    [Senate Hearing 109-963]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 109-963

      LESSONS LEARNED? ASSURING HEALTHY INITIATIVES IN HEALTH INFORMATION
                                   TECHNOLOGY
    =======================================================================
                                    HEARING

                                   before the

                    FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT
                         INFORMATION, AND INTERNATIONAL
                             SECURITY SUBCOMMITTEE

                                     of the

                                  COMMITTEE ON
                             HOMELAND SECURITY AND
                              GOVERNMENTAL AFFAIRS
                              UNITED STATES SENATE

                           ONE HUNDRED NINTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 JUNE 22, 2006

                                   __________

            Available via http://www.access.gpo.gov/congress/senate

           Printed for the use of the Committee on Homeland Security
                            and Governmental Affairs

                                  -------

                         U.S. GOVERNMENT PRINTING OFFICE

    29-506 PDF                 WASHINGTON DC:  2007
    ---------------------------------------------------------------------
    For sale by the Superintendent of Documents, U.S. Government Printing
    Office  Internet: bookstore.gpo.gov Phone: toll free (866)512-1800
    DC area (202)512-1800  Fax: (202) 512-2250 Mail Stop SSOP,
    Washington, DC 20402-0001

            COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS

                       SUSAN M. COLLINS, Maine, Chairman
    TED STEVENS, Alaska                  JOSEPH I. LIEBERMAN, Connecticut
    GEORGE V. VOINOVICH, Ohio            CARL LEVIN, Michigan
    NORM COLEMAN, Minnesota              DANIEL K. AKAKA, Hawaii
    TOM COBURN, Oklahoma                 THOMAS R. CARPER, Delaware
    LINCOLN D. CHAFEE, Rhode Island      MARK DAYTON, Minnesota
    ROBERT F. BENNETT, Utah              FRANK LAUTENBERG, New Jersey
    PETE V. DOMENICI, New Mexico         MARK PRYOR, Arkansas
    JOHN W. WARNER, Virginia

               Michael D. Bopp, Staff Director and Chief Counsel
                 Michael L. Alexander, Minority Staff Director
                      Trina Driessnack Tyrer, Chief Clerk

    FEDERAL FINANCIAL MANAGEMENT, GOVERNMENT INFORMATION, AND INTERNATIONAL
                             SECURITY SUBCOMMITTEE

                         TOM COBURN, Oklahoma, Chairman
    TED STEVENS, Alaska                  THOMAS CARPER, Delaware
    GEORGE V. VOINOVICH, Ohio            CARL LEVIN, Michigan
    LINCOLN D. CHAFEE, Rhode Island      DANIEL K. AKAKA, Hawaii
    ROBERT F. BENNETT, Utah              MARK DAYTON, Minnesota
    PETE V. DOMENICI, New Mexico         FRANK LAUTENBERG, New Jersey
    JOHN W. WARNER, Virginia             MARK PRYOR, Arkansas

                          Katy French, Staff Director
                     Sheila Murphy, Minority Staff Director
                John Kilvington, Minority Deputy Staff Director
                           Liz Scranton, Chief Clerk

                                C O N T E N T S

                                     ------
    Opening statements:
                                                                       Page
        Senator Coburn...............................................     1
        Senator Carper...............................................     5

                                   WITNESSES
                            Thursday, June 22, 2006

    Jodi G. Daniel, J.D., M.P.H., Director, Policy and Research,
      Office of the National Coordinator for Health Information
      Technology, U.S. Department of Health and Human Services.......     8
    Linda D. Koontz, Director, Information Management Issues, U.S.
      Government Accountability Office...............................    11
    Carl E. Hendricks, Military Health System Chief Information
      Officer, U.S. Department of Defense............................    12
    Michael Kussman, M.D., Deputy Under Secretary for Health, U.S.
      Department of Veterans' Affairs accompanied by Robert Howard,
      Supervisor, Office of Information and Technology, U.S.
      Department of Veterans' Affairs................................    15
    Ross Fletcher, M.D., Chief of Staff, Veterans Medical Center.....    17

                         Alphabetical List of Witnesses

    Daniel, Jodi G., J.D., M.P.H.:
        Testimony....................................................     8
        Prepared statement...........................................    33
    Fletcher, Ross, M.D.:
        Testimony....................................................    17
    Hendricks, Carl E.:
        Testimony....................................................    12
        Prepared statement...........................................    77
    Koontz, Linda D.:
        Testimony....................................................    11
        Prepared statement...........................................    48
    Kussman, Michael, M.D.:
        Testimony....................................................    15
        Prepared statement...........................................    89

                                    APPENDIX

    Questions and responses for the Record from:
        Ms. Koontz...................................................   100
        Mr. Hendricks................................................   108
        Dr. Kussman..................................................   137

                       LESSONS LEARNED? ASSURING HEALTHY
                       INITIATIVES IN HEALTH INFORMATION
                                   TECHNOLOGY

                                  ----------

                             TUESDAY, JUNE 22, 2006

                                         U.S. Senate,
                Subcommittee on Federal Financial Management,
            Government Information, and International Security,
                                of the Committee on Homeland Security
                                              and Governmental Affairs,
                                                        Washington, DC.
        The Subcommittee met, pursuant to notice, at 2:27 p.m., in
    room SD-342, Dirksen Senate Office Building, Hon. Tom Coburn,
    Chairman of the Subcommittee, presiding.
        Present: Senators Coburn and Carper.

                  OPENING STATEMENT OF SENATOR COBURN

        Senator Coburn. The hearing will come to order. Without
    objection, I would like my full statement to be included in the
    record.
        Senator Carper. I reserve the right to object. Oh, I would
    not object. [Laughter.]
        Senator Coburn. I apologize. I have to make a speech on the
    floor, so I will not be able to stay for the entire hearing.
        I owned the first IBM System 3 for online inventories and
    used a toll-free telephone system to tell people what we could
    ship and when we could ship it. So I know the power, and I do
    not think anybody disputes the power to save lives, the power
    to save tremendous amounts of money, and the power to markedly
    improve what we know are best practices in health care
    standards in this country.
        I enjoyed my visit at the VA. I have been to approximately
    25 different organizations who are using electronic medical
    records. I am a proponent. I do not think anybody in the health
    care industry, even us older doctors, is going to be resistant
    to the things that we know will help us save money ourselves,
    improve our care, and give us time.
        I am concerned, and I want to be very frank with my
    concern. As I look at what is happening in interoperability, my
    concern is it is becoming a roadblock rather than something
    that is helping, and let me explain that. I formerly shared a
    practice with four other physicians. We have not gone to an
    electronic medical record, and the reason we have not gone to
    an electronic medical record is because we know our capital
    investments is going to double again as soon as you all decide
    on standards. So whatever we buy today is not going to work
    with whatever comes out, and then we are going to have to pay
    to have a system to make our system work. And we are not alone.
    The vast majority of physicians feel that way, and a lot of the
    hospitals who have not upgraded systems are not upgrading
    systems today because this has not come about.
        And so my real concern is: Have we gone about this the
    wrong way? Everybody who has testified before us is working to
    accomplish the same goal. We all want the same goal. But when
    we dangle money from the Federal Government to say, ``Come help
    us do this,'' and then we have the Federal Government saying,
    ``Here is how we are going to do it,'' rather than say, ``Who
    sold the system to VA, who sold the system to the Department of
    Defense, what computer companies are out there, what insurance
    companies, where do they get their software/hardware systems,''
    rather than to ask those people, much like we did in the
    banking industry--there wasn't a government agency that created
    the software security analysis for the banking industry. The
    very fact is that the profit motives created the security, the
    online advancement, and the economic benefit of everything that
    we see happening in the financial industry today.
        So my worry--and I hope to be convinced that we are not
    slowing down interoperable standards, because I have this
    trouble conceiving how it could take longer, if we took
    Microsoft and all these other people, and we took IBM, and we
    took the companies that have actually sold and written other
    software, and the insurance industry and some of the medical
    industry and the hospital industry, and say, ``Go get in a room
    and come back in 9 months and tell us what we need to do,''
    would that have been a better situation? Would we end up with a
    better product at a more timely basis? And why is it important?
    Because if we had health IT today, true electronic medical
    records, we would be saving 50,000 to 60,000 lives. And just
    the economic output of those 50,000 to 60,000 lives would pay
    for everything we are doing.
        Now, we have spent a quarter of a billion dollars already
    on health IT interoperability. A quarter of a billion dollars.
    And nobody can tell me when we are going to have
    interoperability. Nobody will tell. And we are not going to get
    the movement to save those lives until those standards are set
    and people see some finite, fixed consistency to know that
    their investment is not going to have to be duplicated again
    before they do that. So that is my concern.
        I want to thank Senator Carper. We are having this hearing
    at his insistence. There are tons of hearings on IT across the
    Hill, and he has a significant insight and investment in this
    issue, which I appreciate, and my hope is that by having this
    hearing, we can answer some of those questions and kind of move
    it along and look at where it ought to be.
        I may differ somewhat from him. I do not think we have a
    top-down computer--or standard developed by the Federal
    Government. I think the standards that we get ought to be
    developed by the private industry because I think that the
    motivations will be better and the risk-taking will be better
    in terms of getting us a better product. But without that, we
    need a standard, and every day we do not have an interoperable
    standard in health care IT, thousands of people are going to
    die. And the other thing that we know from the Rand Corporation
    studies is anywhere from 5 to 20 percent, somewhere around $300
    billion of missed savings, we are passing up savings of about
    $300 billion a year every year we do not have IT in the health
    care industry. So it is important--lives, quality, and money,
    and time. And we need to get there, and we need to find out why
    we are not.
        Senator Carper, I will apologize to you now for not being
    here. I will try to come back. It will be my effort to come
    back. We will be asking questions, written questions of you,
    and if you would be so kind as to submit those answers within 2
    weeks of the time you receive them, we would very much
    appreciate it.
        [The prepared statement of Senator Coburn follows:]
                  OPENING PREPARED STATEMENT OF SENATOR COBURN

         THE ISSUE--WE'RE NOT WHERE WE SHOULD BE IN HEALTH INFORMATION
                                   TECHNOLOGY

        Most industries are fully online and digitized. People bank
    electronically, shop electronically, pay their taxes electronically,
    plan vacations, weddings, hold videoconferences, you name it. But
    there's one industry that is lagging woefully behind--healthcare--and
    it's literally a matter of life and death that we get up to speed. June
    5-8 was National Health IT Week. It's time that every week was health
    IT week.
        The need is clear and the benefits of sharable--but secure--health
    IT products are many: All your doctors and other providers for one
    patient can communicate, see each other's work, and work together to
    avoid duplication, medical errors, and drug interactions. Patients can
    put their whole health record on a ``thumb'' drive the size of, you
    guessed it, your thumb, and carry it with them on vacation, overseas
    travel, or when they switch insurers or primary care providers.
        Health IT isn't just a neat idea that might have good benefits. In
    today's world, health IT can produce greater efficiency and fewer
    medical errors, with the added benefit of fantastic cost savings for
    patients, providers, health plans and the taxpayers who partially or
    fully support the system. Moving healthcare to the digital universe is
    no longer an option, but a necessity.
        Right now, however, hardly anyone is benefiting from electronic
    health records because they are rarely used--even though studies
    estimate that a well-developed health IT system could save $81-$161
    billion or more annually while greatly reducing sickness and death,
    medical errors and adverse drug events in patients.

