[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]


 
               MEETING THE NEED FOR INTER-OPERABILITY AND
                   INFORMATION SECURITY IN HEALTH IT

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

                                HEARING

                               BEFORE THE

                  COMMITTEE ON SCIENCE AND TECHNOLOGY
                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                           SEPTEMBER 26, 2007

                               __________

                           Serial No. 110-57

                               __________

     Printed for the use of the Committee on Science and Technology


     Available via the World Wide Web: http://www.house.gov/science


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                                 ______

                  COMMITTEE ON SCIENCE AND TECHNOLOGY

                 HON. BART GORDON, Tennessee, Chairman
JERRY F. COSTELLO, Illinois          RALPH M. HALL, Texas
EDDIE BERNICE JOHNSON, Texas         F. JAMES SENSENBRENNER JR., 
LYNN C. WOOLSEY, California              Wisconsin
MARK UDALL, Colorado                 LAMAR S. SMITH, Texas
DAVID WU, Oregon                     DANA ROHRABACHER, California
BRIAN BAIRD, Washington              ROSCOE G. BARTLETT, Maryland
BRAD MILLER, North Carolina          VERNON J. EHLERS, Michigan
DANIEL LIPINSKI, Illinois            FRANK D. LUCAS, Oklahoma
NICK LAMPSON, Texas                  JUDY BIGGERT, Illinois
GABRIELLE GIFFORDS, Arizona          W. TODD AKIN, Missouri
JERRY MCNERNEY, California           JO BONNER, Alabama
LAURA RICHARDSON, California         TOM FEENEY, Florida
PAUL KANJORSKI, Pennsylvania         RANDY NEUGEBAUER, Texas
DARLENE HOOLEY, Oregon               BOB INGLIS, South Carolina
STEVEN R. ROTHMAN, New Jersey        DAVID G. REICHERT, Washington
JIM MATHESON, Utah                   MICHAEL T. MCCAUL, Texas
MIKE ROSS, Arkansas                  MARIO DIAZ-BALART, Florida
BEN CHANDLER, Kentucky               PHIL GINGREY, Georgia
RUSS CARNAHAN, Missouri              BRIAN P. BILBRAY, California
CHARLIE MELANCON, Louisiana          ADRIAN SMITH, Nebraska
BARON P. HILL, Indiana               PAUL C. BROUN, Georgia
HARRY E. MITCHELL, Arizona
CHARLES A. WILSON, Ohio


                            C O N T E N T S

                           September 26, 2007

                                                                   Page
Witness List.....................................................     2

Hearing Charter..................................................     3

                           Opening Statements

Statement by Representative Bart Gordon, Chairman, Committee on 
  Science and Technology, U.S. House of Representatives..........     7
    Written Statement............................................     9

Statement by Representative Ralph M. Hall, Minority Ranking 
  Member, Committee on Science and Technology, U.S. House of 
  Representatives................................................    11
    Written Statement............................................    12

Statement by Representative David Wu, Chairman, Subcommittee on 
  Technology and Innovation, Committee on Science and Technology, 
  U.S. House of Representatives..................................    13
    Written Statement............................................    14

Statement by Representative Phil Gingrey, Minority Ranking 
  Member, Subcommittee on Technology and Innovation, Committee on 
  Science and Technology, U.S. House of Representatives..........    15
    Written Statement............................................    16

Prepared Statement by Representative Jerry F. Costello, Member, 
  Committee on Science and Technology, U.S. House of 
  Representatives................................................    17

Prepared Statement by Representative Harry E. Mitchell, Member, 
  Committee on Science and Technology, U.S. House of 
  Representatives................................................    17

                               Witnesses:

Dr. David E. Silverstone, Clinical Professor of Ophthalmology and 
  Visual Science, Yale School of Medicine; Assistant Chief of 
  Ophthalmology, Yale-New Haven Hospital; Practicing 
  Ophthalmologist, The Eye Care Group, New Haven, CT
    Oral Statement...............................................    19
    Written Statement............................................    21
    Biography....................................................    22

Ms. Noel Brown Williams, President, Senior Vice President, and 
  Chief Information Officer, Hospital Corporation of America 
  Information Technology and Services, Inc.
    Oral Statement...............................................    23
    Written Statement............................................    25
    Biography....................................................    29

Ms. Linda L. Kloss, Chief Executive Officer, American Health 
  Information Management Association, Chicago, IL
    Oral Statement...............................................    29
    Written Statement............................................    31
    Biography....................................................    48

Mr. Michael Raymer, Vice President and General Manager, Global 
  Product Strategy, GE Healthcare Integrated IT Solutions
    Oral Statement...............................................    48
    Written Statement............................................    50
    Biography....................................................    53

Mr. Justin T. Barnes, Vice President of Marketing, Corporate 
  Development and Government Affairs, Greenway Medical 
  Technologies, Inc.
    Oral Statement...............................................    53
    Written Statement............................................    55
    Biography....................................................    57

Discussion.......................................................    58

             Appendix 1: Answers to Post-Hearing Questions

Dr. David E. Silverstone, Clinical Professor of Ophthalmology and 
  Visual Science, Yale School of Medicine; Assistant Chief of 
  Ophthalmology, Yale-New Haven Hospital; Practicing 
  Ophthalmologist, The Eye Care Group, New Haven, CT.............    72

Ms. Noel Brown Williams, President, Senior Vice President, and 
  Chief Information Officer, Hospital Corporation of America 
  Information Technology and Services, Inc.......................    73

Ms. Linda L. Kloss, Chief Executive Officer, American Health 
  Information Management Association, Chicago, IL................    75

Mr. Michael Raymer, Vice President and General Manager, Global 
  Product Strategy, GE Healthcare Integrated IT Solutions........    79

Mr. Justin T. Barnes, Vice President of Marketing, Corporate 
  Development and Government Affairs, Greenway Medical 
  Technologies, Inc..............................................    81

             Appendix 2: Additional Material for the Record

Statement of Good Samaritan Hospital on behalf of the Mid-
  Nebraska Telemedicine Network, provided by Lesley A. Bollwitt-
  Maria, Director, Grants & Special Projects, Good Samaritan 
  Hospital Foundation............................................    84

H.R. 2406, To authorize the National Institute of Standards and 
  Technology to increase its efforts in support of the 
  integration of the health care information enterprise in the 
  United States..................................................    89


  MEETING THE NEED FOR INTER-OPERABILITY AND INFORMATION SECURITY IN 
                               HEALTH IT

                              ----------                              


                     WEDNESDAY, SEPTEMBER 26, 2007

                  House of Representatives,
                       Committee on Science and Technology,
                                                    Washington, DC.

    The Committee met, pursuant to call, at 10:10 a.m., in Room 
2318 of the Rayburn House Office Building, Hon. Bart Gordon 
[Chairman of the Committee] presiding.


                            hearing charter

                  COMMITTEE ON SCIENCE AND TECHNOLOGY

                     U.S. HOUSE OF REPRESENTATIVES

               Meeting the Need for Inter-operability and

                   Information Security in Health IT

                     wednesday, september 26, 2007
                         10:00 a.m.-12:00 p.m.
                   2318 rayburn house office building

1. Purpose

    On Wednesday, September 26, 2007 the Committee on Science and 
Technology will hold a hearing entitled ``Meeting the Need for Inter-
operability and Information Security in Health IT.'' The hearing will 
examine progress toward the broad use of information technology in 
health care and the investments in technology and standards development 
that are needed to create a national system of secure, inter-operable 
health care information technology. Witnesses will comment on barriers 
to the implementation of these systems, with an emphasis on the role of 
technical standards. They will also comment on the need for legislation 
to push toward the adoption of such standards. This includes a 
discussion of H.R. 2406.

2. Witnesses

Ms. Linda L. Kloss is Chief Executive Officer of the American Health 
Information Management Association (AHIMA).

Dr. David E. Silverstone is Clinical Professor at Yale School of 
Medicine and Assistant Chief of Ophthalmology at Yale New Haven 
Hospital. He serves as Chairman of the Health Information Technology 
Committee of the American Society of Cataract and Refractive Surgery.

Mr. Michael Raymer is Vice President and General Manager for Product 
Strategy and New Business Initiatives at GE Healthcare Integrated IT 
Solutions.

Ms. Noel Williams is President of the Hospital Corporation of America 
(HCA) Information Technology & Services, Inc.

Mr. Justin T. Barnes is Vice President of Marketing and Government 
Affairs for Greenway Medical Technologies, Inc.

3. Brief overview

    Information technology (IT) offers enormous potential benefits to 
U.S. health care. According to the Institute of Medicine, as many as 
98,000 people die in hospitals each year from medical errors such as 
incorrect medications and improper diagnoses, many of which are 
preventable. A study by the Health Care Information Management Systems 
Society found that as much as 49 percent of clinical diagnostic testing 
is performed because previous test results are unavailable when needed. 
Applications of IT to health care such as electronic health care 
records (EHRs), computerized ordering of prescriptions and tests, and 
updated medical information for clinical decision support could save 
thousands of lives and billions of dollars by reducing medical errors 
and miscommunication.
    The entry of IT into the health care arena has been slow and 
disjointed. Only 12 percent of practices with five or fewer physicians, 
where most Americans receive their primary health care, have adopted 
EHRs. The health care industry spends only two percent of revenues on 
information technology, much lower than the 10 percent average of other 
information-intensive industries.
    A key barrier to the adoption of a national, inter-operable health 
care information technology (HIT) system is the lack of robust, widely 
accepted technical standards. Despite efforts at the Department of 
Health and Human Services (HHS) since 2004, such standards have yet to 
be fully developed and widely promulgated. Moreover, there is also a 
lack of conformance testing to ensure that products and systems comply 
with established HIT inter-operability standards. In the absence of 
these standards and conformance tests, health care providers are 
reluctant to invest in HIT systems because there is no assurance that 
they will be able to communicate with other systems.
    The Federal Government's lead agency for the development and 
promulgation of technical standards, the National Institute of 
Standards and Technology (NIST), has been involved with HIT standards 
development work since 2005. Because of its extensive expertise with 
issues of system inter-operability, data security and privacy, and 
consensus standards development, NIST is well positioned to make a 
larger contribution to HIT standards development work and speed the 
deployment of a national secure and inter-operable HIT system.
    On May 21, 2007, Chairman Bart Gordon introduced H.R. 2406, a bill 
to authorize NIST to increase its efforts in support of the integration 
of the U.S. health care information enterprise. The bill: (1) directs 
NIST to establish an initiative for advancing HIT integration and 
allows it to assist health care representatives and organizations and 
federal agencies in developing technical roadmaps for HIT standards; 
(2) requires NIST to develop or adopt existing technology-neutral 
guidelines and standards to enable federal agencies to effectively 
select and use HIT systems that are secure, inter-operable, and ensure 
patient privacy; (3) requires the Department of Commerce to establish a 
Senior Interagency Council on Federal Health Care Information 
Technology Infrastructure to coordinate the development and deployment 
of federal HIT systems, the associated technology transfer, and federal 
work with private HIT standards development organizations; (4) requires 
NIST to establish a university grant program for multi-disciplinary 
research in HIT-related fields; and (5) directs the National High-
Performance Computing Program to coordinate federal HIT R&D programs.

4. Issues and concerns

What is the true cost of insufficient use of information technology 
within the U.S. health care system? The burden on U.S. health care due 
to confusion, miscommunication, insufficient or outdated clinical 
information and other information shortfalls is enormous. According to 
a study in the Annals of Family Medicine, miscommunication is a major 
cause of 80 percent of medical errors, including poor communication 
between physicians, misinformation in medical records and misfiled 
charts. Research published in the Archives of Internal Medicine found 
that there are medication errors in one in five doses given in 
hospitals and skilled nursing facilities, and seven percent of those 
errors are potentially life-threatening. A study published in the 
Journal of the American Medical Association estimates that only 
slightly more than half of patients receive the known ``best practice'' 
treatment for their illness. Inter-operable health care information 
systems could allow physicians to share patient medical information and 
lab results between hospitals, labs, and clinics; order drug 
prescriptions; and alert patients of drug recalls much faster than by 
sharing paper records. While quantitative studies across the entire 
health care sector are difficult to conduct, several health 
associations estimate that the potential savings of greater IT adoption 
by the health care industry run into the tens of billions of dollars. A 
study published in the journal Health Affairs estimates that a fully 
inter-operable national health care IT network could yield $77.8 
billion per year in savings, or five percent of annual U.S. health care 
spending.

What can the Federal Government do to accelerate the pace of standards 
development and promulgation leading to inter-operability of HIT 
systems? Are current federal efforts appropriately leveraging all 
resources for this effort? In April 2004, President Bush signed an 
executive order establishing the position of the National Health 
Information Technology Coordinator (National Coordinator) at the 
Department of Health and Human Services (HHS). The first National 
Coordinator announced a plan to achieve health care IT inter-
operability nationwide. As part of this plan, HHS signed a memorandum 
with NIST, transferring $6 million from HHS to NIST to pay for 
technical work in support of HIT. NIST is the primary U.S. agency for 
developing and promulgating technical standards in conjunction with 
industry, standards development organizations, and foreign governments. 
NIST's current HIT work under the memorandum with HHS may not be fully 
utilizing NIST's expertise in technical standards, data security and 
privacy, and electronic commerce, and its familiarity with systems 
inter-operability and device communication issues.

How can a national, inter-operable HIT system be made compatible with 
privacy and data security concerns? An essential feature of a practical 
HIT system is that it protect the privacy and confidentiality of 
patients' medical information. It must also have strong data security 
provisions, so that medical information cannot be tampered with, 
altered, or destroyed by unauthorized entities. HIT standards will need 
to incorporate privacy and security in the original standards design 
(as opposed to a later addition) in order to ensure that these features 
will be a central element of a national HIT system. Within the Federal 
Government, data security standards for all non-classified IT systems 
are set by NIST, under the framework established by the Federal 
Information Security Management Act of 2002 (FISMA). In addition, NIST 
has been deeply involved in the development and adoption of 
information-exchange standards in electronic business and electronic 
voting systems, which have related privacy and data-security 
requirements.

What can be done to improve HIT inter-operability within the Federal 
Government? The Federal Government has not yet adopted inter-operable 
HIT systems. The largest federal electronic medical records systems--
those of the Departments of Defense (DOD) and Veterans Affairs (VA), 
and the Bureau of Indian Affairs (BIA)--are not mutually inter-operable 
or inter-operable with the private sector. The Federal Government 
should set the gold standard on inter-operability of HIT systems, 
particularly as the demands on military and veterans' health care 
infrastructures are increasing due to the wars in Iraq and Afghanistan. 
Demonstrating the efficiency of inter-operable HIT systems in the 
federal health care system could also spur private sector adoption of 
these systems by providing a cost-effective model.

What research and development efforts are needed to anticipate and 
adapt HIT standards for the next generation of medical technologies, 
human-machine interfaces, and patient needs? With the current pace of 
biomedical research and information technology, there will doubtless be 
new demands on HIT systems and new opportunities for IT to play an 
important role in health care. R&D will be needed to enable the 
incorporation of new technologies such as voice or facial recognition 
into HIT systems and to modify HIT systems to respond to new medical 
treatments and procedures, such as remote surgery and active 
implantable medical devices. These R&D activities will need to span 
many disciplines and synthesize work in the medical, biological, 
engineering, information technology and computer science fields, and 
others.

5. Background

    Although the United States is the most technologically advanced 
nation in the world, the U.S. health care system continues to rely on 
pen and paper for the bulk of its information needs. From patient 
medical histories, to prescriptions, to hospital charts, handwritten 
notations are the basis for patient care information. This system is 
costly, antiquated, and prone to dangerous or life-threatening medical 
errors. More than 98,000 Americans die and more than one million 
patients suffer injuries each year as a result of broken health care 
practices and system failures. According to the National Academies, 
between 30 and 40 percent of health care costs--more than half a 
trillion dollars per year--is spent on ``overuse, under-use, misuse, 
duplication, system failures, and unnecessary repetition, poor 
communication, and inefficiency.''
    Information technology offers enormous potential benefits to 
improve the functioning and efficiency of U.S. health care. A fully 
realized national inter-operable health care IT (HIT) system could 
reduce errors, improve communication, help eliminate redundancy, and 
provide numerous other benefits that would protect patients and save up 
to tens of billions of dollars per year. The central challenge to 
achieving such a system is inter-operability--the ability of data 
systems, medical devices and software from different vendors based on a 
diverse array of platforms to share patient electronic health care 
records (EHRs), electronic physician orders for lab tests and drug 
prescriptions, electronic referrals to specialists, electronic access 
to information about current recommended treatments and research 
findings, and other information.
    In February 2006, the Subcommittee on Environment, Standards and 
Technology of the Committee on Science held a field hearing in 
Portland, Oregon, titled ``Health Care Information Technology: What Are 
the Opportunities For and Barriers to Inter-operable Health Information 
Technology Systems?'' Representatives David Wu and Dave Reichert 
oversaw the proceedings, whose purpose was to review the potential 
benefits of IT to both patients and the health care industry, and to 
determine what actions Federal and State governments and the private 
sector should take to speed the adoption of inter-operable HIT systems. 
Witnesses stressed the need for standardization in the HIT industry, 
and encouraged strong investment by the Federal Government, especially 
NIST, in standards development and education and training activities 
for health care providers.

6. Bill summary of H.R. 2406

Section 1. Findings
    Establishes Congressional findings that the National Institute of 
Standards and Technology (NIST) is well equipped to address HIT 
enterprise integration because of its experience with electronic 
commerce, security, and privacy, as well as health care business 
through its Malcolm Baldrige National Quality Program.
Section 2. Health Care Information Enterprise Integration Initiative
    Directs NIST to establish an initiative to advance HIT enterprise 
integration nationally, building on existing efforts at NIST and 
involving government and industry consortia. Technical activities of 
this program may focus on standards and inter-operability analysis and 
the development of technical testbeds, software conformance and 
certification, security and privacy, medical device communication, data 
management and retrieval architecture, conformance testing 
infrastructure, and health care information usability and decision 
support. The initiative may also include assistance to outside 
organizations and federal agencies in developing technical roadmaps for 
HIT enterprise integration, relying on voluntary consensus standards 
where possible. The Director shall report to Congress annually on these 
activities.
Section 3. Federal Health Care Information Technology Systems and 
        Infrastructure
    Directs NIST to develop new or adopt existing technology-neutral 
HIT guidelines and standards for use by federal agencies within six 
months of enactment. The guidelines and standards shall enable agencies 
to select HIT systems that provide security and privacy and are inter-
operable. They shall promote the use of commercial HIT systems by 
federal agencies, include conformance-testing procedures, provide 
privacy profiles, establish inter-operability specifications, and 
include validation criteria to enable agencies to select appropriate 
HIT systems. NIST will report annually on the progress toward and 
barriers to adoption of inter-operable, secure and private HIT systems 
by federal agencies. Directs the Department of Commerce to establish a 
Senior Interagency Council on Federal Health Care Information 
Technology Infrastructure, with responsibilities to coordinate 
development and deployment of HIT systems across the Federal 
Government, associated technology transfer, and federal funding for and 
participation in private standards-development organizations as related 
to HIT.
Section 4. Research and Development Programs
    Directs NIST, in consultation with NSF, to establish a grant 
program for institutions of higher education partnering with 
businesses, non-profits and government laboratories to establish 
Centers for Health Care Information Enterprise Integration. Grants 
shall be awarded on a competitive, merit-reviewed basis. The Centers 
will generate innovative approaches to HIT enterprise integration by 
conducting research on the interfaces between human information and 
communications technology systems, voice-recognition systems, inter-
operability software, software dependability, metrics of the impact of 
information technology on health care, health care information 
enterprise management, and information technology security and 
integrity. Grant applications shall include descriptions of proposed 
projects, efforts to foster multi-disciplinary collaboration, and 
technology transfer and education activities. The National High-
Performance Computing Program established by the High-Performance 
Computing Act of 1991 shall coordinate federal R&D programs related to 
HIT.
    Chairman Gordon. I want to welcome everyone today. This 
hearing is entitled Meeting the Need for Inter-operability and 
Information Security in Health IT. Before we start with the 
hearing, we need to take a moment to deal with some committee 
business, and I am pleased to welcome two new Members to our 
committee. The first is from California. I am pleased to 
welcome Ms. Laura Richardson to the Committee. She is a new 
Member, is also on another committee, and will be coming here 
soon. So we are glad to have Ms. Richardson. She was a member 
of the legislature in California and brings expertise in that 
area. And I also want to welcome Mr. Paul Broun. He brings 
particular expertise in that he is a physician, and this is a 
good way to start your first meeting. You should be one of our 
witnesses, and we want you to be a full participant. And let me 
say, Dr. Broun, just in quick passing, you haven't been here 
long, but you have been here long enough to know that there is 
a little tenseness in the air sometimes. We hope you can find 
that you can put that aside and feel that you can be 
comfortable in getting work done. We have had 29 bills out of 
this committee. All have been bipartisan. All, but one, have 
been unanimous. Even Dr. Gingrey had a decent bill that came 
out of here. There hasn't been a Democrat or Republican bill 
that has been introduced that hasn't gotten prompt action, and 
we want you, again, to use your expertise to help us to do an 
even better job. And you are sitting at the right hand of a 
good mentor, so I would listen to Dr. Ehlers for his good 
advice.
    And since we have some new Committee Members, we have to 
update our Subcommittee rosters. The new Subcommittee roster 
should be in front of you, and I have asked unanimous consent 
that the Committee do ratify the Subcommittee rosters. With 
that taken care of, I will now begin my opening statement.
    Over the past 20 years, we have experienced a dramatic 
change in the way we share information because of the rapid 
emergence of information technology. Nearly every industry 
across our economy from financial services to media to retail 
has embraced information technology and integrated it 
seamlessly into daily operations. Yet the health care industry 
has lagged far behind. The broad use of IT in the health care 
sector could have far-reaching benefits, including cost savings 
in the billions, improved quality of care, and fewer dangerous 
medical errors. Though there are a number of factors that have 
contributed to the slow adoption of health IT, I believe one of 
the most significant is the lack of technical standards for 
inter-operability and the protection of patient privacy.
    I will also note that this is an area that Newt Gingrich 
and Hillary Clinton have agreed upon some time back. I now hope 
that we can take their agreement and put it into some action. I 
am sending copies of this legislation to our fellow colleague, 
Mr. Gingrich, and hope we will have him one day, to come and 
testify here.
    According to most estimates, a fully inter-operable health 
care IT system could save U.S. health care tens of billions of 
dollars a year and help prevent some of the mistakes that lead 
to the deaths of over 98,000 patients annually. But meeting the 
challenge of developing and maintaining such a system is not 
simple. Most Americans get their primary health care at offices 
with five or fewer doctors. These small offices cannot easily 
afford the initial investment in health IT equipment and 
software or the time for training on these complicated systems. 
Doctors and health IT developers also face medical-privacy laws 
that vary state by state, some of which do not support the 
digital exchange of patient information. Much more work needs 
to be done to update laws and regulations in order to encourage 
the adoption of this important technology.
    And let me not forget that Governor Bredesen of Tennessee 
and Governor Douglas of Vermont, a Democrat and Republican, 
have been working on this with the Governor's Association. We 
were in contact with them just the other day. I hope that we 
are going to be able to have inter-operability between Congress 
and the Governor's Association, so they can then push down this 
uniformity of rules and regulations on the local level.
    But the biggest barrier to the broad implementation of 
health IT systems is the lack of technical standards to support 
inter-operability while protecting data security. It is 
wasteful to start investing in technology until we know it is 
inter-operable, as the cost of upgrading to new systems could 
eat up many immediate cost savings. To achieve inter-
operability, we need to have simple technical standards for 
data formats, data-exchange protocols and other systems-
communication needs. These will enable different manufacturers 
and vendors to build and sell medical software and hardware 
devices that are based on the same underlying communications 
technologies. Doctors and hospitals are reluctant to invest in 
health care IT systems that are not inter-operable with other 
such systems owned by other health care providers.
    The National Institute of Standards Technology, NIST, is 
uniquely positioned to meet this challenge. NIST was 
instrumental in the guiding the creation of standards for the 
financial-services industry and others as they transitioned to 
an IT-based business model. It also sets and maintains the 
technical standards for the IT security across the Federal 
Government to protect against data theft and unauthorized 
access. That expertise is essential for helping to create 
inter-operable standards for health care IT.
    In addition to discussing the challenges to implement 
health care IT systems in the U.S., our witnesses today will 
also address, I hope, H.R. 2406, which authorizes NIST to 
increase its efforts to support the integration of the health 
care-information enterprise in the United States.
    This bill is not a complete solution to the problem we are 
discussing today. But it is my hope that it is a starting point 
for the broad efforts needed on the part of the Federal 
Government, State governments, and health care and IT 
industries to move towards a fully inter-operable health care 
IT system.
    The bill is based on the recommendations of a report by the 
President's Information Technology Advisory Committee from 2004 
and a study by the National Academies from 2005. It instructs 
NIST to advance health IT integration while working with health 
care representatives and federal agencies to develop technical 
roadmaps for health IT standards. The bill also requires NIST 
to create or adopt existing technology-neutral guidelines and 
standards for federal agencies. It directs the Department of 
Commerce to establish a senior interagency council on federal 
health IT infrastructure to coordinate the development and 
deployment of federal health IT systems. And finally, it 
mandates a university-grant program at NIST for multi-
disciplinary research in health-IT-related fields. And thank 
you, Mr. Wu, for that recommendation.
    Secure, inter-operable health care IT systems are critical 
for saving time and money. But we cannot lose focus on the 
ultimate goal of all health policy, protecting patients' lives 
as well as saving money.
    I typically do not tell personal stories during hearings, 
but if the Committee will indulge me, this drives home the 
purpose of this legislation. The Committee staffer who has been 
handling health IT issues is a gentleman named Mike Quear, a 
very able, capable, bright public servant. Last year, Mike had 
an open-heart surgery and was diagnosed with diabetes. He was 
concerned what would happen if he ever needed emergency care, 
so he started keeping a record of every condition that he had, 
every specialist that he had visited, and every medication that 
he was prescribed on a small card in his wallet. Unfortunately, 
that card became larger and larger as he had additional 
situations. That card was the only comprehensive record of care 
that Mike had available to him. This past August, Mike had a 
stroke and was taken to the hospital where emergency room 
doctors were immediately able to evaluate his preexisting 
conditions, contact Mike's team of specialists and provide him 
with the best care, because they had that card. Now, 
thankfully, he is now recovering at home, and we welcome him 
and want him back to finish this legislation. But if those 
records hadn't been available, who knows what might have 
happened. I would venture to guess that not many people in this 
room or in this county take the time to record their medical 
history on a wallet card, nor should we need to. Technology in 
this country is far enough advanced that we should be able to 
expect doctors to access our complete medical records in any 
emergency situation.
    So I am eager to hear our witnesses' thoughts and 
recommendations on how to most effectively promote the broad 
implementation of health information technology systems in the 
near future to save money, to save time, and to save lives.
    [The prepared statement of Chairman Gordon follows:]

               Prepared Statement of Chairman Bart Gordon

    I want to welcome everyone to today's hearing on Meeting the Need 
for Inter-operability and Information Security in Health IT. Over the 
past 20 years, we have experienced a dramatic change in the way we 
share information because of the rapid emergence of information 
technology. Nearly every industry across our economy, from financial 
services to media to retail, has embraced information technology and 
integrated it seamlessly into daily operations. Yet, the health care 
industry has lagged far behind.
    The broad use of IT in the health care sector could have far 
reaching benefits, including cost savings in the billions, improved 
quality of care, and fewer dangerous medical errors.
    Though there are a number of factors that have contributed to slow 
adoption of health IT, I believe one of the most significant is the 
lack of technical standards for inter-operability and the protection of 
patient privacy.
    Inter-operable communications for the exchange of information are a 
requirement for conducting business across the country and around the 
globe. Unfortunately, the health care industry has not yet adopted 
common standards to allow for the broad management and transmission of 
health related information.
    According to most estimates, a fully inter-operable health care IT 
system could save U.S. health care tens of billions of dollars a year, 
and help prevent some of the mistakes that lead to the deaths of over 
98,000 patients annually.
    But meeting the challenge of developing and maintaining such a 
system is not simple. Most Americans get their primary health care at 
offices with five or fewer doctors. These small offices cannot easily 
afford the initial investment in health IT equipment and software, or 
the time for training on complicated systems. Doctors and health IT 
systems developers also face medical privacy laws that vary state by 
state, some of which do not support the digital exchange of patient 
information.
    Much more work needs to be done to update laws and regulations in 
order to encourage the adoption of this important technology.
    But the biggest barrier to the broad implementation of health IT 
systems is the lack of technical standards to support inter-operability 
while protecting data security.
    It is wasteful to start investing in technology until we know it is 
inter-operable, as the cost to upgrade to new systems would eat up any 
immediate cost savings.
    To achieve inter-operability, we need simple technical standards 
for data formats, data exchange protocols, and other system 
communication needs. These will enable different manufacturers and 
vendors to build and sell medical software and hardware devices that 
are based on the same underlying communication techniques. Doctors and 
hospitals are reluctant to invest in health IT systems that are not 
inter-operable with other such systems owned by other health care 
providers.
    The National Institute of Standards and Technology (NIST) is 
uniquely positioned to meet this challenge.
    NIST was instrumental in guiding the creation of standards for the 
financial services industry and others as they transitioned to an IT-
based business model. NIST also sets and maintains the technical 
standards for IT security across the Federal Government to protect 
against data theft and unauthorized access. That expertise is essential 
for helping to create inter-operability standards for health IT.
    In addition to discussing the challenges of implementing a health 
IT system in the U.S., our witnesses today will be addressing H.R. 
2406, which authorizes NIST to increase its efforts to support the 
integration of the health care information enterprise in the United 
States.
    This bill is not a complete solution to the problem we are 
discussing today.
    But it is my hope that it is a starting point for the broad efforts 
needed on the part of the Federal Government, State governments, and 
the health care and IT industries to move towards a fully inter-
operable national health IT system.
    The bill is based on the recommendations of a report by the 
President's Information Technology Advisory Committee (PITAC) in 2004 
and a study by the National Academies in 2005. It instructs NIST to 
advance health IT integration while working with health care 
representatives and federal agencies to develop technical roadmaps for 
health IT standards.
    The bill also requires NIST to create or adopt existing technology-
neutral guidelines and standards for federal agencies. It directs the 
Department of Commerce to establish a Senior Interagency Council on 
Federal Health IT Infrastructure to coordinate the development and 
deployment of federal HIT systems. And finally, it mandates a 
university grant program at NIST for multi-disciplinary research in 
health IT-related fields.
    Secure, inter-operable health IT systems are crucial for saving 
time and money. But we cannot lose focus on the ultimate goal of all 
health policy: protecting patients' health and saving lives.
    I typically do not tell personal stories during hearings, but if 
the Committee will indulge me, I want to share a story that drives home 
the purpose of this legislation. The Committee staffer who has been 
handling health IT issues for me is a gentleman named Mike Quear. Last 
year, Mike had open heart surgery and was diagnosed with diabetes. He 
was concerned what would happen if he ever needed emergency care, so he 
started keeping a record of every condition that he had, every 
specialist he visited, and every medication he was prescribed on a 
small card in his wallet.
    That card was the only comprehensive record of care that Mike had 
available to him.
    This past August, Mike had a stroke and was taken to the hospital, 
where emergency room doctors were immediately able to evaluate his 
preexisting conditions, contact Mike's team of specialists and provide 
him with the best care because they had that card. Thankfully, he's now 
recovering at home. If those records hadn't been available, who knows 
what might have happened.
    I would venture to guess that not many people in this room, or in 
this country, take the time to record their medical history on a wallet 
card. Nor should we need to. Technology in this country is far enough 
advanced that we should be able to expect doctors to access our 
complete medical records in any emergency situation.
    I'm eager to hear our witnesses' thoughts and recommendations on 
how to most effectively promote the broad implementation of health 
information technology systems in the near future to save money, save 
time, and save lives.

