 
Year. Today he serves as a board member on the Juvenile 
Diabetes Foundation.
    In his book, Savings Lives and Saving Money, Dr. Gingrich 
speaks directly on many of the issues at the heart of today's 
hearing. He describes a vision of a 21st century system of 
health and healthcare that is centered on the individual, 
prevention-focused, knowledge-intense, and innovation-rich. To 
foster such a modern health system that provides better 
outcomes at a lower cost, Dr. Gingrich launched the Center for 
Health Transformation.
    Dr. Gingrich is CEO of the Gingrich Group, a communications 
and consulting firm that specializes in transformational 
change, with offices in Atlanta and Washington. He serves as a 
senior fellow at the American Enterprise Institute here in 
Washington; a distinguished visiting fellow at the Hoover 
Institution at Stanford University in Palo Alto, CA; the 
honorary chairman of the Nano Business Alliance; and is an 
advisory board member for the Museum of the Rockies. Dr. 
Gingrich is also a news and political analyst for the Fox News 
Channel. He received his bachelor's from Emory and a masters 
and doctorate in modern European history from Tulane.
    Welcome to the subcommittee. We are delighted to have you, 
and you are recognized. Thank you.

 STATEMENTS OF HON. NEWT GINGRICH, FORMER SPEAKER OF THE U.S. 
 HOUSE OF REPRESENTATIVES, THE GINGRICH GROUP; KAREN S. EVANS, 
   ADMINISTRATOR OF E-GOVERNMENT AND INFORMATION TECHNOLOGY, 
  OFFICE OF MANAGEMENT AND BUDGET; DAVID A. POWNER, DIRECTOR, 
   INFORMATION TECHNOLOGY MANAGEMENT ISSUES, U.S. GOVERNMENT 
 ACCOUNTABILITY OFFICE; AND DR. CLAIRE V. BROOME, M.D., SENIOR 
   ADVISOR TO THE DIRECTOR FOR INTEGRATED HEALTH INFORMATION 
   SYSTEMS, CENTERS FOR DISEASE CONTROL AND PREVENTION, U.S. 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Mr. Gingrich. Thank you, Mr. Chairman. I want to thank all 
the members for allowing me to be here. I have submitted 
testimony for the record. I would like to summarize key things, 
particularly in response to the statements that have already 
been made.
    This is a very, very important topic, and it is a very 
bipartisan topic because it goes literally to saving lives. I 
recently had the opportunity to keynote a conference at Brown 
University, chaired by Congressman Patrick Kennedy, and I think 
we both found that there was a great deal of common ground that 
people of all backgrounds could come together on.
    It is particularly important because of the understated 
threat of a biological weapon. In Savings Lives and Saving 
Money we had an entire chapter that Commander Bill Sanders of 
the Navy helped develop as a fellow at the American Enterprise 
Institute, and if we get hit with a serious biological weapon, 
we could literally lose millions of people. And whatever you 
think of September 11, however horrifying it was to lose 3,100 
Americans, I think almost nobody has come to grips yet with how 
dramatic and how serious this problem could be.
    I must say that President Bush has talked about it, Vice 
President Cheney has studied it, and Secretary Thompson has 
done a remarkable job of organizing efforts at the Department 
of Health and Human Services and has probably the finest 
command center in the world today which would be responsive to 
a biological crisis, but below that the rest of the system is 
still not prepared. I also have to say that Dr. Gerberding at 
the Center for Disease Control and Dr. Clancey at the Agency 
for Health Research and Quality have also played a major role 
in trying to think this through.
    Things like the Consolidated Health Informatics initiative 
are the right start, but the Congress should encourage them to 
accelerate dramatically the development of standards. At the 
Center for Health Transformation we recently held a workshop on 
initiatives and incentives for better information technology, 
and a very substantial number of the people participating said 
that getting standards set--this is exactly like the railroad 
era, where you had to change trains at every State border 
because they didn't have a common standard, and so the trains 
couldn't run on the same rails. I cannot overstate the 
importance of getting to a single standard, making sure it is 
flexible and can grow, can evolve, but, nonetheless, that we 
have a starting point that is common. You see this with 
automatic teller machines worldwide, you see it with cell 
phones; all sorts of things people have solved this problem. We 
need to do it with health information.
    I also want to praise the President and Secretary Thompson 
for appointing David Brailer to be the first real leader on a 
governmentwide basis, and I would urge the Congress to look 
very seriously, as a first key step, at creating a permanent 
national health information technology coordinator and giving 
them some substantial ability to have budget review authority. 
Just creating the office without power doesn't get the job 
done. But the fact is the Government is the largest purchaser 
of healthcare in the world, and if it were also the smartest 
purchaser of healthcare in the world, we would have a 
transformation to an information system almost overnight, 
because every player would have to transform in order to meet 
government purchasing. I will come back to that.
    I think there are a couple of principles about the threat, 
and I want to say this very directly. Paper kills. With all due 
respect to those States which are trying to get doctors to 
print legibly, if they spent the same amount of time as 
Congressman Murphy is trying to get them to do, getting doctors 
to use e-prescribing, the savings in lives would be staggering. 
Paper prescriptions kill. Paper records kill. And if there is a 
real emergency, they are going to kill a lot of people, 
probably in the millions if it is a biological threat. So start 
with the idea anywhere you see paper you are seeing an obsolete 
system. And the question is how many lives are we willing to 
lose before we change the system.
    Now, in aviation--I used to serve in the Aviation 
Subcommittee--we have very high standards. In aviation, if a 
plane goes down with 135 people, the National Transformation 
Safety Board reviews it, the Federal Aviation Administration 
reviews it, the manufacturer reviews it, the airline pilots 
review it. It is a concerted effort to say your life matters if 
you are in a plane. By contrast, the institute of medicine says 
we kill between 44,000 and 98,000 people a year through medical 
error, we kill at least 9,000 people a year through medication 
error, and we all shrug and go ``isn't that unfortunate.'' But 
it is really not. It is the failure to impose systems of 
competence and systems of responsibility.
    I want to give you five specific principles for the 
solution. First, do not create a series of silos. There has 
been a terrible tendency in the last 3 years, after September 
11, to want to get by on the cheap by getting to an information 
system for a national emergency. When President Eisenhower, in 
1955, proposed the National Defense Highway Act specifically 
designed to enable us to get people out of cities if we were 
threatened with nuclear war, he did not say let us build that 
as a separate highway and we won't let anybody on it except in 
wartime. He said let us create that as an interstate highway 
system which, by the way, will also enable us to use it 
everyday in peacetime. And that is why middle class Americans 
can travel across this country with remarkable efficiency, 
because of a bill that was a national defense bill.
    Now, our goal should be a 21st century intelligent health 
system in which every American is tied into the system 
electronically, every American has an individual health record, 
and every American knows that the minute there is a real crisis 
we will all be wired together and will respond to the 
biological threat in the shortest possible time. And that is a 
national system, it is not simply a national defense system. 
But it ought to be built in the name of national security.
    Second, the Government, as the largest purchaser, should 
become the smartest purchaser. If the Federal Employee Health 
Benefit Plan, Medicare and Tricare decided that every 
individual was going to have an individual health record, 
electronically, Web-based, encrypted, HIPPA-compliant, exactly 
the model the English are launching this year, very rapidly 
every provider would be doing it because the Federal Government 
is such a huge purchaser that to meet the Federal Government 
standard they would have to do it.
    By the way, just for the record, we have had four firms 
indicate they would bid $10 per record; that is, if you have 44 
million people on Medicare for $440 million, every single 
person could have an electronic record. You could sustain it 
for about $3 a year, or one latte a year. Now, electronic 
medical records with huge bandwidth are much harder, but a Web-
based individual health record would be very inexpensive and 
would overnight change the volume of information available in 
America, and should start, by the Government being the largest 
purchaser, saying why don't our own citizens and our own staff 
have it.
    Third, there should be a radical increase in the potential 
research data available to the National Institutes of Health, 
to CDC, and to the Agency for Health Research and Quality, and 
that should lead to the development of an evidence-based health 
system of extraordinary capabilities. If you imagine how many 
million life years of data are currently sitting in the 
Medicare financial data base that are not being used, it makes 
the Framingham study, which is the biggest longitudinal health 
study in history, trivial by comparison. And yet we have no 
really large scale--I must say that Dr. Zahouni has been trying 
very hard at NIH and that Dr. Clancey has been trying hard at 
the Agency for Health Research and Quality, but compared to the 
scale of the opportunity, we need a much larger effort to 
develop the kind of data use and the kind of data focus. 
Currently, that is what we do after we pay for everything we 
are already paying for that we have been doing forever, and we 
have no notion of how big the opportunity is, I think, to get 
dramatically larger data bases and to lead to dramatically 
better care.
    Fourth, I think it is important in the Congress to pick up 
on the President's challenge and to insist that lives matter. 
President Bush has given more speeches on health information 
technology than all of the previous presidents combined. It 
doesn't get page 1, it is not the sort of thing the news media 
understands how to cover, but he has given speech after speech 
on the importance of health information technology; he has 
called for every American to have a health record that is 
electronic and online. And I think it is important to start 
with the premise that lives really matter, and I would argue 
that it is important to challenge both the Office of Management 
and Budget and the Congressional Budget Office to use private 
sector experience in scoring.
    The Agency for Health Research and Quality reported last 
June that medication errors and other medical errors cost about 
$100 billion a year. Yet it is impossible to score getting to a 
better system as though it was going to save any money at all, 
a single penny.
    My last point. As you are developing this, we need to 
really understand we are in the 21st century. We don't need a 
massive investment in a 1935 public health service. What we 
need to invent is a virtual public health service. There are 
55,000 drug stores that people are used to going to that they 
can find easily. All 55,000 should be wired together into a 
virtual public health service. There are retired doctors and 
retired nurses and retired veterinarians we will need 
dramatically if we have a really big health crisis. They should 
all be wired into the system.
    And, finally, and this may strike you as a bit odd, but it 
illustrates the scale of the problem. If we have a major 
nuclear event, we will literally need every long-term care 
facility within 100 miles and every veterinarian's facility 
within 100 miles, because you will lose all the downtown 
hospitals. That is actually based on a University of 
Pennsylvania study. And that would suggest to me that you want 
all of these systems wired together routinely every morning, 
just as automatic teller machines are wired together, just as 
e-ticket systems are wired. These are not new things. All we 
are trying to do is bring health into the 1980's.
    But I think with this subcommittee's leadership and with 
the President's continued leadership and Secretary Thompson's 
continued leadership, we might actually bring the system into 
the 21st century, and then we would in fact be substantially 
safer.
    Thank you, sir.
    [The prepared statement of Hon. Newt Gingrich follows:]
    [GRAPHIC] [TIFF OMITTED] 98120.007
    