     THE COST--THE fEDERAL INVESTMENT IN hit HAS BEEN SIGNIFICANT--BUT THE
                                RESULTS ARE FEW

        However, I don't think the lack of electronic health records is due
    to a lack of spending. In fact, the U.S. enormous investment in health
    care is staggering: In 2006, total health spending is expected to
    approach $2.2 trillion and account for more than 16 percent of gross
    domestic product (GDP). We spend substantially more than other
    developed countries, both per capita and as a share of GDP.
        Of the billions of tax dollars spent on discretionary and mandatory
    health spending, information technology is not the poor step-child when
    it comes to Federal health investments--in fact, the government has
    spent an estimated $169 million this year alone on HIT initiatives.
    According to a March 2006 GAO report, the Office of the National
    Coordinator for Health IT has awarded $42 million in contracts intended
    to advance the use of health IT, while the Bush Administration has
    pledged $100 million for a national electronic Health Record system. On
    January 27, 2006, President Bush asked for an additional $50 million
    for the Office of the National Coordinator for HealthIT, and his 2006
    budget called for increasing funding for $125 million for demonstration
    projects.

       THE PLAYERS--DOD AND VA AS STANDARD BEARERS IN THE RACE TO WIDELY
                     ACCESSIBLE ELECTRONIC HEALTH RECORDS?

        But HHS isn't the only game in town. Many regard the Department of
    Veterans' Affairs and the Department of Defense as standard bearers for
    health information technology due in part to their joint efforts to
    share medical records and, not least, the fact that they care for a
    combined 14.2 million active military and retired veterans. The
    services the VA and the DOD deliver to our armed forces are vital to
    our national security, and some have commended the VA for some of the
    agency's cutting edge technologies and best practices development.
        The price for innovation and delivery of services at these two
    agencies is not cheap, however: The VA requested about $2.1 billion for
    its FY06 Information Technology programs, and has requested a new
    system and an additional $3.5 billion in funds to overhaul their
    current network over the next 10 years. DOD's health care costs have
    doubled over the past 5 years to $38 billion in 2006, accounting for 8
    percent of DOD expenses. If current trends continue, the department
    would spend $64 billion in 2015, accounting for 12 percent of DOD's
    costs.

                          THE APPROPRIATE FEDERAL ROLE

        As usual, the private sector--where the bottom line drives
    performance--is the place where innovation must grow fastest and best.
    I don't want to fetter the private providers, facilities, and health
    plans with too much government meddling in their efforts. There is an
    appropriate role for the Federal Government in providing leadership for
    data standard-setting and creating incentives for publicly funded
    healthcare to go digital. However, imposing a top-down model like the
    single-payer VA or TriCare systems, can't work in the private sector
    where most people get their health care and want to keep getting their
    healthcare. The Office of Personnel Management (OPM) recently reported
    that the best way to encourage providers to adopt HIT is to promote the
    conditions for a free market. Some would like the Federal Government to
    try to replace that vibrant market with the roll-out of a one-size-
    fits-all interoperable government health IT system. Those waiting for
    such a system will be waiting a long time, given the slow progress
    we've seen so far.
        And that's probably a good thing, because the private sector isn't
    waiting around to get moving on HIT. Kaiser Permanente, which serves 3
    million more people than the VA, has launched a 10-year, $3 billion
    computer overhaul. IBM testified at a recent House hearing that their
    use of employee electronic health records played a major part in
    lowering premiums and keeping employees health. IBM health care
    premiums are 6 percent lower for family coverage and 15 percent lower
    for single coverage than industry norms, and employee illness rates are
    consistently lower than industry levels.

              IN THE WAKE OF POOR MANAGEMENT, INNOVATION FLOUNDERS

        While it is clear to me that there is an enormous amount of effort
    and money being poured by the Federal Government into the health
    information technology field, I'm perplexed as to why we haven't yet
    achieved more measurable results. Some have called the VA the model of
    IT perfection, but the history there of wasted funds and large cost and
    time overruns is less impressive than you might think. I hope we can
    get a clearer picture from some of our witnesses today. I don't want to
    criticize the services that our veterans receive--and they truly
    deserve our thanks and care--but I think we can do a better job serving
    those veterans and the rest of America's taxpayers by better managing
    our resources and investments.
        Both VA and DOD lack detailed management plans for health IT, which
    increases the risk of unaccountability. In fact, two recent GAO reports
    use the phrase ``severely challenged'' when describing VA and DOD long-
    term efforts to provide a virtual medical record in which data are in a
    format that can be acted upon in real time. Both VA and the DOD have
    been criticized for missed milestones and major expenses related to
    their two newest projects, Healthe Vet and ALHTA [``ALTA'']. HealtheVet
    in particular has received some particularly scathing reviews from
    independent review Carnegie Mellon suggesting that the ``VA faces
    unparalleled challenges to manage change to deliver an operationally
    viable [HealtheVet] by 2010,'' and that the plan to spend billions to
    modernize the health care system for that delivers services to 5
    million veterans has unacceptably high risks.

                                   CONCLUSION

        It's not fair to ask future generations--your grandchildren and
    mine--to pick up the tab tomorrow for systems and plans that don't work
    well or on time today. I know that our witnesses have the very best
    wishes in their hearts for the well-being of our Nation's honorable
    veterans and active-duty forces. To serve them with one fraction of the
    competence with which they've served us, we need to ask some tough
    questions today. Thank you for being here, for your time and
    preparation.

                  OPENING STATEMENT OF SENATOR CARPER

        Senator Carper [presiding]. Thanks, Mr. Chairman, and the
    Subcommittee will stand in recess. We are going to watch
    Senator Coburn on a television monitor over here as he gives
    his speech. No, we are not going to do that. Go for it.
        I am delighted that we are having this hearing. I am
    delighted we are having it on this subject. I am an old Navy
    guy. I spent about 5 years on active duty, about 18 years in
    the Reserves, and I remember when I got out, I graduated from
    Ohio State, having been a Navy ROTC midshipman. And I headed
    out for Pensacola for my training, my first active-duty
    training. And when I left Ohio State, they gave me a brown
    manila folder that had my medical records from my 4 years at
    Ohio State, my physicals and that sort of thing.
        I went down to Pensacola. I turned them in, and they kept
    them there for--I do not know--the 6, 7, 8, 9 months that I was
    there. And then I left and went off to Naval Air Station,
    Corpus Christi, Texas, and they gave me back my brown manila
    folder, and I carried it with me in my Volkswagen Karmann Ghia
    to Corpus Christi Naval Air Station. I went to Corpus Christi,
    and I turned it in, and they kept it until I finished up. Then
    I went to North Iowa Naval Air Station, Coronado, and I carried
    it with me over there, and I turned it in. I left there and I
    went up to Moffett Field, California, near Mountain View, Palo
    Alto, Menlo Park, that area, a place where I revisited just 3
    weeks ago and I got to stand in my old squadron. I do not know
    if you have ever heard of Moffett Field, but on Route 101, just
    south of San Francisco, is a big old naval air station. It is
    now a NASA base. It is called Ames. But they still have these
    three huge blimp hangars where we have our Navy P-3 aircraft. I
    got to stand in my old hangar.
        And the one thing I did not have with me was my old brown
    folder with my then thickening naval medical records. I had to
    go overseas. We would go overseas. We would be home for about 8
    months, overseas for 6, home for 8, overseas for 6. And the
    whole time I was in my squadron, they kept my brown manila
    folder.
        When I got out of the Navy in 1973, they gave it back to
    me. By this time it was pretty thick. And I carried it with me
    all the way across America in my Volkswagen Karmann Ghia. And I
    drove to Delaware, which I had found on a map, to go to
    business school. And a week after I started business school, I
    drove up to the VA hospital in Ellesmere, Delaware, and I gave
    them my brown manila folder. And it had all my medical records.
    I wanted to find out what I was eligible for, for benefits.
        And you know what? Today, when people get out of the Navy
    or the Army or the Air Force or the Marine Corps and they want
    to go to a VA facility and find out what they are eligible for,
    they do not carry brown manila folders anymore, do they? They
    do not, because everybody has an electronic health record.
        Down in Louisiana during the evacuation from Hurricane
    Katrina, we had a lot of people evacuated from nursing homes
    and hospitals, and civilians, when they tried to leave, a lot
    of their paper records were destroyed, as we all know. And
    people ended up in Houston, Baton Rouge, and even Delaware, all
    kinds of places, and they did not have their civilian health
    records anymore.
        But you know who had their medical records? The people in
    the VA hospitals, the people in the VA nursing homes, they had
    them, because they had electronic health records. And they were
    able to--folks receiving them in the VA facilities, they knew
    what medicines these folks needed to take. They knew what their
    medical history was, their lab tests, their MRIs, all that
    stuff. Boy, that is a smart idea.
        And it is actually not an idea that the private sector
    brought us. At least I do not think so. It kind of grew out of
    the VA, and it sort of migrated to the Department of Defense.
    And there is a lot there for all of us to learn.
        I sort of come to this issue because I want to save lives.
    We are told that we may lose as many as 100,000 lives a year
    because of medical mistakes. It may be a little more, it might
    be a little less. But we lose a lot of lives. We spend a huge
    amount of money, as you know. We spend more money, I am told,
    than any other country in the world on health care, but we do
    not get the best results in the world. In fact, in some cases,
    if you look at things like longevity and life expectancy and
    all, you could argue we do not end up with the sort of system
    we are paying for.
        In any event, I do not know that there are any silver
    bullets in life. I do not think there are any in this regard.
    But I am convinced we can save lives and we can save money if
    we can figure out how to provide throughout the delivery of
    health care some of the stuff that we have been doing in the VA
    for a while and are trying to do in the DOD.
        The Chairman said that he thinks I am committed to a top-
    down solution here as opposed to a bottom-up, and I just want a
    solution. I am just interested in what works. And my hope is
    that today you will help provide us with what works.
        Meredith, is this something I should read? Thank you. It
    says, ``Hearing script.'' I used to be in the House of
    Representatives, and I was a Chairman of my own Subcommittee,
    and here I get to be the Ranking Member with Senator Coburn,
    which is really a lot of fun. He and I are real interested in
    reducing budget deficits, and when you have run into budget
    deficits of $300, $400 billion a year--they basically continue
    as far as the eye can see--we have got to look for ways to save
    some money, and that is one of the reasons why I am real
    interested in this. So save some money, save some lives,
    improve health care delivery, and actually provide greater job
    satisfaction to the folks that are delivering the health care.
        Here we go, the hearing script. It says, ``Bring the
    hearing to order.'' The hearing will come to order. And we have
    given our opening statements. The Ranking Member--that is me--
    has been recognized for an opening statement. And if there were
    other Senators here, I would recognize them. Some of them are
    over on the floor, probably waiting for Senator Coburn to give
    his statement. And we have a bunch of other Committee hearings
    going on, but we will have some people who drift in and out and
    hear what you all have to say and maybe ask a couple of
    questions.
        I am going to ask our witnesses--and we thank you very much
    for coming, but I am going to ask you to limit your oral
    testimony to about 5 minutes, if you will. Just look for the
    red lights. Do you have a red light out there that you can see?
    What is it right now? Is it green? Is it any color at all?
    Pretty soon it will be green. When you speak you will get a
    green light for 4 minutes, an amber for 1, and then you will
    get a red light. Try to wrap it up about that point in time.
    Some of you have done this before, so this is old hat.
        But your complete written statements will be made part of
    our official record, and I am going to ask that we hold our
    questions until the entire panel has testified.
        Let me just say to our panelists today, thank you for
    coming. You all could have been someplace else. This is real
    important. I think this is important for our country, for the
    people who live in our country, and we are grateful that you
    would testify before us.
        The first person I want to recognize I think is from HHS.
    Is that right? Do you work for Governor Leavitt?
        Ms. Daniel. Yes.
        Senator Carper. Tell him an old governor sends his best. He
    is one of my favorite people.
        We are going to hear from Jodi Daniels, Director of the
    Office of Policy and Research, Office of the National
    Coordinator for Health Information Technology at HHS. Did David
    Brailer work with you?
        Ms. Daniel. Yes, he was my former boss before he resigned
    from his position.
        Senator Carper. I just talked to him a week or so ago. Good
    man.
        And I understand that Ms. Daniels is responsible for
    considering the policy implications of key health information
    technology activities and coordinating health information
    policy discussions and research within HHS. Welcome. Thank you
    for coming.
        Ms. Daniel. Thank you.
        Senator Carper. Second, Linda Koontz, welcome. How are you?
    The Director of Information Management Issues at GAO. You have
    testified before, haven't you? Once or twice?
        Ms. Koontz. Maybe three times.
        Senator Carper. More than that, I bet.
        But from GAO, we are delighted that you are here. We
    appreciate your willingness to testify on this subject, and I
    understand you are responsible for issues concerning the
    collection, the use, and the dissemination of government
    information in an era of rapidly changing technology. And Ms.
    Koontz has great responsibility at GAO for information
    technology management issues at various agencies, including the
    Department of Veterans' Affairs, Department of Housing and
    Urban Development, and Social Security Administration. That is
    a lot.
        Our third witness is Carl Hendricks. I know a Carl
    Hendricks back home, but you are the real Carl Hendricks. We
    are glad that you are here. And I understand you are the Chief
    Information Officer for the Military Health System. Is that
    right?
        Mr. Hendricks. Yes, sir.
        Senator Carper. Terrific. At the Department of Defense, and
    your past public service was as an Army Medical Service Corps
    Officer, and serving in a variety of positions spanning some 26
    years of military service, with a concentration of experience
    in medical information technology and acquisition management.
    Is it Mr. Hendricks or Dr. Hendricks?
        Mr. Hendricks. It is Mr. Hendricks.
        Senator Carper. All right. Mr. Hendricks is the principal
    advisor to DOD medical leaders on all matters pertaining to
    health information management, information technology,
    information protection, enterprise architecture, IT capital
    investment, and IT strategic planning. That is quite a bit.
        Our fourth witness here today is--now, my notes here say
    Dr. Michael Kussman. And for some reason, we just skipped right
    over you, Mr. Howard, but we will come back. [Laughter.]
        Dr. Michael Kussman, Deputy Under Secretary for Health----
        Mr. Howard. I am his shadow, sir.
        Senator Carper. Is that right? Dr. Michael Kussman will be
    delivering testimony on behalf of the Department of Veterans'
    Affairs. And he is joined at the table Mr. Robert Howard. Thank
    you, Mr. Howard, for being here--Senior Advisor to the Deputy
    Secretary with concentration on business operations for the
    Department, and Supervisor, Office of Information and
    Technology, also at Veterans Affairs. And when you testify, Dr.
    Kussman, I am going to look to see if Mr. Howard's lips move at
    all. [Laughter.]
        We will see how he does. We are glad that you are both here
    and thank you for coming.
        And, finally, Dr. Ross Fletcher. who is the Chief of Staff
    at the Veterans Medical Center in Washington, and I understand
    you are going to be able to give us a demonstration as well. I
    have been looking forward to that. Meredith Pumphrey was
    telling me you were going to do that, and that would be great.
        That is a little bit about who you are--this is a wonderful
    panel. I don't know who put this panel together, but whoever
    did, you did good work.
        Could I ask you to go ahead and make your presentations?
    And, Ms. Daniels, if you do not mind being our lead-off hitter,
    we will start with you, and then when we are finished, we will
    ask some questions. But thank you all for coming.
        Ms. Daniels.

