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


 
                     COMMITTEE HEARING ON COST AND 
 CONFIDENTIALITY: UNFORSEEN CHALLENGES OF ELECTRONIC HEALTH RECORDS IN 
                                 SMALL 
                          SPECIALITY PRACTICES 

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

                      COMMITTEE ON SMALL BUSINESS
                 UNITED STATES HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                             JULY 31, 2008

                               __________

                         Serial Number 110-110

                               __________

         Printed for the use of the Committee on Small Business


  Available via the World Wide Web: www.access.gpo.gov/congress/house

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                   HOUSE COMMITTEE ON SMALL BUSINESS

                NYDIA M. VELAZQUEZ, New York, Chairwoman


HEATH SHULER, North Carolina         STEVE CHABOT, Ohio, Ranking Member
CHARLES GONZALEZ, Texas              ROSCOE BARTLETT, Maryland
RICK LARSEN, Washington              SAM GRAVES, Missouri
RAUL GRIJALVA, Arizona               TODD AKIN, Missouri
MICHAEL MICHAUD, Maine               BILL SHUSTER, Pennsylvania
MELISSA BEAN, Illinois               MARILYN MUSGRAVE, Colorado
HENRY CUELLAR, Texas                 STEVE KING, Iowa
DAN LIPINSKI, Illinois               JEFF FORTENBERRY, Nebraska
GWEN MOORE, Wisconsin                LYNN WESTMORELAND, Georgia
JASON ALTMIRE, Pennsylvania          LOUIE GOHMERT, Texas
BRUCE BRALEY, Iowa                   DAVID DAVIS, Tennessee
YVETTE CLARKE, New York              MARY FALLIN, Oklahoma
BRAD ELLSWORTH, Indiana              VERN BUCHANAN, Florida
HANK JOHNSON, Georgia
JOE SESTAK, Pennsylvania
BRIAN HIGGINS, New York
MAZIE HIRONO, Hawaii

                  Michael Day, Majority Staff Director

                 Adam Minehardt, Deputy Staff Director

                      Tim Slattery, Chief Counsel

               Kevin Fitzpatrick, Minority Staff Director

                                 ______

                         STANDING SUBCOMMITTEES

                    Subcommittee on Finance and Tax

                   MELISSA BEAN, Illinois, Chairwoman


RAUL GRIJALVA, Arizona               VERN BUCHANAN, Florida, Ranking
MICHAEL MICHAUD, Maine               BILL SHUSTER, Pennsylvania
BRAD ELLSWORTH, Indiana              STEVE KING, Iowa
HANK JOHNSON, Georgia
JOE SESTAK, Pennsylvania

                                 ______

               Subcommittee on Contracting and Technology

                      BRUCE BRALEY, IOWA, Chairman


HENRY CUELLAR, Texas                 DAVID DAVIS, Tennessee, Ranking
GWEN MOORE, Wisconsin                ROSCOE BARTLETT, Maryland
YVETTE CLARKE, New York              SAM GRAVES, Missouri
JOE SESTAK, Pennsylvania             TODD AKIN, Missouri
                                     MARY FALLIN, Oklahoma

        .........................................................

                                  (ii)

  


           Subcommittee on Regulations, Health Care and Trade

                   CHARLES GONZALEZ, Texas, Chairman


RICK LARSEN, Washington              LYNN WESTMORELAND, Georgia, 
DAN LIPINSKI, Illinois               Ranking
MELISSA BEAN, Illinois               BILL SHUSTER, Pennsylvania
GWEN MOORE, Wisconsin                STEVE KING, Iowa
JASON ALTMIRE, Pennsylvania          MARILYN MUSGRAVE, Colorado
JOE SESTAK, Pennsylvania             MARY FALLIN, Oklahoma
                                     VERN BUCHANAN, Florida

                                 ______

            Subcommittee on Rural and Urban Entrepreneurship

                 HEATH SHULER, North Carolina, Chairman


RICK LARSEN, Washington              JEFF FORTENBERRY, Nebraska, 
MICHAEL MICHAUD, Maine               Ranking
GWEN MOORE, Wisconsin                ROSCOE BARTLETT, Maryland
YVETTE CLARKE, New York              MARILYN MUSGRAVE, Colorado
BRAD ELLSWORTH, Indiana              DAVID DAVIS, Tennessee
HANK JOHNSON, Georgia

                                 ______

              Subcommittee on Investigations and Oversight

                 JASON ALTMIRE, PENNSYLVANIA, Chairman


CHARLES GONZALEZ, Texas              MARY FALLIN, Oklahoma, Ranking
RAUL GRIJALVA, Arizona               LYNN WESTMORELAND, Georgia

                                 (iii)

  












































                            C O N T E N T S

                              ----------                              

                           OPENING STATEMENTS

                                                                   Page

Velazquez, Hon. Nydia M..........................................     1
Chabot, Hon. Steve...............................................     2

