[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]
CAN SMALL HEALTHCARE GROUPS FEASIBLY ADOPT ELECTRONIC MEDICAL
RECORDS TECHNOLOGY?
=======================================================================
HEARING
before the
SUBCOMMITTEE ON REGULATORY REFORM AND OVERSIGHT
of the
COMMITTEE ON SMALL BUSINESS
HOUSE OF REPRESENTATIVES
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
__________
WASHINGTON, DC, APRIL 6, 2006
__________
Serial No. 109-47
__________
Printed for the use of the Committee on Small Business
Available via the World Wide Web: http://www.access.gpo.gov/congress/
house
_____
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COMMITTEE ON SMALL BUSINESS
DONALD A. MANZULLO, Illinois, Chairman
ROSCOE BARTLETT, Maryland, Vice NYDIA VELAZQUEZ, New York
Chairman JUANITA MILLENDER-McDONALD,
SUE KELLY, New York California
STEVE CHABOT, Ohio TOM UDALL, New Mexico
SAM GRAVES, Missouri DANIEL LIPINSKI, Illinois
TODD AKIN, Missouri ENI FALEOMAVAEGA, American Samoa
BILL SHUSTER, Pennsylvania DONNA CHRISTENSEN, Virgin Islands
MARILYN MUSGRAVE, Colorado DANNY DAVIS, Illinois
JEB BRADLEY, New Hampshire ED CASE, Hawaii
STEVE KING, Iowa MADELEINE BORDALLO, Guam
THADDEUS McCOTTER, Michigan RAUL GRIJALVA, Arizona
RIC KELLER, Florida MICHAEL MICHAUD, Maine
TED POE, Texas LINDA SANCHEZ, California
MICHAEL SODREL, Indiana JOHN BARROW, Georgia
JEFF FORTENBERRY, Nebraska MELISSA BEAN, Illinois
MICHAEL FITZPATRICK, Pennsylvania GWEN MOORE, Wisconsin
LYNN WESTMORELAND, Georgia
LOUIE GOHMERT, Texas
J. Matthew Szymanski, Chief of Staff
Phil Eskeland, Deputy Chief of Staff/Policy Director
Michael Day, Minority Staff Director
SUBCOMMITTEE ON REGULATORY REFORM AND OVERSIGHT
W. TODD AKIN, Missouri Chairman MADELEINE BORDALLO, Guam
MICHAEL SODREL, Indiana ENI F. H. FALEOMAVAEGA, American
LYNN WESTMORELAND, Georgia Samoa
LOUIE GOHMERT, Texas DONNA CHRISTENSEN, Virgin Islands
SUE KELLY, New York ED CASE, Hawaii
STEVE KING, Iowa LINDA SANCHEZ, California
TED POE, Texas GWEN MOORE, Wisconsin
Christopher Szymanski, Professional Staff
(ii)
C O N T E N T S
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Witnesses
Page
Magruder, Ms. Joan, Vice President of Development and Planning,
BJC Healthcare................................................. 2
Normile, Dr. Christopher, Medicinae Doctor (Doctor of Medicine).. 4
Price, Mr. Jack, Vice President, Services, HIMSS Analytics....... 6
Gingrey, The Honorable Phil (GA-11), Congressman, U.S. House of
Representatives................................................ 14
Appendix
Opening statements:
Akin, Hon. W. Todd........................................... 20
Prepared statements:
Magruder, Ms. Joan, Vice President of Development and
Planning, BJC Healthcare................................... 22
Normile, Dr. Christopher, Medicinae Doctor (Doctor of
Medicine).................................................. 25
Price, Mr. Jack, Vice President, Services, HIMSS Analytics... 30
Gingrey, The Honorable Phil (GA-11), Congressman, U.S. House
of Representatives......................................... 37
Additional Material:
Kasoff, Ms. Barbara, Women Impacting Public Policy........... 52
Barnes, Mr. Justin, Greenway Medical Technologies............ 59
(iii)
CAN SMALL HEALTHCARE GROUPS FEASIBLY ADOPT ELECTRONIC MEDICAL RECORDS
TECHNOLOGY?
----------
THURSDAY, APRIL 6, 2006
House of Representatives
Subcommittee on Regulatory Reform and Oversight
Committee on Small Business
Washington, DC
The Subcommittee met, pursuant to call, at 2:00 p.m., in
Room 2360 of the Rayburn House Office Building, Hon. W. Todd
Akin [Chairman of the Subcommittee] presiding.
Present: Representatives Akin, Sodrel.
Chairman Akin. The Subcommittee will come to order. The
Ranking Member is trapped in another committee hearing, which
is not surprising. We usually schedule about two or three in
the same time period for anybody in any committee. So she gave
us permission to go ahead and proceed with the hearing. She may
join us a little bit later.
I have a prepared opening statement here.
First of all, I have already said this, but to everybody
good afternoon. Welcome to today's hearing. It's entitled ``Can
Small Healthcare Groups Feasibly Adopt Electronic Medical
Records Technology.''
I especially want to thank those of you who have traveled
here from some distance. Two of our witnesses are from the
congressional district that I am proud to represent. And so we
are delighted particularly to have those of you who have made
the trek up from the St. Louis area, we appreciate that.
In my role as Congressman and Chairman of this Subcommittee
I have had the opportunity to interact with many businesses in
just about every industry. I talk to business owners and CEOs
about the many challenges they face, both domestically and
abroad and time and time again they state that the rising cost
of health care is crippling their firms.
Because many small businesses operate in slim margins, any
increase in costs can turn a profitable business into an
unprofitable one. The rising cost of health care is an
important issue and there are many different voices in the
public square advocating different approaches to offset these
rising costs. Today this Subcommittee will focus on the
electronic benefits derived through the adoption of
technological processes. Is the adoption of electronic medical
records technology feasible for small businesses, specifically
small doctors' practices? We also hope to determine the
challenges these small groups face in adopting such technology.
There is little doubt that the adoption of electronic
medical records can play an important role in increasing
efficiency, reducing paperwork and redundancy and more
importantly, reducing medical errors.