    TESTIMONY OF JODI G. DANIEL, J.D., M.P.H.,\1\ DIRECTOR, POLICY
      AND RESEARCH, OFFICE OF THE NATIONAL COORDINATOR FOR HEALTH
      INFORMATION TECHNOLOGY, U.S. DEPARTMENT OF HEALTH AND HUMAN
                                SERVICES

        Ms. Daniel. Ranking Member Carper and Members of the
    Subcommittee, I am Jodi Daniel, and as you have mentioned, I am
    the Director of the Office of Policy and Research of the Office
    of the National Coordinator for Health Information Technology.
    Thank you very much for inviting me to testify today on some of
    our health information technology activities under way at the
    Department of Health and Human Services.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Ms. Daniel appears in the Appendix on
    page 33.
    ---------------------------------------------------------------------------
        In April 2004, the President signed an Executive Order
    creating the Office of the National Coordinator (ONC) for
    Health IT, within HHS and called for widespread adoption of
    electronic health records within 10 years so that health
    information will follow patients throughout their care in a
    seamless and secure manner. The goal is to improve the quality
    of care and provide better information for patients and
    physicians to improve efficiency.
        Reaching these ambitious goals requires cooperation among
    Federal agencies and cooperation with the private sector. ONC
    works closely with our Federal partners, including the
    Department of Defense and the Department of Veterans' Affairs,
    to ensure synergy in our efforts and to avoid unnecessary
    duplication.
        Two critical challenges to realizing the President's vision
    for health IT are now being addressed. The first is
    interoperability and electronic portability of health
    information, and the second is electronic health records
    adoption, and we are looking at both of these issues in tandem.
        These challenges are being met by key actions currently
    under way in ONC, both through infrastructure contracts that we
    have and through Secretary Leavitt's Federal Advisory
    Committee, the American Health Information Community. Last
    year, Secretary Leavitt announced the formation of the American
    Health Information Community, otherwise known as ``the
    Community.'' It is a national public-private collaboration to
    facilitate the transition to interoperable electronic health
    systems in a market-led way. The Community formed work groups
    that were charged with making recommendations for specific
    achievable, near-term results in four areas: First is consumer
    empowerment; second, chronic care; third, electronic health
    records; and, fourth, biosurveillance. These work groups
    advanced and the community accepted recommendations on May 16,
    and key actions related to these and future recommendations are
    now under way.
        In addition to the formation of the Community, HHS through
    ONC has issued contracts to focus on some of the health IT
    infrastructure issues. There are four sets of contracts that I
    wanted to mention.
        The first, HHS awarded a contract to the American National
    Standards Institute to convene the Health Information
    Technology Standards Panel (HITSP). HITSP brings together U.S.
    standards development organizations and other stakeholders and
    is developing and implementing a harmonization process for
    achieving a widely acceptable and useful set of health IT
    standards to support interoperability among health care
    software applications, particularly electronic health records.
        A process was implemented whereby standards were identified
    and developed specific to real-world scenarios or use cases.
    HITSP is scheduled to have named standards and implementation
    specifications for three use cases this September.
        The second is compliance certification. HHS awarded a
    contract to the Certification Commission for Health Information
    Technology (CCHIT), to develop criteria and an evaluation
    process for certifying electronic health records and the
    infrastructure or network components through which they
    interoperate. The contract will address three areas of
    certification: Ambulatory electronic health records, inpatient
    electronic health records, and the infrastructure components.
        CCHIT has made significant progress toward the
    certification of commercial ambulatory electronic health
    records, and in July of this year, the first set of ambulatory
    electronic health record products will be certified.
    Certification will reduce risk by helping buyers of health IT
    determine whether products meet minimum requirements.
        Third, HHS has awarded contracts to four consortia of
    health care and health IT organizations to develop prototype
    architectures for a Nationwide Health Information Network. The
    goal is to develop real solutions for nationwide health
    information exchange by stimulating the market through a
    collaborative process and the development of network functions.
    In June 2006, this month, the contractors submitted proposed
    functional requirements for a NHIN to HHS, and there is going
    to be a public meeting next week to review those and to try to
    sort through those functional requirements from the four
    different contractors.
        Finally, HHS has awarded a contract to RTI International,
    which is working with the National Governors Association Center
    for Best Practices to form the Health Information Security and
    Privacy Collaboration. Through this contract, health care
    stakeholders, including consumers, within and across 34 States
    and territories will assess variations in organization-level
    business policies and State laws that affect health information
    exchange. These State subcontracts will work with stakeholders
    within their States to then identify and propose practical
    solutions to address this variation and develop detailed plans
    and implementation solutions. State solutions and
    implementation plans will be finalized in early 2007.
        Finally, there is an important initiative I wanted to
    mention given the Subcommittee's interest. In order to promote
    adoption of interoperable health IT systems, last October the
    Centers for Medicare and Medicaid Services and the Office of
    Inspector General at HHS proposed exceptions to the physician
    self-referral law and safe harbors to the anti-kickback
    statute. These proposed rules would allow hospitals and certain
    other health care organizations to donate hardware, software,
    and related training services that meet certain
    interoperability criteria to physicians for both e-prescribing
    systems and electronic health records systems.
        The Department recognizes that interoperable health IT is
    critical in not only transforming how care may be delivered,
    but also in informing patients and other consumers about costs
    of care and some aspects of its quality.
        Thank you for the opportunity to update you on the progress
    we are making in the area of health IT. HHS, under Secretary
    Leavitt's leadership, is giving the highest priority to
    fulfilling the President's commitment to widespread adoption of
    interoperable electronic health records, and it is a privilege
    to be a part of this transformation.
        Thank you very much, and I would be happy to answer any
    questions.
        Senator Carper. Great. Well, thanks for that testimony, and
    don't go away. We will be back to ask some questions. And I am
    sure the Chairman will as well.
        Ms. Koontz, thank you.