    Chairman. Gordon. Mr. Chair--the Chair now recognizes Mr. 
Hall for an opening statement.
    Mr. Hall. You can call me Mr. Chair if you want to.
    Mr. Chairman, I thank you for a good opening statement, and 
I, too, look forward to learning more about health information 
technology inter-operability and information security as well 
as about your bill, H.R. 2406, this morning from our various 
esteemed panel of witnesses.
    As a long-term supporter of Mike, what wonderful guy he is, 
and of course, we keep him in our prayers, and I admire him for 
keeping that list there. I started doing that some-80 years 
ago, and my list got so heavy, I couldn't lift it, but Mike is 
a wonderful guy. He has rendered great service to this 
committee and to this Congress and to our nation, and we have 
him on our prayer list.
    And Mr. Chairman, as a long-term supporter of initiative 
such as Tele-health for rural communities, I understand the 
value of health information technologies, and many sectors of 
our economy rely on information technology to increase 
efficiency and minimize errors. The health care sector should 
not be different. We invest 1.7 trillion, annually, in health 
care, and yet the system is plagued with inefficiency. A recent 
Rand Corporation study stated that if most hospitals and doctor 
offices adopted health information technology, the efficiency 
savings alone would average over $77 billion a year. Of course, 
the good things they do far outnumber the inefficiencies, but 
we, at a time like this, point up the lack of efficiencies and 
hope to look to you as one, two, three, four--five people that 
know more about it than we do or you wouldn't be there because 
we write our legislation based on your information and how you 
back it up, and then we battle it pro or con.
    But the study found that if hospitals implemented a health 
information technology system around 200,000 adverse-drug 
events could be eliminated if they did. It could eliminate that 
many annually. Despite these obvious benefits, developing a 
nationwide HIT network is expensive, and of course, as the 
Chairman said, it is challenging. One of the biggest 
challenges, I guess, involves sharing information from system 
to system, also known as inter-operability. We have to develop 
inter-operable standards so that the systems being developed 
today and tomorrow will function together smoothly, and in 
order to address this need, President Bush established the 
Office of the National Coordinator at the Department of Health 
and Human Services, and that office has put together a 
consortium with public and private entitles, including NIST, to 
develop inter-operability and conformance standards. This 
consortium, the American Health Information Community, AHIC, 
has been working over the last few years on this very important 
task, and I applaud your efforts at bringing a health 
information technology bill before this committee, Mr. 
Chairman, and I would like to know more about H.R. 2406 and how 
it will affect the process currently underway at the Department 
of Health and Human Services. For instance, it appears that the 
bill would give NIST overall authority for writing standards, 
procedures and guidelines for the health care industry. If that 
is the case, I wonder whether NIST is the best vehicle for 
full-scale adoption of standards. While I certainly agree that 
NIST has a role to play, it is my understanding that NIST has 
never before been a body that has set policy. Instead, they 
have taken an agreed-upon policy and set about standardizing 
it. Since there is already a vehicle in place setting policy at 
AHIC, will this bill derail that process, or will this 
legislation establish a parallel process between the two 
agencies, and additionally, I am not sure on where the money 
will come from for NIST to undertake HIT initiatives. Would it 
have to come at the expense of other NIST projects and 
priorities? The Administration asked Congress for $118 million 
for fiscal year 2008 for HIT, and it looks like Congress will 
appropriate somewhere between $60 and $70 million. Will NIST 
projects be cut in order to complete with what the 
Administration has already undertaken? That is a question that 
I hope we can answer today. I think it is clear that we are all 
seeking to improve Health Information Technology Systems as 
quickly and as smoothly as possible, and I look forward to 
hearing from all of the witnesses on this important topic, and 
Mr. Chairman, I really do thank you and yield back the balance 
of my time.
    [The prepared statement of Mr. Hall follows:]

           Prepared Statement of Representative Ralph M. Hall

    Mr. Chairman, I look forward to learning more about Health 
Information Technology, Inter-operability and Information Security, as 
well about your bill H.R. 2406 this morning from our esteemed panel of 
witnesses.
    As a longtime supporter of initiatives such as telehealth for rural 
communities, I understand the value of Health Information Technology. 
Many sectors of our economy rely on information technology to increase 
efficiency and minimize errors. The health care sector should not be 
different. We invest over $1.7 trillion annually in health care, and 
yet the system is plagued with inefficiency. A recent RAND Corporation 
study stated that if most hospitals and doctors' offices adopted Health 
Information Technology, the efficiency savings alone would average over 
$77 billion a year. Moreover, the study found that if hospitals 
implemented a Health Information Technology system, around 200,000 
adverse drug events could be eliminated annually.
    Despite these obvious benefits, developing a nationwide HIT network 
is expensive and challenging. One of the biggest challenges involves 
sharing information from system to system, also known as inter-
operability. We must develop inter-operable standards so that the 
systems being developed today and tomorrow will function together 
smoothly. In order to address this need, President Bush established the 
Office of the National Coordinator at the Department of Health and 
Human Services and that office has put together a consortium of public 
and private entities, including NIST, to develop inter-operability and 
conformance standards. This consortium, the American Health Information 
Community (AHIC) has been working over the last few years on this 
important task.
    I applaud your efforts at bringing a Health Information Technology 
bill before this committee, and I would like to know more about how 
H.R. 2406 will affect the process currently underway at the Department 
of Health and Human Services. For instance, it appears that the bill 
would give NIST overall authority for writing standards, procedures and 
guidelines for the health care industry If that is the case, I wonder 
whether NIST is the best vehicle for full scale adoption of HIT 
standards. While I certainly agree that NIST has a role to play, NIST 
has never before been a body that has set policy. Instead, they have 
taken an agreed upon policy and set about standardizing it. Since there 
is already a vehicle in place that is setting policy at HHS, will this 
bill derail that process? Or will this legislation establish a parallel 
process between two agencies?
    Additionally, I am unclear on where the money will come from for 
NIST to undertake HIT initiatives. Will it have to come at the expense 
of other NIST projects and priorities? The Administration asked 
Congress for $118 million for FY '08 for HIT, and it looks like 
Congress will appropriate somewhere around $60 to $70 million dollars. 
Will NIST projects be cut in order to compete with what the 
Administration has already undertaken?
    I think that it is clear that we are all seeking to improve Health 
Information Technology Systems as quickly and as smoothly as possible. 
I look forward to hearing from all the witnesses on this important 
topic. Thank you Mr. Chairman, and I yield back the balance of my time.

    Chairman Gordon. Thank you, Mr. Hall. I think you raised 
some very important issues. Let me make it very clear that we 
are not interested in NIST setting any kind of policy. That 
should not be the case, but rather, setting standards, not 
picking winners or losers, but rather setting standards. They 
also have the entire situation--they have tests so once those 
standards are developed for both hardware and software they can 
get the Good Housekeeping Seal of Approval, so that a small 
firm or a large hospital can invest with the certainty that 
they are not going to have to see this technology be obsolete 
soon. So you raised some good questions, and I know those are 
things we want to get into.
    Since this is a hearing starting at the Full Committee 
level--we typically go through regular order of bringing things 
up through the Subcommittees. But by virtue of the interest in 
this particular topic, we decided to start at the Full 
Committee level, but I would like to hear from our Subcommittee 
Chairman. I would like to now yield to Mr. Wu for his opening 
remarks.
    Mr. Wu. Thank you, Mr. Chairman, and thank you for holding 
this very important hearing.
    The health sciences continually push the envelope in new 
technologies, new medicine and new research; however, health 
care systems lag far behind in information technology 
capabilities. In an increasingly digital society, paper records 
are still a primary mode of information transfer in health 
care. Improving health care IT will make health care more 
efficient, safer for patients, and a better practice 
environment for health care professionals and may wind up 
saving some money. We need technical standards to create a 
functional, inter-operable IT network, and we should enhance 
the relationship between the Department of Health and Human 
Services and NIST so that they can work together to create the 
standards of the future.
    As the government agency which is responsible for creating 
technical standards, NIST is well equipped to address health 
care IT standards for inter-operability and security. I often 
note the important role of NIST in metrology. If you can't 
measure something, it is not really real in terms of science or 
economics. Similarly, NIST plays a critical role for inter-
operability. If there are not standards to guide folks, 
creating inter-operable IT systems will be extremely difficult, 
if at all possible. While digitizing medical information will 
increase efficiency, we must also address the issue of 
security. NIST can also properly develop standards that not 
only address inter-operability but the need for proper security 
measures as well; it has done so in the past.
    I commend Chairman Gordon for his work to address the issue 
of health care IT by introducing H.R. 2406. This bill will 
increase inter-operability and security in health care IT by 
directing NIST to continue its work in developing standards.
    Earlier this year, the House passed my bill to train health 
care IT professionals, who are knowledgeable in both 
information technology and in health care so that new IT 
systems don't sit on desktops as dark boxes. As we move forward 
with the Chairman's bill and develop secure, inter-operable IT 
systems, we need to ensure these systems can be developed and 
implemented by trained professionals.
    Again, I commend the Chairman for his fine work and look 
forward to the testimony of the witnesses.
    [The prepared statement of Chairman Wu follows:]

                Prepared Statement of Chairman David Wu

    The field of medicine continually pushes the envelope in new 
technologies, new medicine, new research--which improves our overall 
ability to stay healthy. However, health care systems lag far behind in 
information technology capabilities. In an increasingly digital 
society, handwritten records are still a primary mode of record keeping 
in health care. Improving health care IT will make health care more 
efficient, while minimizing medical errors--reducing health care costs 
and ultimately saving lives.
    We need technical standards to create a functional, inter-operable 
IT network. I am pleased with the relationship between HHS and NIST. As 
the government, which is responsible for creating technical standards, 
NIST is well equipped to address Health IT standards for inter-
operability and security.
    I often note the importance of NIST's role in metrology. If you 
cannot measure something, it does not exist. Similarly, NIST plays a 
critical role for inter-operability. If there is no standard to follow, 
creating an inter-operable IT system will be difficult.
    While digitizing medical information will increase efficiency, we 
must also address the issue of security. The sensitive data of personal 
medical records requires sufficient security measures are taken into 
consideration. NIST can also develop standards that not only address 
inter-operability, but the need for proper security measures as well.
    I commend Chairman Gordon's for his work to address the issue of 
Health Care IT by introducing H.R. 2406. This bill will help inter-
operability and security issues in Health Care IT by directing NIST to 
continue its work in developing standards.
    Earlier this bill, the House passed a bill that will provide 
technical training to health care professionals regarding Health Care 
IT. As we move forward with the Chairman's bill, and develop secure 
inter-operable IT systems, we need to ensure these systems can be 
implemented by trained staff.
    I look forward to the testimony of the witnesses, and I yield back.

    Chairman Gordon. Thank you, Mr. Wu. In continuing to try to 
answer some of Mr. Hall's very legitimate questions--one was 
about funding, and I just want to state that the COMPETES Act 
that was passed overwhelming by Congress and signed by the 
President this August put NIST on track to double over the next 
seven years, and we hope this will be a part of that, although 
not take seven years.
    And Ms. Richardson, we welcomed you with great flair in 
absentia earlier, but let me once again point out that Ms. 
Richardson, as a member of the State legislature in California, 
comes with a lot of background and expertise. Also as a 
freshman she had her choice of a lot of committees, and she was 
a top draft choice because she did come with such a good 
background, and we are pleased that you chose the Science 
Committee as one of those committees. So welcome, and you are 
an official Member of this committee now.
    Ms. Richardson. Thank you, Mr. Chairman.
    Chairman Gordon. And Dr. Gingrey, now we welcome your 
opening testimony.
    Mr. Gingrey. Mr. Chairman, thank you, and certainly, I do 
appreciate you giving Chairman Wu and I additional time to 
address today's hearing.
    As you know, Health Information Technology is a topic of 
great importance to me as a physician member, and so I 
certainly appreciate your holding of this hearing, Mr. 
Chairman, on developing inter-operability standards for health 
information technology, an area, as has already been said, of 
critical importance to our health care system, and an area with 
so much untapped potential.
    Health Information Technology is one of the most promising 
ways to tackle today's problems with skyrocketing health care 
costs. It has been mentioned by some of my colleagues in regard 
to the cost savings, but I am quoting an even bigger number and 
this is based on a recently ran study revealing that inter-
operable HIT system, if it is implemented correctly, and of 
course, widely adopted, could/would save the American health 
care system more than $162 billion annually. So that is maybe a 
little bit more than our Ranking Member Hall had said. But who 
knows? Whether it is $77 billion or $160 billion, you are 
talking about a lot of money. I mean there is potential for 
some huge savings in cost.
    Of course, in addition, there are numerous other advantages 
that are also extremely compelling. Properly implemented, HIT 
would enormously increase the efficiency within our health care 
system by increasing access to things like offsite charting and 
flagging of charts for follow-up on recommended procedure. It 
has the potential to eliminate duplicate testing that wastes 
patients' money and times, and yes, often causes patients 
unnecessary pain and discomfort. As the Chairman was talking 
about in reference to our great staff member Michael, what 
could have happened had he not had the foresight to have that 
record on his person? Even more vital is the possibility of 
eliminating medical errors. And not sure of this estimate by 
the National Institute of Medicine is correct, but a number of 
years ago, they come out with a study and said something like 
90,000 deaths occur in a hospital setting on an annual basis 
because of medical errors. It may not be 90,000, but if it is 
9,000 it is too many.
    So I see two important roles for the government in Health 
Information Technology. First, we must make sure that every 
provider is able to adopt HIT. And secondly, we must ensure 
that the technology and standards--this is what the Chairman's 
bill is about--that the technology and standards measure up to 
the 21st century standards so that Health Information 
Technology is implemented properly and promptly so that we get 
the right software.
    In regard to the first issue, I want to maybe toot my own 
bill a little bit and let you know that I am sponsoring H.R. 
1952 in collaborating with Charles Gonzales of Texas. He is the 
Subcommittee Chairman on the Small Business Committee. This 
bill is called the National Health Information Incentive Act of 
2007. The bill that I had introduced as a stand-alone is a 
section of Chairman Gonzales's bill, but it would encourage HIT 
adoption by proving optional financial incentives to small 
health care providers and incentives to implement such an 
infrastructure. And I am so glad that Chairman Gordon has 
called this hearing to explore the second part of this process, 
the creation and implementation of HIT inter-operability 
standards. It is vital that these standards are developed in 
the most efficient way to ensure that HIT is not only 
implemented quickly but properly and promptly. And I am looking 
forward, Mr. Chairman, to hearing from our witnesses, and I 
thank them all for being here today.
    [The prepared statement of Mr. Gingrey follows:]

           Prepared Statement of Representative Phil Gingrey

    Mr. Chairman, I appreciate your giving Chairman Wu and I additional 
time to address today's hearing. As you know, health information 
technology is a topic of great importance to me as a physician Member 
of this body--so I appreciate your holding this hearing on developing 
inter-operability standards for Health Information Technology--an area 
of critical importance to our health care system and an area with so 
much untapped potential.
    Health Information Technology is one of the most promising ways to 
tackle today's problem of skyrocketing health care costs. A recent RAND 
study reveals that an inter-operable HIT system that is implemented 
correctly and widely adopted would save the American health care system 
more than $162 billion annually.
    In addition, there are numerous other advantages that are also very 
compelling. Properly implemented HIT would enormously increase the 
efficiency within our health care system by increasing access to off-
site charting and flagging charts for follow-up on recommended 
procedures. It has the potential to eliminate duplicate testing that 
wastes patients' money and time and often causes patients unnecessary 
pain and discomfort. Even more vital is the possibility of eliminating 
medical errors that that lead to almost 100,000 deaths each year.
    I see important roles for the government in promoting Health 
Information Technology. First we must make sure that every provider is 
able to adopt HIT. Secondly, we must ensure that the technology and 
standards measure up to 21st century standards so that health 
information technology is implemented properly to promote the inter-
operability of HIT software.
    To address the first issue I am sponsoring H.R. 1952, in 
collaboration with Rep. Charles Gonzales from Texas. This bill is 
called the National Health Information Incentive Act of 2007. My bill 
would encourage HIT adoption by providing optional financial incentives 
to small health care providers and entities to implement such an 
infrastructure.
    I am so glad that Chairman Gordon has called this hearing to 
explore the second part of this process, the creation and 
implementation of HIT inter-operability standards. It is vital that 
these standards are developed in the most efficient way to ensure that 
HIT is not only implemented quickly but properly.
    I want to again thank the Chairman for taking the initiative on 
this important matter, and look forward the witness testimony.

    Chairman Gordon. Thank you, Dr. Gingrey. I know you would 
rather hear them than me. But I am so passionate about his. I 
just want to follow up on something you said about the savings. 
You know, right now, we spend more per capita on health care 
than any other nation in the world, yet as you know, we are 
struggling--we have different ways we want to do it--but 
struggling to get all children to be able to have health care. 
Right now, as you well know, there is a 10 percent cut looming 
for doctors in terms of their Medicare reimbursement. But it is 
the fastest-growing part of the federal expense; it is the 
fastest-growing part of our individual--in most cases, our 
expenses. But we are already spending so much as a nation; it 
is hard to just keep stacking more money on. And so if we are 
going to meet these needs, we have got to find a way to find 
efficiencies within this system. This is a way. We don't know 
whether it is tens of billions or hundreds of billions, but we 
know it is many billons of dollars that can be saved, and with 
these savings, hopefully we can capture and use those for those 
other needs within this health care system that are so 
important to our nation. And so we are going to work together 
on this bill. We have got other bills we are going to work 
together on, and I think we are going to meet those needs.
    [The prepared statement of Mr. Costello follows:]

         Prepared Statement of Representative Jerry F. Costello

    Mr. Chairman, thank you for calling today's important hearing to 
examine the need for inter-operability and information security in 
health care information technology (HIT) and legislation that 
authorizes the National Institute of Standards and Technology (NIST) to 
increase its efforts in this area.
    The Science and Technology Committee strives to accelerate 
research, development, and advancements in new technology and 
processes. With all of the advancements in medicine and tools in the 
medical industry, it is shocking to see more than 98,000 people in 
hospitals die from medical errors, including incorrect medications or 
improper diagnosis. Further, it is frustrating that because of high 
costs, at a time when our nation has access to the most sophisticated 
health care technology, as much as 49 percent of clinical diagnostic 
testing is performed due to the lack of accessibility to previous test 
results. These issues can be addressed and I believe we owe it to the 
American people to find solutions to the current challenges in 
successfully implementing HIT.
    Having stated the above, there are obvious vital areas, such as 
unifying national standards, developing security protections to ensure 
patient's information, and addressing the financial costs associated 
with research, development, and full implementation of HIT, that must 
be addressed.
    Technological advancements in the health care industry have been 
enormous. Today, I believe we will hear many of the great 
accomplishments that have occurred in working towards HIT as well as 
the challenges we must overcome to successfully implement HIT. I 
believe we must identify and recognize the work that we have 
accomplished up to this point and be cautious as to not undo these 
advances. Instead, we should build around them with a focus on the 
barriers that exist to succeeding in implementing such a system.
    I thank the witnesses for appearing before our committee and look 
forward to their testimony.

    [The prepared statement of Mr. Mitchell follows:]
         Prepared Statement of Representative Harry E. Mitchell

Mr. Chairman,

    Thank you for organizing this morning's hearing on inter-
operability and security in health care information technology. This is 
an issue that has come up in my work on the Committee on Veterans 
Affairs. The Departments of Veterans' Affairs and Defense are working 
on some demonstration projects in this area and I am eager to learn if 
we are applying any of the lessons learned from their effort on a 
system wide basis.
    To date, the Federal Government has struggled to develop and define 
widely acceptable technology for a national, inter-operable health care 
technology system. In 2004, the Department of Health and Human Services 
was charged to take the lead in developing and implementing a 
nationwide inter-operable health IT (HIT) infrastructure to improve 
quality and efficiency in health care. One obstacle inhibiting progress 
in this effort is the lack of widely accepted technical standards.
    The lead agency for developing and disseminating technical 
standards is the National Institute of Standards and Technology (NIST). 
Developing technical standards that work is NIST's expertise. It is 
experienced in dealing with issues of systems inter-operability, data 
security, privacy issues, and standards development.
    The subject of health information technology produces an eye-
glazing effect on most Americans. Nonetheless, it is a critical factor 
to making our health care system more efficient and economical and to 
improving the quality of patient care.
    Research conducted by the Committee staff in preparation for this 
hearing notes that ``98,000 Americans die and more than one million 
patients suffer each year as a result of broken health care practices 
and system failures.'' Improvements in information technology can 
reduce the incidence of medical error, produce billions in savings in 
health care expenditures, and better protect patients. The significance 
of this matter cannot be understated. . .improvements in health care 
information technology is critical to patient safety.
    I look forward to hearing from today's witnesses, especially in 
regard to legislation our esteemed Chairman has introduced, H.R. 2406, 
a bill designed to support NIST's efforts to advance the progress of 
health information technology integration nationally.
    Mr. Chairman, that concludes my remarks, and I yield back the 
balance of my time.

    Chairman Gordon. Now, at this time, I would like to 
introduce our witnesses. We are glad you are here.
    First is Dr. David Livingstone. He is a clinical Professor 
at Yale School of Medicine and a doctor with the Eye Care Group 
in Connecticut. He is testifying on behalf of the Alliance of 
Specialty Medicine, and he was an advisor early on, and again, 
I thank you for helping.
    Ms. Noel Williams is the President of the Hospital 
Corporation of America, HCA for the ones of you that aren't in 
our area, Information Technology and Services. She is 
testifying on behalf of the American Hospital Association, and 
welcome, neighbor.
    Ms. Linda Kloss is the Chief Executive Officer of the 
American Health Information Management Association. We welcome 
you.
    And Dr. Michael Raymer is the Vice President and General 
Manager of product strategy and new business initiatives at GE 
Healthcare Integrated IT Solutions. GE has certainly been a 
leader in this area.
    And Dr. Gingrey, I know you have a witness here today, and 
I would like for you to introduce him.
    Dr. Gingrey. Mr. Chairman, thank you for giving me that 
opportunity, and the opportunity to have a witness from my 
district, the 11th of Georgia, the Northwest portion of the 
State. I have nine counties, and our witness is from 
Carrollton, Georgia, in Carroll County, almost-Alabama, I call 
it. But that is Mr. Justin Barnes. I have known Justin for a 
number of years. He has worked very diligently as Vice 
President of marketing and corporate development and government 
affairs for the Greenway Medical Technologies Company in 
Carrollton, Georgia, and they develop a lot of software 
programs and have been at this for a number of years. They have 
recruited, actually, some general surgeons and some OB-GYNs 
from the community and have many, many years of clinical 
experience and practice who are now working with the company in 
the development--well, actually they have developed very 
impressive software programs for those specialties in 
particular, general surgery and OB-GYN, and it is something 
that is out there on the market and working very well. Justin 
is such a smart young man, I thought, surely, he was a graduate 
of Georgia Tech, but I had to go over and speak to him to make 
sure about that. And he said, no, Congressman, I am a graduate 
of U. Mass. I won't try to Massachusetts, because I don't do 
very good--but a graduate of U. Mass in legal studies. And I 
very proud to welcome one of our witnesses, Mr. Justin Barnes 
from Greenway. Thank you.
    Chairman Gordon. And do you know, did he have a son that 
played on the Little League team? Didn't you just win the 
world's championship? And that is what? Two out of three?
    Dr. Gingrey. That is right, Mr. Chairman, two out of three. 
I think one time Macon, and this last time Columbia, not 
Carrolton, but pretty close.
    Chairman Gordon. So Dr. Silverstone, if you would, please, 
you can begin with your opening statement. Dr. Silverstone, if 
you will, hit the button there to make it turn on, we will all 
hear you better.

