[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;
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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?
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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:]
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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:]
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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:]
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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:]
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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.
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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:]
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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:]
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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:]
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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:]
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