According to the Department of Health and Human Services it
is estimated that the introduction of health information
technology can reduce healthcare costs by up to 20 percent per
year. The Bush Administration has stated the importance has
stated the importance of implementing electronic healthcare
systems, and made it a priority.
That said, doctors have increasingly faced higher liability
costs, potential cuts in Medicare physician payments, and
additional regulatory burdens resulting in a question as to
whether smaller practices can afford to adopt this innovative
technology.
I look forward to hearing the testimony of the witnesses to
learn more about whether small practices can adopt this
technology.
And because our Ranking Member is not here, I am not going
to yield to her, but we will proceed immediately to our witness
list. I have a very bad reputation in this Committee to keeping
people on time in terms in making their statements. That way we
get out on time, too. So the way we are going to do things will
be I am going to take a five minute statement from each of you.
Usually when there is other Committee members we save our
questions until you get done with making your statements. Now
my recommendation is that you can submit a more extensive
written response which we will accept as part of the record.
And so my recommendation because you have just five minutes, it
is maybe almost better just to put your notes aside and just
say the two or three things that you really want the Congress
to be hearing about what you have to say on this subject. But
if you feel a little bit more psyched out than that and you
want to just read some of your notes, you can do that. But my
advice is maybe just say hey this is what I think about the
subject.
So with that we'll start with our opening witness. Oh, they
are trying to trick me here. They have got Jack first. I go by
the order coming across. So we are going to start with Joan, is
it Magruder?
[Chairman Akin's opening statement may be found in the
appendix.]
Ms. Magruder. Magruder, yes.
Chairman Akin.
Joan, five minutes please.
STATEMENT OF JOAN MAGRUDER, BJC HEALTHCARE
Ms. Magruder. Thank you. Thank you, Mr. Chairman and
Members of the Committee.
My name is Joan Magruder, and I am pleased to be here today
really to talk about a very innovative way we at BJC Healthcare
are approaching the introduction of the electronic medical
record.
We recognize, as you said in your opening remarks, that
technology has an incredible ability to transform and improve
healthcare delivery and have a significant impact on the cost
effectiveness of what we do. We also recognize that the timing
of this is incredibility pivotal on, as the opening remarks
confirmed, our physicians today are in a circumstance where as
a small business, in and of themselves, the margins are slim
and eroding. And in light of the malpractice issues and clearly
the rising cost of healthcare, they really have two very
pivotal role with the electronic medical record. One is as a
self-employed business themselves is that the cost of labor and
benefits of their own employees who is integral to them and,
second of all is obviously providers. They ultimately are the
enablers of this electronic medical record capability.
First just a couple of comments about a context for our
circumstance. BJC Healthcare, as you may know, is headquartered
in St. Louis. We have about 13 hospitals, about $2.5 billion of
revenue. For purposes of the electronic medical record the
important aspect is that we have a very diverse geography, a
very diverse patient population and we have an opportunity to
serve a few rural markets as well as suburban and urban.
Our goal ultimately clearly is to be a national leader on
both patient advocacy, medical research and financial
efficiency.
Today, really, I come to you representing one of my
responsibilities which is our BJC Medical Group. We have a
couple hundred physicians that we employ through our
organization in about a 225 mile radius. All of these
physicians are in small office settings, generally three to
four person situations. And we are working as we speak to roll
out the electronic medical record to these physician offices.
It will represent about 300,000 patients that we will be able
to cover during this time. Almost 20 percent of those are in
the rural markets. These patients really represent a cross
section of subspecialties. Most or about two-thirds of our
providers are primary care, but we really cross the entire
specialty aspect.
BJC has committed to a $8 million investment in the
electronic medical record across these 200 providers. And our
thinking is a couple of things.
One is that we will be able to set up this project to
provide connections to external as well as internal labs. So a
lot of the electronic medical records you hear about today are
actually in self-contained private offices. And one of the
things that we feel responsible to do is to take that precedent
and extrapolate it to interface it with the hospital
connectivity. And so we have actually moved ahead choosing a
product that is very centric to the physician office setting
and we are going to support, underwrite if you will, the
interfaces back to our emergency departments, our hospitals,
etcetera.
The benefit of that, obviously, from the perspective of the
universal patient record is clearly to get the continuity of
care not just outside the hospital, but all the way through to
home care, post discharge, etcetera.
In addition, we recognize there is a lot of unnecessary are
being provided. There is a lot of avoidable emergency
department visits, readmissions for circumstances where
patients are put on contraindicated medications, and obviously
that's a function of the fragmented healthcare system that we
have today.
So the ability to really roll this out across our 13
hospitals enables us to advance what many of you have heard
about, with is the shared records capability. You have heard of
a portal, you have heard of sort of a regional health network
at times. And this shared records capability allows us across
these 13 hospitals to in fact for about 30 percent of the
patients in our market, understand the entirety of care that
has been provided and understand what really would have been
the ideal patient care system.
In addition, we feel strongly as was indicated as well
about this interoperability issue. The concept of requiring the
vendors to really have a product that really can transcend from
one to another.
Our vision ultimately is to take this prototype and create
a community health portal that will allow multiple provides to
access medical records and allow patients to view their medical
records. We think that having records through the internet
will, obviously, be very advantageous and promote from the
perspective of education, advice, etcetera.
In closing, we would say that BJC Healthcare is committed
to the successful introduction of the electronic medical
record. Our hope is that this will catalyze a regional health
wide practice. As we move forward today in our conversations,
we are anxious to talk about some of the obstacles from a cost
and an implementation perspective which will enable the
proliferation to occur.
Thank you.
[Ms. Magruder's testimony may be found in the appendix.]
Chairman Akin. Thank you very much, Joan. And right on the
five minutes. Appreciate that and your perspective and looking
forward to asking some questions.
Next we are going to go to Dr. Christopher Normile. And you
are the doctor of medicine from St. Charles, Missouri, which is
also part of my district. Good.
Would you please proceed?
STATEMENT OF DR. CHRISTOPHER NORMILE, AMERICAN ACADEMY OF
FAMILY PHYSICIANS
Dr. Normile. Mr. Chairman, fellow AAFP member
Representative Christensen, and Members of the Subcommittee,
thank you for the opportunity to provide testimony today.