 STATEMENT OF DR. DAVID E. SILVERSTONE, CLINICAL PROFESSOR OF 
  OPHTHALMOLOGY AND VISUAL SCIENCE, YALE SCHOOL OF MEDICINE; 
  ASSISTANT CHIEF OF OPHTHALMOLOGY, YALE-NEW HAVEN HOSPITAL; 
 PRACTICING OPHTHALMOLOGIST, THE EYE CARE GROUP, NEW HAVEN, CT

    Dr. Silverstone. Wow, that sounds different. Okay, Mr. 
Chairman, and Members of the Committee, thank you for holding 
this hearing on health information technology and the need for 
inter-operability standards that will promote and support the 
integration of private and secure health information 
enterprises. I appreciate the opportunity to present the 
perspective of specialty physicians on your legislative 
proposal, H.R. 2406, which is pending before the Committee.
    I am David Silverstone. I am a practicing ophthalmologist 
at the Eye Care Group in New Haven, Connecticut, where I am 
also a clinical professor of ophthalmology and visual science 
at the Yale School of Medicine and the assistant chief of 
ophthalmology at Yale-New Haven Hospital. I serve as the Chair 
of the American Society of Cataract and Refractive Surgery's 
(ASCRS) Subcommittee on Health Information Technology as well 
as the ASCRS liaison to the American Society of Ophthalmic 
Administrators Executive Board. Today, I am here representing 
the Alliance of Specialty Medicine, a coalition of 11 medical 
societies, representing nearly 200,000 specialty physicians.
    First, we would like to thank you for your efforts to 
advance health information technology, HIT, legislation and for 
including specialty physicians in the development process. We 
believe that your legislation, H.R. 2406, which authorizes the 
National Institute of Standards and Technology to enhance 
efforts to integrate health information enterprises in the 
United States, will help to promote the widespread adoption of 
effective HIT. Health information technology has the potential 
to increase efficiency and quality of care, but this cannot be 
achieved until we have effective standards of communication and 
interaction among systems. In addition, the technology has the 
potential, as you have all indicated, to significantly lower 
costs in the health care industry. In addition, we support the 
development of an electronic-information network that is 
reliable, inter-operable, secure, and protects patient privacy.
    Specialty physicians have been and continue to be actively 
engaged in the quality-improvement area. Through the 
development of measure specifications for service and the 
development of a rational system for collecting, aggregating, 
and reporting data across numerous public and private insurance 
programs in the least burdensome way, we have played a pivotal 
role in shaping the future of our health care-delivery system. 
However, in order to continue making progress in these areas, 
we believe that specialty physicians, and indeed all health 
care providers, must employ reliable and secure HIT systems. 
These systems are a needed and an essential component that will 
help us to continue to participate in these programs and to 
improve the quality of care we provide to our patients. In 
addition, these systems will help us to harness medical 
knowledge to enable health care providers to deliver the most 
effective and up-to-date medical information in an efficient 
and cost-effective manner.
    As you know, the adoption of electronic health care records 
and other health-related information technology has been slow 
to say the least. According to the e-Health Initiative, the 
health care industry invests only two percent of its revenues 
in IT, whereas other information-intensive industries, such as 
financial services, invest 11 percent of revenues in IT in 
order to improve the quality, diversity and efficiency of their 
products and services. We agree that in this age of rapid 
technology advancement, the slow adoption of health IT by the 
health care industry is undesirable. The absence of an 
efficient HIT system is hampering the integration of effective 
treatment plans into mainstream medicine, the effective and 
efficient evaluation of current practices and efforts to 
improve both the quality of medical care and the cost-
effectiveness of health care delivery. We believe that an 
effective quality-improvement program must incorporate the use 
of HIT while recognizing the considerable administrative costs 
that physicians and other health professionals would incur for 
participating in such a program.
    Most physicians and other health professionals lack the 
necessary health IT and administrative infrastructures to 
participate in the majority of quality-improvement programs for 
physician services. As you know, the typical American small 
physician practices and physicians not employed by large 
institutions will continue to face challenges in financing the 
purchase of integrated HIT systems. In addition, many 
progressive practices that were early adopters of HIT are now 
finding themselves with costly systems that are now out of 
date. The cost of updating these systems will be too great to 
bear in the light of the pending health care service 
reimbursement reductions and the lack of inter-operability 
standards. Most physicians do not have HIT systems and are 
watching and waiting. They do not feel confident making such a 
large investment in health IT because of the cost and the 
uncertainty of future system compatibility.
    Therefore, as Congress addresses this legislation and 
similar legislation in the future, we hope that additional 
efforts to promote health IT and inter-operability include more 
financial assistance for physicians to obtain HIT. Efforts to 
ease the burden on physicians seeking to purchase health 
information technology, especially in the face of annual 
updates below medical inflation due to the falling sustainable 
growth rate formula are greatly appreciated and also essential.
    Your bill, which would accelerate the development of inter-
operability guidelines and standards is both a necessary and 
essential step in developing and utilizing IT effectively and 
efficiently in our health care system. IT systems must use 
common standards for data transmission, data sharing, medical 
terminology, communications, security, and other features. 
Developing these inter-operability standards will allow 
disparate IT systems and software applications to communicate, 
exchange data and use that information to both improve the 
quality of care provided to our nation's patients and to 
decrease the cost of providing that care.
    We concur that NIST, with its experience and expertise in 
electronic commerce, information technology, security and 
privacy, coupled with the health care component of the Malcolm 
Baldrige National Quality Program, and its expertise in working 
with the information technology and health care industries is 
well equipped to address the clinical challenges posed by 
health information enterprise integration.
    [The prepared statement of Dr. Silverstone follows:]

               Prepared Statement of David E. Silverstone

    Mr. Chairman and Members of the Committee, thank you for holding 
this hearing on health information technology and the need for inter-
operability standards that will promote and support the integration of 
private and secure health information enterprises. I appreciate the 
opportunity to present the perspective of specialty physicians on your 
legislative proposal, H.R. 2406, which is pending before the Committee.
    I am David Silverstone. I am a practicing ophthalmologist at The 
Eye Care Group in New Haven, Connecticut where I am also a Clinical 
Professor of Ophthalmology and Visual Science at the Yale School of 
Medicine and the Assistant Chief of Ophthalmology at Yale-New Haven 
Hospital. I serve as the Chair of the American Society of Cataract and 
Refractive Surgery's (ASCRS) Subcommittee on Health Information 
Technology, as well as the ASCRS liaison to the American Society of 
Ophthalmic Administrator's Executive Board. Today, I am here 
representing the Alliance of Specialty Medicine--a coalition of 11 
medical societies, representing nearly 200,000 specialty physicians.
    First, we would like to thank you for your efforts to advance 
health information technology (HIT) legislation and for including 
specialty physicians in the development process. We believe that your 
legislation, H.R. 2406, which authorizes the National Institute of 
Standards and Technology (NIST) to enhance efforts to integrate health 
care information enterprises in the United States, will help to promote 
the wide spread adoption of effective HIT. Health Information 
Technology has the potential to increase efficiency and quality of care 
but this cannot be achieved until we have effective standards for 
communication and interaction among systems. In addition, the 
technology has the potential to significantly lower costs in the health 
care industry. Furthermore, we support the development of an electronic 
information network that is reliable, inter-operable, secure, and 
protects patient privacy.
    Specialty physicians have been and continue to be actively engaged 
in the quality improvement arena. Through the development of measure 
specifications for services and the development of a rational system 
for collecting, aggregating, and reporting data across numerous public 
and private insurance programs in the least burdensome way, we have 
played a pivotal role in shaping the future of our health care delivery 
system. However, in order to continue making progress in this area, we 
believe that specialty physicians, and indeed all health care 
providers, must employ reliable and secure health information 
technology systems. These systems are a needed and essential component 
that will help us to continue to participate in these programs and to 
improve the quality of care we provide to our patients. In addition, 
these systems will help us to harness medical knowledge to enable 
health care providers to deliver the most effective and up-to-date 
medical care in an efficient and cost effective manner.
    As you know, the adoption of electronic health care records and 
other health-related information technology (IT) has been slow, to say 
the least. According to the e-Health Initiative, the health care 
industry invests only two percent of its revenues in IT, whereas other 
information intensive industries, such as financial services, invest 11 
percent of revenues in IT in order to improve the quality, diversity 
and efficiency of their products and services. We agree that in this 
age of rapid technological advancement, the slow adoption of health IT 
by the health care industry is undesirable. The absence of an effective 
health information technology system is hampering the introduction of 
effective treatment plans into mainstream medicine, the effective and 
efficient evaluation of current practices, and efforts to improve both 
the quality of medical care and the cost effectiveness of health care 
delivery. We believe that an effective quality improvement program must 
incorporate the use of health IT, while recognizing the considerable 
administrative costs that physicians and other health professionals 
would incur for participating in such a program.
    Most physicians and other health professionals lack the necessary 
health IT and administrative infrastructures to participate in the 
majority of quality improvement programs for physicians' services. As 
you know, the typical American small physician practices and physicians 
not employed by large institutions will continue to face challenges in 
financing the purchase of integrated HIT systems. In addition, many 
progressive practices that were ``early adopters'' of HIT are now 
finding themselves with costly systems that are now out-of-date. The 
cost of updating these systems will be too great to bear in light of 
pending health care services reimbursement reductions and the current 
lack of inter-operability standards. Most physicians do not have HIT 
systems and are ``watching and waiting''; they do not feel confident 
making such a large investment in health IT because of the cost and the 
uncertainty of future system compatibility.
    Therefore, as Congress addresses this legislation or similar 
legislation in the future, we hope that additional efforts to promote 
health IT and inter-operability include more financial assistance for 
physicians to obtain health IT. Efforts to ease the burden on 
physicians seeking to purchase health information technology, 
especially in the face of annual updates below medical inflation due to 
the flawed sustainable growth rate (SGR) formula, are greatly 
appreciated but also essential.
    Your bill, which would accelerate the development of inter-
operability guidelines and standards, is both a necessary and essential 
step in deploying and utilizing IT effectively and efficiently in our 
health care system. IT systems must use common standards for data 
transmission, data sharing, medical terminology, communications, 
security and other features. Developing these inter-operability 
standards will allow disparate IT systems and software applications to 
communicate, exchange data and use that information to both improve the 
quality of care provided to our nation's patients and to decrease the 
cost of providing that care.
    We concur that NIST, with its expertise in electronic commerce, 
information technology, security and privacy, coupled with the health 
care component of the Malcolm Baldrige National Quality Program and its 
expertise in working with the information technology and health care 
industries, is well equipped to address the technical challenges posed 
by health care information enterprise integration.
    As you know, an integrated information enterprise is critical for 
useful HIT. Involving an entity, such as NIST, with the capacity to 
promote guidelines and standards in the public and private sectors will 
encourage functional uniformity among HIT products. Current problems 
resulting from the fragmentation of health care in the United States 
would be greatly diminished and physicians will be able to choose 
products that conform to specific practice needs, while also ensuring 
adequate and appropriate information is available to other providers.
    In addition, encouraging inter-operability between entities through 
research and development grants to institutions of higher education and 
for profit/non profit centers that promise to form ``Centers for Health 
Care Information Enterprise Integration'' will establish a precedent of 
the importance of inter-operability.
    It is also essential to identify, early-on, any problems with HIT 
in order to minimize costs and mitigate risks prior to widespread 
adoption. A realistic timeline for HIT adoption should allow ample time 
to develop, test, and validate appropriate HIT criteria, standards and 
guidelines. Physicians, largely inexperienced with HIT, will also 
benefit from a timeline that allows sufficient time to acclimate to a 
new system.
    On behalf of the Alliance for Specialty Medicine, thank you for 
your leadership in advancing the quality of our health care system by 
addressing the needs of the health care industry in the area of HIT. 
And, thank you again for continuing to include specialty physicians, 
those as myself who will be most affected by practice changes, in the 
process. We applaud the leadership of Chairman Gordon for an extremely 
well thought out plan that promotes the adoption of HIT by authorizing 
NIST and others with expertise in the area of technical standards 
development to take on this monumental task. The Alliance stands ready 
to work with the Chairman and this committee on this legislation and 
the rapid implementation of inter-operability standards.
    At this time, I would be happy to answer questions from the 
Committee Members.
    Thank you.

                   Biography for David E. Silverstone

    David E. Silverstone, M.D., founded Temple Eye Physicians in 1977, 
which merged with Ophthalmic Surgical Associates in 2001 to form The 
Eye Care Group. He specializes in cataract and lens implant 
microsurgery and glaucoma and is board-certified by the American Board 
of Ophthalmology.
    Dr. Silverstone received his undergraduate degree from Columbia 
College and his medical degree from New York Medical College. He 
completed his ophthalmology residency, a glaucoma research fellowship, 
and a chief residency at Yale. He did a fellowship in Intraocular Lens 
Implantation at New York Medical College.
    Dr. Silverstone is a Clinical Professor and Assistant Chief of 
Ophthalmology at Yale. He has served as the Chief of ophthalmology at 
the West Haven VA Hospital and is on staff at the Temple Surgical 
Center and the Hospital of Saint Raphael.
    He was part of the Yale team that developed Timolol, the first 
modern medication for the treatment of glaucoma and has developed 
computer software that has been adopted by ophthalmologists nationwide.
    Dr. Silverstone serves as the Director of Continuing Medical 
Education for the American Society of Cataract and Refractive Surgery 
and sits on the Governing Board of Directors of the American Society of 
Ophthalmic Administrators and the National Board of Certified 
Ophthalmic Executives. He is also a fellow of the American Academy of 
Ophthalmology, which has awarded him its Honor Award, and serves on the 
Executive Committee of the Connecticut Society of Eye Physicians. He is 
also a member of the New England Ophthalmologic Society, the 
Connecticut Glaucoma Society, the Connecticut State Medical Society, 
the Association for Research in Vision & Ophthalmology and the American 
Public Health Association.

    Chairman Gordon. Thank you, Dr. Silverstone. Your full 
testimony is a part of the record, and we are not strict on our 
five minutes, but you are already three-and-a-half over, so we 
would want you to explore more of your interests as we go into 
the questions. And so I will say, we have everybody's 
testimony; we have reviewed that. And you know, Beulah doesn't 
honk at five minutes, and so we want you to get your full 
thoughts in, but we want to try to move along in an expeditious 
way.
    So Ms. Williams, you are next.

 STATEMENT OF MS. NOEL BROWN WILLIAMS, PRESIDENT, SENIOR VICE 
PRESIDENT, AND CHIEF INFORMATION OFFICER, HOSPITAL CORPORATION 
      OF AMERICA INFORMATION TECHNOLOGY AND SERVICES, INC.

    Ms. Williams. Good morning, Mr. Chairman. I am Noel 
Williams, Senior Vice President and Chief Information Officer 
for Hospital Corporation of America, better known as HCA. Of 
our 192 HCA hospitals, 20 are in 11 Congressional districts, 
represented by this committee, with over 16,000 employees. On 
behalf of the American Hospital Association's nearly 5,000 
member hospitals, health systems and other health care 
organization and our 37,000 individual members, I appreciate 
this opportunity to address the Committee on the importance of 
inter-operability and security in health information 
technology.
    The mission of America's hospitals is caring for patients. 
Every day, the women and men of our hospitals strive to improve 
the safety and quality of the care they provide. Research has 
shown that certain kinds of IT such as electronic health 
records, computerized physician order entry, computerized 
decision-support system and bar coding for medication 
administration can limit errors and improve care as well as 
lower cost and improve efficiency. Hospitals have been pioneers 
in harnessing the power of IT for improvement. Our challenge 
now is to extend the use of IT to all hospitals, large and 
small, in both urban and rural areas.
    Last year, the AHA conducted a survey to assess the state 
of IT implementation in America's hospitals. Half of hospitals 
indicated a moderate or high use of IT, up from 37 percent in 
2005. Overall, IT use was higher at larger, urban, and teaching 
hospitals, and not surprisingly, those with positive financial 
margins. These hospitals also reported rates of growth in their 
use of IT compared to their small and rural counterparts.
    Despite these impressive gains, there are still obstacles 
to the goal of universal IT adoption. Hospitals continue to 
cite cost as a major barrier. Hospitals currently bear almost 
all of the cost with no increase in payment for the use of 
these new technologies. And the benefits of IT such as 
decreased need to repeat tests, lower readmission rates, and 
shorter lengths of stay accrue to those who pay for care by 
reducing their costs.
    A lack of inter-operability with current IT systems also 
poses a significant challenge for hospitals. In 2006, 79 
percent of hospitals listed inter-operability as either a 
significant or somewhat of a barrier, compared with 77 in 2005.
    We commend you, Mr. Chairman, for introducing H.R. 2406 and 
for your recognition of the critical role health IT plays in 
improving health care delivery in America. Legislation can help 
create a policy environment in which technology can be best 
used to support a safer more efficient health care system. We 
support the bill's assertion that confidentiality and security 
must be underlying components of any IT standards that may be 
developed or adopted as a result. Hospitals have and will 
continue to work diligently to ensure the confidentiality and 
security of personal health information. We also agree with the 
assessment of the National Institute of Standards and 
Technology. This organization has, through its standards and 
process-development work in many industries, established itself 
as a valuable resource to both the private and public sector, 
but there are already many, perhaps too many duplicative 
efforts launched by the government in attempts to speed health 
care IT adoption. In the past few years alone, the government 
has created or partially funded several overlapping 
initiatives. These organizations lack coordination. The AHA 
believes that what is needed to speed the adoption of health IT 
in America is a common vision for the future of health IT, a 
roadmap and timeline for change, a detailed implementation 
plan, developed together with key stakeholders that articulates 
each stakeholder's roles and responsibilities. We are concerned 
that H.R. 2406 could give NIST overlapping responsibilities 
without addressing the key needs of a national inter-operative 
health IT network. NIST's core competencies are measure 
science, rigorous tracibility, and the development and use of 
standards. While these competencies, combined with NIST's 
resources could serve as a resource to the public and private 
sector, NIST is likely not the organization to provide the 
transformational leadership required in health care. NIST could 
develop resources for health care providers as it has done for 
manufacturing to help hospital leaders, while striving to 
achieve higher standards of quality, safety and efficiency, who 
are limited to local influence. They, therefore, must look to 
national leadership to create an environment that will enable 
them to make significant investments in IT. There must be a 
reasonable expectation on the part of hospitals that they are 
heading towards the same goal and using the same measures of 
success as every other hospital in the country.
    Mr. Chairman, it is the mission of every hospital in every 
community in America to provide the best care possible, and 
health IT is a crucial tool to providing safe and effective 
care to the right patient, in the right setting at the right 
time. We look forward to working with this committee to forge 
ahead towards a shared goal of improving the reach of health 
IT, and as a result our nation's health care community.
    [The prepared statement of Ms. Williams follows:]

               Prepared Statement of Noel Brown Williams

    Good morning, Mr. Chairman. I am Noel Williams, President of HCA 
Information Technology & Services, Inc., a subsidiary of the Hospital 
Corporation of America (HCA). I also have the privilege of serving as 
Senior Vice President and Chief Information Officer for HCA, where I am 
responsible for the day-to-day operation of HCA's extensive information 
technology systems and services, as well as the development of our 
overall technology strategy. On behalf of the American Hospital 
Association's (AHA) nearly 5,000 member hospitals, health systems and 
other health care organization, and our 37,000 individual members, I 
appreciate the opportunity to speak to you and your colleagues about 
the importance of inter-operability and security in health information 
technology (IT).

STATE OF IT ADOPTION IN AMERICA'S HOSPITALS AND HEALTH SYSTEMS

    The mission of America's hospitals is caring for patients, and 
every day the women and men of our hospitals strive to improve the 
safety and quality of the care they provide. Research has shown that 
certain kinds of IT--such as computerized physician order-entry (CPOE), 
computerized decision support systems and bar-coding for medication 
administration--can limit errors and improve care. IT also can be a 
tool for improving efficiency and costs. Hospitals have been pioneers 
in harnessing IT to improve patient care, quality and efficiency; the 
challenge now is to extend its use and integrate it into the routine 
care processes in all hospitals, large and small, in both urban and 
rural areas.
    A 2006 AHA survey of hospitals and health systems sought to assess 
the state of health IT implementation in America's hospitals. The 
survey included questions about the use of IT applications such as CPOE 
and electronic health records (EHRs), perceived barriers to 
implementation, IT financing and the use of non-clinical IT 
applications.
    Over 1,500 hospitals (about one-third of the field) responded to 
the survey. The data again indicated that hospitals are making great 
strides in embracing health IT: about half of the respondents indicated 
a moderate or high use of IT, up from 37 percent in 2005. This figure 
was determined by the number of clinical IT functions a hospital had 
fully implemented, such as medication order-entry, test results review 
or clinical alerts.
    Over two-thirds of hospitals reported either fully or partially 
implemented electronic health records. Larger, urban and teaching 
hospitals were more likely to have fully implemented EHR systems, and 
accounted for 11 percent of the total. Use of CPOE is also becoming 
more common. In 2006, at 10 percent of hospitals, physicians routinely 
ordered medications electronically at least half of the time. For 
laboratory and other tests, orders were placed electronically at least 
half of the time in 16 percent of hospitals.
    One of the most dramatic changes from year to year was in the use 
of computerized alerts designed to prevent negative drug interactions. 
In 2006, 51 percent of hospitals used real-time drug interactions 
alerts, up from 23 percent the year before.
    As with EHR systems, general health IT use was higher at larger, 
urban and teaching hospitals, as well as those with positive financial 
margins. These hospitals also reported greater rates of growth in their 
use of IT than their smaller and rural counterparts.
    Despite these impressive gains, there are still obstacles to the 
goal of universal IT adoption, and, not surprisingly, cost issues top 
the list. Ninety-four percent of hospitals reported that the initial 
costs of adoption were a significant or somewhat of a barrier to IT 
adoption, down just one percent from 2005. Smaller hospitals were more 
likely to see costs as a barrier, but even the largest hospitals 
struggle to afford health IT. Accelerating adoption across the hospital 
field will require a shared investment between providers, payers and 
purchasers. Hospitals currently bear almost all the costs of IT 
investment, with no increase in payment for the use of these new 
technologies. However, many of the financial benefits of IT, such as 
decreased need for repeat tests, lower re-admission rates, and shorter 
lengths of stay, accrue to those who pay for care.
    The lack of inter-operability with current IT systems also poses a 
mounting challenge for hospitals. In the 2006, 79 percent of hospitals 
listed this issue as either a significant or somewhat of a barrier, 
compared with 77 percent in 2005.

PRINCIPLES FOR REALIZING THE PROMISE OF HEALTH IT

    As the survey demonstrates, an increasing number of hospitals and 
health systems are harnessing the power of health IT to improve 
quality, safety and efficiency. However, the hospital field is now 
challenged to extend the use of IT and integrate it into routine care 
processes in hospitals big and small, urban and rural. The AHA strongly 
supports the growing use of health IT. As Congress and the 
Administration consider ways to encourage increased adoption and 
greater information exchange, we will continue to advocate for 
solutions that address major barriers to realizing the promise of 
health IT.
    The AHA believes the following principles should guide efforts to 
extend IT use in health care:

IT is an enabling tool for improving the quality and safety of care. 
Technology adoption is not a goal in and of itself. Investments should 
be driven by quality and safety improvements that can be brought about 
by technology.

A lack of standards is not the problem. Both adoption and information 
sharing will increase when health information and IT applications are 
more standardized. For example, to have data at the point of care, 
laboratory information systems need to be integrated with pharmacy 
systems and the patient's health record. Currently, hospitals devote 
considerable staff and financial resources to creating interfaces 
between systems or other IT ``workarounds.'' The problem is we need to 
select a single set of standards and get consensus among health care 
stakeholders to use those standards.
    Greater standardization across information technologies, and 
improvements that make IT systems easier for caregivers to use, would 
facilitate adoption. Information exchange requires even greater 
standardization across care settings, such as a physician's office and 
a hospital's emergency department.
    Standards-setting organizations have already developed many 
different standards, and the sheer volume of standards from which to 
choose is stunning. A survey conducted by the National Alliance for 
Health Information Technology discovered over 2,000 standards related 
to health IT, and over 400 organizations that either create, maintain 
or license those standards.
    Standards are needed not just for the useful exchange of data, but 
also for a smarter application of IT throughout the health care 
setting. For example, standards can help hospitals prevent errors in 
medication ordering and administration, allow hospitals to verify 
patients' medications, integrate data from IV pumps and other medical 
devices and exchange data between CPOE and pharmacy systems. A first 
standard needed in this area is unique identification of medications at 
the unit dose level using a standard that is common across all 
settings.
    Hospitals now use many different medical devices that produce 
digital health information, including IV pumps, ventilators, pulse 
oximeters, and others. We could improve safety if hospitals could 
connect the pieces of equipment so that, for example, data from an IV 
pump can be shared with a monitor and a ventilator. Another first 
standard needed is a communication standard for medical devices.
    And we still lack the most basic of all--a standardized way of 
matching individual patients to their records.

Information exchange should be promoted as a public resource. Improved 
care comes when the right information is available to the right 
provider at the right time. Data cannot belong to an organization, 
physician or vendor. The community and regional organizations that will 
emerge to accomplish this will require governance structures that both 
promote exchange and articulate the value of doing so.

Funding. Health IT is costly. Most of the initial cost is borne by 
hospitals, while the financial benefits often flow downstream to other 
providers, payers and employers. For this reason, the AHA believes that 
providers and payers must share these investments. Moreover, 
maintenance costs are significant. Adoption of health IT is more 
difficult for small and rural hospitals because they likely have a less 
developed infrastructure and less staff support (both technical and 
administrative). Increased Medicare payments to support the ongoing 
costs of IT, as well as low-interest loans and grants to support both 
hospitals' initial investments in IT and the development of health 
information exchange projects are needed.

Regulatory relief. Many physicians do not have the financial or 
technical resources needed to navigate the complex IT market. As a 
result, despite the links to improved quality of care, only about 20 to 
25 percent of physicians use EHRs. To facilitate the sharing of 
clinical information and improve patient care, hospitals with more 
advanced IT systems than the physicians practicing in their community 
may want to provide physicians with hardware, software, connectivity or 
other assistance that would allow them to maintain EHRs for their 
patients and share clinical data with the hospital. However, hospitals 
cannot do so because of physician self-referral, or ``Stark,'' 
regulations. Some regulatory relief has recently been granted in this 
area: The hospital field would like to see this made permanent in law.

A single set of privacy laws. The multiplicity of privacy rules from 
local, State and Federal Governments, accrediting bodies and other 
organizations makes compliance difficult and can interfere with patient 
care. Simply identifying all of the relevant rules can be a monumental 
task, let alone determining how to comply when the laws may conflict. A 
single set of privacy rules is needed to facilitate the use of IT and 
ensure access by health care providers to needed information at the 
point of care. Specifically, federal privacy laws as laid out in the 
Health Information Portability and Accountability Act (HIPAA) should 
preempt State and local privacy laws.

A uniform approach to matching patients to their records. The 
electronic exchange of health information requires a consistent, 
reliable mechanism for matching patients to their records. This is best 
achieved with an individual health information authentication number. 
Without a single authentication number, there are serious safety risks 
that could arise from attributing a medical record to the wrong 
individual. For individuals with common names, a cluster of demographic 
information may not be sufficient to distinguish between the 37-year-
old Mary Jones with diabetes and a penicillin allergy and the 37-year-
old Mary Jones in perfect health. Mixing up their records could have 
serious consequences.

VIEWS ON H.R. 2406

    We commend you Mr. Chairman and the other co-sponsors of H.R. 2406 
for your recognition of the critical role health IT plays in the 
improvement of the U.S. health care delivery system. Legislation is a 
powerful tool that demonstrates the commitment of leadership not only 
to raise awareness of the issues, but to help create a policy 
environment in which technology can be best used to support a safer, 
more efficient health care system.
    We support the bill's recognition of confidentiality and security 
as underlying components of any IT standards that may be developed or 
adopted as a result. Hospitals have and will continue to work 
diligently to ensure the confidentiality and security of personal 
health information. This too is an essential piece of that larger 
environment that must be in place for IT implementation to succeed. 
Commitment to this concept must be evident along each step of this 
complex process in order to engage the support of the public.
    The AHA shares the bill's acknowledgement of the accomplishments 
and reputation earned by the National Institute of Standards and 
Technology (NIST). This organization has, through its standards and 
process development work in many industries, established itself as a 
valuable resource to both the private and public sectors. Founded in 
1901, NIST is a non-regulatory federal agency within the U.S. 
Department of Commerce. NIST's mission is to promote U.S. innovation 
and industrial competitiveness by advancing measurement science, 
standards, and technology. Four cooperative programs comprise the NIST 
mission: NIST Laboratories conducts research that advances the Nation's 
technology infrastructure; Hollings Manufacturing Extension Partnership 
offers technical and business assistance to smaller manufacturers 
through a nationwide network of local centers; NIST's Advanced 
Technology Program co-funds research and development partnerships with 
the private sector to develop innovative technologies that can benefit 
the entire Nation; and the Baldrige National Quality Program promotes 
excellence in several business sectors, including health care. Through 
its annual Malcolm Baldrige National Quality Award, NIST recognizes 
these quality achievements.
    Currently, there are several--perhaps too many--efforts to lead the 
health IT movement in the U.S. In the past few years, the government 
has:

          Created through the Department of Health and Human 
        Services (HHS) the American Health Information Community 
        (AHIC), ``a federal advisory body, chartered in 2005 to make 
        recommendations to the Secretary of the U.S. Department of 
        Health and Human Services on how to accelerate the development 
        and adoption of health information technology. AHIC was formed 
        by the Secretary to help advance efforts to achieve the goal 
        for most Americans to have access to secure electronic health 
        records by 2014.'' Plans are currently in development to 
        convert the AHIC into a public/private entity by 2008.