    [GRAPHIC] [TIFF OMITTED] 98120.008
    
    [GRAPHIC] [TIFF OMITTED] 98120.009
    
    [GRAPHIC] [TIFF OMITTED] 98120.010
    
    [GRAPHIC] [TIFF OMITTED] 98120.011
    
    [GRAPHIC] [TIFF OMITTED] 98120.012
    
    [GRAPHIC] [TIFF OMITTED] 98120.013
    
    [GRAPHIC] [TIFF OMITTED] 98120.014
    
    [GRAPHIC] [TIFF OMITTED] 98120.015
    
    [GRAPHIC] [TIFF OMITTED] 98120.016
    
    [GRAPHIC] [TIFF OMITTED] 98120.017
    
    [GRAPHIC] [TIFF OMITTED] 98120.018
    
    [GRAPHIC] [TIFF OMITTED] 98120.019
    
    [GRAPHIC] [TIFF OMITTED] 98120.020
    
    [GRAPHIC] [TIFF OMITTED] 98120.021
    
    [GRAPHIC] [TIFF OMITTED] 98120.022
    
    [GRAPHIC] [TIFF OMITTED] 98120.023
    
    [GRAPHIC] [TIFF OMITTED] 98120.024
    
    [GRAPHIC] [TIFF OMITTED] 98120.025
    
    [GRAPHIC] [TIFF OMITTED] 98120.026
    
    [GRAPHIC] [TIFF OMITTED] 98120.027
    
    [GRAPHIC] [TIFF OMITTED] 98120.028
    
    [GRAPHIC] [TIFF OMITTED] 98120.029
    
    [GRAPHIC] [TIFF OMITTED] 98120.030
    
    [GRAPHIC] [TIFF OMITTED] 98120.031
    
    [GRAPHIC] [TIFF OMITTED] 98120.032
    
    [GRAPHIC] [TIFF OMITTED] 98120.033
    
    [GRAPHIC] [TIFF OMITTED] 98120.034
    
    [GRAPHIC] [TIFF OMITTED] 98120.035
    
    [GRAPHIC] [TIFF OMITTED] 98120.036
    
    [GRAPHIC] [TIFF OMITTED] 98120.037
    
    [GRAPHIC] [TIFF OMITTED] 98120.038
    
    [GRAPHIC] [TIFF OMITTED] 98120.039
    
    [GRAPHIC] [TIFF OMITTED] 98120.040
    
    [GRAPHIC] [TIFF OMITTED] 98120.041
    
    [GRAPHIC] [TIFF OMITTED] 98120.042
    
    [GRAPHIC] [TIFF OMITTED] 98120.043
    
    [GRAPHIC] [TIFF OMITTED] 98120.044
    
    [GRAPHIC] [TIFF OMITTED] 98120.045
    
    [GRAPHIC] [TIFF OMITTED] 98120.046
    
    [GRAPHIC] [TIFF OMITTED] 98120.047
    
    [GRAPHIC] [TIFF OMITTED] 98120.048
    
    Mr. Putnam. Thank you.
    Our next witness is Karen Evans. Karen Evans is the 
Administrator of the Office of Electronic Government and 
Information Technology at the Office of Management and Budget. 
Ms. Evans is a 20-year veteran of the Federal Government, and 
prior to joining OMB she was Chief Information Officer at the 
Department of Energy and served as vice chairman of the CIO 
Council, the principal forum for agency CIOs to develop 
recommendations. Previously, she served at the Department of 
Justice as Assistant and Division Director for Information 
System Management.
    Welcome back to the subcommittee, Ms. Evans. You are 
recognized.
    Ms. Evans. Good afternoon, Mr. Chairman, Ranking Member 
Clay, and members of the committee. Thank you for inviting me 
to speak about health informatics and our intergovernmental 
information sharing efforts.
    Until recently, the Federal health information enterprise 
was neither operating at optimum economy and efficiency, nor 
able to fully support critical national health and security 
needs. When handling health data, we seldom spoke the same 
language. Our ability to respond to national medical 
emergencies and bioterrorism is hindered when we are not able 
to share and interpret information quickly and reliably.
    To improve our ability to exchange health-related data 
nationally within and across business functions, the President 
issued, on April 27, 2004, Executive Order 13335, ``Incentives 
for the Use of Health Information Technology and Establishing 
the Position of the National Health Information Technology 
Coordinator.'' This Executive order supports leadership for the 
development and the nationwide implementation of an 
interoperable health information technology infrastructure.
    In addition, the administration has launched governmentwide 
efforts to improve the sharing of health-related data, 
including the Consolidated Health Informatics e-government 
initiative and the Federal Health Architecture [FHA], both led 
by HHS. Together, these activities will improve the quality and 
the efficiency of healthcare.
    Through the CHI initiative, Federal agencies are adopting 
and using health data standards to facilitate communications 
and to achieve interoperability. The implementation of these 
standards will take place as part of the FHA program.
    CHI participants include the Departments of Health and 
Human Services, Defense, and Veterans Affairs, as well as many 
supporting Federal agencies and interagency councils and 
committees. CHI interacts with the private sector through the 
input of the National Committee on Vital and Health Statistics. 
CHI working groups have identified 24 clinical subject matter 
domains where data standards should be considered. These 
domains encompass a significant amount of health-related data. 
Secretary Thompson announced the adoption of the first five 
standard domains in March 2003, and the additional 15 standard 
domains were adopted May 6, 2004.
    As standards are being adopted by CHI, the FHA program is 
creating an architectural foundation by building out the health 
line of business within the Federal Enterprise Architecture. 
FHA has been in existence for over a year and was more formally 
announced as one of OMB's lines of business task forces in 
March 2004. The FHA will provide a framework for linking health 
business processes to technology solutions and standards, and 
for demonstrating how these solutions will achieve improved 
health performance outcomes. FHA and CHI have a governance 
structure well designed to lead activities in a collaborative 
manner.
    In order to achieve intergovernmental cooperation, they 
work to leverage existing interagency efforts and have 
developed a clearly defined organizational structure, 
communication strategy, effective consensus process, and 
sequential proof of concept demonstrations for individual 
health business processes. In May 2004, the new Office of the 
National Coordinator for Health Information Technology was 
established within HHS. The new office will use the efforts of 
FHA and CHI to foster agreements, support progress, select 
health data standards, and ensure uniform and correct 
implementation of those standards.
    Emergency response is one area where Federal performance 
can be improved by more integrated information exchange. FHA is 
developing a target architecture for public health surveillance 
systems to improve interoperability between surveillance 
systems across multiple agencies and in the national health 
community. The program is conducting an assessment of existing 
and planned public health systems to begin the process of 
identifying opportunities for collaboration and possible cost 
savings. Because a realtime surveillance capability depends 
upon the integration of information across agencies, 
implementation at a national biosurveillance initiative will be 
coordinated with the Federal Health Architecture effort.
    The FHA initiative includes the adoption of governmentwide 
data standards through CHI and will create the master plan for 
developing a consistent Federal framework to facilitate 
communication and collaboration among entities across the 
healthcare spectrum. This will enable the quick and reliable 
sharing of information and will improve citizen access to 
health-related information and services.
    This concludes my statement, and I would be happy to take 
questions at the appropriate time.
    [The prepared statement of Ms. Evans follows:]
    [GRAPHIC] [TIFF OMITTED] 98120.049
    
    [GRAPHIC] [TIFF OMITTED] 98120.050
    
    [GRAPHIC] [TIFF OMITTED] 98120.051
    
    [GRAPHIC] [TIFF OMITTED] 98120.052
    
    [GRAPHIC] [TIFF OMITTED] 98120.053
    
    [GRAPHIC] [TIFF OMITTED] 98120.054
    
    Mr. Putnam. Thank you very much.
    Our next witness is David Powner. Mr. Powner is responsible 
for a large segment of GAO's information technology work, 
including systems development and IT investment management 
reviews. He has over 15 years of public and private information 
technology-related experience. In the private sector, Mr. 
Powner held several positions with Quest Communications, 
including Director of Internal Audits, responsible for 
information technology and financial audits, and Director of 
Information Technology, responsible for Quest digital 
subscriber lines software development efforts.
    Mr. Powner has an undergraduate degree from the University 
of Denver in business administration, and is a graduate of the 
Senior Executive Fellows Program at Harvard's Kennedy School of 
Government.
    Welcome to the subcommittee. You are recognized for 5 
minutes.
    Mr. Powner. Thank you, Mr. Chairman, Ranking Member Clay, 
members of the subcommittee. We appreciate the opportunity to 
testify on healthcare information technology. Significant 
opportunities exist to use IT to improve the delivery of care, 
reduce administrative costs, and improve our Nation's ability 
to respond to public health emergencies. This afternoon, I will 
briefly describe several of the key technologies that, in 
addition to improving care and reducing costs, can improve our 
Nation's ability to respond to public health emergencies, 
including, as the former speaker mentioned, acts of 
bioterrorism. I will also discuss the importance of 
implementing standards as new technologies are deployed and how 
a national strategy can greatly facilitate the implementation 
of these technologies and associated standards.
    Starting with technologies. The 2001 anthrax events 
confirmed many beliefs that information sharing during a public 
health emergency has much room for improvement, as participants 
accumulated dissimilar data and principally exchanged it 
manually. Information technology can play a critical role in 
improving this information sharing. For example, surveillance 
systems can facilitate collection, analysis, and interpretation 
of disease-related data; communications systems can facilitate 
the secure and timely delivery of information to responders and 
decisionmakers; and also electronic medical records have the 
potential for creating a wealth of data to feed surveillance 
systems.
    Unfortunately, today's public health infrastructure 
primarily lacks realtime surveillance systems and has 
fragmented communication networks. Efforts are underway to 
remedy the situation. For example, CDC is currently 
implementing its Public Health Information Network, which 
consists of a number of disease surveillance and communications 
systems, including the Health Alert Network.
    Next, standards associated with new technologies. Last 
year, when we reported on the identification and implementation 
of healthcare data and communications standards, we noted that 
standards development remained incomplete across the healthcare 
sector. Since then, progress has been made in identifying 
standards. For example, OMB's Consolidated Health Informatics 
e-gov initiative has identified a number of standards that are 
to be applied to new development efforts to promote the 
interoperability of information across Federal agencies. 
However, implementing these standards remains a work in 
progress. Until these standards are effectively implemented, 
disparate systems that are incapable of exchanging data will 
remain. In addition, legacy systems that haven't incorporated 
the new standards will also remain a problem.
    Finally, turning to the importance of a national strategy. 
To address the challenges of coordinating the many IT 
initiatives and implementing a consistent set of standards, we 
recommended last year that HHS develop an IT strategy for 
public health preparedness and response to include setting 
priorities for IT initiatives and establishing mechanisms to 
monitor the implementation of standards throughout the 
healthcare industry. Subsequently, the President recently 
issued an Executive order which calls for the establishment of 
the National IT Coordinator and an issuance of an even broader 
plan to guide the nationwide implementation of interoperable 
healthcare systems.
    Although it is encouraging that the coordinator plans to 
issue this strategy next week, this huge undertaking will 
require continued leadership, clear direction, measurable 
goals, and mechanisms to monitor progress. Additionally, this 
strategy will need to be aligned with the Federal Health 
Architecture, provide incentives for private sector 
participation, foster intergovernmental and private sector 
partnering, and stress the importance of robust security 
measures that ensure patient confidentiality and resist 
attacks.
    In summary, there are many opportunities associated with 
the implementation of health IT for clinical care delivery and 
public health. The Federal Government is taking a leadership 
role in establishing a strategy and identifying standards; 
however, much work remains, including deploying realtime 
surveillance and communications systems, implementing the 
standards that have now been defined, and carrying through on 
the strategy that is to be announced next week.
    We look forward to working with you, Mr. Chairman, and your 
continued oversight of this issue, which currently includes an 
ongoing review of Federal biosurveillance initiatives.
    This concludes my statement. I would be pleased to respond 
to any questions you or members of the committee have at this 
time.
    [The prepared statement of Mr. Powner follows:]
    [GRAPHIC] [TIFF OMITTED] 98120.055
    
    [GRAPHIC] [TIFF OMITTED] 98120.056
    
    [GRAPHIC] [TIFF OMITTED] 98120.057
    
    [GRAPHIC] [TIFF OMITTED] 98120.058
    
    [GRAPHIC] [TIFF OMITTED] 98120.059
    
    [GRAPHIC] [TIFF OMITTED] 98120.060
    
    [GRAPHIC] [TIFF OMITTED] 98120.061
    
    [GRAPHIC] [TIFF OMITTED] 98120.062
    
    [GRAPHIC] [TIFF OMITTED] 98120.063
    
    [GRAPHIC] [TIFF OMITTED] 98120.064
    
    [GRAPHIC] [TIFF OMITTED] 98120.065
    
    [GRAPHIC] [TIFF OMITTED] 98120.066
    
    [GRAPHIC] [TIFF OMITTED] 98120.067
    
    [GRAPHIC] [TIFF OMITTED] 98120.068
    
    Mr. Putnam. Thank you.
    And our final witness for the first panel is Dr. Claire 
Broome. Dr. Broome serves as the Senior Advisor to the Director 
for Integrated Health Information Systems at the Centers for 
Disease Control and Prevention. Dr. Broome oversees the 
development and implementation of CDC's National Electronic 
Disease Surveillance Program. She is an Assistant Surgeon 
General in the Commissioned Corps of the U.S. Public Health 
Service. Dr. Broome graduated magna cum laude from Harvard and 
received her M.D. from Harvard Medical School. She trained in 
internal medicine at the University of California-San Francisco 
and in infectious diseases at Massachusetts General Hospital.
    Welcome to the subcommittee. You are recognized for 5 
minutes.
    Dr. Broome. Mr. Chairman, members of the committee, thank 
you for this opportunity to discuss information technology and 
intergovernmental information sharing to support public health 
preparedness and emergency response. The Centers for Disease 
Control and Prevention [CDC] is working closely with Federal, 
State and local partners to enhance and integrate information 
systems for public health preparedness. My testimony today will 
focus on the capabilities that public health must have to 
support preparedness and our progress in developing the systems 
to support these functions.
    As you know, CDC's mandate is to protect the country 
against naturally occurring diseases, but also the deliberate 
use of all biological, chemical or radiologic agents. 
Obviously, the target in any major health event is to minimize 
morbidity and mortality by rapid intervention.
    Achieving this target requires capabilities for early event 
detection. I think we all get that. But it also needs the 
capacity for investigation and effective response. Electronic 
laboratory result reporting is a new, I would say, 21st century 
tool which can really help with this, and I will talk a little 
more about our progress in this area. Finally, communication 
among key personnel involved in the investigation and response, 
but also with the public, is an essential part of systems 
needed.
    This is a complicated activity, as you can well imagine, 
partly because of the large numbers of partners involved. In my 
public health career I have found myself working with air 
conditioning engineers, with tampon manufacturers. It is hard 
to predict what you are going to be dealing with. But we know 
the core group of local and State organizations, law 
enforcement, Federal agencies, are all going to be involved.
    Information technology presents the opportunity to 
contribute critically by linking this vast array of partners, 
as well as by supporting the range of capabilities. CDC's 
Public Health Information Network, or PHIN, as we 
affectionately call it, advances national preparedness by 
building critical interoperability tools. It also does this by 
certifying that systems built with preparedness funding are 
actually capable of fulfilling the functions that are needed, 
and also that they work as part of an interconnected national 
public health network, as several of the speakers have referred 
to.
    Health data standards are a critical part of that, and we 
actually have been implementing the Consolidated Health 
Informatics e-government standards that Ms. Evans alluded to. 
Implementing standards are really where the rubber hits the 
road. We are learning a lot about what is involved in making 
these standards work so that systems can actually work 
together.
    We are also looking forward to working with the new office, 
ONCHIT, I guess, or Dr. Brailer's office, as we think the 
intersection with the clinical sector is critically important 
for public health success.
    All of the partners, of course, have information systems to 
meet their own internal needs. The challenge is, first of all, 
to be sure they have that functionality, but, second, to be 
sure that they can work across the different organizations. We 
think it is critical that those information exchanges are 
tested, developed, and regularly used to assure that they will 
be reliably available during an emergency.
    I will now briefly discuss the status of PHIN and hope that 
I have some opportunity during questioning to go into more 
detail.
    Although CDC received the first funding for PHIN in fiscal 
year 2004, PHIN integrates and leverages initiatives which have 
been funded in previous years, so we do have substantial 
progress to report. In early event detection, the PHIN 
component is BioSense, which pulls together virtually realtime 
information from sentinel data sources. This is part of the 
Presidents 2005 biosurveillance initiative, but right now we 
have Phase I up and running. This captures sentinel data in 30 
cities, covering 32 critical metropolitan areas.
    The second area capability that I mentioned was the 
investigation and response. Here we are working with the 
surveillance system, NEDSS, with the electronic lab reporting 
through the Laboratory Response Network and to support through 
the Outreach Management System, investigation and response 
capabilities. For example, in Nebraska we have tripled the 
number of cases that we have heard about and we have taken the 
time from 26 days down to 1 to 3 days.
    Finally, in communications we have a national system, Epi-
X, which provides secure communications capacity for 3,500 
users across State and local health departments. We also have a 
Web site with 10.5 million visitors a month where we have 
targeted information for the media and the public to get 
information out.
    Finally, we have communications channels to distribute 
health alerts, which have gone to millions of recipients, as 
well as distance learning, for example, to get information on 
diagnosing anthrax out to practicing clinicians.
    This is just a sampling of the huge range of efforts that 
are being supported in an attempt to enhance preparedness in 
this country. I would be very happy to talk further about any 
of these areas in detail, and appreciate the committee's 
interest. Thank you.
    [The prepared statement of Dr. Broome follows:]
    [GRAPHIC] [TIFF OMITTED] 98120.069
    