Chairman Akin. Could you get that mike and just sort of
slide up a little closer there.
Do you go by Christopher or Chris or--
Dr. Normile. Chris will be fine.
Chairman Akin. Chris. Okay. Thank you.
Dr. Normile. I am a partner in a two physician practice in
St. Charles, there are only two of us. We are independent, we
are a small business. I am also a member of the American
Academy of Family Physicians, one of the largest national
medical organizations with more than 94,000 members.
Chairman Akin. You are still dropping off. Could you pull
that mike even a little closer there.
Dr. Normile. Your Subcommittee's concern for physicians
practices is well placed. We are small businesses with a
significant impact economically on our communities. Family
physicians and AAFP have been in the vanguard in promoting
electronic health records and they have provided information
that has supported 30 percent of family physicians adopting EHR
so far.
My job I think today was to give you my experience. And
some time ago, say, in '95 I had a palm pilot and it became
very apparent to me the power of these tools in improving
medical care for patients. I convinced my partner to purchase
an electronic health record, and we have been using it for two
years now.
Today on a typical day I will come in and electronically
synchronize my laptop and take information from home and work
that I have done at home and file it into our computer. I log
onto an internet connection with the local hospital, put up
that information on my hospitalized patients. I review labs,
phone messages, all sitting at my desk in just a few minutes.
My efficiency has improved in that regard.
After office hours I dictate notes through a voice
recognition software . I do not need to use transcriptionists.
They cost us thousands of dollars anymore.
In the near future we will communicating more and more with
patients through the internet. And this will be another expense
that we will have absorb.
Currently the time I set aside for electronic
communications with patients is not paid for by insurance
company or Medicare, even though it does improve care and
reduce the medical costs for the whole system.
The benefits for our office have been, you know, longer
stacks of papers. We have information our fingertips. Any
doctor who calls me I have information immediately at hand. The
same when patients call me, I have patient's immediately at
hand to discuss with them about their care.
It is much more easy to manage a diabetic or a chronic care
patient's care and to keep track of those results to improve
quality of their care.
The technology does not come cheap, though. We are fairly
typical among users of the electronic health record. Our
initial cost was about $50,000 and annually we spend about
$10,000 for software upgrades, hardware, etcetera.
Far more significant to the actual financial cost, this
tool has cost me a lot of time and effort. It is a very
complicated system. As those of you who hate setting the clock
on your VCR can only imagine the time and expense and time it
takes to organize and coordinate the medical records. We are a
complex office to start with and the computer makes it even
more complex. So we have learn this and develop it so that it
works for us.
Because of dwindling and third party reimbursements, which
in our market is dominated by a few powerful insurers, we have
found ourselves with progressively shrinking incomes.
Therefore, the system upkeep has landed in my hands. Computer
consultants charge about $150 an hour for their services.
Currently that is more than three times more my hourly income.
Five times more if you calculate the time and effort to put
into the electronic work records and with paperwork, phone
calls, etcetera. So I have to do all of the care of our
computers.
As these systems become more widely adopted, costs will
eventually decrease. But in order to accelerate adoption, the
AAFP recommends that Congress work to provide financial
incentives for small to medium size practices, and; (2)
establish federal standards of interoperability, and; (3)
support technical assistant programs to help small practices
through the cycle of selecting, implementing and redesigning
their work flow. We can use all the support we can.
Thank you.
[Dr. Normile's testimony may be found in the appendix.]
Chairman Akin. Thank you, Chris. You actually redeemed some
of your time there. You should get extra points for that. And
we appreciate your interesting testimony.
Now we have been joined by my very good from Indiana,
Congressman Mike Sodrel. We are just going to finish the
hearing from the witnesses and then we will have things open
for questions, Mike, in just a minute or so.
Our third witness, Mr. Jack Price is Vice President of
Service for HIMSS. Is that His Majesty's Secret Service or
something? Analytics from Melford, Delaware. Maybe that is not
exactly what it means, but we are glad to have you just the
same, Jack.
STATEMENT OF JACK PRICE, HEALTHCARE INFORMATION AND MANAGEMENT
SYSTEMS SOCIETY, HIMSS ANALYTICS.
Mr. Price. Well, thank you very much, Mr. Chairman and the
Ranking Minority Member Bordallo and distinguished members.
Thank you for allowing me to appear before this Subcommittee.
As Mr. Chairman stated, HIMSS is the Healthcare Information
and Management Systems Society and HIMSS Analytics is a
research arm associated with HIMSS.
My role is that I lead a lot of research projects, produce
surveys in order to routinely obtain data that is critical to
efforts to improve the quality and cost efficiency of patient
care.
One of these surveys that I'm currently working on right
now is we are interviewing 2500 physician offices across the
country. And of these 2500 offices we have found out that when
we ask them if they had practice management system, the answer
was always 100 percent yes. We asked them if they had an
electronic medical records system, we found out that only 26
percent of those offices answered yes.
And when we further drilled down and asked the other 70
some percent if they plan on purchasing one in the next two
years, the answer was no. So we are very interested in why they
did not want to purchase that EMR when all the evidence
suggests that on the contrary there are tremendous benefits and
return on invest from purchasing an electronic medical records
system.
And in healthcare we look at ROI two different ways; the
soft side which is more associated with looking at patient
safety factors, improved communication and the ability to
improve clinical processes. We also look at hard ROI, which is
really associated with things like reduction in material and
resource expense, improving patient flow, therefore increasing
revenue. And also improving billing improvements so you can
capture more revenue that way.
So, you know, when you look at hard ROI, when you look at
charts they can be seen on a clinic's computer and patient
encounters can be documented in a few mouse clicks. The flow of
patients through a clinical environment changes dramatically
and as a result, volumes of patients can be increased and then
also as a result of that, more revenue can be achieved.
EMRs also reduce the need for paper, and that is one of the
big pushes for EMR. So you eliminate that paper trail. And when
you do that you can also eliminate the number of transcribers
that are responsible for having to do the transcription. It can
be automated by the physician.