          Created the Office of the National Coordinator for 
        Health Information Technology (ONC). According to the ONC, it 
        ``provides counsel to the Secretary of Health and Human 
        Services and departmental leadership for the development and 
        nationwide implementation of an inter-operable health 
        information technology infrastructure. Use of this 
        infrastructure will improve the quality, safety and efficiency 
        of health care and the ability of consumers to manage their 
        health information and health care. ONC also provides 
        management and logistical support for AHIC.''

          Initially funded the creation of the Certification 
        Commission for Health Information Technology (CCHIT). According 
        to CCHIT, it is ``a recognized certification body for 
        electronic health records and their networks, and an 
        independent, voluntary, private-sector initiative. It is our 
        mission is to accelerate the adoption of health information 
        technology by creating an efficient, credible and sustainable 
        certification program.''

          Initially funded the creation of the Health 
        Information Technology Standards Panel (HITSP), through the 
        American National Standards Institute (ANSI), ``to serve as a 
        cooperative partnership between the public and private sectors 
        for the purpose of achieving a widely accepted and useful set 
        of standards specifically to enable and support widespread 
        inter-operability among health care software applications, as 
        they will interact in a local, regional and national health 
        information network for the United States. Comprised of a wide 
        range of stakeholders, the Panel will assist in the development 
        of the U.S. Nationwide Health Information Network (NHIN) by 
        addressing issues such as privacy and security within a shared 
        health care information system.'' The NHIN is viewed as a 
        ``network of networks'' that will allow the seamless exchange 
        of health information anywhere in the U.S., and is currently in 
        the planning stages. An executive order specifies that any new 
        federal health information system launched after January 1, 
        2008 to be compliant with HITSP recommended standards. HHS 
        Secretary Michael Leavitt has already accepted 30 
        recommendations for inter-operability standards that will be 
        required to build a NHIN.

    We are concerned that there are already too many overlapping, 
duplicative efforts launched by the government to try to speed health 
care IT adoption. These organizations lack coordination, a common 
vision for the future of health IT, a roadmap and timeline for change, 
and a detailed implementation plan that articulates each stakeholder's 
roles and responsibilities. We are afraid that H.R. 2406 could position 
NIST as just another government entity with overlapping responsibility 
without addressing the key needs noted above. It is instead our hope 
that NIST will function as a common resource to the different players 
and help advance the goals we have articulated.
    For example, the ``Technical Activities'' described include 
standards and inter-operability analysis, software conformance and 
certification. These areas are already under intense scrutiny by 
several groups. Coming to agreement on the standards to be used will 
require collaboration and a private-public partnership that prioritizes 
where standards are needed, follows a consensus-building process to 
determine which standards to adopt, and ensures that they can be 
operationalized. Key stakeholders, including providers, payers, 
standards organizations, vendors and regulators must be part of the 
discussion and agree to an implementation process.
    In addition, NIST's core competencies, by its own definition, are: 
measurement science; rigorous traceability; and the development and use 
of standards. While these competencies, combined with NIST resources, 
could serve as a resource to both the public and private sectors, NIST 
is likely not the organization to provide the transformational 
leadership required in health care. However, the AHA believes NIST may 
be able to develop implementation tactics for health care providers, as 
it has done for manufacturing and its associated supply chain 
operations. Toolkits and guidance that enable hospital leaders to 
achieve Baldridge-level quality within their organizations that also 
scale nationally are required for success.

CONCLUSION

    Hospital leaders, while striving daily to achieve higher standards 
of quality, safety and efficiency, are limited to local influence 
within an organization. When we discuss the merits of national health 
care information networks, inter-operability and the resulting 
improvements in safety and efficiency, hospitals must look to national 
leadership to create an environment that will enable a hospital to make 
significant IT investments. This is especially true if the 
beneficiaries of those investments exist outside of the boundaries of 
the individual hospital or hospital network. In order for a hospital to 
make an investment that ultimately benefits the greater good, there 
must be a reasonable expectation on the part of that hospital that it 
is heading toward the same goal and using the same measures of success 
as every other hospital in the country.
    Mr. Chairman, it is the mission of every hospital in every 
community in America to provide the best care possible to people in 
need. Inter-operable health information technology is a crucial tool in 
providing safe and effective care to the right patient, in the right 
setting, at the right time. We look forward to working with this 
committee and staff to forge ahead toward to a shared goal of improving 
the inter-operability and deployment of health IT and, as a result, our 
nation's health care delivery system. Again, I thank you for the 
opportunity to testify before this committee.

                   Biography for Noel Brown Williams

    Noel Brown Williams is President of HCA Information Technology & 
Services, Inc., a wholly owned subsidiary of Nashville, TN-based HCA, 
the Nation's leading provider of health care services. She also serves 
as Senior Vice President and Chief Information Officer for HCA.
    In her second stint with HCA, Williams is responsible for the 
development and operation of the company's extensive information 
technology systems and services as well as the development of HCA's 
overall technology strategy.
    Williams spent 16 years in HCA's Information Services Department in 
a variety of positions, including serving as Vice President of 
Information Services from 1993 to 1995. Prior to rejoining the company 
in 1997, Williams served as Chief Information Officer for American 
Service Group in Brentwood, TN.
    Born in Pasadena, TX, Williams has a Bachelor of Engineering in 
Computer Science and Mathematics from Vanderbilt University and a 
Master of Science in Health Care Financial Management from the 
University of South Carolina. Williams resides in Nashville with her 
husband and two children.

    Chairman Gordon. Thank you, Ms. Williams, and welcome, Ms. 
Kloss.

   STATEMENT OF MS. LINDA L. KLOSS, CHIEF EXECUTIVE OFFICER, 
AMERICAN HEALTH INFORMATION MANAGEMENT ASSOCIATION, CHICAGO, IL

    Ms. Kloss. Chairman Gordon, Mr. Hall, and Members of the 
Committee, thank you for this opportunity to testify on health 
information standards and inter-operability. I am Linda Kloss, 
and I represent the American Health Information Management 
Association as its chief executive officer. This topic is of 
great importance to my colleagues in health information 
management and our over 50,000 members of the association.
    Today our professionals are on the front lines, sort of in 
the trenches if you will, in implementing electronic health 
records and other health information technologies. This 
includes health information exchange among providers, new ways 
for consumers to access their own health information. 
Confidentiality, privacy, security, data integrity, and 
consumer access are core value we bring to this important work.
    Before I begin, I want to thank you for your support and 
passage of H.R. 1467, the Ten Thousand Trained by 2010 Act. The 
Bureau of Labor Statistics, our own research and that of 
others, substantiates the needs for more experienced health IT 
information management and workforce to achieve inter-
operability, and we certainly urge the Senate to follow your 
leadership in addressing the important heath IT workforce 
issue.
    Our prepared comments addressed all of the questions that 
the Committee put forward, but I want to just concentrate my 
oral testimony today on a few subjects relating to integrating 
the health care information enterprise.
    They are: first, the need for uniform and coordinated data 
standards necessary for inter-operability, in other words, some 
focus on what types of standards we are talking about; and 
secondly, the need for a stable long-term strategy for 
standards harmonization that goes to the point Ms. Williams 
made.
    Over the past four years, there really have been quite 
remarkable accomplishments in advancing standards for 
functionality and data interchange for the EHR and Health 
Information Exchange. However, the discussion on data content 
standards, what Dr. Silverstone referred to as the medical 
terminology, the focus of that to date, critical information 
that makes up the EHR and is actually what is transmitted has 
received too little attention.
    I compare these distinctions of building reservoirs and 
pipelines but not addressing the quality of the water that is 
flowing through those pipelines. So I urge that as we are 
thinking of standards, we expand our thinking to take in the 
standards relating to clinical terms and contents that are used 
to describe medical and care services, the critical language of 
medicine. These terms and contents making up the language of 
medicine are embodied in terminologies and classification 
systems that are used to catalog them so that they can be 
stored, exchanged, retrieved, analyzed, and inter-operability 
really requires the sender and the receiver to understand the 
exchange and interpret that information correctly. Terminology 
in classifications systems is critical for not only information 
exchange for patient-care purposes, but for public health, 
quality reporting and other purposes. But today, we have over 
100 terminology and classification systems, and the U.S. has 
not put in place, as other nations have, a way to ensure a 
proper foundation for these systems as critical standards for 
inter-operability. Along with our colleagues from the American 
Medical Informatics Association, AHIMA has looked into this 
issue, and we convened an expert taskforce and prepared a set 
of recommendations under a white paper called Healthcare 
Terminologies and Classification and Action Agenda for the 
United States, and we provided an extract from that white paper 
attached to our testimony. It calls for a formation of a 
public-private authority or an entity to be established to 
ensure that we have robust and up-to-date terminologies and 
classification standards and authoritative ways of keeping 
track of them, and we also call, in that report, for further 
research, planning research, as to how we are going to do this 
well in the United States. So as part of the bill before us 
today, we are pleased to see a focus on research, and we think 
one of the critical areas for research, in fact, is how we are 
going to stand and have the authority and a process for 
terminologies and classifications that will really make health 
care information inter-operable.
    As a second area of focus today, we would just speak to--it 
does ring.
    Chairman Gordon. That is not you. We are, I guess, going 
into session, so please go forward.
    Ms. Kloss. Our second area for comment is regarding 
standards harmonization. We do believe important progress has 
been made towards adoption and use of EHRs, and we acknowledge 
the work of the Office of the National Coordinator, the 
American Health Information Community, the Health Information 
Technology Standards Panel, and the Certification Commission 
for Health Information Technology. All of these efforts have 
really been organized and set in place over the last four 
years, and they have provided a significant boost towards 
inter-operability.
    We do believe there is an important role for NIST in 
bringing both standards development and resources to this. NIST 
has done a lot to harmonize standards and to bring adoption 
guidelines forward, but this is largely a voluntary effort, and 
it is suffering from the woes of many hundreds of people 
working through, essentially, a voluntary effort that is 
contract funded, whereas what we do believe is going to be 
needed is a long-term strategy for standards harmonization. We 
do believe that NIST, well known for its expertise in 
information security and other standards, can supply the health 
information standards harmonization object with ready standards 
that can be applied and harmonized and test laboratories 
contributing to the Certification Commission.
    Chairman Gordon. Ms. Kloss, we have just been called for a 
vote. We have five minutes. So if you would like to quickly 
conclude, then I think we will have time to hear from the other 
two witnesses.
    Ms. Kloss. I actually can conclude here. I would just say 
that we are ready to work with you and the Committee to 
mobilize all available resources to help with this important 
effort.
    [The prepared statement of Ms. Kloss follows:]

                  Prepared Statement of Linda L. Kloss

    Chairman Gordon, Mr. Hall, and Members of the Committee, good 
morning and thank you for this opportunity to testify on the issues 
relating to Meeting the Need for Inter-operability and Information 
Security in Health IT. This topic is of great importance to my 
colleagues in health care information management and has been for many 
years.
    I am Linda Kloss and I represent the American Health Information 
Management Association (AHIMA) as its Chief Executive Officer. AHIMA is 
an association of over 51,000 health information management (HIM) 
professionals deeply committed to and actively participating in the 
adoption of standards-based and inter-operable health IT. Since 1928, 
HIM professionals have worked to improve the accuracy, completeness, 
confidentiality and security of medical record information to support 
clinical care and improve health care of all Americans.
    Today, HIM professionals are on the front lines in implementing 
electronic health records and other technologies to improve health 
care. This includes information exchange among providers and new ways 
for consumers to access their own health information. Confidentiality, 
privacy, security, data integrity, and consumer access are core values 
we bring to this important work.
    As I speak this morning, I must inform you that AHIMA, through its 
Foundation for Research and Education (FORE) has been a contractor for 
several health information improvement projects initiated by the 
Department of Health and Human Services' (HHS) Office of the National 
Coordinator for Health Information Technology (ONC), the Agency for 
Healthcare Research and Quality (AHRQ), and the National Institute of 
Health's (NIH) National Library of Medicine (NLM). These projects have 
included evaluating the mapping of classification systems, studies of 
the potential for improved fraud deterrence through the use of 
electronic health record technology (EHR), analyses of privacy and 
security roadblocks to implementation of EHRs and health information 
exchange, and development of best practices for State level health 
information exchange. The FORE foundation, in conjunction with the 
Medical Group Management Association (MGMA) also addressed aspects of 
the collection and reporting of performance measurement data. AHIMA is 
also one of three organizations that founded the Certification 
Commission for Health Information Technology (CCHIT) which later 
received a three-year contract from ONC and is now an independent not-
for-profit organization recognized by the Secretary of HHS as a 
certifying organization for HIT.
    AHIMA is active in a number of standards activities. Currently 
AHIMA is a voting member of the Health Information Technology Standards 
Panel (HITSP) and representatives are active on its Security Technical 
Committee. AHIMA and several of its members have been active for a 
number of years in the Health Level 7 (HL7) standards development 
organization (SDO). Currently our involvement is in developing EHR 
system and personal health record (PHR) system functional models, legal 
EHR functionality, and the clinical document architecture CDA.
    AHIMA is also an active participant in a number of national and 
international terminology and classification standards organizations. 
We serve as a member of the ICD-9-CM Coordination and Maintenance 
Committee with the American Hospital Association (AHA), the Centers for 
Medicare and Medicaid Services (CMS), and the Centers for Disease 
Control and Prevention's (CDC), National Center for Health Statistics 
(NCHS). We also serve as a member of the Cooperating Parties, the group 
that sets the guidance for use of ICD-9-CM in the U.S., the editorial 
advisory panels for the American Medical Association's Common Procedure 
Terminology (CPT), and the Healthcare Common Procedure Coding System 
(HCPCS) which is operated by CMS. Internationally we have been 
appointed by the NCHS to serve with the World Health Organization's 
(WHO) education, and ICD-10 and ICD-11 reference terminology work 
groups. We also have worked with the International Healthcare 
Terminology Standards Development Organization (IHTSDO), which is the 
standards group that has taken up the SNOMED terminology system.

Costs and Benefits

    Standards-based electronic health record technology is the 
essential building block for much of what we seek to achieve in inter-
operability. After years of slow and inconsistent progress, I believe 
that considerable progress is now being made to define core 
functionality and data exchange standards and to drive their adoption. 
The greater focus on standards over the past five years has led to 
progress by SDOs, formation of the Health Information Technology 
Standards Panel and the Certification Commission for Health IT and 
other collaborative projects which have in effect broken the log jam. 
However, the recent momentum must be supported so progress can continue 
and even accelerate. With the continual evolution of technology and 
growing experience of those who are using it, this work will require 
effective leadership, incentives for adoption, and financial support 
for the effort for some years to come.
    With a solid road map and full support, the benefits of inter-
operability include the ability to:

          Exchange crucial health information between health 
        care providers so that medical treatment for any individual can 
        be rendered accurately and completely.

          Access, transfer and use the extraordinary body of 
        knowledge about medical care and personal health and to grow 
        that body of knowledge through accelerated research and 
        dissemination of learning.

          Report and transfer crucial public health data in 
        seconds to improve effective local and national response to 
        individual and population events and be effective participants 
        in improving global health.

          Achieve a high performing health system in terms of 
        outcomes, safety and cost through performance improvement and 
        public reporting.

          Engage people as full participants in improving their 
        health and wellness.

          Understand effective ways to transform care delivery, 
        including how we pay for it.

    There are numerous forecasts and models about the costs of 
implementing EHRs and health information exchange by researchers at 
RAND, The Center for Information Technology Leadership, the Robert Wood 
Johnson Foundation, and the Commonwealth Fund to name a few, as well as 
studies by AHRQ and ONC. While the specific estimates may vary some 
depending on the sets of assumptions used in the forecasts, the 
conclusion is clear: The benefits will outweigh the cost of investing 
in secure and inter-operable health IT. But it will not be inexpensive 
and the return on investment will not be quick. Any consideration of 
cost must take into account the costs of the current state of health 
care. For example,

          What is the cost of treating patients with limited 
        and inaccessible information about their medical condition and 
        history?

          What is the cost of our inability to manage an 
        individual's care across a multiple number of providers just in 
        trying to get the information needed?

          What is the cost increased administrative duties and 
        operations due to our inability to exchange uniform data 
        electronically for secondary purposes such as research, claims 
        processing and a variety of other administrative activities 
        that are now restricted by our paper-based information system, 
        restrained by our ability to review and analyze paper data, and 
        our ability to locate and exchange information when and where 
        it is needed?

          What is the cost of having our limited data due to 
        the inappropriate use or limits placed on our terminology and 
        classification standards and systems?

          What is the cost in loss of life and poor health, 
        because the right data is not available at the right time?

    Real improvements are being documented by medical practices and 
hospital that are using health information technology. Except for 
delivery systems such as the Veteran's Health Administration, other 
integrated systems and networks such as e-prescribing, improvement are 
for the most part isolated. Without consistent standards it is 
difficult to accrue the values that require inter-operability.

Standards, Guidelines, and Coordination.

    I will address three inter-operability and security issues in my 
comments today that we believe are important for the Committee to take 
into account in its work. These are: terminologies and classifications, 
data stewardship, and the harmonization of standards.
Terminologies and Classifications
    The U.S. needs greater uniformity and coordination of health care 
terminologies and classifications, a type of health information 
standard that is perhaps not as well understood as are other types of 
standards. Clinical terms and concepts are the language of medicine and 
form the information content in electronic health records. 
Terminologies and classifications catalogue these terms and concepts so 
they can be stored, exchanged, retrieved and analyzed. Inter-
operability requires that the sender and receiver understand the 
exchange and interpret it correctly. Terminology and classification 
systems are critical for information exchange, for public health 
reporting, performance measurement, quality reporting, research, and 
billing and payment for health care services.
    AHIMA and the American Medical Informatics Association recently 
published a white paper entitled Healthcare Terminologies and 
Classifications: An Action Agenda for the United States. I have 
attached a short summary of that paper and its recommendations, 
Healthcare Terminologies and Classifications: Essential Keys to Inter-
operability to my testimony. This report was prepared by a joint task 
force of experts who call for the establishment of a public-private 
authority responsible for ensuring the U.S. has:

          Robust and up-to-date terminologies and 
        classifications for inter-operability between systems;

          Standards for developing terminologies and 
        classifications in the EHR and PHR, including implementation 
        guides;

          Principles and guideline for development, 
        distribution, and maintenance of systems and coordination 
        across systems;

          Timely and reliable industry guidance;

          A coherent set of policies and procedures to ensure 
        openness and performance for terminologies, classifications, 
        and the systems that convert data encoded in one terminology or 
        classification to another; and,

          Business process automation to ensure cost-effective 
        development of systems and cost-effective use by providers, 
        payers, and other organizations.

    While federal and private entities have made genuine progress, the 
task force recommends public funding for a research and development 
project to design a permanent governance mechanism and formulate 
strategies and plans for:

          Contemporary and standardized processes for 
        development, adoption, and maintenance of terminologies and 
        classifications;

          The structure, function, and operating practices for 
        a U.S. public/private authority to oversee terminologies and 
        classifications;

          Gaining commitment of terminology and classification 
        stakeholders--developers, end users, and other service and 
        technology suppliers--to principles and guidelines for open and 
        transparent approaches that permit cost-effective inter-
        operability of complete and accurate information; and

          U.S. participation in the IHTSDO--the international 
        organization now addressing SNOMED terminology which we believe 
        is the base terminology for a standard EHR.

    AHIMA and AMIA are prepared to coordinate such an effort, and I ask 
your consideration to support this effort. Without standard and 
consistent data content--which comes from terminologies and 
classifications--the U.S. will not achieve inter-operability of usable 
information. As described in the task force report, the U.S. has fallen 
behind other countries in developing; deploying and using these 
critical and new approaches to coordination are urgently needed.

Data Stewardship
    A second and similar effort is needed in the area of quality 
measurement and secondary data. Recently, AHRQ issued a request for 
information related to the data measures, data sets, or standards used 
for the collection of quality measurement information--the potential to 
have a data steward to coordinate the groups and the group processes 
for developing data collection. This concept was expanded to include 
data also collected for a variety of secondary purposes, research, 
public health, reimbursement, and other public policy requirements.
    As I noted earlier, the ability to use secondary data from a large 
population offers vast opportunities to improve the health of this 
nation and reduce error and costs. At the same time secondary data also 
supports reimbursement for health care services not only in the 
traditional sense of the billing claim, but also in the form of 
information to support effective payment policy.
    As with terminologies and classifications, the U.S. lacks a 
coordinating body with requisite authority to set a vision and 
operating policies for secondary use of data, a data stewardship 
entity. An acknowledged data steward entity would coordinate the 
various public/private groups working on quality measurement and the 
employer/purchaser, research and public health communities which use 
these data. AHIMA's members oversee the collection of these data in 
many health care organizations. They report that lack of uniformity in 
the data sets requested and uniformity of definitions results in costly 
manual work and concerns about the quality and validity of data used to 
measure quality. Standardizing measures and policies regarding 
secondary uses of health information will enable the IT industry to 
design solutions capture data once and use it for multiple legitimate 
and authorized purposes.

Standards Harmonization
    The third area relates to the harmonization of technical standards 
and consistent guidelines for their use, including standards for 
clinical terminologies and classifications, as described earlier.
    In the 1980s HL7 was formed to address health care institutions' 
inability to share data between or among their own data systems and 
programs. Today, HL7 and other SDOs have become and are addressing 
international information exchange.
    Throughout the U.S., industries are sharing data and cutting their 
administrative costs because they are using uniform standards, such as 
the Accredited Standards Organization X12 standards. Besides using 
standards, however, these industries also use and require guideline 
standards--how the particular industry's members will use a chosen 
standard, under what conditions it will be used, and what data sets 
will be used, and so forth.
    This has not been the case in the past in health care. For instance 
today we use standards required by HIPAA. We, therefore, adopted an X12 
standard for claims, the X12-837. Unfortunately as testimony last year 
at the National Committee for Vital and Health Statistics (NCVHS) 
indicated there are now over 1,000 different instructions for the use 
of the X12-837 in the health care industry. If we are to achieve inter-
operability and use standard like other industries, this should not 
happen or be allowed to happen.
    The health care industry has over one million providers, thousands 
of health plans and payers, a potential consumer base of over 300 
million individuals, and some 1.44 million employers offering some 
level of health care, along with numerous government agencies, 
clearinghouses, and vendors. Achieving consensus on complex standards 
and an understanding of their uniform application is a monumental task 
even with a shared vision. In the U.S., our standards data 
organizations are essentially groups of volunteers that come from 
industry and the professions. It is difficult to get and keep 
volunteers who work for provider organizations working on standards, 
yet their participation is critical.
    To address the consistent use of a standard, the harmonization of 
standards--to make the standards work with each other, and to choose 
the collection of standards necessary to perform a function or 
functions requires a significant effort. Over the last three years we 
have seen, through the efforts of HHS, ONC, and the American Health 
Information Community (AHIC), the establishment of the Health 
Information Technology Standards Panel (HITSP). HITSP and its numerous 
volunteers have addressed the need for standards for a variety of 
health care functions and performed the harmonization task. While the 
question of adherence to this harmonization still remains to be seen, 
the task is the first time (outside of some limited and similar work 
done by the NCVHS with e-prescribing and the HIPAA standards) such an 
effort has occurred in health care.
    AHIMA has three concerns with HITSP in its current capacity. First, 
it is largely a volunteer effort and while this improves acceptance, it 
is a slow process. H.R. 2406, introduced in this committee, has the 
potential to provide some of the resources, through the National 
Institute of Standards and Technology (NIST), needed to sustain and 
accelerate the role that HITSP plays. This does not negate the need for 
an industry (public-private) oversight group with a role to approve, 
reject, or amend the final choices for harmonization of standards. 
Public/private involvement is crucial for acceptance, buy-in and use.
    Similarly, NIST could also provide some of the tools for groups 
like CCHIT, whose role is to identify and test that the standards 
harmonized by HITSP and other groups, and ensuring those standards are 
contained and functioning within the products sold on the market. This 
assures buyers that the products they are purchasing technology that 
will allow them to be inter-operable with the industry and the networks 
under development.
    Our second concern related to the need for coordination among 
HITSP, CCHIT, and the entities charged with coordinating terminologies 
and classifications, data stewardship, health information exchange and 
other related functions critical to achieve an secure, inter-operable 
system. Such an entity and role is currently under discussion 
throughout the industry, and I will not comment further at this time 
since that is not the nature of today's hearing.
    Our third concern with HITSP is funding. How does the Nation fund 
such a body that does not itself develop standards, but rather proves 
the harmonization process? In other industries there are councils, but 
no such body exists in health care. If the benefits from harmonization 
and eventual inter-operability accrue to the population, should the 
population, as a whole, pick up this cost? That is a discussion 
Congress should undertake. Should H.R. 2406 become law and the NIST 
involvement occur, the investment in NIST will assume some of the costs 
incurred in the harmonization process, but not all.

Barriers to Inter-operability

    I was asked to address barriers to inter-operability and I have 
already mentioned several. Let me recap: Industry consensus guidelines 
for the prioritization, adoption and use of standards,

          Financial support and staffing for the coordination 
        and harmonization of standards and the development of 
        guidelines,

          A mechanism for uniform adoption and implementation 
        of standards, and

          The current reimbursement system for health care.