    [GRAPHIC] [TIFF OMITTED] 98120.070
    
    [GRAPHIC] [TIFF OMITTED] 98120.071
    
    [GRAPHIC] [TIFF OMITTED] 98120.072
    
    [GRAPHIC] [TIFF OMITTED] 98120.073
    
    [GRAPHIC] [TIFF OMITTED] 98120.074
    
    [GRAPHIC] [TIFF OMITTED] 98120.075
    
    [GRAPHIC] [TIFF OMITTED] 98120.076
    
    [GRAPHIC] [TIFF OMITTED] 98120.077
    
    [GRAPHIC] [TIFF OMITTED] 98120.078
    
    [GRAPHIC] [TIFF OMITTED] 98120.079
    
    Mr. Putnam. Thank you very much.
    Dr. Broome, I would like to talk to you about this past flu 
season about the difficulty in determining which strain to 
develop a vaccine for to have stockpiled in time for that 
year's strain, and that we are overdue to have a super-strain, 
if you will, something akin to the 1918 strain. How prepared 
are we for something like that and how will advances in 
information technology mitigate an outbreak of that magnitude?
    Dr. Broome. Thank you for the question. There are several 
aspects to that. We do think BioSense and analogous syndromic 
surveillance is highly likely to provide early warning of an 
increase in febrile respiratory disease, which is the way that 
influenza would present So we would get close to realtime 
warning, and it has been shown with syndromic surveillance that 
this does go up faster than the traditional flu surveillance 
mechanisms. So we think that can help us identify that 
something is happening and also the geographic extent, how many 
cities is it happening in. However, without turning this 
hearing into a pandemic flu discussion, I would point out that 
there are a number of other activities which are critically 
necessary, such as being able to obtain the actual virus and 
characterize it and rapidly develop vaccines, which will be 
necessary to mitigate the impact.
    Mr. Putnam. Mr. Speaker, you referenced the 1918 strain in 
your written testimony. Do you want to followup on that?
    Mr. Gingrich. Let me just comment, and Dr. Broome can 
correct me if I get too much of this wrong. I think if you were 
to look, 1918 was an unusual event because you had the 
debilitation of the first World War and you had a population 
that was probably more vulnerable than you would normally 
expect. We learned a couple of years ago, with anthrax, that 
with healthy people, with rapid intervention, with all the 
things we can do nowadays, we had a lower death rate than we 
would have expected, I think, theoretically.
    But if you had avian flu crossover, for example, which is 
not impossible, but not likely, but not impossible, and you had 
the characteristics of the spread of flu, which we actually 
don't understand; it shows up in places, so you don't have the 
smallpox quarantine capability. With smallpox you can create 
circles of defense; with flu we don't understand how it 
spreads, so it is a lot more difficult problem.
    I think one of the things that is not part of this 
committee's assignment, but one you should carry back, is we 
really need very basic research in finding a way to manufacture 
vaccines that is a total break from the current growing in an 
egg process, because the current process presumes enough 
foresight that you can catch something in Southeast Asia, and 
by the time it has circled the planet you are ready for it. And 
in the age of the jet airplane, if you had a sudden crossover 
of something, you want to be manufacturing new vaccines to meet 
the new challenges in days, not in months. We have no 
technology today that can do that, and in terms of basic 
research and development into national security, that should be 
one of the highest values, that should be almost comparable to 
where nuclear energy was in the late 1940's. Biologicals in the 
21st century are what physics were in the 20th century, and we 
have not yet, at the resource level caught up with big enough--
it is not your topic for today, but I think it fits what Dr. 
Broome is faced with and what the CDC is faced with with this 
avian flu and with the patterns of the 1918 flu pandemic.
    Mr. Putnam. Next week, HHS will unveil their new IT health 
strategy. Mr. Speaker, recognizing the mechanics of our process 
in policymaking, what should their initial focus be, given the 
magnitude of the challenge?
    Mr. Gingrich. I thank you for the question. I actually 
think there are three parallel areas. The first is to set 
standards. The work that is already being done, I think you are 
discovering, once you work it through, it really makes a big 
difference. And we found, in the Center for Health 
Transformation workshop about a month ago, that almost 
everybody who came who was really sophisticated said, look, if 
you get the standards right, other pieces will start to fall in 
place. But until, at a national level, you get standards, they 
are not going to migrate up from subgroups, because subgroups 
all have their own vested interest, and they have all invented 
it here and they all want their version. So one is standards.
    Second, I can't overstate the importance of forcing CBO and 
OMB, Congressional Budget Office and Office of Management and 
Budget, to calculate what we are wasting. Let me give you an 
example that nobody can quantify today. If you were to try to 
ask in Medicare or in Tricare or in FEHBP how much are you 
spending to Xerox records and FedEx them, nobody knows. But 
because they know what it costs to have an electronic system, 
they score the electronic system as a cost and they absolutely 
refuse to score what you would save by not Xeroxing and 
FedExing. Now, we had Anthony Nolan, who helped develop the 
English health record, and Ralph Portman, who was on the 
advisory board to Prime Minister Blair's government, and they 
both said unequivocally, if you have a Web-based individual 
health record system, as I said earlier, at $10 a person, it is 
inconceivable it is not a net savings. And yet I will guarantee 
you neither CBO nor OMB will score it.
    So I would argue the second thing to look at is how do you 
get governments in America to understand that the information 
age requires an entrepreneurial public management approach 
rather than a bureaucratic public administration approach, and 
then how do you get that kind of change.
    The third place I want to come back to is investments. In 
the private sector, people estimate you should invest somewhere 
between 4 and 6 percent of your revenue into IT. The IT people 
tell you it ought to be more like 8 or 10, but I think people 
would agree 4 to 6. Sutter Health, which is one of the leading 
hospital systems in the United States, information technology 
has been putting in about 4 percent a year for the last 7 or 8 
years. The Federal Government should insist on a minimum of 1 
percent of its own gross spending, which would be, I am 
guessing--somebody here may have a better number, but my guess 
is if you combine all Government health spending, you would be 
at $6 or $7 billion if 1 percent of all health spending by the 
Federal Government went directly into IT. If you did that, you 
would, within 3 or 4 years, have us in a different world, and I 
think you could begin to back off.
    I will say one last thing, and I apologize for adding one 
other thing, but it was a commentary by one of the other 
panelists.
    One of the lessons that the English think they learned is 
you have to have Web-based overlays and you have to have 
middleware, because the cost of replacing all of the legacy 
systems is so massive, and the amount of time and energy to 
implement it is so huge that you cannot wait until you 
restructure the entire country. It would be like arguing Henry 
Ford shouldn't start selling cars until we can replace every 
single horse and buggy in the country simultaneously. You have 
to have a method of overlaying Web-based systems and you have 
to have a method of overlaying middleware systems that 
translate between legacy systems. And when you do, you design a 
very different biosurveillance system, because now you can get, 
at the Federal level, realtime data from every single doctor, 
not coming up through the State public health system in a 1935 
model, but realtime data nationwide through expert systems, and 
it gives you a much different kind of scanning capability.
    Thank you for letting me go on.
    Mr. Putnam. Does anyone wish to add? Dr. Broome.
    Dr. Broome. Well, just as a point of clarification The 
BioSense system that I described is actually similar 
architecture to what Dr. Gingrich was suggesting in that the 
information comes from existing electronic records directly to 
the BioSense platform and then is made available at the same 
time at the Federal, local and State level to authorized secure 
users. And we think there is real potential to work with 
existing data sources. Certainly there is a need to assess and 
define which of those are truly valuable in providing useful 
information. And there is also a need for public health to be 
able to followup and investigate whether it is a true alarm or 
a false alarm. But we agree there are many opportunities that 
need exploring.
    Mr. Putnam. Mr. Powner.
    Mr. Powner. If I can just elaborate on the point of 
implementing the standards effectively. We are well aware and 
it is well documented that even now that these standards are 
identified, you have local hospitals that cannot communicate 
with others even though they are using the same standards. It 
is really in the implementation of these standards. When you 
look at Dr. Brailer's strategy and what he needs to focus on, I 
think one of the key things, if you have a big bang approach, 
it is going to be very difficult. You probably need to look at 
regionalized or local success stories with implementing 
standards, and then you could grow that into some larger 
initiatives. That likely will be important if we can extend 
that to a national level.
    Mr. Putnam. When you say begin with a regional approach or 
a smaller approach, would you start at the--for example, would 
your first cut be at the Federal level, where you would do 
Medicare or Federal employee benefits, VA, or would you let 
geography take its course and let the State of Florida take the 
lead or the State of Pennsylvania?
    Mr. Powner. I think either way. But I think if you focus on 
a smaller scale basis, it is easier to realize some initial 
success stories, whether it is through some of the Federal 
programs or on a regional basis associated with the State or a 
locality.
    Mr. Putnam. Ms. Evans.
    Ms. Evans. And I would like to, first of all, thank you for 
having this panel, because I think it is an important topic. 
The strategy that will be coming out from Dr. Brailer's office 
will be coordinated with all of these initiatives, taking into 
consideration several of the things that have already been 
mentioned by the panel. You know, I am speaking specifically as 
the IT executive here, and a lot of the points that are being 
made are exactly what the CIO does as far as recommending the 
strategy of going forward for the implementation. This is 
already covered in a lot of things going forward that you do 
with a modular approach. The CHI initiative, as well as the 
Federal Health Architecture initiative, are taking into 
consideration small proofs of concept in order to really drive 
at the points that are being made by the distinguished panels 
here so that there is a modular approach. As you do each 
portion of this implementation, you learn from it so that you 
can continuously roll those benefits into the implementation 
and move it forward, versus, as you said, the big bang 
approach, and then you wait for everything all at once, and if 
you have made a mistake, then you have a huge mistake and then 
we haven't moved forward.
    So we are looking and we are working with his office on the 
strategy to ensure that it does address standards, that we 
continue the work of standards, but that we are looking at how 
this technology is going to roll out and how those standards 
will be implemented. As my distinguished colleague said, that 
is where the rubber hits the road.
    Mr. Putnam. Mr. Speaker.
    Mr. Gingrich. I would like to agree if by big bang you mean 
trying to do everything at once. But I would disagree if it 
meant you were going to create a series of local experiments 
without connectivity. Let me make a couple quick points.
    I have been involved in military transformation actively 
since 1979. I helped found the Military Reform Caucus; I was 
the third witness at the initial Goldwater-Nichols testimony on 
jointness; I am the longest serving teacher in the senior 
military; and I am on the Defense Policy Board. So I have spent 
a long time on transformation. If you don't have a clear 
national systems vision and say, great, we will fund all sorts 
of local experiments that are seeds, not silos, and the seeds 
have to have two characteristics that are very different, I 
believe, from most of the thinking up until now in the system. 
This is not a Government problem, this is how the culture has 
evolved. The culture evolved locally and it evolved from 
institutions. So almost all of the solutions tend to be local 
solutions and institution solutions. They are both profoundly 
wrong for this reason: health is essentially--should be 
centered on the individual. What I care about is my health.
    In England, when they started studying this, they 
discovered that a person with cancer in the national health 
service could go to 22 different specialists in five different 
institutions in a 2-year period hand-carrying their records. So 
you start with the idea anything we do--and I think Dr. Brailer 
thoroughly understands and agrees with this--anything we do 
should start with your individual records and how we are going 
to match data up to you as a human being, and it has an 
institutional effect and institutional overlay, but it 
shouldn't be institution-centric or provider-centric.
    Second, the reason it is ultimately going to be Web-based 
is simple: we travel. I mean, consider your own life. Consider 
the life of a retiree. When the baby-boomers start to retire, 
they are not going to sit in one place; they are going to be 
all over the place. So while it is true that 90 or 95 percent 
of health is actually locally provided--and I just had somebody 
yesterday from Ford Motor Co. whose father had a heart attack 
while visiting in Washington, and they had to try to find his 
doctor in Southern Louisiana on a weekend, and it took Johns 
Hopkins 24 hours to be sure what they were doing because they 
couldn't find the patient records. Now, that is all utterly 
absurd in terms of the technology available.
    And so I would hope that, as we design a national 
architecture, I couldn't agree more, implementation building 
blocks should be local, specific, measurable, but the core 
systems architecture should be generally agreed upon, should be 
universal, and should ultimately have a very big Web-based part 
and should be individually centered, not provider-centered or 
institution-centered.
    Mr. Putnam. Mr. Clay.
    Mr. Clay. I thank the witnesses for their testimony today. 
I will start with Dr. Broome.
    Are we in a position today to quickly detect and respond to 
major public health emergencies such as SARS and cases of 
bioterrorism, given the challenges that remain in health IT?
    Dr. Broome. I think it is very important to remember that 
human beings still matter. There really is no substitute for 
having clinicians who are informed and aware and having people 
available at their local or State health departments 24/7. That 
was certainly the system that worked for the anthrax 2001, and 
I think it is going to be an important part of activities; it 
is one of the areas we have been focusing on. At the same time, 
we think IT is a critical complement to complementing and 
enhancing that system.
    We think that BioSense is a very good first step in 
providing an automatic scan of sentinel electronic data bases. 
The President's 2005 initiative for biosurveillance proposes 
very substantial resources to increase the coverage of that 
system so that it would be much more encompassing of the 
private healthcare delivery setting.
    Mr. Clay. Thank you for that answer.
    Mr. Powner, since the Federal Government administers the 
Medicare and Medicaid programs, what lessons can be learned by 
the entire healthcare industry in terms of improving the 
quality and efficiency of care provided to the general 
population? And are we becoming more effective in implementing 
programs that demonstrate positive results in both public and 
private healthcare settings?
    Mr. Powner. I think some of the key lessons that can be 
learned are from Veterans Affairs and DOD, with electronic 
medical records. They clearly both have initiatives underway to 
put those in place. Clearly, they are further ahead than other 
entities, and there is a lot of work going on where they are 
attempting to have a two-way exchange of those electronic 
medical records. There are some challenges there, clearly, but 
there are some lessons learned, too, from those organizations, 
since they are a bit ahead of others.
    Mr. Clay. Thank you.
    Ms. Evans, please give us some examples on how the 
Consolidated Health Informatics initiative is aiding agencies 
in their sharing of health-related information. Are the 
standards recommended being taken to heart by the private 
sector as well as Government agencies?
    Ms. Evans. Based on going forward with the CHI initiative, 
as I mentioned in my statement, they have worked very closely 
together. We do have a consolidated business case which, from 
an OMB perspective, shows that the agencies are taking this 
very seriously. There are over 23 partner agencies that are 
working on this initiative together to define what those 
domains are, to define what the standards are.
    And as I pointed out in my testimony, they have mutually 
agreed to adopt 20 out of the 24 standard domains going 
forward. They have also agreed together, without OMB saying 
this is how it will be, to adopt several of the standards that 
are available for the healthcare industry, and they 
continuously work together because they recognize the 
importance of this initiative.
    We, from an OMB perspective, believe that we have now 
enhanced this and we are trying to help further this initiative 
so that it can get implemented even faster through the Federal 
Health Architecture effort, again, through another consolidated 
business case where they have come together and agreed that 
this is something that they need to do and work together. The 
agencies that are listed in there are like EPA--I mean outside 
of the regular ones that you would think--HHS, DOD, VA. And we 
watch them very closely and ensure that they are hitting their 
milestones through the President's management agenda.
    So there are several mechanisms that we are using, but the 
agencies themselves agree that this is truly important and are 
working together.
    Mr. Clay. Thank you for that response.
    Mr. Gingrich, first let me say that it is a pleasure to see 
you working with both sides of the isle, with friends like 
Patrick Kennedy, on issues that are so important to the health 
and economy of our Nation. In the July 13th Washington Post 
article by C.C. Connolly, you speak of your vision to transform 
the American healthcare system as a more efficient and 
technologically adept arena. Could you expand on whether our 
challenge is more in terms of public resistance to changing the 
current system they know and live with, or are the challenges 
more in terms of technology and its limits?
    Mr. Gingrich. Let me say, Congressman Clay, first of all, I 
am delighted to be here with you, and I would look forward to 
working with you on a bipartisan basis on these things. And you 
might notice that in your hometown, the Mercy health system has 
a remarkable track record in the last 2 years of applying 
information technology and incentives, and has actually 
substantially brought down costs in one of their clients by 
getting people deeply involved in compliance and taking care of 
their own diabetes and taking care of their own heart disease 
in ways that has really changed the cost trajectory in St. 
Louis.
    The core of what I think has to happen is to first of all--
and this goes right back to the lessons that I learned working 
with the Defense Department in the 1980's and 1990's--you first 
have to get a clear vision of where we are going, and then you 
have to start building solutions to fit the vision. We are 
beginning to see that. Again, Congressman Murphy, as an example 
of this, on electronic prescribing. It is very clear by any 
standard that there should not be any paper prescriptions, 
except in the strangest of circumstance. Routinely, they ought 
to be electronic; routinely, they ought to be monitored by an 
expert system to make sure that you don't have a drug problem 
that we already have something else wrong with you and that 
drug is not one you should take; to make sure that it is an 