And so you can also reduce the amount of space that it
takes to actually store these tons of medical records that are
out there.
So there are many benefits along a hard ROI perspective.
And it also provides a very easy way to capture data that
normally could not be captured for billing and submitting it
electronically to the payors.
So from the standpoint of a small business practice, we see
many advantages from using EMRs. And so clinics have reported
doubling or even tripling their case loads with corresponding
jumps in revenue and with only marginal increases in staffing.
And at the same time many report that they more easily pass
regulatory audits than before.
And after EMR implementation practices see decreased
medical liabilities, they see more accurate and thorough
documentation, enhanced patient care and improved quality of
review.
Patients also no longer must wait to see a physician. And
so the patient satisfaction increases dramatically as well.
However, as the results of our recent survey pointed out,
many providers are still reluctant to invest in EMR technology.
And one reason may be the fear factor associated with these
enormous startup costs and the cost of the software, hardware,
implementation, training and support. And you also have to
realize that many physician practices do not have that support
staff that hospitals have when they implement EMR. So a lot of
it falls on the physicians, as we have heard in previous
testimony.
So the amount associated with implementation is a daunting
and can be a very disruptive task for a practice. And perhaps
one of the biggest barriers to overcome is really more of a
resistance to change itself.
But we see ambulatory care clinicians who have implemented
EMRs really have no shortage of advice for their colleagues.
And one of the things that we suggest is that these physicians
continue to be champions and offer a valuable experience,
hands-on experience to those physicians that really need to
grasp EMRs and move forwards. So for small healthcare groups
considering EMR, this is a very valuable resource and must be
tapped.
So with that I will say on behalf of HIMSS and HIMSS
Analytics thank you again, Mr. Chairman and Ranking Minority
Member Bordallo for the opportunity appear before this
Subcommittee.
Thank you.
[Mr. Price's testimony may be found in the appendix.]
Chairman Akin. Thank you very much. And also doing a great
job on time there for us.
The staff that put the hearing together because of the
nature of this Committee, focused a lot of it on small
business, which is appropriate, particularly the small business
of the smaller practices and things. I guess the two questions
that sort of jump out at me, and they are partly small business
related but partly just in general on these medical records, I
would like to toss them out to any of the three of you that
want to take a shot at either of these questions.
The first one it seems like, you know I used to work for
IBM. It seems like there is a technical question as to what
software you use and what sort of format that you use in
transmitting medical information. And I have heard there are
some different theories. One of them is stand back and wait
patiently for a couple of years until somebody in the
government comes up with an absolutely perfect way of doing it.
The other approach seems to be well you are waiting for the
government, you will wait forever. Maybe it is a better thing
just to let free enterprise take over and while there will be a
little bit of some fitful starts and maybe some competing
software, competing approaches, it may be a little harder to
get to some perfectly standardized approach, yet probably the
market will sort that out faster and more efficiently than
letting the government do it.
So if you have a thought on that, or any other thing that
relates to the problem of how do you format the information and
make it so that you can talk from a doctor's office to a
hospital to a hospital somewhere else where somebody is
vacationing, to get that record. And then the second question I
have we have got every since the days of AIDS became a
politically correct disease to protect and everything, we have
got some very, very strong laws regarding patient privacy. And
I am just wondering if that gets in the way also of
transmitting records. You know, Todd lives in St. Louis, works
in D.C., he is vacationing in Massachusetts and has some sort
of bad symptoms, goes into an emergency room or something. Can
Massachusetts pull up the records from St. Louis and
Washington, D.C., all at once the doctor is making a decision
with all of the data? And what are the questions in terms of
the legality of transmitting that information.
I just wanted to toss out, those are the two main things I
had. If you could just give me, anybody who wants to take a
shot at either of those it would be helpful.
Ms. Magruder. I guess I would comment on the question about
how much to allow to free enterprise versus government
interaction. You know, I think for us we have thought that the
ideal is sort of a hybrid of the two, a combination of sort of
a public and private partnership.
The idea behind BJC putting $8 million behind the
electronic medical record is all the earlier testimony about
the risk aversion of the physicians and the fact that it is not
time neutral. And, in fact, in the short term it is costly to
them in many ways. And so our piece of the investment was let
us get them over that hump and hold them accountable for none
of the one time costs, but only the in-office costs.
Now the reason that we thought that was important was your
other point, which is that our experience has been that the
electronic medical records that have been adopted are only in
freestanding independent office situations and feel to really
get at the cost effectiveness of care, needed the benefit of an
interface to the hospitals, the emergency departments,
etcetera. And so the public/private aspect is that we would
like to see a situation where people like ourselves seed large
sums of money and ideally can have a partial match from the
public sector to inscient that that proliferation really be
accelerated but with a clear understanding that it is not a
proprietary product, that it really can continue to move in an
interoperable fashion and proliferate in the community. And
that we can serve somewhat as a financing vehicle for the
physicians that maybe they have to pay back some of it over
time, but make that less onerous in the long run. So sort of a
public/private partnership.
Chairman Akin. The public aspect being that there would be
some maybe tax incentive or something like that to try to help
reimburse the hospital some for your investment in that
technology.
Ms. Magruder. Exactly. Because honestly one of the things
that I was up against, I happen to run our physicians
practices. And most institutions are going to want a product
that is centric to an institutional approach to things, which
is often synonymous with not what is in the best interest of
the physicians. What I really wanted was a product that was
physician centric that really spoke to the ambulatory
environment so that physicians would ultimately adopt it and
find it to be useful.
So the incentive idea was that hospitals or otherwise are
not going to readily approach it in the way that really
inscients a win/win there.
Chairman Akin. Thank you.
Chris or Jack, either?
Mr. Price. I see it as a very complex problem and it does
require a lot of balancing between what is good for the
hospital, what is good for the physician offices sometimes.
And, for example, if you have a system within a healthcare
integrated delivery s stem that you can push out to your
physicians, your independent physicians, as we just heard, may
not really like that type of an approach. And they may want to
have additional systems which would then put an extra burden on
the hospital in being able to support a myriad of different
types of technologies. So that sort of a cost shifting type of
thing.