                               WITNESSES

Tally, Dr. Philip W.,MD, Neuro-Spinal Associates, Bradenton, FL, 
  on behalf of the American Association of Neurological Surgeons.     5
Plovnick, Mr. Robert, Director of quality Improvement and 
  Psychiatric Services, American Psychiatric Association.........     7
Gotlieb, Dr. Edward, MD, FAAP, The Pediatric Center, Stone 
  Mountain, GA, on behalf of the American Academy of Pediatrics..    10
Hale, Dr. Ralph, MD, FACOG, Executive Vice President, American 
  College of Obstetricians and Gynecologists.....................    12
Bort, Dr. Thaddeus, MD, Family Medical Group, Cincinnati, OH.....    14

                                APPENDIX


PREPARED STATEMENTS:
Velazquez, Hon. Nydia M..........................................    33
Chabot, Hon. Steve...............................................    35
Tally, Dr. Philip W.,MD, Neuro-Spinal Associates, Bradenton, FL, 
  on behalf of the American Association of Neurological Surgeons.    36
Plovnick, Mr. Robert, Director of quality Improvement and 
  Psychiatric Services, American Psychiatric Association.........    41
Gotlieb, Dr. Edward, MD, FAAP, The Pediatric Center, Stone 
  Mountain, GA, on behalf of the American Academy of Pediatrics..    46
Hale, Dr. Ralph, MD, FACOG, Executive Vice President, American 
  College of Obstetricians and Gynecologists.....................    51
Bort, Dr. Thaddeus, MD, Family Medical Group, Cincinnati, OH.....    55

STATEMENTS FOR THE RECORD:
American College of Physicians...................................    61

                                  (v)

  


 COST AND CONFIDENTIALITY: UNFORESEEN CHALLENGES OF ELECTRONIC HEALTH 
                  RECORDS IN SMALL SPECIALTY PRACTICES