    TESTIMONY LINDA D. KOONTZ,\1\ DIRECTOR, INFORMATION MANAGEMENT
             ISSUES, U.S. GOVERNMENT ACCOUNTABILITY OFFICE

        Ms. Koontz. Ranking Member Carper, I am pleased to be here
    today to participate in the hearing on health information
    technology. As you know, VA and DOD are engaged in efforts to
    share electronic medical information, which is important in
    helping to ensure that active-duty military personnel and
    veterans receive high-quality health care. Also important in
    the face of current military responses to national and foreign
    crises, is ensuring effective and efficient delivery of
    veterans' benefits. This is the focus of VA's development of
    the Veterans Service Network (VETSNET), a modernized system to
    support benefits payment processes.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Ms. Koontz appears in the Appendix on
    page 48.
    ---------------------------------------------------------------------------
        For the last 8 years, VA and DOD have been working to share
    health information. The Department's long-term goal is
    ambitious: Two-way, seamless sharing of virtual medical
    records. In a virtual medical record, data are not just
    displayed as in a paper record, but are computable--that is,
    they can trigger actions such as alerting clinicians of drug
    allergies. Virtual medical records are, thus, important for
    improving health care and patient safety, and they are the
    foundation of the modern health information systems that both
    Departments are currently developing.
        Besides working on long-term goals for future systems, VA
    and DOD are implementing two near-term demonstration projects
    that exchange limited data between their existing health
    information systems. One of these projects has achieved the
    two-way exchange of health information on patients who receive
    care from both Departments. The second has implemented an
    application that electronically transferred laboratory work
    orders and results between the Departments. According to VA and
    DOD, these projects have enabled lower-cost and improved
    service to patients by saving time and avoiding errors.
        In pursuing their longer-term objectives, the Departments
    have also made progress, but they still have much to do. In
    response to earlier GAO recommendations, VA and DOD have taken
    actions such as establishing a project management structure and
    designating a lead entity with final decisionmaking authority.
    Also, at the end of the month, they plan to begin a pilot to
    share computable data for the first time, specifically
    outpatient pharmacy and medication allergy information. This
    will support drug interaction checking and drug allergy alerts.
        However, the Departments have experienced delays in their
    efforts to begin this exchange, originally scheduled for
    September 2005. According to officials, the delays occurred
    because implementing standards for pharmacy and drug allergy
    data were more complex than originally anticipated. In
    addition, the Departments have not yet implemented our
    recommendation that they develop a project management plan that
    clearly defines the technical and managerial processes needed
    to satisfy project requirements. The lack of such a plan
    increases project risk, including the risk of further delays.
        VA has also been working to modernize the delivery of
    benefits through its development of VETSNET, but the pace of
    progress has been discouraging. VETSNET was originally
    initiated in 1986 to modernize VA's benefits delivery network,
    which the Department relies on to make benefits payments.
        In 1996, after numerous false starts and approximately $300
    million in cost, VA revised its strategy and narrowed its focus
    to modernizing only the compensation and pension system. In
    earlier reviews, we made numerous recommendations to improve
    this program's management, including a 2002 recommendation that
    VA develop an integrated project plan.
        In 2005, the VA's CIO became concerned by continuing
    problems with VETSNET and arranged for an independent
    assessment of the Department's options for the system,
    including whether it should be terminated. This assessment
    concluded that although VETSNET faced many risks, these from
    management, organizational, and program issues rather than
    technical barriers. According to the assessment, terminating
    the program would not solve the underlying problems, which
    would continue to hamper any new or revised effort.
    Accordingly, the recommendation was made that the program not
    be terminated since its goals were as important as ever, but
    instead that the Department take an aggressive approach to
    dealing with these management and organizational problems while
    continuing to work on the program at a reduced pace. In this
    way, VA could make gradual progress on VETSNET while it made
    necessary improvements to its capabilities in system and
    software engineering and in program management.
        In response to the independent evaluator as well as our
    recommendation, VA is now developing an integrated master plan
    for the compensation and pension system, which it plans to
    complete in August. This is a first step toward addressing the
    problems that have hampered the program. Until these are
    solved, it is uncertain when VA will be able to end its
    reliance on its aging benefits technology.
        This concludes my statement. I would be happy to answer
    questions at the appropriate time.
        Senator Carper. Good. And there will be some. Thank you
    very much, Ms. Koontz.
        Mr. Hendricks, you are next. Thanks.

    TESTIMONY OF CARL E. HENDRICKS,\1\ MILITARY HEALTH SYSTEM CHIEF
            INFORMATION OFFICER, U.S. DEPARTMENT OF DEFENSE

        Mr. Hendricks. Ranking Member Carper, thank you for the
    opportunity to come in and discuss the significant achievements
    we have achieved within the Department of Defense as we
    leverage health information technology to enhance care for our
    beneficiaries, both in combat and back here in the States. I
    also appreciate the opportunity to come in and share with you
    the work that the DOD and the Department of Veterans' Affairs
    are doing in exchanging electronic health information, and in
    an incredibly complex spectrum of care.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Mr. Hendricks appears in the Appendix
    on page 77.
    ---------------------------------------------------------------------------
        In the DOD, we are driven to ensure that our soldiers,
    sailors, airmen, and marines receive the same quality health
    care in the combat zone that they receive in our brick-and-
    mortar hospitals here in the States. Evidence of our success
    was noted by the Army Surgeon General, General Kiley, in recent
    testimony in his comment, in which he stated, ``We have
    recorded the highest casualty survival rate in modern history,
    with more than 90 percent of those wounded surviving, many
    returning fully fit for continued service.''
        One of the components of achieving this level of success is
    the incorporation of health information technology. As a mark
    of this success, since January 2005, we have captured
    electronically the encounters of more than 450,000 encounters
    in the combat zones, and those encounters have been transmitted
    back to the States for Clinical Data Repository and are being
    included in the electronic health records of the Service
    members.
        We are using the latest technologies in doing that. We are
    using handheld devices. Every medic in the combat zone carries
    a handheld device, and at the point of injury or illness,
    captures that encounter electronically. When they get back to
    the aid station, that is synched into the health system at the
    aid station and transmitted back to the States to become a part
    of that electronic health record.
        As a point of fact, just last month we captured
    electronically 38,212 encounters from the combat zone, which
    are back in the Clinical Data Repository today. Other programs
    of success include the Joint Patient Tracking Application,
    which allow commanders and patient care providers to track the
    wounded Service members through the evacuation chain. More than
    4,000 users of this application are using it today, and since
    2003, we have tracked over 120,000 injured soldiers, sailors,
    airmen, and marines through the evacuation chain.
        We are also using leading-edge technologies. In those cases
    in which soldiers, sailors, or airmen are evacuated before the
    synchronization of data can take place, research is ongoing for
    electronic dog tags to allow the information to be captured on
    the device, stored on the soldier's body, and go back with them
    during the evacuation chain. To date, we have tested this on
    more than 9,000 Stryker Brigade soldiers in the combat zone.
    Development continues on that device.
        One of the key cornerstones of our success in health IT is
    our electronic health record, AHLTA. It provides day-to-day
    functions of delivering and documenting health care for our 9.2
    million beneficiaries. Today, we have deployed the Armed Forces
    Health Longitudinal Thechology Application (AHLTA) to over 115
    of our 138 sites and will have full deployment of AHLTA by the
    end of this calendar year. What it means is no matter which DOD
    hospital around the world a patient goes to, our providers will
    have access to their electronic health record.
        I mentioned earlier about ensuring continuity of care from
    one level of care to the next being critical, and especially
    true for our Service members that are transferring to the VA.
    Ms. Koontz mentioned the Federal Health Information Exchange,
    which is a one-way push of data from the DOD to the VA. As you
    spoke, you carried your records with you to the VA. We have
    pushed the electronic records of over 3.5 million Service
    members to the VA at time of their separation. Of those, 2.8
    million have presented to the VA for care, treatment, or claims
    adjudication.
        We also have a Bidirectional Health Information Exchange,
    which enables real-time sharing of allergy, outpatient
    medication, demographics, lab, and radiology data. It is
    currently deployed to 14 DOD sites, with more deployments going
    this year.
        The DOD Clinical Data Repository/VA Health Data Repository,
    referred to as ``CHDR,'' is established an interoperability of
    computable data between the two clinical data repositories--the
    Clinical Data Repository of the DOD and the Health Data
    Repository of the VA. That has been tested in the lab
    environment and will go live this month in El Paso, Texas, for
    on-site testing.
        Senator Carper, I would like to thank you again for the
    opportunity to discuss our progress. The DOD holds a strong
    commitment to leverage electronic health information in support
    of the Nation's heroes and families. Much has been
    accomplished, and the groundwork has been laid for even greater
    progress in the future.
        This concludes my comments, and I stand subject to your
    questions.
        Senator Carper. Thanks very much for your comments.
        Before I recognize Dr. Kussman, one of the incidents that
    occurred about a month and a half ago now in Iraq, actually in
    Fallujah, involved a marine who is a former member of my staff,
    my campaign staff and my Senate staff. He was shot in Fallujah
    by a sniper's rifle, and it was buried right in his neck, right
    by his Adam's apple. It missed it, severed his carotid artery
    completely, nipped his jugular vein, came out right by his
    spinal cord, missed it. And he ran to get behind some cover,
    and one of his colleagues, marine colleagues, radioed for help
    but got a Navy corpsman, found him not far away in a Humvee.
    And the Navy corpsman came, administered first aid, they got
    him to a Fallujah hospital within less than 15 minutes. A
    surgeon went to work on him and was able to put his artery back
    together to save his life, flew him to Germany, flew him to
    Bethesda, and about 2 weeks ago he walked out of Bethesda
    Hospital alive. And he has impairment of his shoulders, has
    nerve damage that does not allow him to move his right
    shoulder, but thank God he is alive. And last week, the
    Commandant of the Marine Corps in the building just next door,
    the Russell Building, gave him the Purple Heart. It was great,
    very special. But just from our own family here in the Senate,
    having almost lost one of our own, we are just deeply grateful
    for the extraordinary medical care and attention that he
    received on the spot, just like that, and it literally saved
    his life. I know he is just one of many, so thank you.
        Dr. Kussman.