But to get back to your question--
Chairman Akin. Do you not think that the individual
physicians would tend to kind of go with the main hospital they
work with, though, from a data processing point of view?
Mr. Price. They could or they could be in a scenario where
they are admitting patients to a number of different competing
facilities, and that could create some problems, too.
Chairman Akin. So now maybe you got putting patients into
three different hospitals, each one is on a different system,
and now you really got a headache?
Mr. Price. And some of that drives some of the work that is
being done with the regional health information organizations
in order to ensure that we have this level this communication
between different organizations. So there is great work that is
being done with creating standards, but a lot of it ends up not
being the physical standards as you were speaking to earlier,
but a lot of it is related to sort of like translating. If I am
speaking Spanish and they are speaking English, how do I
translate between one organization and another? Because what I
call a CBC may not be called a CBC in a system that we are
trying to communicate with.
So there are a level of problems that complex that we are
trying to work through. But I think over time we will reach a
point where we can do those types of transmissions very easily.
Chairman Akin. In answer to my other question, do you think
it is a good thing just to let the hospitals and doctors work
on this just in the free side of things instead of saying
``Hey, hold everything. The government in D.C. is going to come
up with a--''
Mr. Price. No, I do not. And I say that simply because I do
not think that that is always going to be a priority for those
organizations. Because you are going to see a competition for
capital and there is going to be much more money being shifted
to buying new MRIs and things of things of that nature, and
there is only a limited amount to spend.
Chairman Akin. So you are saying that you do think that
government should be coming up with sort of a standard format
for the transmission of data?
Mr. Price. The government is working on and through
certification groups is working on standard formats.
And also I believe that the payors are going to have to
play a significant role in this just so that we can find some
other opportunities to help fund the physicians as they start
up these practices. There may also be some relaxation of START
that has to happen in order to eliminate the issues and things
of that nature.
Chairman Akin. Go ahead.
Dr. Normile. You know I think that certainly there should
be a national situation. This is something where we all need to
work together, LabCorps and different labs we use are national
organizations. To be able to communicate with one hospital
group and not another just is not going to work. We need to
have something that will work for everyone. And I can
communicate to a doctor in New York and California just as well
as next door.
Chairman Akin. I think we are okay time wise.
I assume that right now are there vendors that have
software packages? Is that what you went shopping for, Joan?
Ms. Magruder. Yes, we did. We went with a vendor called
NextGen. There are lots of vendors, I think several of whom are
very credible.
I think you asked a question earlier about inferentially
whether the software was where it needed to be. I think the
software, in and of itself, is reasonable as a starting point.
But I think that the real key is that, again, it remains mostly
a silo technology in freestanding physician offices. It is
difficult enough to get individual offices to go up. I think
what we really need to get to is the integration of all
healthcare providers. And I think that that's really going to
cause some alignment of incentives.
I think the payors have to pay a key part of this. I think
that if we are going to advocate transparency, which is part of
what this will do for us, we need to make sure that the payors
treat that as a positive and appropriately. And so I would love
to see a situation where physicians who have been willing to
step up are in fact rewarded for doing so and not at risk for
things going on a website about their information because they
were--
Chairman Akin. The first to stick their head up?
Ms. Magruder. Exactly. Exactly.
Chairman Akin. Okay. Sounds good.
Dr. Normile. Personally my experience has been, you know
this technology really is almost there to the point where it is
a break even situation for me. I think it still has a ways to
go.
Chairman Akin. Okay. Anybody want to comment on the second
part of the question about the privacy of information
transmitted? Is that a problem or is that no sweat?
Mr. Price. No. It is a problem. It is a problem in the
sense that organizations are very aware of what they need to do
to protect that information. And, in fact, some of that has
driven the way some RHIOs have designed their architecture so
that information is not resident in anyone, let us say,
database and that you have processes that can go out through
secure networks and be able to pull information from these
different locations where a patient may have been at some point
in time.
So it is at the forefront of every organization in terms of
addressing security, internally and externally.
Chairman Akin. Are you saying that that is being built into
a lot of the programs in the system's design?
Mr. Price. It is being built into software programs. It is
being built into physical safeguards for facility's procedures,
policies. Auditing is taking on a whole new front. I mean, a
lot of this really started with HIPAA. But it is just the right
thing to do, as we all agree, to protect the privacy of
individuals.
Chairman Akin. Thank you all very much.
And now I will turn to my good friend, Mike, did you want
to ask some questions?
Mr. Sodrel. Yes. Thank you, Mr. Chairman.
I am certainly not a computer wiz, did not grow up in the
era, but I ran a business before I came to the Congress. And,
in fact, this is the first time I have ever served in elective
office. Ad some of the questions that I have been asking of the
American Medical Association, some other doctors I have talked
to about interoperability. You know, I mean how do you get a
system that talks nationwide and talks to the providers and the
payors and everybody else might be appropriate. And the answer
I get is, no offense, Doc, but they said doctors are kind of
like to herd cats. Unless the government provides some carrots
and sticks to the process, everybody will go out and buy
independent systems and they are not necessarily going to talk
to each other or reach the desired end.
And it is kind of a follow up on the Chairman's question,
how do we provide the carrot and stick for the industry to come
up with a standard software practice and standard language and
standard system so that they can talk to each other, both the
hospital to the insurance company to other appropriate
entities? I mean, how do you think we should be approaching the
problem?
Dr. Normile. The primary think I think would be to approach
the software company that produce these and if they start
seeing that there is a common way to communicate, doctor's
practices will want to get on and involved with that. And
doctors, we all want to be able to communicate and that is
vital to our practice. So, you know, I do not think the issue
is really hurting as far as the patient. It is a matter of
getting the software companies to provide it.
Mr. Price. Dr. Brailer is currently heading up a lot of
different approaches that are requiring certification
processes. And what we are hoping is that over time software
vendors will have to adhere to certain certifications. And part
of that certification will require this interoperability issue
to be addressed.
So these types of things are happening right now. But in
the meantime, you still have to conduct business. So there is
still organizations that have to make these types of purchases
and hope for the best in terms of being able to communicate
outside the confines of their office.