                              ----------                              


                        Thursday, July 31, 2008

                     U.S. House of Representatives,
                               Committee on Small Business,
                                                    Washington, DC.
    The Committee met, pursuant to call, at 10:00 a.m., in Room 
1539 Longworth House Office Building, Hon. Nydia Velazquez 
[chairwoman of the Committee] presiding.
    Present: Representatives Velazquez, Shuler, Gonzalez, 
Altmire, Clarke, Johnson, Chabot, and Buchanan.
    Chairwoman Velazquez.  Good morning. I call this hearing of 
the House Small Business Committee to order. In the last few 
decades, information technology has revolutionized virtually 
every American industry. Today previously complex and time-
consuming tasks can be easily accomplished with a click of the 
mouse. But, as with any large-scale shift or system overhaul, 
the adoption of new technology comes with certain growing 
pains. Nowhere is this more true than in our nation's health 
care sector.
    By the year 2014, the national information technology 
coordinator expects the United States to have a nationwide 
network of electronic health records. Today several bipartisan 
proposals supporting this network are working their way through 
Congress. Both Democrats and Republicans recognize the value in 
HIT. After all, it promises to not only control costs but also 
to improve quality. That is an especially appealing prospect 
given the skyrocketing price and declining value of modern 
health care.
    In today's hearing, we will discuss the value of HIT and 
also explore the various concerns surrounding its use. If 
properly implemented, HIT can streamline the flow of complex 
health care data. In doing so, the technology will improve 
communication between doctors and hospitals. And given the 
inherent complexities of medicine, a well-structured 
communication network is of the utmost importance.
    Despite growing support for health care technology, 
particularly in the form of electronic health records, small 
practices have been reluctant to take it up. Whereas, 57 
percent of large care centers use EHR, only a handful of solo 
practitioners do. This is partially due to the high cost of 
implementation.
    When all is said and done, the price tag of EHR 
installation comes to over $32,000 for physician. Meanwhile, 
monthly maintenance fees run close to $1,200.
    By the time heating costs have been factored in, final 
estimates can be $44,000 per doctor with upkeep fees of $8,500 
a month for small health care providers with limited resources. 
These up-front costs are enough to break the bank.
    In addition to the weighty financial obligation, a series 
of legal and privacy concerns has deterred small health 
practices from adopting HIT. As a practical matter, electronic 
information can be transmitted and reviewed more easily than 
paper files. In light of this fact, some health professionals 
worry that HIT holds potential for health care fraud.
    At the same time, others are concerned that the technology 
might conflict with confidentiality issues outlined in the 
Health Insurance Portability and Accountability Act, or HIPAA.
    Finally, some specialty doctors, like neurosurgeons and 
pediatricians, are unable to find appropriate HIT systems. 
Oftentimes this technology caters only to mainstream medical 
practices, leaving the smaller, more specialized businesses 
behind.
    Health information technology has the potential to 
revolutionize American medicine. But, unfortunately, a series 
of concerns is blocking large-scale implementation.
    There is no silver bullet solution to America's broken 
health care system. There are, however, a number of ways to 
address the issue. For one, financial incentives to HIT users 
will help spur uptake. So will strengthening privacy 
regulations for health records.
    As we move forward in the quest to improve health care 
coverage and cut costs, we can look to current technology and 
future innovation. And, yet, in doing so, we must be sure to 
act with caution. Otherwise we risk de-operatizing both small 
providers and the health and security of their patient.
    With that, I would like to take this opportunity to thank 
all the witnesses for coming here today to provide your 
insights regarding this issue. I look forward to their insight 
on the matter and yield to Ranking Member Chabot for his 
opening remarks.
    Mr. Chabot.  Thank you very much, Madam Chair. And thank 
you for holding this very important hearing on this very 
important topic here this morning.
    I would like to thank each one of our witnesses who have 
taken the time out of their busy schedules to provide this 
Committee the testimony that they will be giving us here this 
morning.
    And I would like to extend a special welcome to a fellow 
Cincinnatian, Dr. Thaddeus, or Ted, Bort, who also happens to 
be my personal physician. So I am particularly pleased to see 
him here today, and I will introduce him more formally later.
    Over the past 30 years, nearly every sector of the American 
economy has undertaken a sweeping transformation in the way 
information is collected, managed, and transmitted. As a 
result, productivity and efficiency have consistently 
increased.
    Yet, today health care, one of the most significant, one of 
the most important sectors of the American economy has not yet 
made this transformation, at least completely, although we are 
certainly beginning that at this time. This hearing is an 
important part of letting Congress know what is happening in 
that area at the present time.
    Some of the most serious challenges facing health care 
today, medical errors, inconsistent quality, and rising costs 
can, at least partly, be addressed through the effective 
application of health information technology. Linking all 
elements of the health care system improves information 
available to physicians and boosts quality and enhances 
preventive care and reduces errors.
    On April 22nd, 2004, the President signed an executive 
order which established the position of the national health 
information technology coordinator within the Office of the 
Secretary of the Department of Health and Human Services and 
announced his commitment to the promotion of health information 
technology to lower costs, reduce medical errors, improve the 
quality of care, and provide better information for physicians, 
as well as for patients.
    In particular, the President called for widespread adoption 
of electronic health records and for health information to 
follow patients throughout their care in a seamless and secure 
manner.
    A September 2005 report by the RAND Corporation estimated 
that $77 billion annually could be saved if 90 percent of 
physicians adopted health information technology. The report 
also estimated another $4 billion in savings from reductions in 
prescription errors.
    A new report indicates that more than 35 million 
prescription transactions were sent electronically in 2007, 
which was a 170 percent increase over the year before. Despite 
documented advantages and federal support, physician adoption 
of health information technology has been slow.
    Research indicates that concerns about high cost, 
uncertainty of return on the investment, and worry over the 
usability and obsolescence of new technologies rank highest 
among reasons surveyed of physicians have not yet adopted 
health information technology.
    Doubts about the privacy and security of patient data, 
practice compliance with the Health Information Portability and 
Accountability Act of 1996, and the potential for inappropriate 
disclosure of patient information to third parties ranked just 
behind the financial concerns that I mentioned previously.
    Health information technology is a complex issue. The 
decision to implement health information technology in a small 
medical practice is considered an act of courage by many 
physicians. It will impact their work flow, staff, patients, 
and practice finances.
    Successful adoption of health information technology, 
including electronic medical records, will require evaluation, 
selection, planning, implementation, and effective use of the 
technology.
    Early adopters agree that there are multiple benefits but 
recognize a cultural change is required. Madam Chair, I look 
forward to working with you on this important issue. This would 
be another bipartisan issue that we could work on together, as 
we have done many times in the past. The rest of Congress may 
not do it, but you and I do.
    And, again, I want to thank you for your cooperation in 
this hearing today. And I want to thank the witnesses. We are 
looking forward to hearing their testimony. And I yield back 
the balance of my time.
    Chairwoman Velazquez.  Thank you Mr. Chabot. And I 
recognize Mr. Shuler for an adoption statement.
    Mr. Shuler.  Thank you, Madam Chair.
    It is great to see that this meeting is being held. Before 
my days here in Washington, I actually ran a company called My 
Health Card, which was electronic medical records that people 
carry around in their pocket, a company that we found very 
difficult to get off the ground, very difficult to get the 
hospitals, their programs, whether it be GE Medical or whether 
it be Op Path or whether it be any of the major electronic 
medical record groups to get you to do an interface with their 
systems. But we did find a company that allowed us to do that.
    And in relationship with the University of Tennessee's 
medical system, we actually worked with a geriatric population. 
We gave them all their cards for free. The hospital used it 
more as a marketing tool, but we realized in a very short time 
that it actually saved lives. So it wasn't a chain pharmacy, 
but it was actually a pharmacy that allowed us to be able to 
put the database into their system.
    So a person would go to the primary care physician. That 
information was then downloaded onto the card, had a 119-digit 
encryption code, HIPAA-compliant.
    And then the person would go to the pharmacy. The pharmacy 
then would be able to only look at the information that the 
doctor put on the meds size.
    And we found out we saw drug interactions. They went from 
their primary care physician to a specialist. The specialist 
had no idea what the primary care physician had prescribed. And 
we saw numerous times of drug interaction that was caught by 
the physician. He then had the phone number because it was 
time-stamped and dated on the card. And they recognized very 
quickly that they had a problem.
    In the geriatric population, we saw a decrease in days in 
the hospital. Times in the emergency room significantly 
dropped. The hard part that we had was because of the 
interfaces with the big companies, if you will. They wanted to 
capture that data.
    We had other problems with pharmacies being able to allow 
the other pharmacies--they wanted to capture that data. They 
wanted their data for their own personal use. We didn't look at 
it. We didn't care about the data from the standpoint of what 
meds were being taken. We just wanted to make sure that the 
health and the care of the patient were taken care of first and 
foremost.
    And then we realized that the hospitals actually had no 
idea what was happening internally within their hospital. Now, 
when a person would come to the emergency room because they 
outsource their emergency room, that information technology 
system was different than the one that they have inside the 
hospital. Then they would go to an operating room. Well, the OR 
software is different than the outpatient surgery software. And 
so you had no way to communicate within the hospital.
    So we found ourselves having to implement interfaces with 
all of these systems. By the time we got one interface 
completed, we had to then start all over because it was time to 
complete the interface again.
    So we went through this, a complete circle of finishing the 
interface. And by the time we got it done in order to make the 
card work completely throughout the hospital, we were forever 
doing an interface.
    And that cost money. So I commend you for being here today 
and talking on this very important subject. Actually, one of 
the most important things that we were able to do with the 
country--it seems like we do our philanthropy work more than 
anything--is kids with foster care. The child would go from 
place to place to place. The medical records were never with 
them. And so this card they can take with them.
    So, Madam Chair, I thank you for holding this very 
important hearing. It is a way to cut down costs of our overall 
medical crisis that we are in. And I think this is going to be 
a very important part of making a difference in health care.
    Thank you, Madam Chair. And I yield back.
    Chairwoman Velazquez.  Thank you.
    And now it is my pleasure to welcome Dr. Philip W. Tally. 
Dr. Tally is a neurological surgeon in privacy practice and the 
Chief of Staff for Manatee Memorial Hospital in Bradenton, 
Florida. He currently serves as the Chairman of the Florida 
Medical Association's Health Information Technology Committee 
and is a member of the American Medical Association's HIT 
Advisory Panel. The American Association of Neurological 
Surgeons and The Congress of Neurological Surgeons represent 
more than 4,000 United States physicians trained and certified 
in the specialty of neurological surgery.
    Welcome. You have the timer. We will have five minutes when 
it is going to have the green light. And then red means that 
your time is expired. Welcome.
    Dr. Tally.  Thank you.