    To date, the U.S. health care system has only limited success with 
the adoption and use of standards. The standards chosen to be included 
under HIPAA were reviewed by the NCVHS and the guidelines were written 
by the ASC X12. SDOs normally do not write the guidelines for their 
standards, but there was no other group to do so. The NCVHS, while 
holding considerable public comment would not, today, be considered a 
public/private entity that engages the industry and government. The 
result, as I have noted, is a limited adoption of several of the HIPAA 
standards, and an inconsistent use of the more common claims standard 
and remittance standard.
    More recently we have seen the HITSP work diligently to harmonize 
standards and recommend guidelines, but we have not had an opportunity 
to see if the industry will actually be able to adopt and consistently 
use the standards HITSP has proposed. Without consistent adoption and 
use we cannot achieve uniformity. This does not have to mean that all 
products have to look the same, but the data being exchanged, and the 
mechanisms for transmitting and receiving it have to be standard so no 
one can question the integrity of the data or finds themselves is a 
position of not being able to send or receive the data.
    The HITSP entity and process provide great promise. For the first 
time we have a body that can be seen as providing public/private 
involvement in the harmonization and guideline processes, but HITSP has 
its barriers as well.
    I have suggested the need for financial support and staffing for 
coordination and harmonization. Without this staffing and the financial 
support needed to provide the staffing, the move to identify, adopt, 
guide, and see consistent standards being used will lag. Other nations, 
and industries have addressed this issue and the U.S. must address it 
as well. Perhaps a small fee can be associated with each claim or some 
other mechanism that will allow the industry and its consumers to 
spread the cost of the work that needs to be done. First, we need 
funding to establish the processes and standards, and then later 
maintain the system to keep it refreshed and consistent with medical 
practice and knowledge. Similar funding needs to be examined for the 
groups we suggest for terminologies and classifications and data 
stewardship. While we must maintain industry oversight through some 
inclusive public/private entity or entities, we must also move from a 
volunteer to a full-time mechanism to keep the process progressing. The 
benefits of the standard EHR and systems we are discussing are too 
valuable to wait on a disjointed volunteer effort.
    If we have the funding and the standards and guides, how do we 
compel there use? This is a question I hear very often. Standards have 
been around for many years, yet the health care industry or market has 
not been able to sit down and achieve universal compliance seen in 
other industries and countries. HIPAA was an attempt, but it did not 
have industry involvement and buy-in at the level needed and there is 
no industry pressure to make covered entities abide by the few rules it 
has, including the Federal Government.
    If we cannot develop some entity or mechanism that has the power to 
not only oversee the choice standards and guidelines we have been 
discussing, then we will see a very slow achievement of the steps 
necessary for full inter-operability. This is a somber statement, and I 
want to acknowledge the work of the Secretary, ONC, and AHIC who are 
trying an approach based on the Medicare market and the assumption that 
the Federal Government will adopt and abide by the selected standards 
and guidelines. Essentially, this is an industry-wide voluntary system 
that suggests that others will be as compliant as the Federal 
Government says it will be. We have not seen the results of this effort 
yet and much has to be done. If we do not have the actual up-front buy-
in and then demonstrated compliance from all parties, including the 
federal agencies, even at maximum capacity it will take many more years 
before we get to the exchange of information we are all seeking under 
the current system,. Today, it is not clear who will lead this charge.
    The last barrier related to standards I want to mention is 
reimbursement. Unfortunately, reimbursement runs the show.
    Many physicians indicate they will not even consider adoption of 
HIT and standards until the Medicare and Medicaid reimbursement 
formulas are corrected and they are paid adequately. I understand 
Congress is addressing this concern, but with the Federal Government 
paying such a big portion of the health care bill, reimbursement, 
especially physician reimbursement is a barrier to adoption.
    It is more than the amount of reimbursement. The reimbursement 
process controls other aspects of standards use that affect the 
achievement of inter-operability. The U.S. use of classification 
systems that reflect 21st century medicine have been thwarted 
continually because many health plans and payers do not want to convert 
to a contemporary system. In the U.S., our ICD-9-CM classification 
system is seen as part of the reimbursement system. Quality 
measurements are similarly fast becoming viewed this way as well--
administrative data, rather than information something that can be 
accurately used to actually describe our care, diagnoses, and 
treatment.
    As we build processes like quality measurements and data 
repositories like the personal health record, the reliance on health 
care claims data raises questions regarding the completeness and 
accuracy of the information for clinical use or analysis. We must keep 
our clinical data free from manipulation for reimbursement purposes, 
and require our reimbursement processes to find another way to develop 
their payment mechanisms rather than to appropriately control or impact 
our collection of clinical data. If we cannot rely on the integrity of 
clinical data any inter-operability benefit will be greatly diminished.
    As we build the system to adopt and harmonize standards and design 
guidelines and implementation, we have to build it as intended to 
provide data that accurately describes the patient and medical 
encounter. Yes, payers or health plans need to be involved in these 
processes, but lets build our EHRs and information systems to maximize 
our health information and ensure data integrity.

Security and Privacy

    HIM professionals have been deeply involved in the need for 
confidentiality and security, and committed to implementing and 
enforcing laws, regulations, and best practices to assure maximum data 
and individual protections. We see our role as to provide maximum 
protection for the consumer and the information. HIM professionals are 
often the privacy officer in health care institutions, and are usually 
involved in the process of releasing an individual's health information 
for its intended use. I have attached to my testimony a recent 
statement on the issue of confidentiality that we produced jointly with 
AMIA.
    AHIMA and its members have been involved in the recent process of 
reviewing laws, regulations, and practices associated with 
confidentiality, privacy, and security across the states and the 
Federal Government. Many of these laws and regulations go back decades 
and are intertwined with purposes now forgotten. It will take time to 
unravel these relationships and allow the states and the Federal 
Government to develop uniform laws that protect health information. I 
can assure the Committee that we are engaged in and see a tremendous 
amount of effort directed as developing maximum uniform protection and 
developing the security mechanisms necessary to secure our data and 
networks.
    HIM professionals believe that use of standard electric health 
records will permit more secure protections for personal health 
information than what exists for the current paper record. We are in a 
transition period, moving from a paper-based system to an electronic 
record. This change is not without confusion and gaps that must be 
addressed are being addressed. I want to note our support for H.R. 
2406's approach to having NIST assist in the identification of 
potential security standards that should be considered under the HITSP 
process. NIST has a demonstrated expertise in this arena that can 
benefit and accelerate the industry's efforts considerably.
    With the adoption of electronic health records we have the 
technology to provide confidentiality or privacy through a variety of 
security processes. Just how we adopt and use security processes or 
standards is under considerable and appropriate debate. Identified 
health information flows throughout the health care industry, and other 
industries, as well as to consumers themselves, and in some cases 
employers. This flow is through consumer request, reimbursement 
systems, government reporting requirements, school requirements, and so 
on. The process is complex and some of the uses of technology just as 
complex. Therefore, we must be careful to use technology wisely or we 
could impede the movement of information when it is most needed.
    Surveys indicate that most individuals want their health 
information where it is most needed for their own clinical care and for 
the benefit of the population. What consumers do not want is to have 
their health information misused. They do not want to be 
inappropriately discriminated against because of their health status or 
information.
    In addition to uniform rules, regulations and technology to achieve 
health information confidentiality and security, AHIMA believes in 
essentially three basic principles for over all protection:

        1.  Personal health information should be protected wherever it 
        lays or is transported--whether or not the entity or person 
        accessing, transferring, storing, or holding the information is 
        a health care entity or covered by HIPAA.

        2.  Individuals should be protected against inappropriate 
        discrimination on the basis of their health information--this 
        would include situations of employment and insurance.

        3.  Individuals should be protected against the intentional 
        misuse of their health information.

    There are two caveats to these three principles. To be effective 
laws and regulations related to discrimination and misuse must include 
provisions for active prosecution and penalties, and the public must 
see active prosecution and penalties.
    There are and probably never will be absolute secure systems that 
will provide the confidentiality or privacy sought by some of the 
public and expected by all of the public. But inter-operability will be 
a failure if we cannot build trust in the system of EHRs, PHRs, and 
health information exchange. We can never undue an actual disclosure of 
an individual's health information, but we can take steps to ensure 
that any one intentionally discriminating against an individual or 
misusing health information will know that they face severe penalties 
for doing so.

Global Harmonization

    My comments on terminologies and classifications gave a glimpse of 
international collaboration. Many of the classifications used in the 
U.S. are actually either international standards, or a U.S. version of 
an international standard. The SNOMED terminology, for instance has 
recently moved from a U.S.-based standard to an international standard. 
The HL7 standards are international standards. There are other 
standards as well. Disease and public health are not controlled by 
state or international borders. So we have to consider the global 
harmonization of some of the standards we use in U.S. health care, 
especially terminology and classification standards used for clinical 
care.
    I am sorry to report that the U.S. is behind in this matter. I 
alluded to the restraints in some of our classification systems. While 
most of the world is using the current WHO ICD-10 classification 
standard for disease or a modification of it, the U.S. remains over 10 
years behind, still using ICD-9-CM for morbidity reporting, a version 
developed in the 1970's. While U.S. uses ICD-10 for reporting mortality 
information, we run into situations such that, currently, until the 
next change in codes, the U.S. can report that you died of avian flu, 
but cannot report that you survived avian flu. Similar delays have 
occurred with other outbreaks since the ICD-9-CM numeric classification 
cannot accommodate the WHO ICD-10 alpha-numeric codes, making it 
necessary for the U.S. to manufacture an alternative code when needed 
and when possible. When we exchange information with most other 
countries, the codes must be converted, and information coming from 
outside the U.S., has to be maintained in a separate database.
    WHO has begun the process to update ICD-10 to the next version ICD-
11. A final ICD-11 classification is expected in eight or nine years. 
ICD-11 is based on the ICD-10 structure, and its development will be 
based on the use of ICD-10, which limits U.S. input. We are concerned 
that the failure to move our national terminologies and classification 
forward in sync with international progression leaves our health care 
industry behind and exposes our public health system to additional 
barriers and costs because we have not kept up with public health in 
the rest of the world.
    We believe our recommendations related to terminologies and 
classifications will help change our role in the international 
community. Groups like the HL7 should continue to be encouraged to 
develop standards for clinical care information exchange that are 
international in flavor. While our reimbursement systems might differ, 
our ability to share data for clinical care, research, and public 
health should not be restrained. The U.S. is a world leader in health 
research and technology and a move to insure international standards 
can only help make our role internationally stronger.
    Mr. Chairman, Mr. Hall, this concludes my responses to the 
Committee's questions. There has been remarkable progress in the last 
four years to move health care from paper to a technology enabled 
inter-operable system. Developing and deploying standards is 
fundamental prerequisite. But so is sound policy and sound governance 
to ensure that technology and policy are aligned and are being advanced 
over time. This is an effort that requires the full engagement of all 
three sectors of our society, government, industry and the private non-
profit. It is not a project like Y2K that has an end point. It is a 
process that requires a long-term view and a public and private 
commitment to the public good. Federal and State funding is required as 
is the authority that can only come through intelligent government 
action. The HIM profession and AHIMA stand ready to work with Congress, 
the Administration, and our health care colleagues to continue on a 
path that becomes ever more critical.
    I thank you for your invitation, your time, and your attention, and 
I am ready to answerer any questions you might have.
    Thank you again.

    

                      Biography for Linda L. Kloss

    Linda L. Kloss, MA, RHIA, is Chief Executive Officer of the 
American Health Information Management Association (AHIMA), the premier 
association of 51,000 members serving the health information management 
(HIM) community. Founded in 1928, AHIMA today has a staff of 125 and is 
comprised of 52 component state chapters and the Foundation for 
Research and Education (FORE). Kloss serves on the Board of Directors 
for AHIMA and FORE.
    In her role at AHIMA, Kloss is responsible for delivering services 
to the fast changing HIM community, promoting its mission and values, 
and executing the Association's strategic plan. She also oversees 
AHIMA's industry outreach and partnership activities with key 
stakeholder organizations. Kloss led the Association's efforts to co-
found the Certification Commission for Healthcare Information 
Technology, a private industry initiative to accelerate the adoption of 
inter-operable health care technology. Additionally, Kloss serves on 
the Steering Committee of Connecting for Health, a public-private 
partnership funded by the Markle Foundation and Robert Wood Johnson 
Foundation; the Board of Directors for National Alliance for Health 
Information Technology (The Alliance); the Leadership Council for the 
e-Health Initiative; and as a delegate to the International Federation 
of Health Records Organizations.
    Prior to joining AHIMA in 1995, Kloss served as one of the founding 
officers for MediQual Systems, Inc., a developer of computer based 
clinical performance improvement technology and data tools, and 
InterQual, Inc, a quality improvement consulting and education company. 
Her health information management leadership experience also includes 
both academic and practice positions.
    Kloss holds a Master of Arts degree in Organizational Development 
with a concentration in Change Leadership from DePaul University in 
Chicago, and a Bachelor of Science degree in Medical Record Science 
from the College of St. Scholastica where she now serves as a member of 
the Board of Trustees. Other designations include Certified Association 
Executive (CAE), and Fellow of AHIMA (FAHIMA).

    Chairman Gordon. Thank you, Ms. Kloss, and Mr. Raymer?

  STATEMENT OF MR. MICHAEL RAYMER, VICE PRESIDENT AND GENERAL 
 MANAGER, GLOBAL PRODUCT STRATEGY, GE HEALTHCARE INTEGRATED IT 
                           SOLUTIONS

    Mr. Raymer. Well, good morning, Chairman Gordon and 
Committee Members. My name is Michael Raymer, and I am vice 
president and general manager, responsible for global product 
strategy for GE's Integrated IT Solutions. I appreciate the 
opportunity this morning to testify.
    As a large purchaser of health care services, GE very much 
supports the goal of creating a nationwide health-information 
infrastructure that we believe will save time, money, and most 
importantly lives. To that end, we support initiatives to 
coordinate the work of the various Federal and State agencies 
and the private sector in achieving that goal. It is important, 
however, that this coordination does not interfere with the 
valuable work that has been done today.
    The National Institute of Standards and Technology, or 
NIST, is charged with developing and promoting measurement, 
standards, and technology to enhance productivity, facilitate 
trade and improve the quality of life. While NIST's portfolio 
is not specific to health care, much of the research done at 
NIST's laboratories with respect to advancing the Nation's 
technology infrastructures is directly applicable to the 
creation of an NHIN, or National Health Information Network. 
H.R. 2406 envisions an expanded role for NIST in the 
development of HIT. GE supports NIST's increased involvement, 
but not at the expense of processes that have been working 
well, to date.
    We believe there are four areas in which NIST can provide 
and can be most valuable in advancing this national resource. 
One is to facilitate coordination among the federal agencies. 
The 2005 memo of understanding between Health and Human 
Services and the Department of Commerce charges NIST with the 
responsibility of strategic policy and program coordination 
among the federal agencies. While such an effort is a lot like 
herding cats, we believe NIST has the capability and should be 
given the opportunity to fill this mandate. NIST's role would 
not be to create standards or to certify standards, but to work 
with other governmental agencies to ensure that existing 
standards are implemented appropriately.
    Secondly, we believe that NIST can enhance the already 
effective HITSP process. HITSP recommends a best practice in 
public/private collaboration. We should be wary of any action 
that would result in diminishing the effectiveness of this 
group. That said, we believe it is possible to build upon the 
current successes of HITSP and CCHIT, and NIST can play a very 
important role in that process. To ensure this, we suggest that 
HITSP be specifically recognized in this legislation and that 
NIST authority should enforce federal agency compliance with 
standards, and implementation should be strengthened.
    Thirdly, to provide coordination for testing of inter-
operability standards: the utility of inter-operability testing 
is to demonstrate that products comply with a defined set of 
standards. Over the past 10 years, the IHE Connectathon has 
proven to be an effective, transparent testing process. 
Development of a parallel testing process, as currently being 
contemplated by CCHIT, would waste certification resources on 
duplicative efforts. To the extent there are testing processes 
not within the scope of the Connectathon, and there is room for 
CCHIT or other entities, either alone or in combination in the 
context of both private and public collaboration to develop 
their own testing processes, NIST could help oversee these 
efforts to ensure there is no duplication.
    Finally, fourth, focused research on areas not covered by 
HITSP or other public/private-sector activities: there is 
certainly room among all of the other activities for NIST's 
extensive research capabilities, especially in areas where the 
agency has particular expertise. These would include, one, 
investigating information technology to support and pay for 
performance; secondly, harmonization of security standards and 
practices; and third, working with the private sector to 
provide clarity in HIPAA security regulation and guidance.
    In summary, NIST has played a role and continues to play an 
effective role in coordinating the efforts of public and 
private sectors towards developing HIT. Our support for 
extending or expanding NIST's participation in these activities 
is contingent upon the agency leveraging its strengths and not 
duplicating or reinventing good work that is currently being 
carried by other public/private entities. On behalf of GE 
Healthcare, Mr. Chairman, I want to express my gratitude for 
the opportunity to share with you our own perspective on 
creating a nationwide health-information infrastructure. I 
would be happy to answer any questions that you and the 
Committee may have.
    [The prepared statement of Mr. Raymer follows:]

                  Prepared Statement of Michael Raymer

    Good morning. My name is Michael Raymer, and I am Vice President 
and General Manager of global product strategy for GE Healthcare 
Integrated IT Solutions. I want to thank the Committee for giving me 
the opportunity to testify today.
    GE supports the goal of creating a nationwide health information 
infrastructure. To that end, we also support initiatives to coordinate 
the work of various federal and State agencies and the private sector 
in achieving that goal. It is important, however, that this 
coordination does not interfere with the valuable work that has been 
done to date.

GE's Role in Promoting Inter-operability

    GE has a long history of successfully driving open, standards-based 
data exchange with other vendors. The earliest example is the Digital 
Imaging and Communications in Medicine (DICOM) standard, which has 
enabled diagnostic imaging devices and software systems to exchange 
images and related information regardless of vendor. Diagnostic imaging 
vendors historically created proprietary formats for the CT or MR 
images created by their systems. While image exchange was inter-
operable between systems supplied by the same vendor, this was not the 
case among systems supplied by competing vendors. This lock-in limited 
the flexibility of hospital radiology departments to utilize imaging 
technology in an optimum fashion. DICOM allowed images to move from 
system to system, enabled hospitals to centralize storage of images to 
reduce costs, and led the radiology department to move towards 
diagnosing images on a computer screen. Consequently, DICOM enabled the 
creation of today's $2 billion picture archiving and communications 
systems (PACS) market, while also enabling many hospitals to eliminate 
one of their highest expenses from their operating budgets: film. PACS 
has transformed the work flow within the radiology department, leading 
to increased efficiency and higher quality of care. Physicians at 
different locations can consult while simultaneously examining the same 
images and comparing them with other clinical results to get a more 
complete picture of the patient's condition.
    GE has been instrumental in HL7 standards efforts, representing 
users and vendors in the definition of clinical document sharing and 
context setting (user and patient) standards. GE's Centricity EMR was 
the first major health care information system to provide a production-
ready CCOW-compliant product. GE also worked with the HL7 board and 
industry vendors to define strategies for broad vendor adoption of 
CCOW.
    And, GE is one of the founders of the Health Information and 
Management Systems Society (HIMSS) EHR Vendor Association (EHRVA), a 
group of the top 42 EHR vendors committed to making EMRs inter-operable 
and to accelerating EMR adoption in hospital and ambulatory care 
settings. EHRVA is playing a pivotal role in creating and driving a 
single set of standards for electronic health records inter-
operability, similar to the role NEMA played in transforming diagnostic 
imaging inter-operability in the 1990s. Standards for electronic 
medical records are complex, because they involve multiple types of 
data and terminologies that are not 100 percent congruent from one 
specialty to the next--or even from one hospital to the next.
    GE is a co-author of the EHRVA Inter-operability Roadmap--an effort 
to articulate an achievable path to inter-operability. The roadmap sets 
out a phased timeline for the inter-operability needed to implement a 
nationwide health information infrastructure (NHIN). The first phase of 
that roadmap was demonstrated at the HIMSS Conference in 2006, with GE 
joining 37 other IT vendors, including the VA and DOD, in showcasing 
multiple inter-operability use-cases. One of the NHIN pilot 
implementations used several aspects of the roadmap, and GE and EHRVA 
are reaching out to other stakeholders to encourage further 
implementation and convergence of the roadmap.\1\
---------------------------------------------------------------------------
    \1\ The EHRVA inter-operability roadmap can be found at http://
www.himssehrva.org
---------------------------------------------------------------------------
    Don Woodlock, GE Healthcare's General Manager of Imaging Solutions, 
was the only speaker at the Secretarial Summit on Health Information 
Technology, July 21, 2004, to advocate open, standards-based inter-
operability. And numerous GE employees contribute their time and energy 
to establishing and staffing bodies, including the Certification 
Commission for Health IT (CCHIT) and the Health Information Technology 
Standards Panel (HITSP).

IHE: A Proven Inter-operability Development Process

    GE has also been a long-term leader in Integrating the Healthcare 
Enterprise (IHE), an industry-led initiative that is creating a 
standards-based framework for clinical IT. IHE was established in 1998 
by the Radiological Society of North America (RSNA) and HIMSS. At that 
time, the popularity of DICOM led to the desire to improve imaging 
information exchange beyond the radiology department to other clinical 
IT systems in the hospital. Early on IHE recognized that solving health 
care inter-operability problems sometimes requires multiple standards, 
and established a process that allowed multiple standards to be 
profiled and specified in a precise manner to resolve work flow 
challenges while maintaining plug-and-play capabilities.
    IHE defines precise inter-operability specifications to ensure 
truly compatible implementations by different vendors. IHE couples 
these specifications with a comprehensive testing process, the IHE 
Connectathon. These inter-operability showcases, held at major industry 
conferences, encourage competing vendors to build and demonstrate data 
exchange between their products, in a collaborative and transparent 
process. This includes laboratory results, radiology images, medical 
summaries, and cardiology reports--the very information that today is 
often still faxed, couriered, or mailed between the majority of health 
care organizations in the U.S. Beginning with the 2005 HIMSS Conference 
IHE Cross-Enterprise Showcase, 14 companies--including seven EHRVA 
members and NIST--demonstrated the document-sharing health information 
exchange concept using medical summary information, lab reports, static 
text reports (.pdfs), and structured information. The product 
demonstrations focused on use cases that would enable plug-and-play 
inter-operability with the types of clinical information that patients 
and clinicians utilize in typical medical settings.
    IHE's implementation and testing process has been leveraged by many 
countries and regions around the world, including the United States 
(through HITSP), France, Canada, Austria, Italy, and Japan. In the 
spring of 2005, for example, 16 European vendors participated in the 
IHE-Europe Connectathon for cross-enterprise information exchange; this 
has since grown to more than 70 companies participating in the North 
American and European IHE Connectathon process. The IHE Cross-
Enterprise Document Sharing (XDS) profile and associated integration 
profiles achieved connectivity between inpatient and ambulatory EHR 
systems (including products from different EU countries) that had not 
previously communicated. By establishing a larger-scale market for HIT 
inter-operability, IHE helps reduce the cost of achieving inter-
operability and makes the inherent technology risk more acceptable for 
vendors. The backbone of the HITSP health information exchange 
infrastructure utilizes many of the same IHE inter-operability 
specifications that are already recognized and being deployed around 
the world.

The Role of NIST Today

    The National Institute of Science and Technology (NIST) is charged 
with developing and promoting measurement, standards, and technology to 
enhance productivity, facilitate trade, and improve the quality of 
life. While NIST's portfolio is not specific to health care, much of 
the research done at the NIST Laboratories with respect to advancing 
the Nation's technology infrastructure is directly applicable to the 
creation of an NHIN. Further, virtually all of NIST's projects are 
conducted in cooperation with a wide variety of public and private 
stakeholders.
    Within the health care realm, NIST Information Technology 
Laboratory has been involved with IHE on the development of XDS, which 
was adopted by EHRVA as the approach to electronic health information 
sharing for the Inter-operability Roadmap. NIST provided a test 
environment for vendors to test their implementations, and coordinated 
specification development with the web-services standards development 
organization OASIS that provided the standards used to implement XDS.
    NIST is also an invaluable resource in the area of data security 
and privacy. Because of the sensitivity of personal medical 
information, consumer opposition to an NHIN largely centers on concern 
about unauthorized access to and misuse of medical records. Among the 
methodologies pioneered by NIST is role-based access control--
technology that limits the type of information that can be viewed by 
any individual depending on that individual's function. So, for 
example, hospital-billing clerks would be authorized to see only the 
parts of a patient's medical record necessary to generate invoices for 
a specific admission, while physicians with access to the same system 
would be able to see the patient's entire medical history. NIST's 
expertise in data security can both accelerate the process of achieving 
an NHIN, and enhance public confidence in those efforts.

A Future Role for NIST

    H.R. 2406 envisions an expanded role for NIST in the development of 
HIT. GE supports NIST's increased involvement--but not at the expense 
of processes that are already working well, such as HITSP. We note also 
that NIST has not yet been allowed to fulfill its role under the 2005 
Memorandum of Understanding (MOU) between the Department of Health and 
Human Services (HHS) and the Department of Commerce (DOC).
    The areas where we believe NIST can be most valuable are:

          Facilitate coordination among federal agencies.

           The 2005 MOU charges NIST with the responsibility for 
        strategic, policy, and program coordination among federal 
        agencies. While such an effort is often likened to ``herding 
        cats,'' we believe that NIST has the capability and should be 
        given the opportunity to fulfill this mandate.

           The Federal Government is the largest health care payer in 
        the country, and therefore stands to benefit the most from the 
        increased efficiencies and cost-savings that can be garnered 
        through HIT. NIST's role would not be to create or certify 
        standards, but to work with other government agencies to ensure 
        that existing standards are being implemented appropriately.

          Enhance the already effective HITSP process.

           HITSP represents a best practice in public/private 
        collaboration. We should be wary of any action that would 
        result in diminishing the effectiveness of this group. That 
        said, we believe it is possible to build on the current 
        successes of HITSP (and of CCHIT), and NIST can play an 
        important role in doing so. To ensure this, we suggest that 
        HITSP be specifically recognized in this legislation.

           As a facilitator and coordinator among other federal 
        agencies, NIST can help to accelerate the HITSP process by 
        working between meetings to achieve consensus among the public 
        sector participants. And NIST's authority to enforce federal 
        agency compliance with standards implementation should be 
        strengthened.

           NIST's track record of promoting collaboration through IHE 
        demonstrates that it can also play an effective facilitation 
        role in the private sector.

           Finally, NIST can serve as a resource to State governments, 
        helping to disseminate information about technology roadmaps 
        and other information that is available to support local HIT 
        efforts.

          Provide coordination for testing inter-operability 
        standards.

           The utility of inter-operability testing is to demonstrate 
        that products comply with a defined set of standards. Over the 
        past 10 years, the IHE Connectathon has proven to be an 
        effective, transparent testing process. Development of a 
        parallel testing process, as CCHIT has proposed, covering the 
        same standards can be done only to the detriment of the 
        industry. We should not waste certification resources on 
        duplicative efforts, and we should not ask vendors--who have 
        already contributed to creation of the IHE process--to pay a 
        second time, in the form of increased CCHIT certification 
        costs. And if the parallel processes yield disparate results 
        for the same product, it would undercut the underlying 
        rationale for certification.

           To the extent there are testing processes not within the 
        scope of the Connectathon, there is room for CCHIT or other 
        entities--either alone or in the context of a public/private 
        collaboration--to develop their own testing processes. NIST 
        could help to oversee these efforts and ensure that there is no 
        duplication. NIST's position within the DOC makes it uniquely 
        suited to drive global standards harmonization.

           In other industries, NIST has effectively served as a single 
        clearinghouse for testing tools, whether they were created by 
        NIST or by another entity. We suggest that NIST should be given 
        the same responsibility with respect to inter-operability 
        standards, working in conjunction with HITSP.

          Focus research on areas not currently covered by 
        HITSP and other public/private sector activities.

           There is certainly room amid all these other activities for 
        NIST's extensive research capabilities, especially in areas 
        where the agency has particular expertise. These include:

                1.  Investigating the information technology necessary 
                to support pay-for-performance program.

                2.  Harmonization of security standards and practices, 
                especially with respect to the ``four As'' identified 
                by HISPC (authentication, authorization, access, and 
                audit), and making robust authentication more 
                accessible to the consumer.

                3.  Working with the private sector and HHS to provide 
                clarity in HIPAA security regulation guidance.

Summary

    NIST has played, and can continue to play, an effective role in 
coordinating the efforts of the public and private sectors toward 
developing HIT. Our support for expanding NIST's participation in these 
activities is contingent on the agency leveraging its strengths, and 
not duplicating or reinventing the good work that is currently being 
carried out by other public/private entities. NIST's research 
activities should be directed to the areas where there are currently 
gaps, such as data security.
    With respect to HISTP, we believe that NIST's highest and best use 
is to facilitate communication and consensus among the government 
entities represented. NIST can also help coordinate efforts in the 
private sector with respect to the efficiency and effectiveness of 
inter-operability testing.

                      Biography for Michael Raymer

    Mike Raymer leads a strategic team that drives global clinical and 
financial/administrative product strategy, evaluates new business 
initiatives, provides market analysis and research, optimizes strategic 
partnerships, and monitors government relations across all product 
lines in the GE Healthcare Integrated IT Solutions organization.
    Raymer's team impacts GE software solutions for inpatient and 
ambulatory care, including such capabilities as enterprise clinical 
information systems; ambulatory electronic medical records; 
departmental systems; Picture Archiving Communication Systems (PACS) 
and imaging information; solutions for patient access, patient 
accounting and practice management; and Web-based portals for both 
patients and referring physicians.
    Prior to GE's acquisition of IDX, Raymer served as Senior Vice 
President and General Manager of the IDX Carecast Operating Unit (now 
part of GE Healthcare), responsible for total profit and loss for the 
IDX CarecastTM enterprise clinical system (now GE Centricity 
Enterprise), as well as leadership of IDX's 500-employee Seattle 
office.
    Prior to joining IDX in 2002, Raymer served as Vice President, 
Products for Shared Healthcare Systems, where he was responsible for 
product development, quality assurance, web services and data 
warehousing. There, he completed development cycles for two new, web-
based clinical products, while maintaining three legacy software 
products.
    Earlier in his career, Raymer was General Manager/Director of the 
Clinical Information Systems Division at Nellcor Puritan Bennett/
Mallinckrodt Corporation, the world's foremost supplier of pulse 
oximetry and a leading supplier of airway management (ventilator) 
devices. In this role, he oversaw marketing, engineering, operations, 
training and support activities, and led the market launch of a point 
of care system for mobile health care workers, as well as a wireless 
ventilator monitoring product.
    During a 10-year period, Raymer led a start-up operation to a 
consistent level of quarter-by-quarter profitability. At Continental 
Healthcare Systems, Inc., he served as Vice President of Marketing, 
responsible for the definition and market position of multiple hospital 
information systems--including automated pharmacy and materials 
management systems--as well as product management and marketing 
communications.