We have addressed a lot of that with HIPAA for the
financial side of the equation, and it may be beneficial to
have things that are similar on the clinical side to be able to
share that type of information back and forth. But a lot of
that is like the train is already moving on that.
Mr. Sodrel. The other thing that occurs to me is you lose a
paper trail when you go to electronic records that a hot site
is going to be really important. I mean if you look at Katrina,
Rita, tornados go through the midwest. You are a doctor and the
system is gone in an F3 tornado, those records need to be
someplace else on a clone or some system that is running
parallel where you can get them back up in a short period of
time. So it seems to me that is a risk as well of losing the
data.
Dr. Normile. Those are becoming more available where you
can copy information to another site. And certainly in our
practice we copy all the data to a tape and I take it home at
night with me. It is one of our biggest fears that our system
would go down. It would be devastating. But we do have backups
for patient information. And all that information is on a tape
and I have it at home.
Ms. Magruder. I think the other form of redundancy goes
back to this issue of whether these EMRs are going to be self-
contained in an ambulatory setting or connected to the in-
patient settings. Because you then, obviously, have another set
of redundancy.
In our circumstance we are trying to create the backbone
and allow physicians to choose to attach to it or not. And so
whether they have the option to back it up in their office and
we then have the backup, if you will, at the organizational
level. So that becomes sort of a double protection.
I do think, though, that whatever we do in this regard if
we really think we want to get at sort of the cost
effectiveness and the universal care aspect, I think we are
going to have to figure out a way to get the in-patient centers
to get moving, not just the physician setting. Because right
now there are so many things that are being vested upon in the
in-patient setting, this is really not a top priority. And so I
think that that is something we just do not want to lose track
of as we try to think that we are targeting a very universal
comprehensive record. I think that will be important.
Mr. Sodrel. Thank you, Mr. Chairman.
Chairman Akin. If I could just do a follow up question
about Mike was saying. At least it seemed like to me, maybe one
thing that might be helpful, maybe this has already been done,
but the information that you are going to be collecting if you
could define what the fields are? In other words a treatment
date and have some common definition for what that is or
whatever the other basic things that would go with it
regardless of what software, how to design the database. If
your definitions of what this, that and the other term meant,
it would seem like it would make it much, much easier to make
things interoperable if you are using a common set of
definitions. Has that been thought of is that already being
taken of or is that something that maybe some sort of national
group could help with?
Mr. Price. I believe SNOMED, which I can't remember exactly
what that stands for, but it is a common vocabulary that is
being looked at as one of the key sort of integration languages
to use for this interoperability. This sort of translation
between the Spanish and the English. But get everybody to speak
the same using SNOMED vocabulary in the way they define
diseases, the way they--
Chairman Akin. Is that a commercial--
Mr. Price. Yes. It has been used in pathology for a number
of years. Yes.
Chairman Akin. So it is one that is already somewhat
established and it is almost one that is starting to take on a
sort of standard in and of its own, to some degree?
Mr. Price. Right. And there is discussion about other
formatting types of capabilities whether it be a continuity of
care record or some other mechanism for being able to ensure
that these data elements were defined properly and they are the
same, whether you are talking in an ambulatory and acute care
setting.
Chairman Akin. Okay. That covers it pretty well.
Okay. I did not have anything else particularly. I just
wanted to thank you all for coming in.
We have broken our witnesses into two panels and if you
would like to stick around, you will see that we have saved an
interesting witness for our second panel here, a colleague of
ours, a medical doctor who is a friend of ours and somebody
from the city of Atlanta who we like to harass, but in a
friendly sort of way.
Thank you all so much for your testimony. And we will just
proceed right into the second panel.
Mr. Price. Thank you.
Ms. Magruder. Thank you.
Chairman Akin. Welcome to the Subcommittee, Congressman.
Mr. Gingrey. Thank you, Mr. Chairman.
Chairman Akin. Congressman Phil Gingrey is also a doctor
and a honorable, and from according to my notes, Georgia 11. I
have been there, but I did not know it was 11. But we are
delighted to have you, Phil. If you would like to proceed. I
understand that you have some legislation that you are working
on, and we are all ears. We would like to hear what you have
got.
STATEMENT OF THE HONORABLE PHIL GINGREY (GA-11), U.S. HOUSE OF
REPRESENTATIVES
Mr. Gingrey. Mr. Chairman, thank you very much. I didn't
realize that a panel could be a panel of one, but I am proud to
be here not as a VIP or a DV, as a doctor member of the House.
And it is an honor to be here before this Subcommittee,
Chairman Akin, Representative Sodrel. I know Ranking Member
Bordallo, a very good friend, and other members of the
Regulatory Reform and Oversight Subcommittee.
I have got some written remarks, Mr. Chairman. I would like
to go through those and submit them in their totality for the
record.
Chairman Akin. Without objection.
Mr. Gingrey. But let me just say that on behalf of the
citizens of Georgia's 11th Congressional District, and I thank
the Chairman for visiting in my District and holding a field
hearing, thank you all for allowing me the opportunity to
testify before you today.
Every day we read in the headlines about the rising cost
of healthcare and what it means to every American in this
country. There are many ways to tackle the problem of
skyrocketing healthcare costs, but today I am here to focus on
healthcare information technology, just as the previous panel.
Why does Congress need to be invested in the adoption of
healthcare information technology? Well, in September of 2005
the RAND organization released a study that showed how a health
information technology system that is implemented correctly and
as the previous panelists said, widely adopted could save the
American healthcare system more than $162 billion annually.
Since we all know the tremendous stress our healthcare
system is currently operating under, these savings alone are
very compelling justification for congressional involvement.
Even more important than saving money. Integrating technology
into our healthcare system will reduce medical errors and save
lives. However, it was not until I went out into my District, I
met with physicians like the physician from Missouri and
representatives from the health IT industry, I realized the
answer to the question of congressional action.
The key to the RAND report and my personal research centers
around the concept of, as I said, widely adopted. And this is
why we are here today. What role can and should the government
play in ensuring healthcare information technology is widely
adopted?