accurate data so, for example, if the doctor, by accident, puts 
in the wrong number, an expert system should come back and say 
that would kill them, as happened to a young girl here in 
Washington last year, because they misread the prescription.
    So I start with the idea that on almost every front--what 
happened in Britain is interesting. They discovered that you 
were three times as likely to die of breast cancer in Britain 
as in France. And that was politically so unacceptable that 
they had to confront reforming the national health service. And 
the national service didn't review itself, but the Exchequer, 
which is their treasury department, brought in a retired 
banker, not somebody from health, and said look at the system 
and tell us what is going on; and the banker came back and said 
if I had the information systems in banking that you have in 
health, we would go broke in 3 days. And that was the base of 
their entire effort to create a national system.
    So I start with the idea you--and what we talk about the 
Center for Health Transformation is very straightforward: how 
do you incentivize people to take care of themselves? And this 
applies to Medicaid, it applies to Medicare, it applies to 
private sector plans. If you can incentivize people so they are 
winning when they are winning, they change their behavior. 
Second, how do you inform them and give them a chance to inform 
themselves so they know how to take care of themselves? And, 
third, how do you take all that data and get it into research 
capability so whether it is a realtime information going to the 
Center for Disease Control that says, gee, 39 people this 
morning got the kind of drug you would give somebody if they 
had SARS; I wonder if we better check it.
    And I couldn't agree more with what Dr. Broome said. I 
would recommend this subcommittee or the full committee go down 
the street one building, visit HHS and see what Secretary 
Thompson has done with his command post, which is literally, I 
think, the best command post today and the most modern in the 
world. But then recognize that if you don't have a competent 
trained professional at the other end of all that technology, 
it is literally worthless. And so it has to be a total systems 
approach, not just a single magic bullet approach, and that is 
harder, it is somewhat more expensive, but in the long-run I 
think it is going to be dramatically better.
    I would also say one other thing where both, I believe, 
Tricare and Veterans have missed the boat, although I think 
Veterans are starting back to catch up on it. An individual 
health record is very different from an electronic medical 
record. An individual health record is Web-based, relatively 
simple, can be downloaded over a rural doctor's office on a 
telephone line. An electronic medical record is massive, it has 
every MRI, every lab report, everything ever done to you, and 
it takes huge bandwidth.
    We could have for the entire country an individual 
electronic health record online for something on the order of 
$3 billion, and we could sustain it annually for about $1 
billion a year. Totally different proposition. An electronic 
medical record for every American would be, I think, well over 
$100 billion.
    Mr. Clay. Thank you.
    Mr. Putnam. Ms. Miller.
    Ms. Miller. Thank you, Mr. Chairman. I appreciate all of 
the testimony here today, particularly the sweeping vision of 
what we ought to do with our healthcare system, and certainly 
what Congress needs to move more expediently toward some of the 
settings. But unlike my colleague Dr. Murphy here, I am 
struggling myself with some of these different terms and 
understanding all of this.
    I had an incident in one of my local hospitals just during 
the break during the 4th where I went to--this is sort of a 
rural hospital; not completely rural, but very small town. And 
this was a hospital where the doctors had previously just run 
around with clipboards, right? They are going into each 
individual place with their patient with their clipboard. Now 
they have an electronic notepad. It is sort of in the front of 
each patient's room; it is on the wall. They can write on it 
whatever they are doing; they can take it from there and move 
it into the individual patient's room. So I think one of the 
biggest problems they are having, though, is getting the 
doctors to really use these things, because there is a big push 
back, they don't want to change, if they think it is a nurse's 
job to use all this technology. And I know that is not a huge 
thing on the global scheme of things, but it is having a huge 
impact in this one particular rural hospital, and they were 
very, very proud of themselves.
    And I just wonder if you have some comments about, for 
instance, in a rural hospital, where they wouldn't have the 
availability in a big city hospital facility of duplicating all 
those kinds of things, or having the doctors on staff for all 
the different kinds of challenges that they might meet. Do you 
have any comment on what some of these smaller hospitals might 
be able to do to access information electronically from a 
larger facility or spread that out where you might have a 
command post of some type in a rural hospital, where they could 
take care of half a dozen beds, monitor what is going on there, 
something along those lines?
    I just throw that out there.
    Ms. Evans. I will start from a purely IT perspective, 
because what you are talking about is a challenge that we face 
regardless of whether it is at the Federal level or local 
level. My husband, I will share with you, happens to be a 
dentist, a healthcare provider. And so trying to automate his 
office is exactly what you are talking about; it is a change 
management issue. And so as we are working through these and as 
we continue to work through these types of projects, that is a 
very clear issue that needs to be addressed through small 
modular types of approaches, to be able to try out different 
types of approaches for implementation to deal with that, and 
what would be the best way to handle that.
    We can't give you necessarily a blanket ``this is the way 
it is going to work,'' but we would apply what we learn as we 
continuously roll that out. And you are right, it is going to 
be different in a rural area than it would be in a large 
metropolitan area, and that is one thing that we are cognizant 
of at a Federal level when we are trying to put things together 
about what that impact would be at a local jurisdiction.
    I don't know if my colleague from the CDC has something to 
say.
    Dr. Broome. I think, as Ms. Evans has indicated, and I 
think has come up previously, you need to think on several 
different levels in terms of what kind of solutions you are 
proposing, and they do need to fit with the technologic 
capacity as long as you have the big picture vision of where 
you are trying to get to. In the public health sphere we 
actually recognize that some of our local health departments 
didn't even have broadband Internet connections, so one of the 
preceding initiatives to PHIN was Health Alert Network, which 
really focused on getting broadband 24/7 Internet connectivity 
to about 1,000 core local health departments so that they could 
play. And that is one of the reasons why this is so complex, 
that you are trying to build infrastructure capacity at the 
same time that you want to make sure there are applications, 
there are useful things for people to do with that broadband 
connectivity; it is not just a point of hooking them up to the 
Web, it is saying, OK, now we will give you a simple Web screen 
where you can actually report something that is happening and 
you can also get alerts, you can find out e.g., that there is 
an increase of gastrointestinal disease.
    So it is a highly complex undertaking, but we recognize the 
need to think about folks who are in the more rural areas or 
who don't have the kind of resources.
    Mr. Gingrich. You raise a really good point at a couple of 
levels. First of all, at a broader level we need to look at the 
right incentives. If we were prepared to quantify what an 
electronic record will save in terms of Xeroxing and FedExing, 
and share half of that savings with the doctor, every doctor in 
your rural hospital would learn how to change their behavior. I 
mean, health is one of those places it is a little bit like 
education; we keep trying to get behavioral change without 
paying for it, and then we are shocked that people don't 
change. But why should a doctor go out and have to learn a 
brand new workflow, a whole new way of doing things, etc., for 
no compensation? And I think that is a significant part of the 
problem.
    Second, you need to look at large systems that are really 
working. Visi-Q is a Johns Hopkins spinoff, it is an electronic 
intensive care unit. Every small hospital in the country should 
be tied into, whether it is done State-by-State or in some 
manner, but they should have that kind of quality that is 
bringing world-class information into local hospitals. The 
University of Texas medical system, which actually runs the 
Texas prisons' medical systems, is proof of the concept that 
you can deliver extraordinary quality of information, you can 
run emergency rooms on a 24/7 basis with centralized 
information flow. It is a system worth your looking at.
    I just had somebody come by the other day from the American 
Medical Group Association with a wristwatch that the current 
generation is a 250 megabit computer and the next generation is 
a 2 gigabyte computer, where the doctor could literally walk 
into a room, plug in the watch, use the keys and the screen--
and you are totally HIPPA compliant because it is never going 
over the Internet. It is half gimmick but half fascination 
about where the world is going.
    Last example of complexity. I think we should be bar 
coding. We should be bar coding single-dose medication; we 
should be bar coding medical technology; we should be bar 
coding hospital supplies. If you are a small hospital and you 
could get pre-bar coded all that material, you would save a lot 
of money. One of the interesting problems is that the Federal 
child safety laws make it impossible to have single dose 
medication that is too easy to get to for certain things, and 
so certain things aren't produced in a single dose medication 
model, because it wouldn't find the tamper-proof system. Very 
interesting complexities that are in there.
    But one of the things you should be looking at from a rural 
hospital standpoint and a small hospital standpoint is how do 
we maximize the ease of migrating into the information age so 
that they are getting the benefit of the cost savings as the 
system modernizes, rather than having to pay intermediate 
costs. Today, if you bar code, you have to pay an intermediary 
to re-bar code most of the medicines into a single-dose 
packaging for you. That is an extra cost, and small hospitals 
just won't do it.
    Ms. Miller. That is interesting. Perhaps we need to take 
the lead on really trying to encourage and incentivize, as you 
say, in some ways, through HHS or what have you, for the 
different doctors and that.
    I guess my other question would be, we just went through 
this Medicare reform with the prescription drug benefit now 
for, I don't know, by anybody's interpolation, how many 
millions of seniors will advantage themselves of this, 
hopefully. But is the Federal Government, as we are capturing 
all of this information, whatever information we are capturing 
from these seniors, are we doing anything with that 
electronically? Is there some best practice that we might be 
able to point to or some idea? I don't know if any of you are 
familiar with what is happening with that particular bit of 
information, but you have all of this new information that we 
are going to be capturing here.
    Dr. Broome. There is a provision in the law which 
encourages that, and we actually had a discussion at the Health 
and Human Services Data Council inviting all of the different 
operating divisions to work with CMS to consider how this could 
be most advantageously used to provide valuable information for 
improving healthcare quality and safety. And I am sure they 
will also engage private sector, probably through the National 
Committee on Health and Vital Statistics, to participate in 
that planning.
    Ms. Miller. I see.
    Ms. Evans. Also what is happening in that particular area 
is that the Social Security Administration is working directly 
with HHS to deal specifically with what you are talking about, 
the collection of the information, what is the best way to do 
that, and to ensure that we do it efficiently and effectively.
    It is also probably critical to mention that this, of 
course, will put a paramount concern on the security of the 
information and the privacy.
    Ms. Miller. Thank you, Mr. Chairman.
    Mr. Putnam. Thank you.
    Mr. Murphy.
    Mr. Murphy. Thank you, Mr. Chairman.
    Since you have seen fit to mention my bill a couple times, 
I would just like to use this to talk a little bit about it and 
how this would work. It is H.R. 4805 of the Ensuring Medication 
Safety for Seniors Act, and it would establish a demonstration 
program under the Secretary of Health and Human Services and 
offer grants to Medicare providers to offset the costs of 
establishing electronic prescribing systems, and set this up in 
a region where the hospitals, pharmacists, and physicians are 
connected in realtime so that it increases patient safety by 
eliminating confusion and errors from handwritten 
prescriptions, provide realtime access to consultants, allow 
doctors to view information on alternate medications, dosage 
levels, drug interactions, generic availability, and improve 
the quality of care by providing doctors with the information 
that really is not available in a paper and pen system, and, 
most importantly, reduce patient risk. We have to keep 
reminding ourselves that the current death rate is about 20 
people a day, I think. It is huge; 19 or so.
    Having worked in hospitals for 25 years myself, in 
hospitals and clinics, I recognize that oftentimes when I would 
see a patient, that I would be on volume 3 of a chart and each 
volume would be about two inches thick, and I would be dealing 
with a baby that was perhaps 2 months old. It was absolutely 
impossible, impossible to go through there and have any sense 
of all the detail that was in there; and it was ripe with 
potential for errors. Now, luckily there were so many people 
involved in every case, many doctors, nurses, etc., double-
checking and triple-checking things, that we minimized the 
chance for those risks. But the point is when somebody else 
comes on shift, they should have that information immediately. 
In today's world, too, if we are looking for another way of 
cutting costs, and you recognize to sit and try and review 
these charts in what you may be allowed in your schedule, 5 or 
10 minutes to see a consult, where it requires hours of 
perusing a chart, it contributes massively to the cost of 
healthcare, and I add that to your savings.
    But I would like to mention this, Mr. Speaker. One of the 
things that has come up is that there is a lack of uniform 
standards that really prevent us from knowing the full benefits 
of healthcare IT initiatives. And I know from exploring my 
bill, that is one of the things that has happened. They talk 
about somewhere between 6 months and several years before we 
get to know all these standards. I think the current deadline 
is several months away.
    I wonder if you and other members of the panel can talk 
about why it is taking so long to develop these minimum 
standards and what can we do to speed these things up, because 
that is a huge hurdle we have to face.
    Mr. Gingrich. Let me start with that and then talk about 
the system you just described for a second.
    My conclusion, doing both national security and health, is 
that it is this hard in part because health is about 30 times 
more complicated than national security, and it is actually 
much harder to do. It is much more decentralized; there are 
many more kinds of professions involved; the rhythm of each of 
those subcultures is very different. Having done a lot of work 
on how you transform the Defense Department, that is easy. This 
is much, much denser and more complicated. So some of it is 
legitimate.
    The second difference is a lot of us who were very big on 
computers very early--and I started looking at them at Georgia 
Tech in 1965--we were right about where they would eventually 
get to, but they weren't there. And I would argue in some ways 
it is only in the last decade that we are beginning to get to 
usable realtime capabilities. And a lot of people who were 
early pioneers burned out and said I don't want to go back and 
do that again, or they watched their friends do it and they 
said I don't want to be involved in that mess. So I think you 
have to understand at one level the experience of some of it.
    But let me go through your points for a second. The Mayo 
Clinic in Jacksonville has been paperless since 1996. One of 
the advantages is doctors can access the patient record from 
home or on vacation. So if they want to think about something, 
they can actually get the data in realtime, at 10 at night, and 
think about it, which is your point. It is not just staring at 
the chart now, but you think over the weekend about a 
particular problem, you would like to have access. That is why 
online will always beat having a smart card. Ultimately, you 
want a Web-based system, not a smart card system.
    Second, Gold Standard Multimedia is an overlay in Florida 
on top of a e-prescribing system. The State of Florida got them 
involved with Medicaid. They are currently, according to the 
State of Florida, saving $6,000 per Medicaid doctor by three 
things: realtime reporting of less expensive medicines that are 
available, stopping medication errors, and detecting fraud; 
people who went to five doctors the same week to get the same 
drugs to sell them. Six thousand dollars net per doctor per 
year is what Florida is now getting out Gold Standard 
Multimedia.
    Evra-Care is a United Health product that takes care of 
senior citizens. The minute they create an electronic data base 
about the senior citizens in nursing homes, most of them over 
80, many, one-third with Alzheimer's, they almost always reduce 
the number of drugs they are getting, because once they see the 
total record, they realize three different doctors have been 
prescribing, not talking to each other, and, in fact, the 
person is over-medicated; dramatic reduction in hospital 
admission.
    Last example, though, what I mean about the scoring 
problem. In Rhode Island in the early 1990's, the estimate was 
made that every fourth emergency room visit by senior citizens 
was a medication error. Well, if you went in and said, great, 
if we could eliminate half of those, how much would we save on 
emergency room visits? Could we count that against the cost of 
e-prescribing? The answer would be no. It is always every 
improvement in health is a plus even if it saves money and 
saves lives; you never get the advantage of the change. And I 
would just suggest that is intellectually wrong, and it is a 
major inhibition to adopting new, better systems.
    Mr. Murphy. I would just like to move to pass my bill 
tonight, if we could do that.
    Mr. Putnam. I think you would find widespread support in 
the subcommittee, but I am not sure we have enough juice.
    Ms. Evans, there are several different paths being pursued, 
the working groups in food safety, health services and 
electronic health records, interoperability, and public health 
surveillance, all under the FHA. They will develop target 
technical standards and a business architecture for the health 
line of business. Could you give us a status report on each of 
these, please?
    Ms. Evans. We are currently working forward on that, and we 
have consolidated it into what we are now calling the line of 
business. So they have specific targets that they are working 
on. I do not have the specific deliverable dates under each of 
those, I would be glad to go back and look at that. They are 
working on the plans for what they are going to be requesting 
for their path forward in fiscal year 2006. We are working on 
that consolidated business case right now for all the agencies.
    We do continue to work on the CHI initiative as well, and 
there is going to be a second phase of that to address the 
additional domains that have not been agreed upon yet. Both of 
these will roll up together and will be reflected in the 
strategy that is coming forward from HHS dealing with this 
overall. So there will be a general timeline in that as well, 
when that strategy is released.
    Mr. Putnam. If you could get those dates for us. I think 
that is an important piece of what we are after.
    Ms. Evans. Sure.
    [The information referred to follows:]
    [GRAPHIC] [TIFF OMITTED] 98120.080
    