    Chairman Gordon. Thank you, Mr. Raymer. Right on time.
    Mr. Barnes.

STATEMENT OF MR. JUSTIN T. BARNES, VICE PRESIDENT OF MARKETING, 
CORPORATE DEVELOPMENT AND GOVERNMENT AFFAIRS, GREENWAY MEDICAL 
                       TECHNOLOGIES, INC.

    Mr. Barnes. Thank you very much, Chairman Gordon, Ranking 
Member Hall, Dr. Gingrey, and distinguished Members of the 
Committee and staff. My name is Justin Barnes. I am the vice 
president of marketing and government affairs for Greenway 
Medical Technologies, a leading provider of integrated 
electronic health record practice management and inter-
operability-software solutions for physicians practices. It is 
always a great honor and pleasure to work with Members of 
Congress and their staff, as I believe we all have a common 
goal to shape the face of the health care industry by utilizing 
the vast contributions that you have heard about today that IT 
offers health care providers, patients, and payers in achieving 
goals of reduced medical errors, lower costs, better quality, 
and improved efficiency within our nation's health care system.
    In addition to representing Greenway, I am a board member 
of HIMSS Electronic Health Records Vendors Association, the 
EHRVA, which is comprised of the Nation's leading EHR 
companies, currently representing roughly 96 percent of all 
EHRs implemented in America today. In addition, I reside on the 
Board of the National Governors Association Health Information 
Protection Task Force and the Certification Commission for 
Healthcare Information Technology, CCHIT, Privacy Expert Panel.
    My perspective today will be that of a small business 
software and services provider that is actively engaging every 
facet of the health care industry to support developing a 
national strategy for the widespread adoption of health-
information technology and for converting this adoption into 
quality and efficiency improvements. The faster we align 
incentive, technical standards, and guideline requirements, the 
faster we improve care, increase quality, contain costs, and 
save lives.
    This statement focuses on Greenway's and our industry's 
dedication to assisting Congress, the U.S. House Committee on 
Science and Technology, and the National Institute of Standards 
and Technology in their goals of supporting the integration of 
the health care information enterprises. In this pursuit, 
Greenway, HIMSS, and the EHRVA support a truly transparent 
process and equal cooperation of public and private entities. 
This collaboration has proven, recently, to reduce barriers 
with federal regulations as well as barriers with harmonizing 
standards. Over the past few years, Greenway and the entire 
health care industry has made significant strides with EHR 
adoption, standards convergence, inter-operability, and 
improving ROI for long-term sustainability of our nation's 
health care transformation process. Specifically, Greenway 
customer practices now have the opportunity for inter-
operability among their local community which encompasses 
regional care providers, patients, and hospitals. Our customers 
alone have realized annual $21,000 to $81,000 on post-
implementation return on investment per physician. With 
paperwork reduced, collections increased and coding improved, 
physicians provide a higher quality of care and also operate a 
more efficient business.
    While HIT and EHR adoption currently grows at a record 
pace, we possess the responsibility to ensure that every policy 
enacted and every rule that is proposed must sustain our 
current investment and progress. We applaud the focus that the 
President, Congress, and HHS have applied to this industry 
transformation, but we must ensure that all decisions are 
created by entities that have the essential experience, 
dedication and factual evidence necessary to put plans and 
policy in place. An example of a Greenway-, HIMSS- and the 
EHRVA-endorsed article of legislation is H.R. 2377, the ADOPT 
Act of 2007, which uses section 179 of the tax code to provide 
physician purchasing incentives that can further increase HIT 
adoption by reducing upfront practice costs of the first year 
of EHR implementation. This bill has currently been introduced 
in the House.
    Greenway applauds the efforts to authorize NIST to increase 
its efforts in support of the integration of the health care 
information enterprise. NIST already plays and import role in 
public and private sector collaboration, such as Integrating 
the Healthcare Enterprise (IHE), and the Health Information 
Technology Standards Panel (HITSP), and that role should be 
maintained. In addition, NIST should be encouraged to work 
collaboratively to make these initiatives even more effective, 
and Congress can assist by formally recognizing HITSP in any 
legislative language. HITSP is a best practice because of its 
public and private collaboration, transparency, and use of 
multi-stakeholder processes like IHE. IHE has a 10-year legacy 
of standards and testing harmonization with global 
ramifications, and for that reason, it is imperative for NIST 
to recognize HITSP and IHE processes.
    From a financial investment standpoint, it is estimated 
that the private sector has invested $50 to $100 million, 
collectively, in the past few years following IHE, HITSP and 
certification initiatives, and that has resulted in the 
important areas of HIT adoption and inter-operability. More 
momentum has been created nationally and internationally in 
these areas than ever before. While this momentum could be 
better, it is crucial that influential bodies like Congress, 
the President Administration and NIST work together to maintain 
this impetus and not create alternative de facto testing 
standards or certification authority.
    It is an exciting time to help and guide and sustain the 
momentum in the health care information technology industry. We 
have the opportunity to create the most efficient health care 
system in the world, and while this is daunting challenge, it 
is certainly achievable. If we continue to work together in 
public and private collaboration, build on present successes 
with HITSP and take the prudent and fiscally reasonable steps 
necessary, we will achieve health transition goal and recognize 
the estimate $100 to $200 billion in U.S. annual saving with a 
fully integrated and inter-operable health care system.
    Speaking on behalf of the private sector, we are ready as 
an industry to continue our process and partnership with 
Congress and federal agencies in making these goals a reality. 
Chairman Gordon and distinguished Members of Congress and 
staff, I want to thank you for this opportunity and your 
dedication to the integration of the health care information 
enterprise. I hope my comments will help steer ideas and 
thoughts that can be transmitted into innovative policies 
shaping the future of health care in this country. Thank you 
very much.
    [The prepared statement of Mr. Barnes follows:]

                 Prepared Statement of Justin T. Barnes

    Thank you very much Chairman Gordon, Ranking Member Hall and 
distinguished Members of the Committee and staff. My name is Justin 
Barnes and I am the Vice President of Marketing and Government Affairs 
for Greenway Medical Technologies, a leading provider of integrated 
electronic health record (EHR), practice management and inter-
operability software solutions for physicians' practices. It is always 
a great honor and pleasure to work with Members of Congress and their 
staff as I believe we all have a common goal to shape the new face of 
the health care industry by utilizing the vast contributions that 
information technology (IT) offers health care providers, patients and 
payers in achieving goals of reduced medical errors, lower costs, 
better quality and improved efficiency within our nation's health care 
system.
    In addition to representing Greenway, I am a board member of the 
HIMSS Electronic Health Record Vendor's Association (EHRVA) which is 
comprised of the Nation's leading EHR companies currently representing 
roughly 96 percent of all EHR's implemented in America today. In 
addition, I reside on the board of the National Governors Association 
(NGA) Health Information Protection Task Force and the Certification 
Commission for Healthcare Information Technology (CCHIT) Privacy Expert 
Panel. My perspective today will be that of a small business software 
and services provider that is actively engaging every facet of the 
health care industry to support developing a national strategy for 
widespread adoption of health information technology (HIT) and for 
converting this adoption into quality and efficiency improvements. The 
faster we align incentives, technical standards and guideline 
requirements, the faster we improve care, increase quality, contain 
costs and save lives.
    This statement focuses on Greenway's and our industry's dedication 
to assisting Congress, the U.S. House Committee on Science and 
Technology and the National Institute of Standards and Technology 
(NIST) in their goals of supporting the integration of the health care 
information enterprise in the United States. In this pursuit, Greenway, 
HIMSS and the EHRVA support a truly transparent process and equal 
collaboration of public and private entities. This collaboration has 
proven recently to reduce barriers with federal regulations as well as 
barriers with harmonizing standards. Over the past few years, Greenway 
and the entire health care industry has made significant strides with 
EHR adoption, standards convergence, inter-operability and proven 
return on investment (ROI) for long-term sustainability of our nation's 
health care transformation process. Specifically, Greenway customer 
practices now have the opportunity for inter-operability among their 
local community which encompasses regional care providers, patients and 
hospitals. Our customers alone have realized an annual $21,600 to 
$81,500 post-implementation ROI per physician. With paperwork reduced, 
collections increased and coding improved, physicians provide a higher 
quality of care and also operate a more efficient business.
    While HIT and EHR adoption currently grows at a record pace, we 
possess the responsibility to ensure that every policy enacted and 
every rule that is proposed must sustain our current investments and 
progress. While we applaud the focus that the President, Congress and 
the U.S. Department of Health & Human Services have applied to this 
industry transformation, we must ensure that all decisions are created 
by entities that have the essential experience, dedication and factual 
evidence necessary to put self-sustaining plans and policy in place. An 
example of a Greenway, HIMSS and EHRVA-endorsed article of legislation 
is U.S. House bill 2377, the ADOPT HIT Act of 2007, which uses Section 
179 of the tax code to provide physician purchasing incentives that can 
further increase HIT adoption by reducing up-front practice costs over 
the first year of EHR implementation. This bill has been introduced in 
the U.S. House.
    Greenway applauds your efforts to authorize NIST to increase its 
efforts in support of the integration of the health care information 
enterprise in the United States. NIST already plays an important role 
in public and private sector collaborations such as Integrating the 
Healthcare Enterprise (IHE) and the Health Information Technology 
Standards Panel (HITSP) and that role should be maintained. In 
addition, NIST should be encouraged to work collaboratively to make 
these initiatives even more effective and Congress can assist by 
formally recognizing HITSP in any legislative language. HITSP is a best 
practice because of its public and private collaboration, transparency 
and use of multi-stakeholder processes like IHE. IHE has a 10-year 
legacy of standards and testing harmonization with global ramifications 
and for that reason, it is imperative for NIST to recognize HITSP and 
IHE processes.
    From a financial investment standpoint, it is estimated that the 
private sector has invested $50 million-$100 million collectively in 
the past few years following IHE, HITSP and certification initiatives 
and that has resulted in a health care transformation in the important 
areas of HIT adoption and inter-operability. More momentum has been 
created nationally and internationally in these areas than ever before. 
While this momentum could be better, it is crucial that influential 
bodies like Congress, the President's Administration and NIST work 
together to maintain this impetus and not create a new alternative de 
facto testing, standards or certification authority.
    This is an exciting time to help guide and sustain the momentum in 
the health care information technology industry. We have the 
opportunity to create the most efficient health care system in the 
world and while this is a daunting challenge, it is certainly 
achievable. If we continue to work together in public and private 
collaboration, build on present successes with HITSP and take the 
prudent and fiscally responsible steps necessary, we will achieve our 
health care transformation goals and recognize the estimated $100-$200 
billion of U.S. annual savings with a fully-integrated and inter-
operable health care system. Speaking on behalf of the private sector, 
we are ready as an industry to continue our progress in partnership 
with Congress and federal agencies in making these goals a reality.
    Chairman Gordon and distinguished Members of the Committee and 
staff, I want to thank you for this opportunity and your dedication to 
the integration of the health care information enterprise. I hope that 
my comments will help steer ideas and thoughts that can be transmitted 
into innovative policies shaping the future of health care in this 
country. Thank you very much.

                     Biography for Justin T. Barnes

    As a health care software executive and public policy expert, 
Justin Barnes manages Greenway's Strategy, Marketing, Corporate 
Development and Government Affairs departments. With a background in 
health care information technology (HIT), corporate operations and 
legislative policy, Barnes is responsible for building and executing 
Greenway's corporate strategy, industry and government relations. 
Barnes resides on several HIT and Electronic Health Record (EHR) 
industry governance boards and brings the essential continuum of 
experience from Silicon Valley Start-up's to Industry-leading Fortune 
20 conglomerates.
    Prior to Greenway Medical Technologies, Barnes was a member of the 
founding team and Vice President of Sales Operations and Account 
Development at Healinx Corporation. Today, Healinx is known as the 
RelayHealth Division of McKesson and continues as the premier provider 
of secure online health care communication services linking patients, 
health care professionals, payors, and pharmacies efficiently, 
affordably and securely.
    Before joining Healinx, Barnes held several Sales and Operations 
positions with HBO & Company that subsequently merged with McKesson in 
1999. He served under the Enterprise Group and was responsible for 
sales operations of the Pathways Smart Medical Record (SMR) 
application.
    Barnes has formally addressed Congress and the President's 
Administration on seven occasions between 2005 and 2007. Barnes has 
also been published in 27 journals, magazines and broadcast media 
outlets relating to national leadership of HIT and EHR adoption 
efforts.

Elected and Appointed Governance & Advisory Positions

Member of National Governors Association (NGA) Health Information 
        Protection Task Force of the State Alliance for E-Health

Board Member of the HIMSS Electronic Health Record Vendors Association 
        (EHRVA)

Board Member of Georgia Tech's Center for Health, Healthcare and 
        Eldercare Innovation (CHHEI)

Member of Certification Commission for Healthcare Information 
        Technology (CCHIT) Privacy Expert Panel