There are a variety of thoughts, opinions and pieces of
legislation centered around this particular question. The RAND
study simply states that in order to take full advantage of
this potential savings, we needed incentives for physicians to
buy quality systems and integrating system. So the question
becomes not only what would be the most effective way to
incentivize physicians, but what is the most fiscal responsible
way to incentivize the physicians.
I was anxious as a physician member to go out and visit
doctor's offices that were already utilizing health information
technology to see what differences it makes out in the real
world. And make no mistake about it, the physicians in the
trenches have already lead the charge. You know, I know the
government is very important, that we get it right. But there
are a lot of systems out there, Mr. Chairman, that are already
operating and operating well. It was just three short years ago
that I stopped practicing medicine. I remember vividly the
overwhelming burden of administrative paperwork. It robbed
physicians of time with their patients, literally taking away
from them the real joy of the profession. And what I saw in a
paperless medical practice when I went out recently was just
amazing to me.
I visited a three doctor OB/GYN group, that is my
specialty, in my District, Carrolton, Georgia. And they had
purchased their electronic health records system in 2002. We
are talking four years ago.
I was able to watch Dr. Rick Martin of West Georgia OB/GYN
as he demonstrated the established routine he follows during a
patient visit utilizing his computer tablet. Not a paper chart.
He stated that the vendor company that they had worked with,
they had worked very hard to ensure the process flowed to his
liking and the words and the phrases that he used most
frequently were utilized in the chart template.
It was amazing to me how efficient the system was in
documenting a patient's chart and any necessary tests and
imagines, all at the point of care when it was needed. I saw
how revolutionary health IT was to the health care world. It
transfers how physicians do business on a daily basis by
streamlining the process, giving them the tools and the
information they need when they need it.
It even left me thinking if this political career work out,
I might want to go back, jump into medicine and
enthusiastically embrace this new paradigm.
What I heard from my discussions were how satisfied the
customers were. The physicians I spoke with are enjoying a
higher quality of life, more efficiency in follow up with their
patients, the flexibility to complete charts and, indeed, even
take calls from the comfort of their homes.
The office managers spoke emphatically about the almost
immediate increased revenue from automating their coding and
billing process. Not only did they receive payment from
insurance companies, third party payers we call them, quicker
but they received more accurate payments. An increase in
revenue to a physician's bottom line is one of the biggest wins
in purchasing electronic health record system. The system not
only automatically codes the patient's visits, but correctly
codes the visits to ensure the physician is reimbursed
accurately for the services rendered.
Early in their career physicians learn quickly that it is
easier to actually down code a visit than to submit a claim
that ends up being rejected by the insurance company which
requires your office to then resubmit the claim, wasting
valuable staff time and taking money away from the practice.
But different sections in the healthcare system and the Federal
Government that there are numerous, maybe too many hurdles
preventing physicians from practically incorporating health IT
into their offices. These concerns range from the time and
energy required of physicians to learn a new system, teach an
old dog new tricks, a potentially unsustainable decrease in
productivity over the short haul and a natural apprehension
that comes with any large financial investment. However, I want
to present an example of what one practice saw as a return on
investment in their first year of purchasing a complete health
IT system.
I would like to submit for the record an example
administered by Microsoft Windows Service System, Mr. Chairman.
They performed a customer solution case study on a five doctor
OB/GYN practice in New York. For this practice implementing an
integrated electronic health record system has cut down on the
administrative work required by each doctor by one hour a day.
And it has allowed them to see an additional 25 patients each
week and given them a first return on investment of $400,000.
It is for this particular reason that I believe the best
thing Congress can do is to create incentives for physicians to
incorporate health IT and then get out of the way.
And, Mr. Chairman, you alluded to it at the beginning of my
testimony. This is why I introduced HR 4641 the Adopt Health IT
Act. This is what it does. It creates these incentives by
increasing the deductions offered under Section 179 of the tax
code for health care providers that purchase an EHR system.
I have heard from physicians and industry alike that
Section 179 is a strong incentive for their decision to invest
in health IT. But under the current law the maximum deduction
is not adequate to increase adoption among all physician
groups. Under current tax code small businesses can deduction
around $100,000 of the cost of a qualified business expense
that are placed into service in that tax year.
Basically what my legislation does is it increased this
maximum deduction in the first year from $100,000 to $250,000,
therefore creating a more realistic incentive to spur adoption
among physician practices of all sizes. Current small
businesses have a maximum threshold of $400,000 for qualified
equipment purchases in any given year. My legislation would
further increase that amount to $600,000, again, narrowly
defined to include only those healthcare professions that
purchase an EHR system.
The logic behind the idea, Mr. Chairman, is that physicians
like all small business owners look at what the tax code can
offer them as they consider purchasing equipment for their
business. And HR 4641 allows section 179 of the tax code to
better represent the actual cost of EHR systems.
For example, the cost of a system for an average practice
including four to six physicians, like a single specialty OB/
GYN practice, can be as much $200,000. This then restricts what
other medical equipment that office can purchase that year. So
that is why we increased the overall amount from 400,000 to
600,000.
By appealing to a physician's business instinct and
allowing the tax code to provide incentives we can create a
much more effective way of getting healthcare information
technology into every physician's office around the country.
These incentives will work far better than simply dumping
federal grants into the healthcare system.
So, Mr. Chairman, in closing I want to again express my
gratitude for this opportunity, respectfully ask for your
consideration of the initiative that I am laying out to you
this afternoon.
Mr. Chairman, I am prepared to respond to any questions or
comments you or Representative Sodrel or other Members may have
about the legislative proposal that I am recommending.
[Congressman Gingrey's testimony may be found in the
appendix.]
Chairman Akin. Thank you for your testimony.
I gave you a little extra time because you are a
Republican.
Mr. Gingrey. Thank you, Mr. Chairman. I appreciate that.