    Mr. Putnam. Mr. Powner, you cited the VA as being one of 
the leading innovators using information technology to bring 
greater efficiency to healthcare. Have you done any of the work 
on the Bay Pines computer pilot project fiasco?
    Mr. Powner. I have not, Mr. Chairman.
    Mr. Putnam. OK. Then I won't ask you any questions about 
it.
    And, Mr. Speaker, we have referred a great deal to the U.K. 
model of healthcare delivery, but your comments, your 
references to it were new to me, so I would like you to take an 
opportunity, please, to describe where they were, where they 
are going, and how they made their transformation, 
understanding that they face the same friction that we would 
face here, on perhaps a smaller scale, but, nevertheless, the 
same issues.
    Mr. Gingrich. Well, it is a national health service, and 
they have certain advantages because they actually employ most 
of the doctors. They, for a very long time, have had a fair 
amount of information electronically available inside any 
particular facility, but not available nationally. And I think 
they are going to have a lot of teething pains; it goes back a 
little bit to why the big bang can be more exciting than you 
want it to be.
    But what they designed was five regional systems networked 
together by what they call a national spine. The national spine 
would really contain the individual health record; the regional 
systems would contain the medical records. And the health 
record is built up by simply copying automatically out of the 
electronic medical records. So you would end up with everybody 
in England--it is in England, not Scotland, Whales, and 
Northern Ireland. But in England you have about 55 million 
individual health records. They are beginning to launch them 
this summer. They are having teething pains, but the 
theoretical model that they are working off of is of three very 
different things. First, this is an excuse to replace the 
legacy systems and they are going to spend a fair amount of 
money, about 6 billion pounds plus, over the next 5 years, 
which would translate roughly into about $10 billion. And this 
population is slightly larger than California, to give you a 
sense of scale for an American model. And there they are going 
to try to actually replace the legacy systems. We have talked, 
for example, with IDX, which is very deeply involved--and IBM 
are very deeply involved with the biggest hospital system in 
London, trying to replace their entire legacy system.
    Second, they have the regional centers that are being set 
up and run by a variety of companies. There were five different 
bids. And companies like Excenture of Hujitsu won those bids, 
BT, formerly British Telecom. And then BT, or British Telecom, 
as they used to be, won the national spine, which is putting 
together this data so that wherever you go in England you will 
have access to this. And it will be on the Web, so literally 
wherever you went in the world, if you get access back into the 
system, you can get it. That piece is, I think, the most 
revolutionary because it is individually centered, Web-based, 
it is secure, and it allows the information to follow you 
everywhere.
    I suspect sometime this summer we will start to see it 
actually happening. But I would think of it as three different 
projects with three different cost centers. The least 
expensive, ironically, is the individual health record for the 
whole country. The most expensive is replacing the legacy 
systems, which is going to be very expensive. And as several 
people have alluded to, once you get involved in the workflow 
problems and all the different things that happen at that 
level, it is a big challenge.
    Mr. Putnam. Thank you very much.
    Ms. Miller, do you have any additional questions for the 
panel?
    Ms. Miller. I don't, Mr. Chairman. Thank you.
    Mr. Putnam. Well, in that case, I want to give each of you 
the opportunity to rebut or add to anything that any of your 
fellow panelists have said, answer the question that you wish 
you had been asked, or give any parting comments, beginning 
with Dr. Broome.
    Dr. Broome. This has been a wonderful opportunity, I think, 
to talk about some issues that are really critically important 
for the country. I think it is helpful to get down to the 
fairly practical areas of what are going to be the payoffs for 
this, and so we are really trying to implement the Public 
Health Information Network in a way which lets us document 
payoffs for the health system. And the one area that I would 
like to just say a few more words about is the area of 
electronic laboratory reporting, because I think that 
demonstrates the kind of payoffs that we are already seeing. It 
also shows standards in practice. This employs the CHI 
standards for messaging specifications and for what we call 
controlled vocabulary, SNOMED and LOINC, and it lets a clinical 
laboratory trigger an automatic notification to public health 
that a condition of public health importance has occurred. So 
that is helpful to us. As I think I mentioned, we actually 
tripled the number of cases we heard about from one single 
laboratory. Using this kind of automatic notification doesn't 
require the lab to think, oh, I have to notify public health.
    More to the point, the same standards could be used to 
notify the FDA about an adverse event related to a vaccine or 
drug. They could be used to notify the FDA, USDA, CDC about 
food safety laboratory results. They could be used to notify 
the EPA about safe water results. So I think you can sort of 
see the options; you can either go the route of sort of chaos 
and putting a burden on laboratories to communicate, or you 
really can expedite and solve a lot of problems by doing this 
right.
    Mr. Putnam. Mr. Powner.
    Mr. Powner. Two points, Mr. Chairman. One, a lot of the 
initiatives associated with PHIN that Dr. Broome mentioned are 
steps in the right direction, but clearly where we need to go 
with that is nationwide implementation and full functionality. 
We talk about different phases and when additional phases are 
going to come on board. It is very important that these things 
get deployed with full functionality and on a nationwide basis. 
We have a good start, but I think we need to keep the momentum 
and we need to continue to drive that progress with solid 
milestones and accountability over those systems. Realtime 
surveillance and communication will be extremely important as 
we respond to public health emergencies down the road.
    Second point is implementation of standards. There is a 
good discussion going on here about what we need to do with 
implementing standards. That is very difficult. And the scale 
that we are discussing right here is just a huge, huge 
challenge; and hopefully Dr. Brailer's strategy will lay out 
some milestones and steps that we can take in moving that in 
the right direction.
    Mr. Putnam. Ms. Evans.
    Ms. Evans. As always, sir, I would like to thank you again 
for highlighting the e-government initiative in this area that 
is so important to this administration, but also giving the 
opportunity to talk about other initiatives and showing how 
they all come together here, for example, the President's 
initiative on broadband, which would address the rural issues 
that we were talking about being able to establish that 
connectivity; the Executive order on health, as well as our 
initiative going forward on biosurveillance. But I think all of 
these really show the President's commitment to a citizen-
centered government using e-government as his tool, using 
information technology to be able to bring those services to 
the citizen.
    So I thank you, and I thank you for the opportunity to 
appear with my esteemed colleagues today.
    Mr. Putnam. Thank you.
    Mr. Gingrich. Thank you very, very much for having this 
panel and for asking these questions, and for allowing 
particularly my colleagues on the panel who have worked for the 
U.S. Government and done so much to try to bring their 
professional capabilities and their integrity to this.
    As a historian politician, if I could close this out, I 
would say if you go back to your colleagues and tell them that 
the biggest problem is that we don't have a threat of urgency. 
If I had a single slogan, it would be ``we have been warned.'' 
People, right after September 11, said why weren't we ready. 
From 1347 to 1349 the Black Death killed a third of the people 
of England. In 1918, more people died from the flu than died in 
the entire first World War in 4 years. And we recently watched 
SARS briefly emerge and then, fortunately for us, disappear. 
The Center for Disease Control watches the avian flu every day 
and is desperately hoping that it doesn't cross over and become 
a human susceptible system.
    I think there are three simple questions that the Congress 
has to ask itself: What is the value of life? If it is a car 
wreck, we will get a helicopter to take you to the emergency 
room. If it is a heart attack, we will get the ambulance to 
show up. So what is the value? Because we could be in a 
situation where we could lose a million people, and we are not 
making the kind of investing saving a million lives would be 
worth.
    Second: How real is the risk? You could bring in a panel of 
Nobel winning biologists and ask them that question, and if it 
is a closed hearing, what they will tell you would be really, 
really sobering, because it probably won't happen; but if it 
did happen tomorrow, we really couldn't stop it. We can stop 
smallpox. Smallpox is not the problem. It is painful, it is 
difficult, it is dangerous, but in the end you can quarantine 
smallpox. That is how we beat it last time. But you get 
something like the flu that spreads the way the flu does, we 
are in big trouble.
    Last: How vital is health information technology to the 
safety of our Nation? I think it is absolutely central. I 
regard a biological threat as a greater threat than a nuclear 
threat. And I think that what these folks are doing and what 
the agencies they represent are doing is as central to our 
survival as the strategic air command was in the cold war.
    And I really thank you very much for taking the time to 
hold this hearing, and I hope that you will share with your 
colleagues how really serious this is. Thank you very much.
    Mr. Putnam. Thank you, Mr. Speaker. And thank all of you 
very much for your outstanding contributions to this hearing, 
and for this sobering and somber assessment of where we are, 
but certainly giving us a path toward progress.
    With that, the subcommittee will stand in recess while we 
reshuffle the cards for the second panel.
    Thank you again for your assistance.
    [Recess.]
    Mr. Putnam. The subcommittee will reconvene. I want to 
thank our second panel for their patience. I know we are 
running a little bit behind. And I want to thank the diehards 
in the audience for sticking around, even though the rock stars 
have gone.
    At this point I would like to swear in the second panel. 
Please rise and raise your right hands.
    [Witnesses sworn.]
    Mr. Putnam. Note for the record that all the witnesses 
responded in the affirmative. We will move immediately into 
testimony.
    Our first witness is Dr. Seth Foldy. Is that correct?
    Dr. Foldy. That is right.
    Mr. Putnam. Dr. Foldy recently ended a 6-year term as 
commissioner of health in Milwaukee, WI, where his innovations 
in disease surveillance, electronic communications, and multi-
jurisdictional and public/private collaborations earned him the 
American Public Health Association's Roemer Prize for creative 
local public health work and other awards. Dr. Foldy also 
chaired the Information Technology Committee for the National 
Association of County and City Health Officials, and served on 
the Foundation for e-Health Initiative Board, the CDC's 
Information Council, and other groups devoted to public health 
information infrastructure. A board certified family physician, 
Dr. Foldy is associate clinical professor of family and 
community medicine and health policy at the Medical College of 
Wisconsin, and offers consultation on population health 
strategy, health informatics, and health policy.
    Welcome to the subcommittee. You are recognized for 5 
minutes.