Co-Chair, Government Relations, National HIT Week

Chairman of Membership Committee of EHRVA

Member of HIMSS Advocacy and Public Policy Steering Committee

Member of e-Health Initiatives Policy Work Group

Member of EHRVA Government Relations Work Group

Member of HIMSS HIT Advisory Council

Member of HIMSS Government Relations Roundtable

                               Discussion

    Chairman Gordon. I bet you were getting ready to say 
something good there.
    Mr. Barnes. Thank you.
    Chairman Gordon. We have only two minutes, so we are going 
to have to go vote. I hope we will be back in 15 or 20. And so 
the Committee will be in recess.
    [Recess.]
    Chairman Gordon. Ms. Williams, you had, I think, indicated 
some concern that there is a number of folks working on this 
issue, and would NIST just be one more, and there is going to 
be a problem. You know, hopefully that is not the case. I think 
the intention is that we need to have somebody that is going to 
coordinate these activities, and I would remind you back, I 
guess it was in 1990, that HHS was directed, through the 
Nutrition and Labeling Education Act, to develop standards for 
baby food. Eight years later, they didn't get it done, and so 
they turned it over to NIST, and six months later it was done. 
That is what we want to try to accomplish.
    And Ms. Kloss, you have generally been positive about the 
health IT standards panel process, of which you are a member, 
but as you point out, it is largely a voluntary organization 
with a lack of professional staff resources. For such a 
critical task as advancing health care IT and operability, 
doesn't it make sense that the primary-standards-harmonization 
work be guided by a federal agency such as NIST rather than a 
voluntary organization?
    Ms. Kloss. Well, we think it is quite important that this 
process remain a public/private process, and certainly the 
resources and services of NIST would be a huge additional 
resource to HITSP, but there does just need to be some public/
private mechanism because it is aiding adoption and learning as 
we go to----
    Chairman Gordon. I think that you are right, and I think 
that is really the beauty of NIST in that it is a non-
regulatory agency, so we can bring everyone together without 
fear of regulation. This is what they did a few years ago with 
financial data security. They brought the financial industry 
together, helped them through a collaborative process, set 
those common standards, not picking winners or losers, and then 
being able to have the test beds there to make sure that they 
would work.
    Mr. Raymer, you note that NIST has not yet been allowed to 
fulfill its role under the memorandum of understanding between 
NIST and HHS, and you further note some of the work NIST is 
doing through the MOU. So wouldn't you also agree that 
codifying this role at a central location to ensure development 
of technical standards would be a worthy endeavor?
    Mr. Raymer. Absolutely. I think the testimony, you know, 
covered a variety of things that we would encourage the 
Committee to look at with respect to what their role would be, 
but we clearly see that there is a need for NIST in the 
process. And we believe as it was originally conceived under 
the memorandum of understating, that that would be an 
appropriate direction for the Committee to head, with the 
caveats that we placed in the testimony.
    Chairman Gordon. And back to a real, live doctor, Dr. 
Silverstone, to what extent would improved inter-operability 
with health care IT systems in hospitals, labs, and other 
medial facilities give medial specialty practices the 
confidence to make the investment in health care IT?
    Dr. Silverstone. You know, physicians really need to know 
that the investment that they are making is going to be a 
worthwhile investment. I mean our practices are being 
challenged on a daily basis by reimbursement and inter-
operability is that key that we need to know that the systems 
that we purchase are going to be able to work with other 
systems.
    You know, as a specialty physician, I am not the primary-
care provider most of the time, and patients are referred to 
me, and when they are referred, we have to recreate the wheel 
each time. We have to recreate histories. We oftentimes have to 
repeat tests because we don't have access to the tests. Very 
often, patients have been cared for elsewhere, and we might be 
able to get that data in paper format. Often, we can't even get 
that. If we could get the data in an electronic format, then we 
would be able to continue to analyze the data and to put the 
data that we are creating alongside that and provide better 
patient care. So these standards, we feel, are absolutely 
critical.
    Chairman Gordon. That is how we save money and save lives.
    Dr. Silverstone. Absolutely.
    Chairman Gordon. And as I pointed out earlier, most 
Americans are treated by physicians and practices of five 
physicians or less, and with the reduction in reimbursements, 
with difficulties that many practices face right now, it is 
difficult to justify trying to make that investment, 
particularly if you are not comfortable that it is going to be 
a long-range investment, and that is that whatever software you 
are going to buy is going to still be the premium software, or 
it can be inter-operable with the various groups that you deal 
with. So that is what we want to try to accomplish. But we need 
to do more than that.
    The purpose of this bill is not to integrate it into the 
health care offices, but rather to establish, again, those 
standards so that software can be developed. Then, quite 
frankly, we go to Ways and Means and we go to the Energy and 
Commerce Committee, where we need to provide incentives, both 
in terms of making it a government standard as well as trying 
to--I would hope we can provide financial incentives for doctor 
and hospitals through rapid write-off or other types of ways 
that we would encourage them to get on this system.
    Dr. Silverstone. Chairman Gordon, I can't agree with you 
more. I mean this will absolutely jumpstart the whole process 
of making health information technology a cornerstone of 
American medicine and will enable American ingenuity to really 
flower. I congratulate you on this.
    Chairman Gordon. Well, again, I want to thank our witnesses 
for being here. My time is up. I would like to ask Dr. Baird to 
chair the Committee, and I am sure that Mr. Hall will give him 
plenty of help.
    Mr. Baird. [Presiding] Mr. Hall.
    Mr. Hall. Thank you, Mr. Chairman. Mr. Barnes, you said 
that the private sector has invested $50 to $100 on 
certification initiatives for HIT. If H.R. 2406 were passed 
into law, could that slow down the progress that has already 
been made to date, and if so, why. And if no, why not?
    Mr. Barnes. In its current form, I think it could be a 
disruption to the progress that we have made over the past 
several years. We are committed to the progresses that we have 
made. I outlined them in my statement. I think that NIST 
certainly has a role. We have outlined that here, on the panel, 
and also several Members up there. NIST does have a history of 
public and private collaboration, so as long as NIST followed 
those guidelines and processes, which I am sure they would, 
then they would certainly have a positive influence on the 
process. But completely owning the process and not working more 
collaboratively with HITSP and taking what HITSP has done by 
name, not just by process or anything else, but literally, by 
name, then I think we could slow down adoption and the progress 
that we have made.
    So if we could take specifically HITSP's progress and move 
that into a forum where NIST has authority and maintain its 
progress and build upon that as a foundation, then I would 
support that.
    Mr. Hall. Mr. Raymer, you said that NIST helped to pioneer 
``role-based accessed-controlled technology that limits the 
type of information that can be viewed by any individual, 
depending upon that individual's function.'' Can you elaborate 
a little on that?
    Mr. Raymer. Yes, and specifically its role and application 
in health care is that as there becomes more widely available 
health-information system, a national health information 
infrastructure, we think the idea of role-based security is 
really critical so that those individuals that have the need to 
know during the care-delivery workflow at the appropriate time 
are given the appropriate access to the information that they 
need.
    We believe NIST could play an important role relative to 
those security standards that could be more widely adopted. And 
NIST has some history of having successfully done this in other 
areas outside of health care and inside of health care.
    Mr. Hall. And you also state in your testimony that you 
support an increase in NIST involvement, but not at the expense 
of the processes that are already working well. Would you 
elaborate a little on that, sir?
    Mr. Raymer. Well, I think Mr. Barnes covered that to some 
extent in his statement. It is just HITSP, we believe, has been 
a valuable process. IHE has a Connectathon that happens each 
year, where even a wider array of vendors each year are coming 
together to demonstrate the inter-operability of their 
products. So to the extent that NIST would derail current 
things that are working, we think that it would be better for 
NIST to apply their resources; like the one area would be 
compliance among the federal agencies. It is one of the largest 
purchasers of health care in the world, and certainly in this 
country.
    The government would greatly benefit from the utilization 
of standards, even within its own health care delivery system. 
So I think we have outlined in the testimony some specific 
areas that are gaps today.
    Mr. Hall. It is an area to be careful in, isn't it?
    Mr. Raymer. Yes, absolutely.
    Mr. Hall. And did you crank into your computer the fact 
that NIST has never before been a body that set policy?
    Mr. Raymer. Yes.
    Mr. Hall. You state in your testimony that you ``support an 
increase in NIST involvement, but not at the expense of the 
processes that are already working well.'' And you stated that. 
Now, do you believe that the passage of H.R. 2406 could 
potentially hurt progress that has already been made in health-
information technology?
    Mr. Raymer. I think to the extent it circumvents or slows 
down the work of HITSP, of IHE, and other successful 
initiatives, it would be very damaging. I think that, you know, 
if the Committee listens to the testimony today, and I think 
focuses the bill on directing NIST towards the areas in which 
we are currently gapped from our National Health Information 
infrastructure and technology platform, that what you would do 
would be accelerate the rate of adoption, because you are 
ensuring that resources are being brought to bear in an area in 
which there is not appropriate focus today.
    Mr. Hall. Well, I think that is a good answer. And I think 
that when the Chairman introduces a bill, it is often that we 
need to support that bill if at all possible, but we need to 
point out the pitfalls that might show, and I think this is a 
very good panel to give us those answers. And I think my time 
is up, so I yield back my time.
    I will have some questions that I wasn't to submit to each 
of you in writing, and if the Chair agrees to allow us to do 
that--I ask unanimous consent that the panel be asked to answer 
our questions that we submit to them in conjunction with this 
hearing.
    Mr. Baird. Without objection.
    Mr. Hall. Thank you, sir. I yield back.
    Mr. Baird. I am sorry I wasn't able--I had another hearing, 
as we often do here. From what I hear the situation seems to be 
that you have got some positive initiative going forward that 
seems to be moving at pace. We all recognize that, and there 
seems to be consensus that, we need to adopt this as quickly as 
possible. The question is NIST does not necessarily have to 
approach this by saying we are kings here. We are going to set 
the standards for you. Do you have objection to NIST providing 
a facilitative role? Or maybe that is what you were saying, Mr. 
Raymer, a facilitative role to work together with the various 
established processes to see if they can't move things a little 
more quickly, because it seems that is going more slowly, so I 
want to open that up to anybody. And then, as part of that, how 
does H.R. 2406 relate to that in your judgment?
    Mr. Raymer. Well, to respond to your question about 
facilitation, we think that there are some important roles that 
NIST could play. One, as I mentioned before would be to ensure 
compliance to the standards by the federal agencies themselves, 
and the government would benefit from that.
    Secondly, as you go through any kind of collaborate, both 
public and private collaborative, like HITSP, having this be 
the coordination to ensure that the dialogue continues on the 
public side within the governmental agencies is kind of being 
that guiding, facilitation mechanism we think would be very 
good.
    The other area is that there is some good work that goes on 
with regard to testing and certification today, but as the 
standards move forwards, and let us say in the areas of role-
based security, there may be a specific thing and specific role 
that NIST may play, then, in covering gaps of where 
certification or testing activities today are not appropriately 
validating the inter-operability between products.
    So we do view there to be a role of facilitation, both 
within government, outside of government, and more importantly, 
there could be specific roles that NIST might have in providing 
gaps that would accelerate the adoption of health care IT in 
the country.
    Mr. Baird. Ms. Williams, you seem to have something you 
want to add. You might want to hit your mic there. I am not 
sure it is on.
    Ms. Williams. Thank you. I generally concur with Mr. 
Raymer. We think that NIST could probably play a strong role in 
enforcing the standards, perhaps in implementation of those 
standards. I am just not sure that they are the appropriate 
group to bring the public and private sectors in step.
    Mr. Baird. Ms. Kloss.
    Ms. Kloss. I would add that, with respect, specifically, to 
the Certification Commission for Health IT and the work Mr. 
Raymer just referred to, that organization is now beginning to 
build a testing resource and is hopeful that there will be 
collaboration and that NIST will bring its expertise in 
building testing beds. Secondly, certainly, bringing forth 
standards in the area of security would be very valuable to the 
work going forward. And thirdly, as I mentioned earlier, we 
think we need a new mechanism study on how to look at clinical 
terminologies and classifications and bring that more robustly 
and squarely into the standards process.
    Mr. Barnes. I actually would like just to add just a little 
bit to that and especially where NIST, if they were involved 
before now, could have played a more positive role. In the area 
of CCHIT and certification, they have chosen a testing bed 
called miter, and whereas that could be considered a 
duplicative process because they could have chosen IHE, which 
NIST has been very involved in. And from a vendor standpoint, 
that is expensive for us. We now have to create tools to work 
with miter and their testing bed, and we have tools already 
that we paid for and use on IHE. So there certainly is a role 
for NIST in this. I almost wish it was a little bit, maybe 
sooner regarding that CCHIT item. So that is certainly to 
continue on in their efforts. Yes.
    Mr. Baird. One of the things we are working on elsewhere in 
a different committee is this whole issue of national health 
care, and I am a big believer in that you ought to give 
patients upfront information about what their options are and 
what the empirical data are and what their costs are, and I 
think that ought to be standardized across insurance policies, 
so we all get the same kind of information. Is that kind of 
issue being addressed? Or is it right now, you are focusing 
mostly on the technological aspect? But that is related, 
because will your technology allow for that kind of data, both 
collection and presentation to patients?
    Ms. Kloss. I would comment that that was the reason behind 
our discussion on classification and vocabulary as a type of 
standard that we feel have not gotten sufficient attention. It 
really is the common language of medicine that will allow this 
information to be understandable across the industry, and more 
work needs to be done on that to bring together disparate 
processes for developing, maintaining those systems and keeping 
them up to date, creating crosswalks between them, all of this 
internal information-management work.
    Mr. Baird. Thank you. My time has expired. I want to yield 
to Dr. Gingrey.
    Mr. Gingrey. Dr. Baird, thank you.
    You know, the entire hearing has been very, very 
informative, and of course, with the background of the 
Chairman's bill, I think all of us want to understand exactly 
what role that NIST will have in regard to, if this legislation 
is approved.
    And I guess my main question is, the President said a 
couple of years ago that we want to have a fully integrated, 
inter-operability, electronic medical records systems by 2014, 
I think, was the deadline. I think we ought to get there, 
hopefully, before then. I think the need is so great. When we 
sit here and talk about the various studies that suggest the 
amount of savings anywhere from $75 billion to $160 billion a 
year, and we just vote on a bill, the S-Chip program, which is 
by anybody's standards a fairly massive expansion, we still 
have 40 million people in this country uninsured. We have got 
other needs, war-fighting, not the least of which. I mean so we 
are talking about real money here. And the quicker we can get 
to the point of achieving those savings and saving lives, the 
better.
    So I guess the main question for all the witnesses--I will 
start with Mr., Barnes, my friend from my district from a 
courtesy--but you know, is there something about what we have 
been doing with the national coordinator, the HITSP that just 
gets into the realm of moving too slow, foot-dragging, not 
getting the job done? And what is that NIST can do to put on 
the afterburners, if you will, to make it better, and to not 
to--I think Mr. Barnes was expressing some concern about what 
would happen to the small vendors, and Mr. Raymer, too, in 
regard to the large vendors, GE, if you have already gone down 
a certain road, based on what ONC and HITSP have recommended, 
then we don't want to undo all of that process. So that is 
really my question: what can we do to make it better, other 
than the fact that maybe NIST is more recognizable acronym than 
HITSP or ONC.
    Mr. Barnes. Thank you very much, Dr. Gingrey. Most 
certainly, there has been a lot of work and progress over the 
last couple of years, through the ONC and leadership through 
HHS and by the President. And this progress, I don't think it 
is going to be--hopefully, it will not be undone, but you have 
seen--you have heard in my testimony that though standards 
harmonization certification, we have really increased adoption.
    We obviously could have done it better. There is always a 
better way to do items and perform tasks, but in my personal 
opinion, I think it has gone as smoothly--actually surprisingly 
smoothly, as any of us have anticipated. GE and my company, we, 
initially, when we were embarking upon learning about 
certification and standards harmonization, we certainly, 
naturally, had a lot of questions and concerns, and I think, 
now, speaking for my company directly, we were pleasantly 
surprised on the progress and how our investment that we have 
made--my company alone has made over $500,000 in investments in 
this, and not just on the personal investment side, but 
watching what this has done in the industry, watching inter-
operability come together. So it is exciting.
    I mean we are watching our customers. We have got 17,000 
across the county that just came from a user conference, and 
they are excited. They are seeing how inter-operability is 
changing their lives, their patients' lives. So it out there. 
It is successful. It could be better. This is where NIST can 
come in. I mean they have essential experience. They have long-
valued experience in this area of standards and testing, and so 
I think bringing that knowledge to bear within the current 
processes would be invaluable. So I mean I certainly would 
encourage NIST. The more minds that come together to make this 
a better process, I think is certainly welcome, just not to 
modify or derail all of the progress that we have invested in.
    Mr. Gingrey. I am short of time, but I welcome any other 
comments in regard to that.
    Ms. Williams.
    Ms. Williams. It is a daunting challenge that we have, and 
I would say that IT is a tool to help us solve a complicated 
problem in the health care system. It isn't that we don't have 
any standards. Part of the problem is that we have too many 
standards. The National Alliance for Health Information 
Technology did a survey recently, and the result was that, in 
fact, we have over 2,000 standards in the health care industry, 
with over 400 organizations that are either developing 
standards, maintaining standards, or licensing standards. So we 
need to invest the authority in some coordinating body to sort 
through all of this. That starts with a vision, and the 
President laid out a very high-level vision for what we need to 
achieve by 2014. We need to agree on a common vision, you know, 
sort of on how we are going to get there, and then we need to 
agree on a set of standards that will help us get there. That 
would be sort of the rules of the road or the roadmap. So we 
need a common vision; we need standards; we need a roadmap; and 
then, we need an implementation process. And perhaps--NIST 
definitely has role there in perhaps enforcing and helping with 
the implementation process.
    Mr. Gingrey. Thank you. My time expired. And thank you, Mr. 
Chairman.
    Mr. Baird. Thank you, doctor. Mr. Wu.
    Mr. Wu. Thank you, Mr. Chairman. My apologies, I was called 
away earlier for what I thought would be a quick vote, which 
took a long time, and now, I have been told again, I have been 
called for a quick vote in my other committee, but I will risk 
that briefly. And I want to ask this panel a non-standards-
oriented, a non-NIST-oriented question. In a field hearing and 
in roundtables that we held on this topic, in addition to the 
challenge of inter-operability and standards, there are other 
significant barriers to adoption of health care IT, one of them 
being the misalignment of cost and benefits. For example, if a 
small medical group were to adopt health care IT, they would 
have to bear the preponderance of costs, whereas a 
preponderance of benefits would go upstream somewhere, if you 
will, to Medicare or an insurance company and so on. Do you 
have thoughts on how to either better align these financial 
costs and benefits or for some way for the beneficiaries to 
help finance the cost of health care IT?
    Mr. Raymer. Well, certainly, GE has been a large purchaser 
of health care services in this county and are concerned about 
the misalignment that takes place today in the care-delivery 
environment. I think the movement towards pay for performance, 
I think, is an important movement, and to have part of the pay 
for performance tried in-process clinical measures that are 
only possible when you have an electronic system in place. So 
you can choose to do it on paper, but your cost of reporting 
that in an in-process basis would be more expensive than the 
cost of the system itself. Also, I remind you that CMS put of 
1303-P last fall, which provided a relaxation of Stark and a 
Safe Harbor or health care entities to offset the cost of 
donation for physicians. I conducted research last fall----
    Mr. Wu. Mr. Raymer, my apologies. Let me interrupt you. 
This time, they tell me it is really for real, and it is really 
urgent, but I would like the witnesses, if possible, to proceed 
to answer the questions, and I look forward to reading the 
answers, and my deepest apologizes to you all for this 
multiple-ring affair that we have going in the Congress.
    Mr. Raymer. Well, I was just going into 1303-P last fall, 
created Safe Harbor and the exception to Stark to allow health 
care entities like hospital systems or integrated delivery 
networks to offset up to 85 percent of the cost of the EMR for 
physicians. I did research last fall with an independent group 
that identified that that regulatory change will stimulate 
adoption and probably likely double the rate of adoption over 
the next three years by physicians. So you know, I think it is 
a combination of a move towards pay for performance that is 
based on in-process measures. And the number-one barrier for 
adoption for physicians in studies that we have done is all 
about economics. And so if you couple, you know, that 
reimbursement will be better when you provide better care, and 
the methodology by which you do that is--IT is one tool to 
accomplish that.
    Ms. Kloss. I would add that we also have to guard against 
any failure in implementation. That is these implementations 
need to go very well, and we need to be seeing providers really 
benefiting from the technologies, and so the work that you have 
done on workforce development is key, and additional insights 
into best practices and workflow improvements. So it is not 
just getting them in. It is really making them work well and 
return.
    Ms. Williams. And I would add that that is an ongoing 
process. In my written testimony, we did outline that hospitals 
with more advanced IT systems than what physicians currently 
have could provide help in both hardware and software 
implementation and ongoing support. But we can't do so today 
because the physician-referral or Stark regulations. Those have 
been recently relaxed to some extent. We would like to see the 
relaxation made permanent.
    Dr. Silverstone. My perspective is a little bit different, 
because it comes from the trenches. It comes from the 
physician's office. And I have talked to many, many physicians 
over the years, especially specialists, and they really want 
this technology.
    They can see that at its best, this technology can really 
help them to provide exceptional care to patients and make that 
exceptional care the norm. But there is a tremendous problem 
with the cost, and there is a tremendous fear with the cost. 
And physicians are small businessmen. Most physicians do not 
have very, very close ties to hospitals and don't want those 
ties. They want to remain independent business concerns, and 
they want to be able to control their lives. And they need to 
be able to afford it, and they need to be able to know, going 
into the future, that they will be able to continue to afford 
the technology.
    So the financial aspects, yes, are a major one, and the 
financial aspects really need to be addressed. Physicians are 
also looking at what it takes to maintain these systems in 
their offices, and as soon as you get inter-operability, as 
soon as you get standards, as soon as you take your hundreds, 
and hundreds of sets of standards and get an organization that 
can combine them and can take the best of all of the sets of 
standards and really make them routine, then you are producing 
a system that requires less maintenance and a system that 
physicians' offices can really afford. I have the advantage of 
being in an 11-doctor practice. In that practice, we have a 
full-time HIT person, a full-time person to manage our networks 
and our systems, and most practices can't afford that.
    Mr. Barnes. I would like to follow up with a quick comment 
here.
    Mr. Baird. It is going to have to be real quick, because I 
have a couple of other Members who want to----
    Mr. Barnes. Well, just real quickly, I think that if I was 
a physician, I wouldn't think about not investing in 
technology. They do need to streamline their practices. Most of 
my customers, which I have a very hands-on relationship with, 
do not have any HIT staff in their office. They are four-, 
five-, and six-doctor practices across America, and if you have 
the right system made for your specialty, you do not need--I am 
saying that if they do their due diligence, they will receive 
the benefits.
    Mr. Baird. All right. Dr. Broun.
    Mr. Broun. Thank you, Mr. Chairman. I am a physician. In 
fact, I am a primary care provider and I have done a full-time 
house-call practice the last few years just prior to just 
recently being elected to Congress. When I was in an office, 
and then as a sole practitioner, I looked into doing electronic 
medical records for my own patients, and what I found after 
doing a through investigation is, frankly, I could not afford 
it. I don't have Dr. Silverstone's blessing of having a large 
practice of being able to afford a full-time IT person, and so 
I think affordability, practicality for small, community 
practitioners--sometimes we have one, two or three doctors in a 
practice who want to be independent, who is not tied to a 
hospital. It is a certainly a tremendous probe that we need to 
face, and I could not overcome the cost, as well as it was 
difficult for me to try to figure out how to go up the learning 
curve to be able to integrate information technology into my 
own practice.
    The other thing is our local hospital in Athens, Georgia, I 
have talked to the administrator recently, and they are trying 
to develop an IT system through Athens Regional Hospital where 
all of the doctor in the community are all tied into one 
computer system, and I think that is a very laudable goal, but 
the thing that concerns me is privacy and confidentiality. I 
would, in my own practice, all of my employees knew that if 
anything went out of the door of my practice, it was immediate 
grounds for dismissal, no questions asked. Fortunately, I never 
had to dismiss anybody.
    But last year, the U.S. Department of Veterans Affairs 
announced that the theft of laptops contained information 
concerning, I think it is 26.5 million veterans and active-duty 
military members, and we have government workers losing laptops 
all of the time with confidential, even top-secret information, 
on those computers. And it just really concerns me that people 
social security numbers, not only in these instances that I 
just mentioned, but as a medical doctor, I am really concerned 
about the privacy of my patients and the confidentiality and 
when you set up this information sharing, I see a very real 
potential for discrimination against parents for insurability, 
discrimination in hiring practices, and these types of things.
    So could you all please answer to me how we can ensure that 
confidentiality, how we can prevent the discrimination to my 
patients in a new IT type of world.
    Mr. Raymer. I will take that to start with. I think that 
the conundrum you are in is that the paper record is also not 
very secure, so the reality that is if you walk into a hospital 
today, and it has got a lot of paper charts, there is ready 
access to the public to that.
    The majority of technology solutions that we are talking 
about is not having the data stored in one location, but more 
of a federated model where the data resides back in the 
practice, and the individual practice has control of that, and 
that you, when you have a patient referred into your practice, 
that you, with the appropriate credentials, have the ability to 
go out under the patient's HIPAA concurrence to go out and 
secure other relevant data, whether it be problem lists, 
medication, allergies, which are all important things that you 
would like to know about a patient being referred into your 
practice.
    So we do believe that NIST can play a role, particularly in 
the security and privacy side. And my testimony talked about 
the need for role-based security and how critical of importance 
that will be, so you know, I think that it is certainly 
something that is internalized, but it is very personal, so 
that one thing you can say about health care is it affects 
everyone in this room. And so I think that in both the public 
and the private area GE is very concerned about this very issue 
as you look to the future of genomics, which is a whole other 
universe of personal medical information that, you know, could 
be accessed, so it is a big concern that we have.
    Ms. Kloss. I would add that the Certification Commission 
for Health IT in the foundational testing that they are doing 
for all certified electronic health records is meeting certain 
privacy and security common standards and that those are being 
ratcheted up over time as all of us learn to use systems with 
more robust certification and privacy controls. So I think that 
is one of the step-wise processes in the standards deployment 
now. What we have, however, and what the e-Health--the State e-
Health Alliance and other groups are looking at is the wide 
disparity among states and how, in fact the current law is 
actually being put into place. We just do have more need for 
education across the board and practices. It is not all 
technology standards.
    Mr. Baird. Those buzzers you have been hearing means we 
have a vote underway, and so we have just enough time for Mr. 
Akin to ask a couple of questions, and then we will----
    Mr. Akin. Thank you very much, Mr. Chairman. Actually, one 
of the questions was asked--I was just curious about the, you 
know, legal problems, but in terms of data security, is that 
something that we have to change the laws, because we get 
pretty hyper-sensitive about anybody, you know, knowing whether 
you had a 101-degree fever or something? I mean it wasn't quite 
that bad, but we really go pretty hyper about his. Do we have 
to change the laws any in that regard, and is that a big 
problem?
    Mr. Barnes. I will start with that one. I think that that 
is probably being scoped right now. I mean I sit on the 
National Governor's Association Privacy Board for that exact 
reason, and we are looking at all of the 50 states' privacy 
laws as well as HIPAA to see what recommendations that we will 
made to all 50 states and to Congress on does HIPAA need to be 
modified? Does it just need to be enforced? Better interpreter? 
Or what do we need to do across state lines? I mean every state 
sees consent and authorization differently, and so we are 
trying to provide guidance, and that is underway, currently, 
right now. We meet every month to discuss this and should have 
some further recommendations at the end of this year, so I 
don't know if there is a yes or no answer quite yet. There 
might be by some panel----
    Ms. Kloss. There is a gap, and that is the gap in genetic 
non-discrimination disclosure, where we have been advocating 
for law in that area, specifically to cover an area of 
vulnerability.
    Mr. Akin. You do need some additional protection, no easing 
off on things that already exist?
    Ms. Kloss. That is correct.
    Mr. Akin. Are there places where we need to ease off things 
where we are too strict, or not necessarily?
    Ms. Kloss. I think we have always viewed HIPAA as a floor, 
and that a floor, over time, as we gain more experience and get 
that in place, we should look to, you know, raising the bar as 
technology enable things like robust audit trails and other 
mechanisms to really keep raising the bar. And I think we need 
a commitment to that over time.
    Mr. Akin. I mean I was thinking--what I am talking about is 
maybe it was too high. I remember there were times that you 
couldn't tell the dentist that the patient had AIDS or 
something, and then you have people that are--their health is 
at risk and things like that. So I was wondering if we get--you 
know, if there was a balancing act. I mean it seems to me there 
would be a balancing act, not that you are always ratcheting 
something up.
    Mr. Barnes. I think that adding interpretation also might 
be an answer. It might be a regulatory guideline or regulatory 
interpretation, maybe not on the legislative side. It's in what 
you are trying to uncover because HIPAA is just misinterpreted, 
and so unfortunately, people interpret it as conservatively as 
possibly so they don't enter any hot water, so I think that is 
what we are still ungoverned.
    Mr. Akin. And then the second thing, is there--I used to 
work for IBM and the magnitude of this question is sort of mind 
numbing to me, but is there any single organization now that 
can do some systems design and at least define some interfaces 
so that as people design systems that the things can plug 
together at the--or is this something that is still--but is 
there any one, single organization that is trying to define 
what the system might look like?
    Mr. Raymer. Well, certainly, there is from a standards 
standpoint, a definition. No one is trying to write a standard 
that defines one system. In the State of Vermont, GE happens to 
be the provider of the regional health information 
infrastructure in that we are providing a product, but there 
are other states that are doing something similar. We are all 
leveraging the same work product that is coming out of HITSP, 
so the standard shouldn't define a de facto product solution. 
The standard should define what a product should look like, and 
then there should be the incentive, commercially, to develop a 
system that is responsive to those standards.
    Mr. Akin. So it is a two-tier thing. You have some 
standards, and then you let the private sector work those, and 
that is the way we--because those of us in government are very 
sensitive to the fact that, you know, we are not effective as 
business in terms of being able to put products in good 
quality. You know, at the same time, there needs to be some 
kind of guidance, and so is that balanced? You think that this 
bill sets that balance about right from what you see?
    Dr. Silverstone. I would agree with that. I would say that 
is exactly what it does do: it provides the framework, the 
foundation that enables the private sector to be able to come 
in and create the programs and the systems that we need.
    Mr. Akin. And my hope is--of course, all of us can see the 
benefits of it. I am a prostate cancer survivor, so you say you 
got to go see--you are going to get surgery and this and that, 
and if those statistics are really recorded well, it is going 
to be a tremendous tool, medically, to know all kinds of 
different things. But yes, I am hoping the day will come when 
the individual practitioner--that there is stuff that is cheap 
enough off the shelf and that it is not too complicated, but I 
also walk into a room with computers, and they start laughing, 
so I am one of the guys that needs two IT people. Thank you. We 
have got to go vote.
    Mr. Baird. Mr. Akin, we are down to five minutes.
    I want to thank the panelists and the witnesses and 
everyone else who attended here. I also want to thank my 
colleagues. The record will be open for additional statements 
for two weeks for Members and for answers to any follow-up 
questions. If you have additional things that we didn't cover, 
but you feel are important to submit for the record, please do 
that, and Members, of course, have that prerogative as well.
    And with that, the hearing stands adjourned. Thank you all 
very much.
    [Whereupon, at 12:15 p.m., the Committee was adjourned.]

                              Appendix 1:

                              ----------                              


                   Answers to Post-Hearing Questions


Submitted to David E. Silverstone, Clinical Professor of Ophthalmology 
        and Visual Science, Yale School of Medicine; Assistant Chief of 
        Ophthalmology, Yale-New Haven Hospital; Practicing 
        Ophthalmologist, The Eye Care Group, New Haven, CT

    These questions were submitted to the witness, but were not 
responded to by the time of publication.

Questions submitted by Chairman Bart Gordon

Q1.  What are the major factors that discourage medical specialist 
practices from investing in health care IT (HIT) systems? To what 
extent would improved inter-operability with HIT systems at hospitals, 
labs, and other medical facilities give medical specialty practices the 
confidence to make investments in HIT?

Q2.  How could an inter-operable HIT system better enable practicing 
specialty physicians to keep up-to-date on the latest medical 
treatments and diagnosis procedures? How do specialty physicians 
currently track the latest advances in medical information and the 
recommended best-practice treatments in their field?

Q3.  How are the needs of specialty medical practitioners different 
from those of hospitals and general-medicine providers? What are some 
examples of these needs, and how can HIT standards be made flexible 
enough to accommodate the needs of specialists?

Questions submitted by Representative Ralph M. Hall

Q1.  I understand that the Administration supported establishment of a 
health IT standards harmonization process in 2006 through the 
Healthcare Information Technology Standards Panel (HITSP) which has 
made considerable progress over the past two years in the development 
and harmonization of data and technical standards for inter-operable 
health information exchange. How do you see this bill building on the 
current standards harmonization process through the HITSP?

Q2.  In August 2006, the President issued Executive Order 13410, which 
requires federal agencies to utilize, where available, health 
information technology systems and products that meet inter-operability 
standards recognized by the Secretary of Health and Human Services. The 
American Health Information Community (AHIC) has recommended several 
sets of standards that HITSP has developed or harmonized. How do you 
feel this bill would affect that process, given HHS' expertise in 
health IT standards?

                   Answers to Post-Hearing Questions

Responses by Noel Brown Williams, President, Senior Vice President, and 
        Chief Information Officer, Hospital Corporation of America 
        Information Technology and Services, Inc.

Questions submitted by Chairman Bart Gordon

Q1.  You have suggested the problem with adoption of health care IT 
(HIT) is that the industry has not yet selected a single set of inter-
operability standards and gotten consensus among health care 
stakeholders to use those standards. Given NIST's long history of 
acting as a neutral government body working with industry and other 
groups to select consensus technical standards in a broad array of 
technical fields, isn't NIST well positioned to guide this very 
necessary standards-selection and standards-buy-in process?

A1. The short answer is yes. NIST is well positioned to play an 
important role in the standards selection and buy-in process. The lack 
of a single set of inter-operability standards is just one reason for 
the slow adoption of HIT. While the best standards are created through 
a consensus process, there must be commitment on the part of 
stakeholders to make the necessary investments to implement those 
standards. Commitment to implementation involves vendors, providers, 
laboratories and a broad array of stakeholders with a legitimate need 
to share health data. NIST could make a valuable contribution to this 
piece of implementation. Other components of the commitment process 
include initial financing, maintenance costs, payment and privacy 
policies, as well as quality reporting and other issues we believe are 
best resolved by other efforts and agencies already in place.

Q2.  You cite as one example of the lack of HIT standards the fact that 
there is no standardized method to associate a patient with his or her 
medical records. What is the consequence of this lack of HIT standards, 
and what does it prevent health care providers from being able to do 
for patient care?

A2. The lack of a standardized method to match a patient with his or 
her medical record is a fundamental problem that must be resolved 
before we can attain the vision of an interconnected, nationwide health 
information network. A provider can never be 100 percent certain that 
the record under review belongs to the right patient without such 
measures in place. Both false negatives and positives have consequences 
and could affect patient safety, as well as expose the physician to 
liability if the wrong information is used during an episode of care.

Q3.  How would a fully inter-operable HIT system within the Federal 
Government advance the adoption of HIT in the private sector?

A3. A fully inter-operable federal HIT system would advance the 
adoption of HIT in the private sector by demonstrating, once in place, 
that inter-operability reduces costs, improves patient safety and the 
efficiency of the care process. Furthermore, a government system could 
be used to pressure the private sector into compliance with its system 
in order to expedite payments and claims handled by the Centers for 
Medicare & Medicaid Services.

Questions submitted by Representative Ralph M. Hall

Q1.  I understand that the Administration supported establishment of a 
health IT standards harmonization process in 2006 through the 
Healthcare Information Technology Standards Panel (HITSP) which has 
made considerable progress over the past two years in the development 
and harmonization of data and technical standards for inter-operable 
health information exchange. How do you see this bill building on the 
current standards harmonization process through the HITSP?

A1. This bill builds upon the progress already made by HITSP by adding 
NIST's expertise to transform the result of HITSP's consensus-based 
decision-making process into a set of tools and guidelines that would 
enable the implementation of the decisions made. HITSP's expertise is 
in guiding stakeholders to consensus on which standards should be used; 
NIST takes it to the next logical step of implementation.

Q2.  In August 2006, the President issued Executive Order 13410, which 
requires federal agencies to utilize, where available, health 
information technology systems and products that meet inter-operability 
standards recognized by the Secretary of Health and Human Services. The 
American Health Information Community (AHIC) has recommended several 
sets of standards that HITSP has developed or harmonized. How do you 
feel this bill would affect that process, given HHS' expertise in 
health IT standards?

A2. Given the uncertain future of AHIC and its role in this process, 
this bill would allow NIST, HITSP, AHIC and HHS to identify where 
NIST's expertise could best be leveraged We believe NIST could, if 
positioned correctly, complement rather than constrain progress.

                   Answers to Post-Hearing Questions

Responses by Linda L. Kloss, Chief Executive Officer, American Health 
        Information Management Association, Chicago, IL

Questions submitted by Chairman Bart Gordon

Q1.  You noted AHIMA's support for the approach in H.R. 2406 of having 
NIST work on security standards for health care IT (HIT). How important 
is robust security and confidentiality of medical information for the 
broad public acceptance of HIT systems? How can it best be achieved?

A1. AHIMA members, health information management (HIM) professionals, 
believe that for public acceptance of HIT and electronic health 
information exchange (HIE) there must be trust that the electronic 
systems and manual practices involved include the necessary functions 
or steps taken to secure their personal health information (PHI) and 
maintain confidentiality subscribed to in the agreements between 
consumers and entities that hold or transfer PHI. In addition to a 
number of confidentiality practices and physical security, ``security'' 
includes a number of software elements including, but not limited to, 
identification and authentication, access controls, system audits and 
access tracking, data integrity, and so forth.
    Security is not a new issue in the exchange of health information. 
HIM professionals have made this a key element of our practice for 
decades, but when it comes to having acceptable standard security 
software systems; the health care industry has remained behind other 
industries. Development of functional security standards have been an 
important activity of NIST, and AHIMA believes the resources of NIST in 
combination with health care industry oversight must be brought 
together so that the industry can have available the security tools and 
resources necessary to combine with conscientious confidentiality 
practices in order to ensure the public's trust in our collection, 
storage, and transfer of their PHI.
    Although not under the jurisdiction of NIST, AHIMA believes that 
penalties are an essential element of robust confidentiality 
requirements and building broad public acceptance of HIT systems. 
Penalties need to be severe and should encompass security and 
confidentiality breaches along with non-compliance with laws, 
regulations and standards. The HIPAA Privacy Rule has now been in 
effect since April 14, 2003 (April 14, 2004 for small health plans) and 
non-compliance, at this stage, is inexcusable.

Q2.  What are the research and development needs to ensure that 
advances in information technology and medical technology can be 
incorporated into HIT standards in the future?

A2. Standards must be chosen that meet the current functional needs and 
can be harmonized with other standard that also must support a 
particular functional model. This means that the bodies harmonizing 
standards must review not only the potential transaction, terminology, 
or classification standard(s) involved, but also ensure that the body 
that develops and maintains the standard and subscribes to principles 
such as:

          Transparent and open business practices by all 
        participating organizations--this includes end users of the 
        standard or the data included or represented by the standard,

          Organization, mechanisms, and a timely process 
        necessary to keep standards robust and up-to-date with current 
        medical practices and technology (national and international). 
        Section 201 of H.R. 4157, the ``Health Information Technology 
        Promotion Act'' in the 109th Congress, provided good language 
        to reduce the time and streamline the process to modify and 
        update HIPAA standards,

          Standard development principles and guidelines for 
        development, distribution, and maintenance of systems and 
        coordination across systems,

          The provision of timely and reliable guidance on the 
        use of the standard (also a role for any coordinating body).

Q3.  In your testimony you noted that there are over 2,000 standards 
related to HIT and over 400 organizations that either create, maintain, 
or license those standards. If the most important job in making HIT a 
reality is to work towards a single set of standards and get consensus 
on using that set of standards, isn't the leadership of a neutral 
government body such as NIST, with its long history of working with the 
private sector on consensus standards development, essential?

A3. The numbers in your question were not part of AHIMA's testimony. 
Even so, there are many standards and many organizations. Yet, the 
issue of choosing or harmonizing standards remains. The active 
involvement of a skilled neutral group, such as NIST, will do much to 
accelerate the harmonization process, but there also has to be 
consensus and buy-in from the health care industry, which is currently 
operating on a public-private model--the Health Information Technology 
Standards Panel (HITSP) and the American Health Information Community 
(AHIC). Were the health care industry not so invested in this model, 
the NIST leadership role you suggest might be an acceptable 
alternative. However, the current Administration has pushed for a 
public/private model and the industry has invested considerable 
resources and time to make this approach work. We appreciate the 
Committee's acceptance of the roles of HITSP and CCHIT and working NIST 
into the current model will to help accelerate the harmonization 
process, support security standard development, and provide the needed 
testing mechanisms.

Q4.  What would be the benefits to public health, in terms of tracking 
disease outbreak, adverse drug reactions, or other issues, from a fully 
inter-operable HIT system?

A4. Presuming the health care industry can arrive at uniform and 
consistent use of terminologies and classifications in electronic 
health records (EHRs); address confidentiality concerns through the use 
of good security standards, compliance and enforcement; establish the 
network and decision support necessary to determine reporting paths; 
and, use the same network to provide public health notices and 
guidelines, then the benefits of collecting data for population health 
purposes (public health, research, and similar reporting) are expected 
to be enormous. Currently, none of these activities and reporting 
mechanisms (networks) are in place. Most reporting is done by hand, 
systems operate in silos, and the classification systems in use are 
mapped in few systems, but not capable of reporting, in any detail, 
21st century diseases or medical practices and technology. Moreover, 
because of our nation's inconsistent use of uniform and consistent 
terminologies, we are unable to efficiently exchange information with 
most of the international community including the World Health 
Organization and its Global Outbreak Alert and Response Network. This 
is severely detrimental to our ability to track the progress of 
outbreaks of diseases as avian influenza, SARS and potential 
bioterrorism events.
    Substantial efforts are underway to achieve this vision for 
population health. The Science and Technology Committee's attention to 
the terminology and classification standards coordination and 
improvements needed as well as the harmonization of transaction, 
functional, and security standards will give this movement a 
considerable boost.