     TESTIMONY OF MICHAEL KUSSMAN, M.D.,\1\ DEPUTY UNDER SECRETARY
     FOR HEALTH, U.S. DEPARTMENT OF VETERANS' AFFAIRS, ACCOMPANIED
        BY ROBERT HOWARD, SUPERVISOR, OFFICE OF INFORMATION AND
            TECHNOLOGY, U.S. DEPARTMENT OF VETERANS' AFFAIRS

        Dr. Kussman. Thank you, and good afternoon, Ranking Member
    Carper. On behalf of the Department of Veterans' Affairs, I am
    pleased to take this opportunity to discuss the comprehensive
    electronic medical record used by VA to provide world-class
    medical care and to support our veterans. I am also pleased to
    discuss the significant progress we have made toward the
    development of secure, interoperable technologies to achieve
    sharing of health data within the Department of Defense. VA and
    DOD are working closely together to ensure the seamless
    transition of medical services for our men and women returning
    from Operation Iraqi Freedom and Operation Enduring Freedom.
    ---------------------------------------------------------------------------
        \1\ The prepared statement of Dr. Kussman appears in the Appendix
    on page 89.
    ---------------------------------------------------------------------------
        VistA, or the Veterans Health Information Systems and
    Technology Architecture, is recognized as the most
    comprehensive electronic health record in use anywhere. It
    allows VA to provide better, safer, and more consistent care to
    more than 5.3 million veterans in all VA hospitals, outpatient
    clinics, and nursing homes--more than 1,400 points of care all
    across the Nation. Using VistA, doctors and other clinicians
    can easily pull up computerized patient data, including images.
    Clinicians can use the system to update a patient's history,
    place orders, and review test results. They can quickly review
    information from previous visits, access clinical guidelines,
    and view medical publications to find the latest treatments in
    medication. All of this information is available wherever the
    patients are seen--in acute settings, clinics, exam rooms,
    nursing stations, and offices. Tools such as electronic health
    care prompts, computerized order entry, and barcode-assisted
    medication administration systems have largely eliminated
    transcription and medication errors while strengthening patient
    safety.
        VA is proud of its leadership role in health information
    technology, and we are continuing to enhance VistA. We are now
    working to supplement the capabilities of VistA to capture the
    advances of new and emerging health care technology and
    improved care for veterans. The next generation of VistA will
    have the flexibility to better support integrated ambulatory
    care, home-based health care, tele-health, and improved
    response times. Next generation VistA will strengthen the
    existing privacy and security protections, and it will support
    a more robust sharing of patient data with our partners in the
    Department of Defense and other care providers. Like the
    current version, next generation VistA will remain in the
    public domain and available to other Federal agencies and
    providers in rural and underserved communities.
        VA and DOD efforts to achieve interoperable health
    technologies are guided by the VA/DOD Joint Electronic Health
    Records Interoperability Plan--known as JEHRI. Since we began
    implementation in 2002, we have steadily progressed toward the
    final goal of exchanging standardized computable health data
    between our Departments. The first phase of the plan, FHIE, as
    you heard, resulted in the development of a one-way flow of
    electronic DOD health information to the VA, which allowed our
    clinicians to view all pertinent DOD historical electronic
    information. Later, we developed the capability to support the
    real-time bidirectional exchange of electronic medical records
    or data between DOD and VA hospitals and clinics. The
    bidirectional system delivers electronic outpatient pharmacy
    data, laboratory reports, radiology reports, and food and drug
    allergy information.
        The next phase of our plan includes the sharing of
    computable allergy and pharmacy data between our next
    generation systems. Both VA and DOD are in the process of
    working together to ensure that our next generation data
    repositories now under development are interoperable and
    capable of sharing standardized data. Thus far, we have
    demonstrated this capability in a laboratory test environment
    and are preparing to begin production testing of the software
    in July 2006.
        The Departments also are working together as VA modernizes
    its existing imagine solution and DOD explores acquisition of
    new imaging technology. The Departments are actively exploring
    a collaborative imaging solution that will use VA technology to
    support shared access to images such as radiologic studies in
    both DOD and VA facilities. The bidirectional exchange of
    electronic health data between different health information
    systems is a monumental accomplishment. The work is dependent
    upon the adoption and implementation of health data and
    communications standards. VA and DOD are breaking new ground in
    this area and remain at the forefront of health data
    collaboration and exchange activities within the Federal
    Government.
        I now wish to briefly discuss the existing protections that
    ensure that our DOD/VA health data exchange initiatives are
    secure and fully protect the personal health information of our
    veterans and military beneficiaries.
        Our sharing systems are in full compliance with the VA
    Office of Cyber Security policies and DOD Information Assurance
    policies. These projects also comply with the privacy
    regulations contained in the Privacy Act and the Health
    Insurance Portability and Accountability Act meant to protect
    the unauthorized use or transmission of personal health
    information. To ensure the highest level of protection for
    these clinical data, we employ a double-encryption method using
    a hardware-based Virtual Private Network (VPN). After having
    passed an initial and subsequent review of security
    protections, our systems framework received a VA-issued renewal
    of the Authority to Operate in December 2005. DOD information
    security officers concurred with and accepted this rigorous
    review. As sharing partners, VA and DOD take very seriously our
    duty to protect the sensitive health data entrusted to us in
    the course of caring for veterans and military beneficiaries.
        Health information technology is not about technology, but
    it is about improving the quality of care and health outcomes
    for patients. VA is fully committed to ongoing collaboration
    with VA to do just that.
        Sir, this completes my testimony, but my colleagues and I
    are happy to answer any questions that you or the Chairman, if
    he returns, or any other Member who comes have.
        Senator Carper. OK, good. Dr. Kussman, thank you very much.
        Dr. Ross Fletcher, welcome, sir. Thank you. We are glad you
    are here. What are you going to show us today?