 STATEMENTS OF DR. SETH FOLDY, M.D., FORMER CHAIR, INFORMATION 
 TECHNOLOGY COMMITTEE, NATIONAL ASSOCIATION OF COUNTY AND CITY 
HEALTH OFFICIALS [NACCHO], FORMER HEALTH COMMISSIONER, CITY OF 
 MILWAUKEE, ASSOCIATE CLINICAL PROFESSOR, FAMILY AND COMMUNITY 
  MEDICINE, MEDICAL COLLEGE OF WISCONSIN; RICHARD S. WEISMAN, 
  COORDINATOR, WEAPONS OF MASS DESTRUCTION RESPONSE PROGRAM, 
   JACKSON MEMORIAL MEDICAL CENTER, DIRECTOR, FLORIDA POISON 
    INFORMATION CENTER/MIAMI, RESEARCH ASSOCIATE PROFESSOR, 
 PEDIATRICS, UM/JACKSON MEMORIAL HOSPITAL; AND GORDON AOYAGI, 
 FIRE ADMINISTRATOR, MONTGOMERY COUNTY FIRE AND RESCUE SERVICE

    Dr. Foldy. Thank you very much. Thank you, Chairman Putnam, 
members of the committee, and all of my colleagues here for 
seeking the input of the Nation's 3,000 local health 
departments who play a critical role in the Nation's health 
protection. To my qualifications I would add I was also a 
family physician who was among those who, about 20 percent of 
the patients I saw, I did not have medical records on to make 
decisions. Many of the admissions that I made were due to lack 
of information.
    Although we are talking about very complex issues today, it 
boils down to the most critical issue, which is making sure 
that the clinician or the public health official have the 
information in front of them that they need when they need it 
to make a critical decision.
    My rather unlikely involvement with health informatics came 
from moving to Milwaukee in the aftermath of two serious events 
there, the first in 1993, where a waterborne outbreak sickened 
more than 400,000 people at the same time with a severe 
diarrheal illness that killed more than 100. This was an 
illness that went unnoticed by the public health system for as 
many as 7 to 8 days after the increase in illness had begun, 
and an even longer period after environmental cues could have 
triggered public health awareness and response. The year before 
I arrived, the severe heat wave in 1995 was brought to public 
health attention not by hospitals, not by clients, but by the 
morgue and by the coroner's office.
    So my goal as health commissioner in the city of Milwaukee 
was to greatly shorten by any means necessary the period 
between an event and the earliest possible opportunity to 
engage in public health action, which obviously was sub-optimal 
at that time. We have gone a long ways. My staff has finally 
developed their diarrhea meter that can show me simultaneously 
the number of EMS runs, hospital visits, nursing home illness, 
laboratory requests that all relate to diarrheal disease. We 
have similar monitors for respiratory disease.
    Last year was a banner year for us in many years. First, 
looking at the top-down model, when CDC asked the healthcare 
community to start surveilling for SARS, within 72 hours we had 
all the emergency rooms in the community using a standardized 
screening form that alerted them to possible SARS in the 
community. They were also able to electronically report to us 
once a day, the volumes of SARS-like symptoms that they saw. 
Because of the Internet and interlocking health applications 
that were in use in more than two dozen cities across the 
country, three other cities adopted the same system, this was a 
local-to-local cooperative effort, and were able to initiate 
SARS surveillance near realtime in our communities.
    On the other hand, from the bottom-up perspective, when we 
found one individual who had kind of a strange illness and had 
been in contact with a sick prairie dog, this was the second 
case, this was the case that tipped the balance, that caused us 
to begin investigating what ended up being the hemisphere's 
first outbreak of monkeypox, a virus that, if I studied it in 
medical school, I surely forgot about. We had one opportunity 
to make sure that this virus did not become established in the 
domestic and wild animals of our community, so our cats were 
not bringing it in into our homes on a regular basis. Local 
public health and the city of Milwaukee had to manage 30 
patients on an urgent basis, 90 contacts, hundreds of animals 
in a data nightmare. Our goal, of course, was to isolate, to 
quarantine, to act, to contain. It was done successfully. This 
outbreak ended up involving 11 States and overseas, but it 
certainly gave rise to our understanding that we really need to 
share health information rather than just push it around.
    This raises two important points: one, NACCHO fully 
endorses the President's vision of a rapid ascension to 
electronic medical records and national health informatics 
infrastructure. We strongly support the efforts at HHS of Dr. 
Brailer; two, you cannot underestimate the importance of this 
project to local public health, and I need to warn you that 
local public health is not in a great position to fully avail 
themselves of the benefit of this new opportunity.
    Dr. Gingrich raised the example of ``what if CDC, through 
its automated data gathering systems, learned about 39 SARS-
like patients?'' Then it becomes incumbent on the local health 
officer, wherever that outbreak may be occurring, to identify 
those patients, not just to know that they are there, but to 
interview them, to quarantine them, to identify their contacts, 
to send laboratory tests, to bill for those laboratory tests, 
to quarantine contacts; a very huge labor-intensive process of 
work. What you need to understand is that the local health 
departments of this country are the eyes and ears and hands and 
feet of public health, not the Centers for Disease Control. CDC 
is critical, very important, but the actual success of our 
outcome will not be because CDC knows something is going on, 
but because the local public health foot soldier on the ground 
has the capacity to respond immediately, confidently, with 
excellent health information.
    That leads me to our recommendations. I will make one 
point. The point was made by Dr. Broome that Federal funding 
had gone far to bring what had once been fewer than half of the 
Nation's local health officials online with rapid Internet 
access and email. That was because Congress mandated that 
bioterrorism funds go to that purpose, that 85 percent of a 
particular fund line go to local public health infrastructure 
to make sure that they can participate in the electronic 
revolution in health. We think that kind of effort needs to 
continue. Unfortunately, the 2005 request of the President, has 
actually taken money from local and State preparedness to spend 
on the BioSense initiative. The BioSense initiative is a great 
experiment in syndromic surveillance, but we can't be robbing 
the local Peter to pay the national Paul, because when it comes 
to actually doing the work of fighting an outbreak, in the end 
we will lose.
    My written testimony includes seven very specific 
recommendations: To make sure that we have real access to real 
health information. The first and perhaps most important of 
these, is the measure we use to know if this system is really 
going to make a difference. That measure needs to be that the 
local partners on the ground demonstrate that they can exchange 
information electronically. If that measure is not established 
at the national level, tracked at the national level, then we 
could be building castles in the sky and leaving the local 
partners out of the loop; and I suggest strongly that the 
Federal policy not make that mistake.
    Thank you.
    [The prepared statement of Dr. Foldy follows:]
    [GRAPHIC] [TIFF OMITTED] 98120.081
    