Q5.  How could an inter-operable HIT system better enable practicing 
physicians to keep up-to-date on the latest medical treatments and 
diagnosis procedures? How could inter-operable HIT systems support 
decision-making by practicing physicians and other health care 
providers?

A5. AHIMA would interpret ``inter-operable'' in this question to mean 
uniform and consistent use of contemporary medical terminologies and 
classifications as well as the adoption of a standard EHR and networked 
health information exchange (HIE).
    If the medical community is capable of reporting findings and 
questions in the same uniform and consistent language, then a variety 
of public and private organizations, including the CDC, AHRQ, NIH, NLM, 
and various private foundations and medical research organizations, can 
respond with what is known regarding a particular disease or problem 
and provide guidelines for how to respond.
    Currently, the language of medicine in the U.S. is not consistent 
or uniform which limits communication both to asking the question as 
well as providing an answer. The ability to use either uniform 
terminologies to exchange the actual health record, or classifications 
to identify diagnoses, procedures, and technology, must be detailed, 
and the ability to transmit such information uniformly then permits the 
use of computer technology to scan information and provide links to 
potential responses or experts. Today, most communication is visual and 
the data is limited, therefore reducing the ability and increasing the 
time to search the vast body of knowledge available. Time is a very 
important factor with physicians, both in the time they have available 
and the timely needs for information as they are treating individuals 
and reporting key information for population health purposes, research 
and so on.

Q6.  To encourage the rapid adoption of HIT systems by health care 
providers, it is important to guard against failures of implementation, 
which would reduce confidence in the benefits of HIT systems and make 
other providers reluctant to invest in them. How will technical test 
beds for testing HIT products help prevent implementation failures? 
What other actions can reduce the risk of implementation failures?

A6. The technical test beds discussed in AHIMA's testimony were 
recommended to allow for certification of HIT products to ensure the 
purchaser that the product: included applicable, adopted (HITSP/AHIC) 
standards; provided the capability for inter-operability; and possessed 
the capability to be upgraded as the industry upgrades its standards, 
systems and system requirements, and so forth.
    HIT vendors must have their own test beds to ensure their products 
meet the industry and customer demands, and some of this testing could 
use the same technical test beds suggested for development by NIST and 
harmonization by HITSP. Vendors must also be able to test their product 
against any networking or HIE that exists in the purchasers 
environment.
    Implementation, however, is more than buying a good, a certified 
HIT product, that has the capacity to use uniform contemporary 
terminologies and classifications. Implementation requires careful 
planning, work flow and other administrative changes, new ways of doing 
business for the clinicians, patients, and the other professionals and 
administrative persons involved, and on-going maintenance and education 
after implementation has occurred. If successful implementation of a 
standard EHR and HIE is going to be accomplished across this country, a 
workforce of educated and trained health information management and 
informatics professionals must be present and available to the 
organizations, physician practices, and other entities involved with 
implementing these systems et al. The Science and Technology Committee 
took significant steps to address this need in passing H.R. 1467, and 
we hope that the Senate will soon pass complementary legislation.

Questions submitted by Representative Ralph M. Hall

Q1.  How could an inter-operable HIT system better enable practicing 
physicians to keep up-to-date on the latest medical treatments and 
diagnosis procedures? How could inter-operable HIT systems support 
decision-making by practicing physicians and other health care 
providers?

A1. AHIMA would interpret ``inter-operable'' in this question to mean 
uniform and consistent use of contemporary medical terminologies and 
classifications as well as the adoption of a standard EHR and networked 
health information exchange (HIE).
    If the medical community is capable of reporting findings and 
questions in the same uniform and consistent language, then a variety 
of public and private organizations, including the CDC, AHRQ, NIH, NLM, 
and various private foundations and medical research organizations, can 
respond with what is known regarding a particular disease or problem 
and provide guidelines for how to respond.
    Currently, the language of medicine in the U.S. is not consistent 
or uniform which limits communication both to asking the question as 
well as providing an answer. The ability to use either uniform 
terminologies to exchange the actual health record, or classifications 
to identify diagnoses, procedures, and technology, must be detailed, 
and the ability to transmit such information uniformly then permits the 
use of computer technology to scan information and provide links to 
potential responses or experts. Today, most communication is visual and 
the data is limited, therefore reducing the ability and increasing the 
time to search the vast body of knowledge available. Time is a very 
important factor with physicians, both in the time they have available 
and the timely needs for information as they are treating individuals 
and reporting key information for population health purposes, research 
and so on.

Q2.  To encourage the rapid adoption of HIT systems by health care 
providers, it is important to guard against failures of implementation, 
which would reduce confidence in the benefits of HIT systems and make 
other providers reluctant to invest in them. How will technical 
testbeds for testing HIT products help prevent implementation failures? 
What other actions can reduce the risk of implementation failures?

A2. The technical test beds discussed in AHIMA's testimony were 
recommended to allow for certification of HIT products to ensure the 
purchaser that the product: included applicable, adopted (HITSP/AHIC) 
standards; provided the capability for inter-operability; and possessed 
the capability to be upgraded as the industry upgrades its standards, 
systems and system requirements, and so forth.
    HIT vendors must have their own test beds to ensure their products 
meet the industry and customer demands, and some of this testing could 
use the same technical test beds suggested for development by NIST and 
harmonization by HITSP. Vendors must also be able to test their product 
against any networking or HIE that exists in the purchasers 
environment.
    Implementation, however, is more than buying a good, a certified 
HIT product, that has the capacity to use uniform contemporary 
terminologies and classifications. Implementation requires careful 
planning, work flow and other administrative changes, new ways of doing 
business for the clinicians, patients, and the other professionals and 
administrative persons involved, and on-going maintenance and education 
after implementation has occurred. If successful implementation of a 
standard EHR and HIE is going to be accomplished across this country, a 
workforce of educated and trained health information management and 
informatics professionals must be present and available to the 
organizations, physician practices, and other entities involved with 
implementing these systems et al. The Science and Technology Committee 
took significant steps to address this need in passing H.R. 1467, and 
we hope that the Senate will soon pass complementary legislation.

                   Answers to Post-Hearing Questions

Responses by Michael Raymer, Vice President and General Manager, Global 
        Product Strategy, GE Healthcare Integrated IT Solutions

Questions submitted by Chairman Bart Gordon

Q1.  How should NIST interact with the Healthcare Information 
Technology Standards Panel (HITSP), and in what ways would that 
interaction further the rapid adoption of consensus technical standards 
for health care IT (HIT)?

A1. Interaction between NIST and HITSP is already occurring. Two areas 
that could enhance this interaction to accelerate adoption of standards 
are:

        1.  Utilize NIST's experience in security standards technology, 
        e.g., role based access controls.

        2.  Leverage NIST to enforce the harmonization of a single set 
        of test tools it has championed through its private sector 
        collaboration with Integrating the Healthcare Enterprise (IHE). 
        NIST has already played a key role in providing test tools/
        methodologies to test conformance of HITSP standards.

Q2.  How would a fully inter-operable HIT system within the Federal 
Government advance the adoption of HIT in the private sector?

A2. A fully inter-operable HIT system within the Federal Government 
would be a positive step forward if it would encourage further adoption 
of the HITSP specifications. This is important because it helps drive 
harmonization of standards throughout all of health care (public and 
private) and it would ensure the positive momentum that HITSP has 
encouraged the last two years. Additionally, use of the HITSP 
specifications would enable improved inter-operability between the VA 
and the DOD HIT systems.

Q3.  American patients are very concerned that HIT systems must protect 
the confidentiality of their personal medical information. How has NIST 
contributed to the security of HIT systems to date, and what further 
contributions could it make to ensuring patient confidentiality?

A3. As we noted in our testimony, NIST is widely recognized for its 
expertise in security standards, most notably role-based access control 
standards and associated policy and processes for its implementation. 
This technology has been widely used in just about every economic 
sector, and NIST has helped champion its usage in the health care 
sector. In addition, NIST championed the development of the 
infrastructure standards identified by HITSP to enable secure exchange 
of health information in the Nationwide Health Information Network. 
NIST's collaborative involvement with IHE in developing these health 
information exchange standards has accelerated the ability to securely 
exchange health information not only in the U.S., but in health 
information exchange projects globally. The global use of these 
standards helps enable commerce and national security by promoting 
common standards to support clinical research and enable health 
information sharing for pandemic surveillance.

Questions submitted by Representative Ralph M. Hall

Q1.  I understand that the Administration supported establishment of a 
health IT standards harmonization process in 2006 through the 
Healthcare Information Technology Standards Panel (HITSP) which has 
made considerable progress over the past two years in the development 
and harmonization of data and technical standards for inter-operable 
health information exchange. How do you see this bill building on the 
current standards harmonization process through the HITSP?

A1. The bill would allow NIST to help existing collaborative efforts by 
using its subject matter expertise in areas such as testing and 
security standards development to accelerate the implementation of HIT 
standards in the private sector. It is critical to ensure that NIST 
support the positive momentum of multi-stakeholder efforts such as 
HITSP. Lending its expertise in the promulgation of security standards, 
working collaboratively with HITSP, would be a positive step.

Q2.  In August 2006, the President issued Executive Order 13410, which 
requires federal agencies to utilize, where available, health 
information technology systems and products that meet inter-operability 
standards recognized by the Secretary of Health and Human Services. The 
American Health Information Community (AHIC) has recommended several 
sets of standards that HITSP has developed or harmonized. How do you 
feel this bill would affect that process, given HHS' expertise in 
health IT standards?

A2. For clarification, AHIC does not and did not recommend standards. 
Rather, AHIC provided areas of health care delivery that could be 
greatly improved through the use of HIT. Once these delivery scenarios 
(i.e., use-cases) were identified, HITSP then identified the standards 
necessary for HIT systems to enable these new ``use-cases.'' NIST does 
not have the expertise to determine what use-cases would impact U.S. 
health care. Nor does NIST have expertise in the health care-specific 
standards needed, including vocabulary and terminology standards. 
Therefore, the bill would not and should not affect those areas 
relating to health care delivery use-case prioritization or the health 
care specific standards related to their implementation. However, there 
are specific areas, such as security standards, information exchange 
infrastructure standards, and related testing tools/resource expertise 
that NIST provides. NIST also provides a culture of collaboration with 
the private sector that would benefit the health care sector.

                   Answers to Post-Hearing Questions

Responses by Justin T. Barnes, Vice President of Marketing, Corporate 
        Development and Government Affairs, Greenway Medical 
        Technologies, Inc.

Questions submitted by Chairman Bart Gordon

Q1.  How are the economic incentives for investment in health care IT 
(HIT) systems different for small versus large health care providers?

A1. Economic incentives tend to be more valuable for smaller physician 
group practices than larger physician group practices. The relative 
cost of HIT adoption is greater for a small practice because the costs 
are not shared by as many providers and stakeholders. In larger 
physician group practices, the cost of HIT adoption is usually shared 
over a greater number of providers and stakeholders, thus the ``per 
provider'' cost is lower.

Q2.  Can small practitioners expect a financial return on their 
investment in HIT systems in the same timeframe as large hospitals and 
large practices?

A2. For the most part, yes. Smaller physician practices can expect a 
return on investment (ROI) from their HIT implementation in similar 
timeframes as larger practices. It may take an extra few months for 
smaller practices but in overall, both groups realize the ROI benefits 
6-12 months after implementation. Sometimes even sooner if the practice 
thoroughly researched products and purchased an integrated and inter-
operable electronic health record (EHR) that was proven to perform well 
in their specialty. This is a very, very important factor in 
recognizing ROI from HIT and EHRs.

Q3.  How could an inter-operable HIT system better enable practicing 
physicians to keep up-to-date on the latest medical treatments and 
diagnosis procedures?

A3. Many of the leading HIT and EHR solutions today automatically 
receive regular updates electronically that keep treatments, protocols, 
procedures and coding updated. These updates are automatically 
integrated seamlessly into HIT and EHR work flows and are added 
monthly, quarterly, semi-annually or annually based on practice 
preferences.

Q4.  How could inter-operable HIT systems support decision-making by 
practicing physicians and other health care providers?

A4. Many of the leading HIT and EHR solutions today have financial and 
clinical decision support tools and modules integrated into their 
functionality. Practices, colleagues, peers and medical associations 
can all share treatment protocols, best practices and much more to 
increase care quality through the utilization of inter-operable HIT and 
EHRs.

Q5.  How would a fully inter-operable HIT system within the Federal 
Government advance the adoption of HIT in the private sector?

A5. Not sure it would unless it was referenced as an example or ``best 
practice'' on increasing care quality, saving lives and decreasing 
costs. If those were shown to be proven factors of a Federal Government 
HIT system, then it should lead the private sector to adopt and 
implement a fully inter-operable HIT system to ascertain those same 
results. I feel the issue here is that the Federal Government does not 
operate in a similar manner to the private sector so many do not 
compare or correlate results and experiences.

Q6.  Could you provide us with some examples of the drawbacks of a lack 
of coordination of technical standards in the realm of conformance-
testing for HIT systems?

A6. The drawbacks would be significant certainly in the areas of time, 
lives and money. Coordination of these efforts will get inter-
operability promulgated much more quickly and therefore we begin 
increasing care quality, saving lives and decreasing health care costs 
more rapidly. If there is a lack of coordination, it would add on 
several more years to achieve full health care industry inter-
operability and therefore unnecessarily reducing care quality, losing 
more lives to medical errors and increasing wasteful spending on 
duplicative measures.

Questions submitted by Representative Ralph M. Hall

Q1.  I understand that the Administration supported establishment of a 
health IT standards harmonization process in 2006 through the 
Healthcare Information Technology Standards Panel (HITSP) which has 
made considerable progress over the past two years in the development 
and harmonization of data and technical standards for inter-operable 
health information exchange. How do you see this bill building on the 
current standards harmonization process through the HITSP?

A1. This bill authorizes NIST, whose primary mission is to promote U.S. 
innovation and industrial competitiveness by advancing measurement 
science, standards, and technology in ways that enhance economic 
security and improve our quality of life, to increase its efforts in 
support of the integration of the health care information enterprise in 
the United States. NIST has a successful history of collaboration with 
Health Information Technology Standards Panel (HITSP) and Integrating 
the Healthcare Enterprise (IHE) and that role should be maintained. 
This bill further encourages this collaboration to make these 
initiatives even more effective, efficient and comprehensive.

Q2.  In August 2006, the President issued Executive Order 13410, which 
requires federal agencies to utilize, where available, health 
information technology systems and products that meet inter-operability 
standards recognized by the Secretary of Health and Human Services. The 
American Health Information Community (AHIC) has recommended several 
sets of standards that HITSP has developed or harmonized. How do you 
feel this bill would affect that process, given HHS' expertise in 
health IT standards?

A2. This bill could negatively affect HITSP progress if NIST was 
authorized to lead any health care standards-creating, setting or 
harmonizing processes. Additionally, if this bill authorized the 
creation of any alternative health care standards outside of the HITSP 
process, that would be confusing and distracting to our current 
industry progress. It is best that NIST plays a supporting role in 
health care standards and continues their important collaboration with 
HITSP.
                              Appendix 2:

                              ----------                              


                   Additional Material for the Record


                  Statement of Good Samaritan Hospital
           on behalf of the Mid-Nebraska Telemedicine Network

   Rural Telehealth Success Story: Mid-Nebraska Telemedicine Network

               Provided by Lesley A. Bollwitt-Maria, MPA
                  Director, Grants & Special Projects
                   Good Samaritan Hospital Foundation
                           Kearney, Nebraska

    Mr. Chairman and Members of the Committee, thank you for this 
opportunity to provide testimony in support of the use of health 
information technology to enhance access to health care services.
    My name is Lesley A. Bollwitt-Maria, and I am Director of Grants & 
Special Projects with Good Samaritan Hospital in Kearney, Nebraska. One 
of my primary objectives over the last seven years has been to assist 
with the expansion and enhancement of the services provided through 
Good Samaritan's Mid-Nebraska Telemedicine Network.

Organizational Description

    Good Samaritan Hospital (GSH) located in Kearney, Nebraska is a 
not-for-profit, 501 (c) 3, health care system affiliated with Catholic 
Health Initiatives of Denver, Colorado, a faith-based organization. 
Good Samaritan, a U.S. Designated Regional Referral Center, is a two-
hospital system serving approximately 350,000 people throughout central 
and western Nebraska, northern Kansas and northwestern Colorado. The 
overall service area encompasses a region approximately the size of the 
State of Indiana. Good Samaritan is one of only three American College 
of Surgeons accredited Level II Trauma Centers in Nebraska.
    Good Samaritan serves as the hub facility for a thirteen member 
Critical Access Hospital Network and for the Mid-Nebraska Telemedicine 
Network, a Telehealth network including twenty-two rural hospitals 
located in both Kansas and Nebraska. Good Samaritan Hospital is also 
one of the founding members of the Nebraska Telehealth Network, a 
project connecting every hospital and public health department in the 
State of Nebraska for telehealth services.
    Members of the Sisters of St. Francis of Colorado Springs 
established Good Samaritan Hospital in 1924. Now licensed for 207 beds, 
Good Samaritan Hospital (GSH) is the largest regional referral center 
between Lincoln, Nebraska and Denver, Colorado. In addition, in 1987 
Good Samaritan purchased Richard Young Hospital, an 80-bed behavioral 
health hospital also located in Kearney that provides care for 
children, adolescents and adults. Established in 1981, the Good 
Samaritan Hospital Foundation directs all fund-raising activities for 
the health system.
    The Mission of Good Samaritan and Catholic Health Initiatives is to 
nurture the healing ministry of the Church by bringing it new life, 
energy and viability in the 21st century. Fidelity to the Gospel urges 
us to emphasize human dignity and social justice as we move toward the 
creation of healthier communities.

Defining the Problem: Increasing Access to Health Care

    Rural communities across the State of Nebraska are faced with the 
challenge of providing access for all citizens to quality health care 
services. Numerous barriers exist which make this challenge even more 
daunting. These barriers often include: distance to specialty health 
care services, hazardous driving conditions due to harsh Nebraska 
winter weather, lack of a state-wide public transportation system, 
increased poverty for rural citizens resulting from the struggling farm 
economy, the increasing age of patients and the crisis level shortage 
of health care professions.
    According to the Nebraska Rural Health Plan for the Critical Access 
Hospital Program (2002), the rural health care system exists in a 
fragile environment. Rural Nebraska faces many challenges, including a 
loss of population in some areas, a growing number of uninsured and 
under-insured, and an increase in the Medicare and Medicaid 
populations. Given the lack of employment opportunities and the rising 
cost of health care these trends are likely to worsen over the next few 
years.
    Additionally, the report indicated that about 19 percent of the 
state's population must travel for thirty minutes or more to visit a 
doctor. In rural areas, this travel time significantly increases when 
that doctor needed becomes a specialist. The distance of the rural 
communities from a tertiary care center can represent travel time of 
one to three hours one way. Travel also becomes more difficult as the 
populations of these rural communities age. The total percent of 
individuals over the age of 65 for the state averages 13.6 percent; 
however, in the rural areas, like central Nebraska, this percentage 
jumps to 21 percent. In most cases, a family member must accompany an 
elderly individual to their doctor's appointment in a larger community 
like Omaha, resulting in missed time away from work and family. This 
travel time becomes increasingly more difficult when the weather is 
bad.

Improving Health Care Access Through Technology

    The use of technology to improve access to health care services in 
Nebraska is not new. Actually, Nebraska has the distinction of 
introducing the world to the concept of using video-conferencing for 
clinical applications. Leaders in the field of telemedicine/telehealth 
suggest that the current state of technology is moving from its second 
generation into its third. The ``first generation'' can be traced as 
far back as the 1950s. One of the earliest uses was at the University 
of Nebraska where psychiatric consultations were conducted on two-way 
closed circuit TV using microwave technologies.
    Established in 1994, the Mid-Nebraska Telemedicine Network is an 
interactive video and data network. The major functions of the Network 
are to improve quality and access to care, particularly in rural 
Nebraska and Kansas, to provide patient, provider and community 
education and to provide another communication source in the event of a 
natural, man-made or terrorist emergency.
    The Mid-Nebraska Telemedicine Network has the distinction of being 
one of the longest federally funded telehealth networks in the county 
with funding beginning in 1994 and continuing through today. The 
network was just awarded its third USDA/RUS DLT grant so funding will 
continue beyond 2007. Funding has been received through the Office of 
Rural Health Policy, Office for the Advancement of Telehealth (OAT) and 
the USDA/RUS DLT grant programs. These federal dollars have been put to 
successful use in improving access to health care services in rural 
areas, like Nebraska and Kansas. Since becoming fully functioning in 
December 1995, the network has totaled over 11,000 Patient Encounters, 
30,000 Teleradiology, and 3,000 Educational Programs.

Statement of Experience

    The Mid-Nebraska Telemedicine Network (MNTN) became operational in 
December 1995 as a result of a start-up grant through the Office of 
Rural Health Policy. The network included the hub site of Good 
Samaritan Hospital (Kearney) and five rural network members consisting 
of Tri-Valley Hospital (Cambridge), Cozad Community Hospital (Cozad), 
Callaway District Hospital (Callaway), Jennie M. Melham Memorial 
Medical Center (Broken Bow) and the Sargent Hospital (Sargent), 
Nebraska.
    In October 1997, the Good Samaritan Hospital Foundation received a 
second grant through the Office of Rural Health Policy. Through this 
second grant award, the MNTN expanded its services to include five 
additional rural hospitals located in Rock County Hospital (Bassett), 
Dundy County Hospital (Benkelman), Valley County Hospital (Ord), 
Phillips County Hospital (Phillipsburg, KS), Norton County Hospital 
(Norton, KS). In 1999 the Sargent District Hospital closed and 
Gothenburg Memorial Hospital (Gothenburg) took its place.
    In August 2000, the Office of Rural Health Policy awarded a third 
grant. Through this third grant, the Mid-Nebraska Telemedicine Network 
expanded its services to include the two additional rural hospitals of 
Franklin County Memorial Hospital (Franklin) and the Chase County 
Hospital (Imperial).
    In September 2004, the Good Samaritan Hospital Foundation received 
notification that the MNTN was awarded a congressionally mandated 
grant. Through this funding, six additional sites were added to the 
network. These sites included: Kearney County Community Hospital 
(Minden), Webster County Hospital (Red Cloud), St. Anthony's Hospital 
(O'Neill), Jewell County Hospital (Mankato, KS), Brown County Hospital 
(Ainsworth, Nebraska) and the Smith County Community Hospital (Smith 
Center, KS).
    In September 2005, the Good Samaritan Hospital Foundation was 
awarded the program's second congressionally mandated grant. Through 
this funding, two additional sites were added to the network. These 
sites included: Harlan County Health Systems (Alma, Nebraska) and Tri-
County Hospital (Lexington, Nebraska).
    The Mid-Nebraska Telemedicine Network has also been a recipient of 
funding through the USDA-RUS Distance Learning and Telemedicine grant 
program in 2004, 2006 and 2007. Through the 2006 USDA-RUS DLT grant, 
two additional rural hospitals were added to the network: Community 
Hospital (McCook, Nebraska) and Phelps Memorial Health Center 
(Holdrege, Nebraska).
    As of 2007, the Mid-Nebraska Telemedicine Network includes one hub 
site (Kearney), which includes additional site capabilities in the 
education department, telemedicine room, emergency room, Family 
Advocacy Network and at the Richard Young Hospital campus, and twenty-
two rural remote sites in both Nebraska and Kansas. Of the MNTN 
members, eighteen of the nineteen Nebraska members are certified as 
Nebraska Critical Access Hospitals (CAH). The only non-CAH facility is 
the hub/end-user site of Good Samaritan Hospital.



    The mission of the Mid-Nebraska Telemedicine Network is to use 
technology to improve access to quality care by providing consultation 
and treatment in both routine and emergency situations, to increase 
health-related educational opportunities for providers and the 
community, and to provide a venue for health-related administrative 
meetings.

System Uses: The Mid-Nebraska Telemedicine Network provides for a wide 
variety of uses, including:

          Patient consultations including specialty areas 
        (orthopedics, cardiology, neurology, oncology and others);

          Behavioral Health video consultations;

          Teleradiology and the transmission of other digitized 
        clinical images in areas such as cardiology;

          Connection to abuse examination and interviewing 
        (Family Advocacy Network);

          Trauma and emergency room care;

          Continuing medical education for health care 
        professionals;

          Education leading to licensure or certification of 
        health care professionals;

          Education for emergency services providers;

          Administrative meetings;

          Support groups and community education programs;

          Emergency communications and bioterrorism 
        preparedness training;

          Video medical interpreting services for persons who 
        do not have English as their first language.

    In addition, the Nebraska members of the Mid-Nebraska Telemedicine 
Network are also connected into the Nebraska Telehealth Network, which 
helps to promote the long-term project sustainability. Good Samaritan, 
as a leader in Telehealth activities in Nebraska, has served as the 
catalyst for the development of the statewide Telehealth network. The 
Nebraska Telehealth Network is an interactive video and data network 
that provides integration among the hospitals, public health 
departments, public health laboratories and other entities across the 
entire State of Nebraska. The major functions of the Network are to 
improve quality and access to care, particularly in rural Nebraska, to 
provide patient, provider and community education and to provide 
another communication source in the event of a natural, man-made or 
terrorist emergency.

Advantages of Telehealth

    The Mid-Nebraska Telemedicine Network provides value to the 
network's users in a number of ways, including the following:

        1)  The Network improves the access of the public to medical 
        consultation resources, thus improving the quality of care 
        available;

        2)  The Network serves as an aid in the training, retention and 
        recruitment of the rural health care workforce;

        3)  The Network provides another avenue for bringing community 
        education and information to rural Nebraska;

        4)  The Network, through its ability to help strengthen the 
        rural health care resources, helps strengthen the local 
        economy;

        5)  The Network provides an additional resource in case of an 
        emergency caused by a man-made, natural or bioterrorist threat 
        as well as providing another avenue for education on how to 
        deal with these emergencies;

        6)  The Network provides an avenue for bringing together 
        entities in public health, the health care field, education and 
        government as well as other quasi-public and private agencies 
        through the participation in the Nebraska Telehealth Network.

    As a member of the Nebraska Telehealth Network, members of the Mid-
Nebraska Telemedicine Network has adopted the following project goals.

Project Goals: To bring together the hospitals within the state into a 
single connected system that can:

          Provide patient clinical consultation;

          Offer health care providers continuing education and 
        professional development as well as advancement opportunities;

          Provide an avenue for administrative meetings;

          Provide access to Teletrauma and Emergency Mental 
        Health services via hospital emergency rooms;

          Expand access for the hospitals to Nebraska's Public 
        Health Departments, State Government and State Bioterrorism 
        Labs in order to facilitate emergency alert capabilities, as 
        well as educational opportunities pertaining to bioterrorism 
        acts and other naturally occurring emergencies;

          Provide a structure that can bring together resources 
        beyond just those of health care to create an environment of 
        sharing of resources throughout the State of Nebraska;

          Invite other potential partners in this network, 
        including education at various levels (elementary through post-
        secondary and community education), and various governmental 
        agencies, whether local, regional, State or national;

          Develop an organizational structure that supports 
        these goals in a cost effective, efficient and sustainable 
        fashion and addresses the identified critical success factors 
        involving technical support, hospital and provider training, 
        scheduling and technology upgrades;

          Provide the backbone for the development of a 
        statewide electronic medical record project through the 
        Nebraska Medical Association.

Testimony Summary

    On behalf of the members of the Mid-Nebraska Telemedicine Network, 
thank you for this opportunity to describe the journey that our 
organizations have taken down the path of implementing technology to 
improve access to health care services in rural America. The success 
that our network has had over the past thirteen years is a direct 
result of the continued investment by the Federal Government in health 
information technology. By providing funding opportunities through 
various grant programs, these federal dollars have the opportunity to 
work in concert with local matching monies to expand and enhance the 
services being offered over telehealth networks, like the Mid-Nebraska 
Telemedicine Network and the Nebraska Statewide Telehealth Network. As 
a representative of a rural health care provider, Good Samaritan 
Hospital, and a rural health care consumer, thank you for your 
continued interest and attention to the vital role that health 
information technology plays in our health care system.



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