      TESTIMONY OF ROSS FLETCHER, M.D., CHIEF OF STAFF, VETERANS
                     MEDICAL CENTER, WASHINGTON, DC

        Dr. Fletcher. Thank you. What I plan to show is the
    electronic health record that we use at our hospital and across
    the system everywhere.
        Senator Carper. Tell us a little bit about your hospital,
    if you would.
        Dr. Fletcher. We can see you from our hospital. It is
    straight up North Capitol Street, and I am at the VA in
    Washington, DC, and we are tertiary care hospital that does
    cardiac surgery and a wide range of activities.
        We have been involved in the IT process for many years and
    have often instituted things first in our place, but we accept
    everything that has been done elsewhere in the system. So we
    now have a system that we feel very proud of and we enjoy a lot
    and tend to demonstrate to lots of people who come by.
        Senator Carper. Good. Well, thanks. We are glad you are
    here and look forward to your presentation.
        Dr. Fletcher. The lights can be dimmed.
        Senator Carper. Can the lights be dimmed?
        Dr. Fletcher. It would be nice.
        Senator Carper. Apparently, if we dim the lights, then we
    are unable to record.
        Dr. Fletcher. That is fine. I think that shows up
    relatively well. This is the way the record shows up when we
    open it up to a given patient. We have an active problem list,
    active medications. We have a list of their allergies and
    postings and their vital signs.
        We have tabs that are very user friendly. The nice thing
    about the system at the moment is the intern or resident can
    come, without knowing anything about the system, and be
    operating it very quickly, maybe 2 hours of training at the
    most, and be taking care of patients that day, that evening,
    and liking it better than the systems they have been on in the
    past. And that we have shown many times.
        If we go across the tabs, we see the problem list so that
    the problems can be changed at will. We have medications and
    all of the orders are done in the system. We are able to do
    inpatient, outpatient medication orders, imaging orders. If I
    simply click on ``Imaging,'' you can see that if I want general
    radiology, I can get it. Chest, PA, and lateral is now being
    ordered. If I say accept the order, it is in my Radiology
    Department. The patient goes down and gets his X-ray, just
    having told the clerk at the desk who he is.
        If I want to order medications, I simply order these. I
    have order sets as well, which are typical for our hospital,
    but we are using the standard software across the system.
        If I go into ``Notes,'' I can immediately see the notes
    that are available. I can see a list of all the notes that are
    here. And if I open up our imaging system by, in this instance,
    clicking down here, you can see that we have EKGs, X-rays on
    the patient, as well as any other pieces of data.
        If I move on to the discharge summaries, you can see that
    those are listed. If I go into ``Labs,'' we have the ability to
    look at each lab report that has come through, like you might
    see in a paper record. But, more importantly, I can take that
    information into a worksheet and ask for the data for all time
    for this particular patient. It is now in a spread sheet where
    I can easily see it in a graphic format, the sodiums being
    quite low when the patient first came in.
        If I want to see any of the other values, I can see that
    the hemoglobin was also quite low, and the white count was
    quite high. This patient had an elevated white count in the
    face of paralysis on the right leg first and then on the left
    leg second. He had been in another hospital for 2 months and
    was sent over to us. We did draw a Lyme disease titer, found
    out that he had deer tick disease, gave him the appropriate
    antibiotic, dropped his white count down, and he was able to
    walk in about 3 months.
        You can see that when he came in, his weight was quite
    low--again, we go to ``All Results``--and came gradually up to
    normal weights, but started to have other kinds of problems out
    over to the right.
        I can expand that by simply clicking my zoom button, and he
    came in with a pleural effusion on his right side. I will move
    this over slightly. And when we saw the pleural effusion--this
    is a pleural effusion he had on the other side. As I go up and
    look at the X-rays, you can see that I can see fairly marked
    changes. Indeed, he had a pleural effusion on the other side,
    which I can simply put up next to that X-ray and compare.
        When he was on the left side, I simply asked him how he
    slept. He said, ``I sleep on the left side.'' That fits. We
    thought he had heart failure. Usually you have effusions on
    both sides. But I knew that he had one on the right side
    before, and I asked him if he always sleep on his left side. He
    said, ``No. I used to sleep on my right side until I had a hip
    fracture,'' which you can actually see by the X-ray in place
    here. And the fix for that was to put a hip nail in place. And
    you can see that comparison.
        The heart failure that he had was easily elucidated by an
    MRI. We saw when we did an MRI that his heart out laterally was
    moving quite well, but the heart on the septum was not, and
    that is because his electrocardiogram showed left bundle branch
    block. I will show you one more view.
        Senator Carper. I am sorry. What did it show?
        Dr. Fletcher. Left bundle branch block. Left bundle branch
    block is an electrocardiographic feature which is seen--I will
    move this over--right here, and it had gotten wider and wider
    and wider. And that prevented the septum from moving in the
    right direction. It moved towards the right heart instead of
    the left heart and caused the heart failure, which we can see
    easily on this other film. Notice that if I put the arrow on
    the septum, which should be moving to the right, in actual
    fact, if anything, it is moving over to the other side.
        So this man was brought in and treated. At any time, at any
    point of care, we could see all of these images and make our
    decisions. We also could see any images that he might have had
    anywhere else in the VA system because we have remote image
    view. And, indeed, we had him followed in his home, and these
    particular very tight values that you see were taken on a scale
    in his home. They were digitally transmitted to the hospital
    and moved into his records. So I can see his weight when he was
    in the hospital and when we were taking off his effusions, but
    I also can see every weight at home, and notice that we did not
    bring him back into the hospital because once he got up close
    to this other weight, we would increase his lasix and bring the
    weight down. So we have home-based care for this particular
    patient.
        Many of our other patients, we are able to put them on a
    program we call My HealtheVet, and they have a cover sheet.
    Everything in the record on the thousand patients we have in
    the pilot site is being downloaded. Notice they have a problem
    list, they have progress notes that you can see as a list, and
    at home they can actually enter in their own weights and follow
    those along. They can also enter in their own blood pressures,
    which you can see that they follow graphically as well.
        They frequently are putting in comments, like they had too
    much salt, when the blood pressure gets up, so they are
    treating themselves very nicely and taking the role of the
    clinician between the visits. We might see them every 3 months,
    but they see themselves every day and are taking these values.
    When they get high, we are automatically triggered at our
    hospital to see them so that we have a very nice patient-
    centered record. Everything that happens to the patient goes in
    one record. Anytime the patient is seen, we see what's happened
    at home, what's happened in the outpatient clinics, what's
    happened in the hospital, and can correlate those pieces of
    information for the best possible care for the veteran.
        Senator Carper. Good. Thank you very much. That is
    impressive.
        Let me start off with a question of our friends from the
    VA. Just if you will kind of go back in time and give us some
    idea of the genesis of the VA's revolutionary work with respect
    to IT, harnessing IT in the delivery of health care. How did it
    start?
        Dr. Kussman. Thank you for the question.
        Senator Carper. What sustained it to the point that we have
    just seen today with Dr. Fletcher's presentation?
        Dr. Kussman. Yes, sir. One of the exciting things about the
    historical development of the VA's electronic health record is
    it started with the people who are in the foxhole providing the
    care. One of the things that we have seen and one of the
    resistances for the deployment of an electronic health record
    around the country--and I concur wholeheartedly with the
    Chairman's comments that he made--a lot of times physicians
    resist things happening to them, especially if it is pushed on
    them from someplace else.
        Senator Carper. It is not just physicians, too. It is
    nurses, it is others.
        Dr. Kussman. Well, society in general, perhaps. But, in
    truth, a lot of the case histories where the implementation of
    electronic health record in the civilian community have failed
    when the providers themselves, the doctors and nurses,
    particularly the doctors, have not been brought into the system
    right from the beginning and felt confident that this was
    value-added to them and their patients.
        One of the strengths for us has been that we were able to
    develop that from the users, and over a period of time this
    evolved to the point where everybody learned from everybody
    else. There were developments made and ultimately cascaded into
    what we believe is the premier electronic health record in the
    country.
        I might ask Dr. Kolodner, who works in Information
    Management for us, to make a comment on that if you don't mind,
    sir. And tell us again your affiliation.
        Mr. Kolodner. I am the Chief Health Informatics Officer in
    the Veterans Health Administration, Department of Veterans'
    Affairs.
        Senator Carper. All right. Well, welcome.
        Mr. Kolodner. Thank you. Yes, the opportunity to work
    together hand in hand with our IT colleagues has been really
    the characteristic that allows us to have succeeded as well as
    we have with both the delivery of the software but, even more
    importantly, the acceptance of it and the growth of it over
    time. So we started this 20 years ago. Ten years ago, we
    upgraded our system to have the application that you saw here
    today, which we call CPRS, and that point-and-click system was
    one that just was very easy for our clinicians to use and to
    accept.
        As we put it out, the doctors and nurses and psychologists
    and social workers around the country would work with us and
    provide back suggestions for how to improve it. We are
    currently on version 26 of this software, and it has been
    something that we find is extremely widespread so that, for
    example, 81 percent of our encounters, our patient encounters,
    have an electronic note within 24 hours.
        Senator Carper. Say that percentage again?
        Mr. Kolodner. Eighty-one percent within 24 hours, and we
    have 57 million encounters per year. So this is something that
    is used in all of our hospitals, clinics, and long-term care
    facilities, the same software. And our providers are the ones
    who use it and also provide suggestions on how to improve it
    and really have a sense of ownership as we roll it out.
        Senator Carper. In terms of lessons learned from what the
    VA has gone through over the last--it sounded like 20 years. I
    thought it was more like 10 years, but it sounds like it is
    longer than that. But in terms of the lessons learned within
    the VA for the rest of us, for the rest of us within
    government, I think especially about Medicare and Medicaid
    where costs are exploding, and we cannot pay for those already;
    we cannot afford those already. And the costs are getting
    larger. The boomers are heading toward retirement territory. So
    the pressure is going to be even greater financially on us.
        But what are some of the lessons learned as we attempt to
    harness IT, health IT, and bring it to other parts of our
    Federal Government?
        Mr. Kolodner. There are a few things that certainly we are
    able to bring forth, as well as our colleagues at the
    Department of Defense, where they also have an extensive use of
    their system as well. One of the things is that it must be
    something where there is a partnership by the end users with
    the people who are providing the system or requiring the
    system. It also is something where the alignment of payer-
    provider incentives is very important. We are able to gain the
    benefit of the system--of having the IT system in place because
    we give better quality care to our veterans; we are able to see
    that as providers. That is very reinforcing. And we also have a
    savings by not having unnecessary tests or unnecessary
    hospitalizations.
        If a provider is asked to have a system and there is no
    sharing of that overall savings within the system, then it does
    create a barrier, as the Chairman pointed out. And so we need
    to look at how to make sure that those incentives are there in
    place.
        Senator Carper. How might we do that?
        Mr. Kolodner. I think that is one of the challenges that we
    are wrestling with as a Nation, and certainly Secretary Leavitt
    and the AHIC are looking at how to provide the business case,
    how to provide those right incentives, and how to make sure
    that the barrier for entry is low enough that we, in fact, can
    bring the Nation along, either by a pull from the providers or
    by also educating the consumers so that they can provide a push
    and indicate to their clinicians how important it is for their
    clinicians to have the electronic health record since most of
    us don't receive all of our care from one particular provider.
    Even in VA, we estimate that 40 percent of the veterans we
    treat each year get care outside of VA. So the
    interoperability, whether it be with the Department of Defense
    where we have several hundred thousand veterans who get care
    each year, both at VA and DOD, or whether it is in the private
    sector, where we have additional hundreds--actually, millions
    of veterans who get care outside of VA. The interoperability is
    critical for us.
        Dr. Kussman. Sir, I might add to that that the Chairman's
    comment about the economic reality of--even in his group he was
    talking about that everybody is waiting because you want to
    know the standards or you do not want to invest in something
    that you will have to reinvest in. I am the VA's representative
    to the House of Delegates at the American Medical Association,
    and just talking to people in the private sector, a lot of that
    is discussed because they want to know what the value-added for
    them is, and they certainly do not want to make a significant
    economic commitment, and then find out that they have to do it
    again a year or two or three from now.
        So one of the incentives I think would be--and this is just
    talking personally--trying to figure out what those standards
    are as soon as we can get them out and assure people that their
    investment will be worth it and have some sustaining value for
    at least a finite period of time.
        Senator Carper. Has there been an effort to take the work
    that you do in the VA and to be able to share it with other
    providers outside of the VA? I believe the answer is yes, but
    talk about that effort. How has it succeeded? Where has it gone
    well and maybe where has it not gone well?
        Mr. Kolodner. There are two types of efforts. Because our
    system is public domain, we actually have our code posted on
    the Web, and it has been downloaded and used by other entities.
        Senator Carper. By a lot of other entities?
        Mr. Kolodner. A few other entities. The issue there is
    support, and one other aspect of success is that this is not
    like installing a word processor or a spread sheet. It is a
    complex system. It has various standards. It needs support of a
    vendor or an organization to make sure that this is successful.
    And until recently, that was not an infrastructure that was
    available to support the VistA system. That is not within our