    [GRAPHIC] [TIFF OMITTED] 98120.082
    
    [GRAPHIC] [TIFF OMITTED] 98120.083
    
    [GRAPHIC] [TIFF OMITTED] 98120.084
    
    [GRAPHIC] [TIFF OMITTED] 98120.085
    
    [GRAPHIC] [TIFF OMITTED] 98120.086
    
    Mr. Putnam. Thank you.
    Our next witness is Dr. Richard Weisman. Dr. Weisman is an 
associate professor of pediatrics at the University of Miami 
School of Medicine at Jackson Memorial Hospital and the 
director of the Florida Poison Information Center in Miami. Dr. 
Weisman received his undergraduate training in pharmacy at 
Temple University and his doctorate in clinical pharmacy from 
Duquesne University. He is board certified in toxicology and a 
fellow of the American Academy of Clinical Toxicology. Dr. 
Weisman serves as the Medical Information Office for south 
Florida's Metropolitan Medical Response System, a member of the 
Terrorism Advisory Task Force, and as a toxicologist/
pharmacologist with the Department of Homeland Security, FEMA, 
Disaster Medical Assistance Team, and the International Medical 
Surgical Emergency Response Team.
    Welcome to the subcommittee. You are recognized for 5 
minutes.
    Mr. Weisman. Thank you very much, Mr. Chairman, members of 
the subcommittee. My name is Dr. Richard Weisman. I am director 
of both the Hospital Terrorism Response and the Florida Poison 
Information Center in Miami.
    Jackson Memorial Hospital is the largest public hospital 
and a safety net in Florida. With over 1,500 beds, Jackson 
Memorial provides the highest level of care to an inner city 
culturally diverse population. The Florida Poison Information 
Center in Miami provides service to a population of 5 million 
people and has 63 hospitals within its region. Jackson Memorial 
Hospital is the largest hospital within the Poison Center's 
region.
    I would like to describe the experience we had at the 
epicenter of the anthrax attack in Florida and to highlight the 
problems that could be prevented with enhanced information 
technologies at our Nation's hospitals and poison control 
centers.
    On the morning of Thursday, October 4, 2001, Steven Wiersma 
the Florida State Epidemiologist, released to the public that 
the State laboratory had confirmed that a patient, Robert 
Stevens, at JFK Hospital in Palm Beach County, had inhalation 
anthrax. This was followed by a press conference in which the 
Florida commissioner of health and State epidemiologist 
announced that the public should not be concerned, that anthrax 
was a naturally occurring disease, and that this could not 
possibly be a terrorism event.
    It is important to set the stage of the public's mind-set 
on this date. Most notably it was occurring in the shadow of 
September 11, where virtually every television and radio 
station was still on a 24-hour post-September 11 frenzy. What 
may not have been evident to the rest of the country is that 
the infectious disease physician at JFK made the diagnosis 
because that week the local news had reported that two of the 
September 11 hijackers had attempted to rent a crop-duster at 
nearby Lantana Airport. When the inhalation anthrax story went 
front page, the media immediately connected the dots and 
concluded that it was terrorism and supported their hypothesis 
with the CDC data that there were only 18 inhalation cases in 
the past 100 years, the last occurring in 1978.
    It was too coincidental in the wake of the Lantana Airport 
story. The commissioner of health kept insisting that this was 
an isolated occurrence and a rare disease, until 4 days later, 
when a second patient was identified in south Florida. The 
public became very confused, very angry, and lost confidence in 
our government's response to the crisis.
    I first learned about the anthrax case in the emergency 
department at Jackson Memorial Hospital, when a patient who had 
been watching the press conference on television in the waiting 
room came in and asked me what I thought of anthrax. I thought 
he was talking about the 1990's rock group. In the emergency 
department, we are very disconnected from the world and need a 
new way of being kept up to date while actively seeing 
patients. Most emergency departments in the United States have 
telephones, fax machines, and receive electrocardiograms from 
the field from paramedics. We truly are well into the 1970's. 
We have a computer terminal that links us to the hospital's 
data base that allows us to look up some lab data, if it had 
been entered, but it really doesn't allow us to receive e-mails 
or to access the Web, because that would be a violation of 
security, and certainly someone is sitting there waiting to 
hack into our data system.
    On Friday, October 5th, the Poison Center received about 
calls related to anthrax. Approximately 50 were from coworkers 
at the American Media International, or AMI, building who had 
direct contact with Mr. Stevens, half were from the emergency 
department physicians in search of recommendations for patients 
requesting prescriptions for cipro, and the remainder were from 
the media in search of additional information about anthrax. 
Thirty-six hours after the initial press conference, the Poison 
Center finally received a fax sheet from the CDC discussing 
anthrax and providing much needed guidelines to treat only 
patients that had been in the AMI building for at least 1 hour 
within the last 3 months. Not knowing if this valuable fax 
sheet was going to get to our emergency department physicians, 
we faxed the document to every emergency department in our 
catchment area. We subsequently learned that only half of the 
hospitals ever received it from CDC, and only 10 percent got it 
at the total end from the Poison Control Center.
    On Monday, October 7th, all hell broke loose. The emergency 
department at Jackson Memorial saw an additional 65 patients. 
Many hospitals in the area also had a dramatically increased 
census. The Poison Center went from receiving about 300 calls a 
day to over 300 calls per hour. The actual number of calls that 
the Poison Control Center received we will probably never know 
because the automatic call tracking system kind of stopped at 
about 4,000 calls, and that was reached sometime by about 2 in 
the afternoon. By afternoon, the Poison Center abandoned trying 
to record the cases because the phones were ringing so quickly, 
and people that had real poisonings could not get through on 
the standard number. An additional four poison information 
specialists were brought in, and all of the rotating medical 
students, pharmacy students, and medical residents were asked 
to help with the telephone.
    When an additional staff person arrived with a newspaper, 
we learned for the first time what had happened. The headline 
stated that the anthrax spores had been found by the CDC in the 
AMI building. Later that day information were released that 
spores had also been found in the nasal swab of another AMI 
worker. Rumor also began to circulate that a second patient, 
also from AMI, was being investigated as a second victim in a 
Miami hospital. By day's end, his identity was known, Mr. 
Ernesto Blanco. He was at Cedars Medical Center, immediately 
across the street from where we were located, and he was Mr. 
Stevens' boss in the mailroom at AMI. They had received a 
threatening letter containing a white powder. The media was now 
announcing that this was another terrorism attack and that 
anthrax had been sent through the mail. Before it was over, 
hazardous materials response teams had to respond to 15,000 
false calls for white powders. Nationwide, it exceeded over 
65,000.
    The call volume at the Poison Center and the patient volume 
in the emergency department continued to be out of control for 
about 7 days, finally returning to some level of normality 
about October 14th. The contacts were primarily occurring 
between the hours of 8 a.m. and 9 p.m., and on October 13th the 
Florida Department of Health began to refer all of their calls 
into the Poison Control Center. The normality was very short-
lived. On about October 16th letters arrived at CBS, ABC, the 
New York Post in New York, and the Hart Office Senate Office 
Building here in Washington. The high profile exposure stood in 
stark contrast to the death and illness of the less well-known 
postal workers. Anthrax was killing the common man. The barrage 
of calls would continue through October to just before 
Thanksgiving. The calls now began to be mixed with inquiries 
about adverse reactions that were occurring with a high 
frequency of people and the over 5,000 that were not having to 
take cipro.
    We have a remarkable opportunity to improve patient care 
through improved communication strategies and e-technology. An 
investment at the healthcare delivery will allow us to be 
better prepared for an array of adverse events such as a SARS 
outbreak or any newly emerging infectious disease or chemical 
or nuclear event.
    I have four recommendations. There needs to be a secure 
means of communicating the most accurate, up-to-date 
information.
    Mr. Putnam. If I may, let me make that one of my first 
questions to you. I am worried about us getting caught by a 
vote, and I want everyone to have an opportunity to go. So if 
you would, just hold that thought and I will come back to that.
    Mr. Weisman. OK.
    [The prepared statement of Mr. Weisman follows:]
    [GRAPHIC] [TIFF OMITTED] 98120.087
    
    [GRAPHIC] [TIFF OMITTED] 98120.088
    
    [GRAPHIC] [TIFF OMITTED] 98120.089
    
    [GRAPHIC] [TIFF OMITTED] 98120.090
    
    Mr. Putnam. Our third witness for this panel is Gordon 
Aoyagi.
    Mr. Aoyagi. Correct.
    Mr. Putnam. Did I say that right?
    Mr. Aoyagi. Yes, very well.
    Mr. Putnam. Mr. Aoyagi is the fire administrator for 
Montgomery County, MD. He directs the efforts of approximately 
950 career employees and 800 volunteers. Mr. Aoyagi also 
coordinates the fire and rescue services which are provided 
through 19 local volunteer departments. He serves as a disaster 
manager of the Emergency Management Group, responsible for 
emergency preparedness in response for Montgomery County. He is 
also Chair of the local Emergency Planning Council and 
commissioner on Maryland State Fire Prevention Commission. Mr. 
Aoyagi has over 30 years of public administration and public 
policy experience. He is a graduate of Colorado College, with a 
master's degree in public administration from the University of 
Colorado.
    Welcome to the subcommittee. You are recognized for 5 
minutes.
    Mr. Aoyagi. Thank you very much, Chairman Putnam. I 
appreciate the opportunity to provide the perspectives of a 
local government emergency manager on this topic.
    Slide 2 shows that Montgomery County is a growing suburb of 
the region, plays an important role, and is well practiced in 
responding to emergencies. Montgomery County has made 
significant investments in our public safety communication 
networks and our wireless data systems. Effective health 
informatics and other emergency response systems will depend 
upon robust, redundant, and reliable wireless data systems. We 
encourage continued congressional support for this technology. 
Push this technology down to local government; it is the battle 
front of our local communities where first responders confront 
the emerging terrorist threats, as well fulfill their daily 
mission of keeping our communities safe and saving lives.
    Technology infrastructure is a necessary element for health 
informatics, but is it sufficient? Ingredients for success 
include: planning, collaboration, and communications. And I 
would like to use Montgomery County as an example.
    Montgomery County has a disease surveillance system called 
ESSENCE II. Through the leadership of our Maryland 
congressional delegation, we received a 2002 Federal Byrne 
Grant, which was used to develop a test bed for a sophisticated 
disease surveillance system. ESSENCE II, described in slide 3, 
is the first system to integrate both the military and civilian 
indicators for disease surveillance. It uses traditional and 
non-traditional health indicators in syndromic groups, coupled 
with advanced analytical techniques. The Applied Physics Lab of 
Johns Hopkins University developed ESSENCE II in collaboration 
with the Department of Defense Global Emergent Infection 
Systems and other State and local partners.
    ESSENCE IV, which is our new generation, will in fact be 
installed throughout the region and Northern Virginia and the 
State of Maryland.
    Slide 4 shows the various sources used by ESSENCE II for 
biosurveillance. Among these sources are hospital laboratories, 
911 calls, over-the-counter drug purchases, etc. Other 
variables are also considered.
    Slide 5 shows the syndromic grouping used for analysis. 
Baseline data is projected and any unusual spikes are 
investigated. Any significant event allows us to detect, 
respond, and contain locally, regionally, and statewide.
    Slide 6 shows the application of ESSENCE II in predicting 
the recent influenza and the tracking of its incidents through 
that same disease surveillance system.
    Planning is also important. The Emergency Management Group 
established a bioterrorism task force to plan, discuss 
respective roles, and develop a unified command system for 
bioterrorism incidents. This framework served us well in the 
anthrax response in 2001. In planning for future events, we are 
provided pre-distribution biomedical packs to our first 
responders, and we continue to plan for SARS and other events.
    Collaboration is essential. We recognize that hospitals are 
key elements of our emergency response system and engage them 
in extensive collaboration efforts. Our five hospitals are on 
our 800 megahertz radio system. Administrators or doctors may 
talk to other hospitals, public health representatives, our 
emergency communication center, as well as the incident 
commander. We also share decontamination protocols. The county 
recently executed a Memorandum of Understanding with our five 
hospitals, National Institutes of Health, Navy Medical, and 
Kaiser Permanente to rapidly provide supplies, equipment, and 
credentialed medical personnel to maximize medical services 
during emergencies in the county and in the region.
    Lateral and horizontal communications are also required. 
Our public health division uses email and hot faxes to provide 
public health alerts to physicians and clinics. The RICCS 
system in this region provides notification to our regional 
policy leaders, healthcare providers, and Federal officials.
    In the State of Maryland we have what we call FRED, the 
Facilities Resource Emergency Data base, which provides state-
wide hospital capabilities, as well as a secure method of 
notification to hospitals throughout the State.
    In closing, I believe the prescriptions for success involve 
ongoing support for local governments to respond to 
emergencies; enabling the transfer of effective technologies to 
local governments; funding of robust, reliable, and redundant 
wireless technology to support healthcare and emergency medical 
providers; and, last, coordinated, collaborative, and 
integrated planning and response systems at the local, 
regional, State, and Federal levels.
    Thank you.
    [The prepared statement of Mr. Aoyagi follows:]
    [GRAPHIC] [TIFF OMITTED] 98120.091
    