Chairman Akin. But I thought your comments were very
helpful and in good order. You came to the end what I was going
to ask, just some sort of basic numbers. One of these systems
can cost you 200,000 bucks if you are a physician. Is that
hardware and software or is that--
Mr. Gingrey. Mr. Chairman, that is right. That is hardware
and software. And that would not be an individual physician
cost, but a group of about five members; that is about what
that cost would be. And, of course, it is a first year cost but
it does include an update and a training part in addition to,
as you point out, the hardware and software.
Chairman Akin. So that is basically the package to get you
up and going in a way?
Mr. Gingrey. That is indeed the package to get you up and
going and actually probably covers a couple of three years of
upgrades to the software system and hand-holding, if you will,
training of the office personnel, not just physicians. But the
front and back office people.
Chairman Akin. You say that is a five doctor group, maybe?
Mr. Gingrey. That would be for about a five doctor group.
Chairman Akin. What would happen if you were just one or
two or something? Would it start to get pretty iffy in terms of
cost justifying it?
Mr. Gingrey. A great question, Mr. Chairman. The way these
systems work. of course, is you would not be able to divide
that six member group by six and come up with a cost of
$30,000. It is going to be significantly more than that for
just one person. And there are those one and two person
practices out there, believe it or not, that just like to work
independently. Maybe it is an OB/GYN, maybe it is a family
doctor that is making house calls. But they need, and I think
the previous panel would agree, that we need to make sure that
everybody is into this system and can afford to do that because
the chain is only as strong as your weakest link. And if we do
not have those small group practices that really cannot afford
to come up $75,000 to $100,000, let us say for a smaller group,
they are not going to do it. And patients lives are going to be
in jeopardy because of that. So this is an opportunity to
incentivize them. It is not the government necessarily giving
out grants and deciding who needs some money, is it a big
hospital system that needs a big government grant or is it the
small doctor situation. And I am afraid if we look at it from
that perspective, most of the time the big doctor organizations
will win out in any grant proposal. And they probably can
afford to invest on their own a lot better than a small medical
doctor group can.
Chairman Akin. Okay. Thank you very much for that. I think
that made a couple of things clear.
Let me just ask if you have different physicians motivated
to use this technology, now they are getting a tax break in a
sense to try to get this thing up and going, are you going to
have any trouble with just the format of the medical records so
that you are going to have all kinds of different systems that
do not really work together. And have you thought about that,
or is that something where there is enough standardization
going on now that increasingly they are going to be able to
talk back and forth?
Mr. Gingrey. Mr. Chairman, that is a hugely important
issue. And, of course, the previous panel as I caught the end
of their testimony talk about it. And Dr. Brailer, who is the
National Coordinator for Healthcare IT under Department of HHS
is working as far as credentialing and making sure that we get
it right, that the RHIOs are established and that there is
connectivity. I am kind of like Representative Sodrel. I am not
a computer wiz kid and I have got to learn a lot about this and
the acronyms and that sort of thing. But it is very, very
important that the software companies that have been involved
in this business for six years now, like the company in
Carrolton, Georgia that have developed a very good software
program, kind of unique maybe to the general surgery specialty
or the OB/GYN specialty, we cannot all of a sudden have the
government create a program that carves them out when many of
these physicians, they are out there, they have marketing
people, they have salesmen that are selling these programs and
doctors that have bought in at about an average price of
$200,000. We have to make sure that they're not left on the
sideline holding a bill of goods that now becomes worthless. It
is very important that we work together with them.
Chairman Akin. Is it your understanding then that there is
an ongoing cooperation between the software developers and
people defining what the fields mean? So that we are talking
the same language, more or less?
Mr. Gingrey. Well, it is my understanding, Mr. Chairman. I
think that is true. But I think there is an angst and heartburn
among some of these vendors who are sort of on the outside
looking in and they are concerned. And obviously they want
their member of Congress, you, Mike Sodrel, myself to make sure
that we represent them at the table. And that is a part of why
I am here, and that is part of why I have introduced this bill.
Chairman Akin. Thank you.
And, Mike, would you like to ask questions?
Mr. Sodrel. I think you stole all my good questions, Mr.
Chairman.
Thank you.
Chairman Akin. Well, I really appreciate your leadership on
this and particularly the fact that you are coming at it from
being a doctor and understanding what those practices are like.
It is really important.
It sounds like you have got a pretty good balance, too,
between some sort of structure that we are trying to provide
and at the same time letting the market develop products.
I just have one last question. How far away are we on not
just your OB/GYN office talking to the local hospital, but my
wife being off on vacation somewhere and their being able to
tap in so that the doctor making a decision away from home has
the same data that her doctor would have at home?
Mr. Gingrey. Mr. Chairman, a great last question. I am so
glad you asked that. You know, the President has said that he
wants to see a fully integrated operational system by I think
the year 2014. I really believe we can and desperately need to
do it before then. At $162 billion cost savings per year, that
is a lot of money. That could pay for a lot of Head Start
programs and other things that we want to do that we maybe
cannot afford to fund as fully as we would like to.
It is hugely important that we get this done sooner rather
than later, as you point out. I think we can do it. I think we
are on the track to do it. I hope that we can get this done
maybe within five years.
And you mentioned an example of your wife. I was just
recently in Antarctica on a trip and I was able with my
American Express card to get U.S. dollars so I could buy some
souvenirs at the New Zealand Station. And that was a wonderful
thing. And yet I could not help but think if I had slipped down
and fallen and hit my head on the ice, there was plenty of that
there not much grass, and gone to an emergency facility and was
unable to speak, you know they would not know that I had open
heart surgery three years ago and I am on four medications and
that I am a little goofy to boot that they would know how to
treat me. And I think it is just so important that we are able
to do that. And even more so in, let us say, a country where
they do not speak your language. And that is why we really need
to get this done.
Chairman Akin. Well, I really appreciate the wisdom of your
answers, Congressman, and also the courage of a southern boy to
go all the way to Antarctica. It would not have thought it
could have happened.
Thank you.
Mr. Gingrey. Thank you, Mr. Chairman. Thank you,
Representative Sodrel and the Committee. I appreciate the
opportunity to present to you.
Chairman Akin. Committee's hearing stands adjourned.
[Whereupon, at 3:07 p.m. the Subcommittee was adjourned.]
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