    mission or our funding. So, recently, there are other companies
    that have come forth and are supporting VistA in non-VA
    settings.
        In addition, one other effort that is going on in the
    Federal Government is one that HHS has undertaken through the
    Centers for Medicare and Medicaid Services, CMS, and that is a
    project called VistA Office EHR, and they are responsible for
    that, so I would need to turn to HHS. I don't know whether Jodi
    is in a position to comment on it or whether she would want to
    defer.
        Senator Carper. Ms. Daniel, would you care to comment on
    that?
        Ms. Daniel. Sure. I cannot talk in too much detail about
    it. It is a CMS project, but basically the----
        Senator Carper. How would you explain what you are talking
    about in laymen's terms so that anybody who might be listening
    or watching would understand it.
        Ms. Daniel. Sure. There has been some interest in using the
    VistA system for physicians' offices, but there are very
    different types of needs in a physician's office compared to an
    inpatient setting. So CMS has been working toward modifying the
    VA system in order to make it useful for a physician's office.
        They are currently doing a demonstration right now. It is
    in beta testing. They are trying to see if this is something
    that is workable, if it is something that is useful in a
    physician's office, and they are still in the testing phase
    right now. We are planning to work with CMS to see what kind of
    results they find through that process.
        One of the significant issues that we see, though, is that
    there is an expense of the technology, but there is also needs
    to have training and ongoing support for use of an electronic
    health record system, which also can be a challenge in a small
    physician's office. So while this may be one possible approach
    that can help with adoption, there are many other possible
    approaches, and there are some challenges that still lie ahead.
        Senator Carper. All right. Thank you.
        I think I would like to go to our friends from the
    Department of Defense, and talk to us, if you will, about the
    effort to sort of better interface between DOD active duty and
    the VA and how those efforts have gone. If you could just talk
    about that a bit, I would appreciate it.
        Mr. Hendricks. Yes, sir. We have worked a number of years
    with the VA and sharing data between the two Departments. The
    approach that was taken was to basically break down the type of
    data that the providers are going to need. One of the critical
    decisions that was made early was to separate it into what is
    necessary from a viewable standpoint, what data do you simply
    need to see, versus what data needs to be computable.
        The Bidirectional Health Information Exchange (BHIE) is a
    huge breakthrough for both Departments, which allows a
    provider, when a retiree who is disabled and is getting care
    from the VA goes to either the DOD or the VA site where they
    have BHIE, that provider can pull up the records from the other
    Department and actually view it. When the patient leaves, the
    data goes away, so, therefore, you do not have the security
    challenges with that. So making viewable data has been worked,
    allowing us to expand many types of data sets.
        But there is also computable data that is necessary.
    Computable data and sharing that is significantly more
    difficult in that you have to map the data elements from both
    systems such that the computer can understand the terms and the
    data elements that are coming across. And that is the work that
    we are doing in El Paso, Texas, as we speak.
        What this allows is for medications and for allergies, so
    instead of having the provider understand that I may be
    allergic to Tylenol and if they are giving me codeine, to
    understand that that particular codeine has Tylenol as a
    carrier with it, the computer automatically knows because the
    data is computable and can give the alert to the provider.
        The computer also know that there are secondary allergies,
    and during the computable data match, it mirrors both systems.
        So, again, I think the biggest success we have achieved is
    by looking at the types of data that we are looking to exchange
    and what is necessary as a part of that exchange.
        Senator Carper. Thank you.
        Some of us in the Senate are contemplating introducing
    legislation this summer that would require insurance companies
    that cover Federal employees or families or dependents or
    Federal retirees to require within a period of a year or so for
    those health insurance companies to provide electronic health
    records for Federal employees or Federal retirees and our
    family members.
        Would any of you care to comment on the wisdom of that?
    Good idea? Bad idea? Well-intended but maybe flawed? Or if you
    have some advice as to how we might go about and how we might
    craft the legislation, I would appreciate that. Anybody at all.
        Dr. Kussman. I guess no one else is volunteering, so, sir,
    I think that from the VA's perspective, we are looking at
    aggressively, as we buy health care in the community, and
    looking at our contracts and looking at how we do that, to try
    to be sure, as much as possible, and try to write this into the
    potential future contracts, that whoever we buy the care from
    would have the ability to accept and transfer electronic
    information.
        The challenge, the obvious one, is that does not exist in
    many places around the country. So when you are trying to get
    care, how do you do that? And so I think it is a challenge that
    really goes back to the original thing. How do we encourage the
    health care community around the country to want to become part
    of an electronic record to better the care for our patients as
    well as the interoperability and transfer of information.
        Senator Carper. Let me hear from some others. Mr.
    Hendricks.
        Mr. Hendricks. Yes, sir. In writing contracts for
    electronic health records, I think one of the challenges we are
    going to run into will be how do you write the contract. Do you
    write the contract such that you keep them current with each
    standard? Which is the released number of standards could be
    difficult to have the audit trail to ensure that they are in
    compliance with that? The work of the Office of the National
    Coordinator and the American Health Information Community, I
    think, is taking this a long way down a path that could make
    that a little easier. They have established a certification
    process for electronic health records by requiring those
    contracts to state that you must be compliant with the
    certification process. I think it would make it far easier for
    us to then audit the contracts in place.
        So, I would simply suggest as long as the language doesn't
    focus on standards per se and focuses on certification, it
    would make it a lot easier for implementation.
        Senator Carper. Thank you. Ms. Daniel.
        Ms. Daniel. Yes, there are two points I wanted to make with
    regard to this.
        First, we recently had, as I had mentioned, recommendations
    made by the American Health Information Community, and one of
    those recommendations was to try to consider ways to
    incorporate standards and certification into our contracts, as
    some other folks had mentioned. So we are thinking now about
    how we can include those kinds of processes and standards in
    the contracts that we currently have, and we have a Health IT
    Policy Council that has represented us from DOD, VA, and OPM,
    as well as other Federal agencies, that are sitting around the
    table together to try to figure out how to address that type of
    issue as well as other issues related to health IT.
        The one point that I would like to note and that I would
    want to caution is that using health plans may not be the best
    approach because claims data may not be complete and is often
    delayed. It is not real-time data like clinical data would be.
        So there are some concerns about claims data as opposed to
    clinical care data that are important to consider, and also
    focusing on the health plans rather than the clinicians has
    some consequences to it.
        So I just wanted to raise that point as you are thinking
    about that legislation
        Senator Carper. OK, good. If we are interested in some
    further guidance, could we come back to you?
        Ms. Daniel. Absolutely.
        Senator Carper. All right. Good. You are a Federal
    employee, aren't you?
        Ms. Daniel. Yes.
        Senator Carper. Any input and guidance you could give us,
    we would be grateful.
        Ms. Koontz, could I direct the next question to you? I may
    have mentioned in my opening statement, I believe, that the
    health care providers outside of the VA and the DOD can learn
    some valuable lessons from these two Departments about how to
    best implement and use health information technology. Do you
    also believe that there are some lessons that can be learned
    from these Departments? And if so, do you want to share those
    with us?
        Ms. Koontz. I do. In fact, GAO has previously reported on a
    number of lessons that were learned from the VA/DOD
    interoperability experience that we thought might be applicable
    to the larger effort to develop national health information
    records. And among the lessons learned that we mentioned are
    many of the ones that Dr. Kolodner already previously went
    over, and I would be happy to submit the whole list for the
    record.
        Some of the ones, though, that we specifically talked about
    was the interaction with stakeholders and the need to bring
    those together in order to develop the initiative.
        Senator Carper. Is that something that needs to be done
    early on?
        Ms. Koontz. Absolutely. As early as day one. And, also, I
    think we also emphasize the importance of----
        Senator Carper. Whenever I am trying to get somebody to go
    along with me if I have an idea, I try to first convince them
    it was their idea. [Laughter.]
        And that they are convincing me to go along with their
    idea.
        Ms. Koontz. I do not know if our lessons learned went that
    far.
        Senator Carper. I understand.
        Ms. Koontz. I think the other thing that we mentioned, too,
    as well as many others, was the importance of adopting common
    standards, terminology, and performance measures, in developing
    the health IT records.
        Senator Carper. Talk to us just as a follow-up to that
    about the development of the standards. Legislation has
    actually been introduced in the Senate, I think last year,
    offered by Senator Frist, Senator Enzi, Senator Clinton, maybe
    all of the above, and that legislation has passed the Senate, I
    think unanimously and is over in the House. I do not know that
    the House has focused much on it.
        Ms. Daniel, is that something you are familiar with? I see
    you nodding your head.
        Ms. Daniel. Yes, I am.
        Senator Carper. Could you talk to us a little bit about
    what the Senate has done and what the House might be
    contemplating?
        Ms. Daniel. As you had mentioned, the Senate has passed a
    health IT bill last fall. I believe that the House has a bill
    that has passed out of committee, out of both Ways and Means
    and Energy and Commerce.
        Senator Carper. How do the two approaches compare and
    contrast? Can you help me with that? And if somebody else who
    might be sitting in the row behind any of you would like to
    share their insight, you are welcome to step to the table, and
    we will hear from you as well. Anybody who has special
    insights?
        Back to you, Ms. Daniel. If you are able to compare and
    contrast the legislation, the two approaches, that would be
    fine.
        Ms. Daniel. I am not really prepared to do that today. I
    apologize.
        Senator Carper. If you could just do that for the record,
    that would be fine. That is all right. I do not expect you to
    know everything.
        One of the things that has been mentioned is training. I
    was in a health care setting the other day--actually, last
    week, and the folks that were taking me through said--it was
    actually a nursing home, one that had some people in reasonably
    good health and some people in very bad health. And they said
    about half the people who come there to live go home and about
    half who come there to live, live there for the rest of their
    lives.
        They indicated to me that it was difficult to get their
    staff to accept and to literally be trained on using the
    systems that had been introduced, and they actually talked
    about the reluctance of, in this case, some of the nursing
    staff not wanting to type information into the system.
        I suggested to them to maybe consider asking Delaware
    Technical Community College to consider offering training
    programs for folks in all kinds of health settings to use
    systems of this nature if the in-house training was not good
    enough.
        When I was governor, we tried to harness the technology and
    put it in our schools, a lot of computers in our classrooms. We
    sought to get our teachers to use them and try to relate our
    academic standards to the technology and to use the Internet
    and so forth to bring the learning into the classroom. We found
    that there is a lot of reluctance. We had a better ratio of
    computers to students than any State in America. We had a
    reluctance on the part of the teachers to use the stuff, except
    for the new teachers, the ones recently out of college who were
    familiar with the technology, comfortable with the technology.
        Eventually what happened was we contracted with the
    Delaware Technical Community College, and they started training
    some of the veteran teachers, and we had the younger teachers
    who came out of colleges and began teaching, and they sort of
    trained the veterans. And between the two, we finally got to
    the point where we are doing a much better job of harnessing
    technology to promote learning in the classrooms.
        But just in terms of training doctors and nurses--not just
    registered nurses but LPNs and others--to use these systems,
    what seems to be working and maybe what does not work?
        Mr. Kolodner. What we have found over the years is that you
    really had to have a tremendous amount of help, what we call
    ``help at the elbow,'' help right there early on. Simply
    putting in the technology, doing a quick class, and then
    walking away does not help people to change that practice and
    to get comfortable with the system.
        So what we end up doing is having people deployed
    throughout the facility, whether that is inpatient or
    outpatient settings, to be there, especially early on when the
    system first goes up, to answer any questions, to go around and
    check with the users to see what are those little things that
    they have not gotten comfortable with yet or that they have not
    figured out how to work with very smoothly, and for what we
    call our clinical application coordinators to be there and help
    them through that.
        We also use a process of having clinical champions. Dr.
    Fletcher was one when this first came out and he was Chief of
    Cardiology. And they are the advocates. It is not pushed in
    from the outside. It is actually drawn in from the inside, and
    you find those early adopters, have them make sure that the
    system really does work, work out whatever little barriers
    there might be, get those smoothed out, and then----
        Senator Carper. Sort of a kind of bottoms-up approach that
    the Chairman was talking about?
        Mr. Kolodner. Absolutely. And once it reaches a certain
    level, like 40 or 50 percent of the users, at that point the
    top-down management saying this is the target that can drive it
    to completion. But doing that too early actually gets
    resistance, and doing it too late wastes the opportunity to
    have it used widely.
        Senator Carper. Good. Thank you. Dr. Kussman.
        Dr. Kussman. Sir, on top of that, you had mentioned there
    are cultural and age differences. The new group of interns and
    residents that Dr. Fletcher mentioned, they take to this very
    easily. They have grown up with computers. They feel
    comfortable with it. Some of us are little dinosaurs, and when
    we went through the process, it took a little longer to adapt
    to it because early on--for me anyway, I do not type too well
    or too fast, I use two fingers. When I was going to write a