    [GRAPHIC] [TIFF OMITTED] 98120.092
    
    [GRAPHIC] [TIFF OMITTED] 98120.093
    
    [GRAPHIC] [TIFF OMITTED] 98120.094
    
    [GRAPHIC] [TIFF OMITTED] 98120.095
    
    [GRAPHIC] [TIFF OMITTED] 98120.096
    
    [GRAPHIC] [TIFF OMITTED] 98120.097
    
    [GRAPHIC] [TIFF OMITTED] 98120.098
    
    [GRAPHIC] [TIFF OMITTED] 98120.099
    
    Mr. Putnam. Thank you very much.
    Dr. Weisman, why don't you wrap up the four recommendations 
that you had for us, now that we know we have time?
    Mr. Weisman. There needs to be a secure means of 
communicating the most accurate and up-to-date information to 
all of our hospitals, emergency departments, poison centers, 
pre-hospital care providers, private physicians' office, and 
health departments. Too often we are depending upon CNN and Fox 
News to be able to get ``accurate'' information. The word 
``accurate'' is certainly in quotation marks.
    At present, there is no effective means of getting 
lifesaving technical information to our Nation's front-line 
healthcare providers. That needs to change.
    Hospitals, poison centers, emergency medical services, and 
health departments in areas of the United States considered to 
be at risk for terrorism must be provided the resources to be 
able to manage a surge of affected patients. Information 
technologies will allow us to provide optimal care and to 
utilize our scarce resources most effectively; however, if our 
large inner city hospitals are at 105 percent occupancy and 
there are patients waiting in the emergency department, it is 
going to be very difficult for us to be able to accept a surge 
of patients, and our response to the catastrophe will be less 
than optimal.
    The Federal Government must make immediately available to 
the media, knowledgeable and informed experts. We witnessed 
experts' opinions on anthrax from retired microbiologists who 
were honored to give their very uninformed opinion and to add 
to the confusion and hysteria. A media campaign needs to occur 
in advance of the next crisis to educate the people about the 
investigation of a disease outbreak or terrorism event. They 
need to understand that events take time to investigate and 
that in the very beginning or very early hours the amount of 
information may be very limited, and that it will grow 
exponentially as the powers are brought to work on the 
particular crisis. But what they are doing right now is they 
announce the crisis and then try to fill the next 24 hours with 
media, and it basically whips the public into a mystical 
frenzy.
    This is something that we found to be absolutely contra to 
the grain of what we are trying to do and resulted in numerous 
patients coming into the emergency department that just didn't 
need to be there, and often them got there by ambulance, tying 
up very critical resources.
    Thank you very much for this opportunity.
    Mr. Putnam. Thank you.
    Considering the benefits--we have heard an awful lot about 
all the benefits of using better information technology for 
health informatics--why haven't we seen greater adoption of 
these benefits by providers and payors? Dr. Foldy.
    Dr. Foldy. I think many of the factors were alluded to in 
the last session. Whereas the cost of the information systems 
is in itself a barrier, I think the two larger barriers are 
uncertainty and the workflow and the recruitment of the work 
force into doing work in a different way. Certainly it was true 
in my department, as it is in the healthcare setting. The 
uncertainty relates to the fear everybody has in making an 
investment in the next great system that ends up not meeting 
the soon-to-be or later-to-be announced standards. 
Standardization is a requirement, giving both the informatics 
industry, the healthcare industry, and even the little public 
health department the confidence to go ahead and invest.
    I have to tell you that many of the steps that we took that 
involved information management are still manual, because the 
standards were not quite yet ready, and I could not really move 
forward knowing that what is going to be for us a fairly long 
legacy of hardware and software. Because of the small amount of 
dollars available in local public health, I need to make sure 
it is going to work and integrate right the first time.
    Finally, revolutionizing the flow of information from paper 
to electronic interface devices is going to require changes in 
the work of a large number of healthcare professionals, and 
that will be a difficult task. Very worthwhile, however.
    Mr. Putnam. Anyone else wish to take a crack at that? Yes, 
sir.
    Mr. Aoyagi. I certainly can't speak from the patient 
perspective, because my perspective is really one of a local 
emergency manager. And I can say that as I talk to colleagues 
across the country, as Dr. Gingrich referred to, there are a 
number of silos out there, and emergency management has a silo, 
health and human services has a silo, public health has a silo. 
I think what is emerging at your local government level are 
very strong efforts to break those silos down and to work in a 
more collaborative way; but it isn't easy. There are a number 
of turf issues, and it really comes down to focusing on 
delivery of service to the citizens, making sure they are safe, 
and leveraging of resources in the most effective way.
    I think Federal leadership is important. It was important, 
when the Pentagon occurred, for the general to stand before all 
his troops and say the first responder is the incident 
commander. And I think as a result of that statement all the 
local resources that were available at that time were 
seamlessly inserted to that response. If we were to encounter a 
major bioterrorism event, and say the impact is local, if we 
suddenly had a Federal official announce that they were in 
charge, you would find mass confusion at the local level trying 
to determine do we wait or do we move. And I would just 
encourage that we all embrace the national incident management 
system and acknowledge the role of local government in 
responding first to the incident and then receiving the support 
of the State and Federal Government upon declarations of 
emergencies.
    Mr. Putnam. Does the current homeland security structure 
reinforce what you just said?
    Mr. Aoyagi. Yes, it does, both that and the announcement of 
the President with regard to the national incident management 
system reinforces a structured incident command system that 
acknowledges and recognizes the role of unified command at the 
local level.
    Mr. Putnam. Dr. Weisman, did you want to add anything on 
why more people haven't adopted these standards practices?
    Mr. Weisman. I think that the particular area that we are 
interested in looking at is a relatively easy one, and I am not 
sure why it hasn't been adopted. The CDC has an excellent 
communication system called Epi-x that allows the CDC to very 
rapidly communicate information out to 3,500 health 
departments, State health departments, local health 
departments. This type of same system needs to be brought down 
to probably populations of 3 or 4 million and allow that same 
technology to be transferred in so that we can link all of the 
hospital physicians that will be caring for patients, all the 
infectious disease physicians, all the hospital emergency 
departments, so that instantly, when a problem is identified, 
they can begin to know that they have to change the way that 
they are practicing. Very similar to the way Epi-x works, I 
envision them being referred to a Web site, which they would 
then be able to log into with their secure certificate and be 
able to identify the information that they need to provide care 
to the patients. And this would be standardized because it 
would be coming from the highest authority, the most 
knowledgeable people.
    The second thing is that I envision on the same Web site 
the possibility of being able to log in and to record patient 
information for patients that have similar symptoms that would 
have been detected under syndromic surveillance that are now 
being seen in that area, and that this data would then 
immediately become available to the local, State, and 
eventually the CDC to manage.
    These are all very simple things that only require pushing 
out this Epi-x package that has been so well developed by CDC 
to a more local area, because currently the CDC system is 
limited with the fact that you can't send out a page, a 
telephone call, a call to home and a call to work to a billion 
different physicians across the country with all of those means 
of communication. What you need to do is to bring it down to 
one or two or three of these units existing for every 10 or 15 
million population, and you would be able to effectively 
communicate the most accurate information down to the 
clinician, and we can turn Fox News off.
    Mr. Putnam. There are some concerns that biosurveillance 
initiative data bypass State and local officials, and that it 
will have the effect of making the response more difficult. 
Traditionally, as you know, public health data has flowed up, 
but with the BI, some data, especially commercial data, may go 
straight to the feds. Do you think that there are safeguards in 
place to rapidly communicate the findings back to you, when 
that is essentially the reverse direction?
    Dr. Foldy. If information is going to travel at the speed 
of electrons, it doesn't necessary matter where it goes first, 
so long as all the good rich information reaches the local 
actor extremely promptly. It would not do me a great deal of 
good to be told that there is a hypothetical problem, there is 
a problem of unknown significance occurring in my area, but, 
unfortunately, we can't provide you with the names of the 
individuals affected, where they were seen, or where they live. 
I would be left with an alarm without clear action.
    I see no reason, in the long-run, why information from such 
national data bases cannot travel through the CDC to the local 
health officer including these important personal identifier 
information types to which local health officers are authorized 
to have access in fighting infections. But until that part of 
the link is built, BioSense by itself comes nowhere close to a 
meaningful surveillance system that will actually generate 
action.
    What this means, practically speaking, is although Web-type 
interfaces can do a lot of work for us, the real name of the 
game here is the ability to exchange electronic messages that 
give each of our agencies the information they need. Those 
messages obviously need to be kept secure and confidential, 
they need to reach only the type of official authorized to get 
them. But ultimately, ideally, patient information flows in a 
secure fashion from the point at which healthcare is being 
produced to the point at which it needs to be acted on by the 
local public health authority.
    I just say the backward corollary is also the same There is 
no way I am going to recruit all of the physicians of the world 
to come to my great public health Web site; they are too busy 
doing work. What would be an ideal is that the physician, in 
their practice is busy doing work and receove an alert from me, 
the local health officer, saying be aware there are two cases 
of whooping cough in our community. If you see somebody 
coughing, you should think about it. That image literally can 
pop up on the screen as they are doing work in their own 
healthcare application, because my application has messaged 
their application. This, rather than wishing that everyone was 
going to check my Web site every 8 hours.
    So, as you can see, we are all likely to continue using the 
applications to which our systems are wedded, just like we 
continue to live on the residential streets in which we have 
always lived. What we need is the freeway system whereby we can 
get from a residential system in Milwaukee to a residential 
street in Washington in short order, and that is what I think 
Dr. Gingrich was talking about, the ability to send information 
out to our existing legacy systems.
    Mr. Putnam. Dr. Weisman, have the poison control centers 
been asked to submit information through the BI?
    Mr. Weisman. We are one of the data sources that are 
currently being considered for BioSense and a couple of the 
other programs. The poison centers nationally have a realtime 
data surveillance. We standardized all the definitions about 12 
years ago, and all of the data is collected and analyzed and 
mined by the American Association of Poison Centers and CDC at 
10-minute intervals, and they are looking for some of the early 
markers that would indicate either biological, chemical, or 
nuclear events; and that is available in all 50 States, so it 
is a good system at the present time.
    Mr. Putnam. You received the HANs?
    Mr. Weisman. Excuse me?
    Mr. Putnam. The health alerts?
    Mr. Weisman. That gets as far as the health department and 
the county health department. That, I do not get. I was able to 
get Epi-x as a poison center director. I was very surprised. I 
share the information that I get with our hospital 
epidemiologist, who then also applied and was actually turned 
down to get on it. You see a person like that who is at a major 
point, and it is unfortunate because it is limited by the size 
of the system and how many users can be hooked into it. So that 
certainly that type of thing ought to change as we try to 
improve the flow of information.
    Mr. Putnam. Well, those were the vote bills going off, so 
we are going to need to bring this in for a landing. Very 
quickly, any final comments? Mr. Aoyagi.
    Mr. Aoyagi. Well, I just want to re-emphasize and thank the 
committee chair for holding this hearing and to underscore the 
role of local governments in responding to major emergencies, 
and that we are a partner to both State and Federal agencies. 
We need the information at our level. We shouldn't be preempted 
from using that information in order to respond, and we hope 
that the promise of health informatics makes the services that 
we deliver more effective and more efficient.
    Mr. Putnam. Thank you.
    Dr. Weisman.
    Mr. Weisman. Final comment is that if I had to summarize 
into one sentence, we need desperately to get a very effective 
bi-directional flow of information in and out of hospitals. To 
date, it only is going to the level of the county health 
department, and then the communication seems to break down. So 
that I think that the next major step is to get it out to the 
level of the person actually taking care of the patient.
    Thank you.
    Mr. Putnam. Dr. Foldy.
    Dr. Foldy. In a way echoing the remarks of the other two 
speakers, information travels when there is trust, and then 
when there is a system. In Milwaukee we use systems that other 
people had already built for their own use, such as the EM 
system secure Internet. So we could take the information from 
CDC and push it out to emergency rooms. We weren't able to do 
that for doctors in their clinics because no such system or no 
such relationship existed. But I think that the national health 
infrastructure vision is likely to grow because local 
communities and all of the players in those communities get 
together and agree to share information the way Mr. Aoyagi says 
is what is happening in Montgomery County. Regional health 
information infrastructures will be built that have to learn 
all the hard lessons about how and when to communicate what 
types of materials, and to overcome the medical, legal, and 
other barriers.
    At the same time, the Federal Government needs to play a 
critical role by really pushing standardization, using its 
purchasing power to encourage standardization, focusing 
resources on the efforts of these regional collaborations, and 
as lessons are learned at the regional level, to make them 
available to all of those nationwide who want to build the same 
kind of infrastructure.
    Thank you.
    Mr. Putnam. Thank you. Thank you all very much. We 
appreciate all of the input and testimony that all of our 
witnesses have provided. This was the subcommittee's first 
opportunity to explore the consolidated health informatics e-
government initiative and the current state of IT and 
information sharing in the healthcare industry. As we have 
seen, all the players in the game agree it is time to bring 
healthcare forward into the information technology era, and we 
have also seen that the crux of the task is the development and 
widespread use of standards and the collection and transmission 
of data. Without these standards, all the diligence in the 
world in collecting the data and all the newest technology for 
storing and transmitting that data will be worthless unless the 
information that is collected is interoperable. If we can 
achieve this, we will not only make great strides in improving 
the delivery of healthcare, but also in improving the 
coordination among private healthcare providers, public health 
officials, and emergency responders in the event of a 
biological emergency, be it terror-related or a natural 
disaster. In either case, improved communication and 
coordination are vital to lead to quicker identification, 
containment, and response, and in these cases time saves lives.
    I want to thank everyone for their participation and staff 
for their hard work inputting this together. And, with that, 
the subcommittee stands adjourned.
    [Whereupon, at 5 p.m., the subcommittee was adjourned, to 
reconvene at the call of the Chair.]
    [Additional information submitted for the hearing record 
follows:]
[GRAPHIC] [TIFF OMITTED] 98120.100

[GRAPHIC] [TIFF OMITTED] 98120.101

[GRAPHIC] [TIFF OMITTED] 98120.102

[GRAPHIC] [TIFF OMITTED] 98120.103

[GRAPHIC] [TIFF OMITTED] 98120.104

[GRAPHIC] [TIFF OMITTED] 98120.105

[GRAPHIC] [TIFF OMITTED] 98120.106

[GRAPHIC] [TIFF OMITTED] 98120.107

[GRAPHIC] [TIFF OMITTED] 98120.108

[GRAPHIC] [TIFF OMITTED] 98120.109

                                 
