[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


                              -------

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        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.
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    \1\ The prepared statement of Ms. Daniel appears in the Appendix on 
page 33.
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    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.
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    \1\ The prepared statement of Ms. Koontz appears in the Appendix on 
page 48.
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    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.
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    \1\ The prepared statement of Mr. Hendricks appears in the Appendix 
on page 77.
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    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.
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    \1\ The prepared statement of Dr. Kussman appears in the Appendix 
on page 89.
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    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.]

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