    prescription for somebody, it took me a minute or two to go
    through the steps of writing it. I could write a prescription
    in 15 seconds. And so I had to learn, but the value-added, as I
    got better with it and became inculturized with it is really
    learning and feeling comfortable with it. And that is the
    process that Dr. Kolodner was mentioning.
        But most people, when they get comfortable, realize that it
    is a quantum leap improvement in the delivery of care.
        Senator Carper. I would think if I were a provider, maybe a
    doctor or maybe a nurse or an LPN or someone who is even less
    senior than that, but if this was a skill that I learned--in
    some of these settings, especially nursing homes--there is huge
    turnover. But my sense was that if I was someone working in one
    of those places, if I could learn these skills, learn these
    systems, I just think it would make me more marketable, more
    employable, and hopefully to earn more money. Is that the case?
        Mr. Kolodner. It is, but even more importantly, what we
    find is that the people who have that skill then either choose
    to stay at that facility because it has the capabilities and
    they know that they are able to give better care.
        Or they look for facilities that have that, so that it
    becomes a driver in the system as well. The first time that we
    have a nurse who does not give a medicine because the barcode
    medication administration system stopped him or her from giving
    medicine, they become a believer in the system.
        Senator Carper. Yes. I have been to hospitals, VA
    hospitals, where they are actually using that barcode, and it
    is pretty impressive to see how that works.
        Ms. Daniel, I have a question for you and then maybe a
    couple more, and then we will perhaps wrap it up. I understand
    that the Office of the National Coordinator has experienced
    some pretty big changes this year, not just with the departure
    of Dr. Brailer, but with the addition of four new intra-
    offices. I do not know much about this, but can you just give
    us some further details on the reasoning behind the expansion
    in the roles of these new offices?
        Ms. Daniel. Sure, I would be happy to.
        Senator Carper. What are they?
        Ms. Daniel. There are four new offices and an immediate
    Office of the National Coordinator. The four offices are the
    Office of Health Information Technology Adoption, the Office of
    Interoperability and Standards--so those are sort of the two
    goals that I had mentioned that we are working towards--and
    then the Office of Policy and Research, which is the office
    that I had up; and the Office of Programs and Coordination.
        The reason that these new offices were formed is that
    originally it was sort of just a very small group of folks when
    the office was first founded that were trying to pull all this
    together. And just last summer, there was a formalization of
    the office. The Secretary's office had played a role in
    figuring out what the best approach was for formalizing the
    office and setting up the different structures so that we can
    be responsive in a variety of different areas and different
    approaches.
        So we have the National Coordinator, a Deputy, Directors of
    those four offices that I mentioned, and then staff below all
    of those four Directors.
        As you mentioned, we have recently, sadly, lost Dr.
    Brailer. He resigned last month. I believe that from what I
    hear, the Department is currently looking for a new candidate
    to fill his role, and I do not have any information about where
    that stands at this point.
        Senator Carper. All right. Good.
        A question, if I could, maybe for Mr. Hendricks, please.
    Mr. Hendricks, in Delaware, we raise a lot of chickens. In
    fact, in Delaware, there are 300 chickens for every person who
    lives in our State. So for anybody in the audience who is
    eating chicken these days, God bless you. Keep it up.
        We have a concern in Delaware about avian flu because what
    happens when there are scares of avian influenza, an avian flu
    pandemic around the country or around the world, people stop
    eating chicken and it hits the bottom line, hits us in the
    pocketbook on the Delmarva Peninsula. So it is something that
    gets our attention.
        There is concern about avian influenza on the Delmarva
    Peninsula and throughout this country, and I think around the
    world. And it is not just avian flu but other potential
    outbreaks of this nature, but we are just focused on this kind
    of pandemic, future potential pandemic right now. But being
    able to identify outbreaks early seems to be the key to
    properly responding and helping to control their spreads.
        I was just wondering, what does AHLTA stand for?
        Mr. Hendricks. AHLTA is the Armed Forces Health
    Longitudinal Technology Application.
        Senator Carper. Of course. Thank you.
        Any way that AHLTA can help our Nation deal with these
    kinds of potential risks?
        Mr. Hendricks. Yes, sir. If you look at the structure of
    AHLTA, you are going to find that it is somewhat different than
    that structure of the VA's system and that AHLTA is built far
    more utilizing structured date. And we utilize that simply
    because of the mission of the Department of Defense. We have
    some other challenges that we have to be cautious of, and that
    is chemical and biological agents that we want to be aware of.
    And to do that, we use structured data for signs and symptoms
    of patient encounters. And many systems today across the Nation
    will go off with a diagnosis, and then you will do surveillance
    based off those diagnoses.
        Well, to get to a diagnosis, it may take a week to 2 weeks
    to get to the diagnosis. By looking at signs and symptoms, you
    perhaps in avian influenza could catch that by simply looking
    at flu-like symptoms and following the temperature. And Dr.
    Kussman will probably have to help me out here. I suspect the
    avian influenza is more noted by a rapid increase in
    temperature of the patients.
        So by looking at the signs and symptoms of the AHLTA
    database, which happens to be in 70 hospitals and will be in
    over 400 medical clinics around the world, if you look at the
    signs and symptoms and trends of a geographical nature, perhaps
    you can see outbreaks that would warrant further investigation
    to see if perhaps the Nation is seeing something that could be
    an avian influenza.
        Senator Carper. Thank you. Dr. Kussman, do you want to add
    to that?
        Dr. Kussman. Yes, sir. As we speak, actually, with DOD we
    are, as I mentioned in my prepared remarks, in 1,400 sites
    around the country. We are partnering with CDC and other
    organizations to be the sort of canary in the mine. We are
    constantly monitoring reporting already, clusters of symptoms
    that automatically are reported to the CDC so they can monitor
    that if it was in Delaware or Texas, or wherever it was, if
    there was an outbreak of something we can then react early. It
    does not necessarily mean that we need to know the diagnosis,
    as Mr. Hendricks mentioned, but, rather, that there is an
    outbreak of something. And then the epidemiologists and the
    other clinicians can make the diagnosis.
        So this is very important to us, not only with avian flu,
    but all kinds of other potential outbreaks of things, whether
    it is biological, chemical, or whatever it would be.
        Senator Carper. All right. Thanks.
        A vote has begun, and I have asked Meredith Pumphrey, who
    is sitting right behind me, to let me know when there is 5
    minutes remaining. We usually have 15 minutes to get there to
    vote, and when the clock ticks down to 5 minutes, we are going
    to probably adjourn.
        Before we do that, Mr. Howard, could I ask a question of
    you?
        Mr. Howard. Yes, sir.
        Senator Carper. As you know, it is estimated that over 40
    percent of our veterans seek health care services--I think that
    was mentioned earlier--outside of VA medical facilities. Do you
    know, does the VA have any plans to exchange electronic health
    records with health care providers outside of the VA network?
    Have you heard any talk of that?
        Mr. Howard. Well, Dr. Kussman knows more about that than I
    do, sir, but I believe we already do. We have research going on
    where some of that takes place, and we also have private sector
    support involved in some of the diagnoses and what have you.
    But I will let Dr. Kussman answer that.
        Senator Carper. Thank you.
        Dr. Kussman. Yes, sir, as we and Dr. Kolodner mentioned,
    particularly with DOD, for instance, not all veterans are
    retirees, but all retirees are veterans, and so we have a sub-
    segment of our population that can go back and forth from DOD
    to the VA. And so now we are able to make sure that data works
    because someone like those of us who are retired here in
    Washington can go to Walter Reed or Bethesda and the Washington
    VA, and it is very important for that information to be easily
    accessible.
        As we mentioned, we are trying to work with the civilian
    community and HHS to maximize our capability, but as you
    alluded to and the Chairman alluded to, the use of the
    electronic health record in the civilian community has been
    less than we would like to see. And as that expands, more and
    more capability would be able to be achieved.
        Senator Carper. I want to ask one last question of each of
    you. As I said earlier in my comments, we are spending a ton of
    money in this country for health care, much more, I am told, on
    a per capita basis than anybody else in the world. The results
    are not necessarily the best in the world, at least by a number
    of measures. No silver bullets, but one of the ways--it seems
    we work in the VA and DOD and other civilian installations
    where we have begun to harness health IT. We are starting to
    see some results in terms of holding down costs, saving lives,
    providing better care, and also seemingly to provide greater
    job satisfaction for some of the folks who are using the
    technology.
        We serve here in the Senate--a couple of us are doctors,
    most of us are not, but we all care about trying to save lives
    and care about improving our health care for the rest of us and
    care about saving money because we do not have it in great
    abundance these days. But as we, as legislators, attempt to
    find the appropriate role for us and help get our country on
    the right track, what closing words of advice would each of you
    have for us in the Senate, and particularly on this
    Subcommittee? Ms. Daniel.
        Ms. Daniel. Thank you, Senator. From our standpoint, we
    have been working under our existing authorities that we have
    in order to do all of the work that we are doing, the
    collaborative processes that we have in place to work towards
    standards, developing certification, getting public-private
    collaboration through our American Health Information
    Community, looking at the Stark and kickback regulations or
    other areas where we can make changes in order to help
    encourage adoption and encourage interoperability.
        So we are working under our existing authorities, and we
    believe we have the authorities that we need in order to pursue
    the work that we are doing. We have been working very close, as
    I said, with our Federal partners, and I think those
    collaborative efforts are really working and I think are going
    to show some really strong results in the near future.
        So the one piece of advice I would say, if you are
    considering legislation, is to assure that legislation does not
    impede the current good work that we are doing and does not
    cause us to take steps backward in the work that we are doing
    but lets us continue to progress.
        Senator Carper. Good. Well, we just need to have a good
    dialogue with you, and we look forward to that.
        Ms. Koontz, please.
        Ms. Koontz. I will just comment that I think what DOD and
    VA are doing in terms of trying to achieve a virtual medical
    record is a very important initiative, and GAO has made a
    number of recommendations, I think, which have improved what
    they are doing.
        Senator Carper. And I understand they have been accepting
    of those recommendations.
        Ms. Koontz. Generally so. We have some still outstanding,
    and we are working with them on that. And I would just only
    encourage the Congress to continue their oversight over these
    issues.
        Senator Carper. All right. Thank you. Mr. Hendricks.
        Mr. Hendricks. Yes, sir, just a short comment, just a
    suggestion. It is very easy to jump to the return on investment
    and expect immediate savings on implementation of any
    electronic health system. And I would just caution that I think
    that for the Nation, electronic health records savings will
    come more in the long term. The electronic health record will
    allow us to do such things as disease management, to give
    better control on the diabetes and the asthma, and these are
    things that we will not see an immediate return. Those will be
    years out.
        Senator Carper. That is a good point. Thank you. Mr.
    Howard.
        Mr. Howard. Sir, I only have one suggestion, and for
    obvious reasons, due to our most recent incident regarding data
    security. And it is very easy to exchange information, in the
    digital age, lots of it. So I would say, in whatever
    legislation is proposed, we get into the exchange of data among
    DOD, VA, other government agencies, and I really think that
    needs to be continually highlighted. I think the VA has pretty
    good controls over all that in the health area, but we have
    seen how easy it is to fall into the trap of passing
    information around without proper security.
        Senator Carper. OK. Thank you, sir. Timely and well spoken.
    Dr. Kussman.
        Dr. Kussman. Sir, I think we would like, as mentioned, to
    work with you as you develop the legislation to potentially add
    whatever experience we have to that. I think it is a mix of a
    carrot and a stick to get people to do things that they may not
    feel comfortable with. And I think that as Mr. Hendricks
    mentioned, a lot of it is concern about sunk costs with the
    benefit later on, and I think that has to be addressed. If it
    is not, there will be continued resistance to spending money
    without an obvious payback for that.
        Senator Carper. All right. Thank you. The last word.
        Mr. Kolodner. I think it is important to recognize that
    where we are today is very different than 5 years ago. There
    really is progress, there really is momentum. It is important
    to reinforce that and not have a force that comes in, as Jodi
    Daniel mentioned, that is in conflict or competition.
        I think in that sense, what Congress can do is to look to
    make sure that the environment and the parameters are right for
    this to move forward. And you might think in terms of the
    Internet. Nobody mandated the Internet as a solution. In fact,
    if they had come in with solutions, they would have gotten in
    the way. But to create the right environment, the right
    reinforcements, and the right incentives, and to then do that
    in alignment with the other activities.
        Senator Carper. Good. Well, this has been a terrific
    hearing. I am delighted I was here. And I am delighted that you
    were here. I want to express my thanks to Meredith Pumphrey,
    who is sitting right behind me, to the Chairman for his
    willingness to have a hearing on this subject, and to the
    members of his staff for helping to plan it and to get all of
    you to come.
        We would ask that you be willing to respond to some further
    questions in writing, and we look forward to collaborating with
    you as we go forward.
        On behalf of all of us on this Subcommittee and our full
    Committee, and, frankly, I think probably on behalf of all of
    us in the Senate, thank you for the good work that you are
    doing, especially for those of you that are serving our
    veterans and our military personnel and those who are trying to
    help us take those lessons and extend them to the rest of our
    civilian population. You are doing the Lord's work. It is
    important work, and we are grateful.
        Thank you, and with that, the Subcommittee stands
    adjourned.
        [Whereupon, at 4 p.m., the Subcommittee was adjourned.]

                                A P P E N D I X

                                  ----------

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]