STATEMENT OF PHILIP W. TALLY, M.D., NEUROSURGEON, NEURO-SPINAL 
     ASSOCIATES, ON BEHALF OF THE AMERICAN ASSOCIATION OF 
NEUROLOGICAL SURGEONS AND THE CONGRESS OF NEUROLOGICAL SURGEONS

    Dr. Tally.  Good morning, Chairwoman Velazquez, Ranking 
Member Chabot, and members of the Committee. Thank you for 
inviting me to appear today to discuss the challenges small 
physician specialty practices face in adopting electronic 
medical records.
    My name is Philip Tally. And I am one of three 
neurosurgeons in a small but full-service neurosurgical 
practice in Bradenton, Florida. I am here, as you stated, 
representing the neurosurgeons. I have been the Chairman, as 
you have stated, of the two committees.
    I would like to spend my time with you this morning telling 
you my story about how we integrated electronic medical records 
into our practice, some of the challenges we faced, the costs 
we incurred, and ultimately the benefits that we have reaped, 
both for our practice and our patients.
    In 1992, our practice was the fifth medical practice in the 
country and the first neurosurgical practice to go fully 
paperless. Implementing this new system was no easy feat. We 
could not simply plug in the machine and flip the switch.
    Because these systems are set up in a one-size-fits-all 
manner, it took over 1,000 hours to configure our system and 
create neurosurgical templates since there were no existing 
specialty-specific programs. All told, implementing the first 
system required about a year of prep time to purchase, 
configure, and implement. In addition, it took about another 
year to refine it and for our practice to become proficient 
with it.
    The costs of setting up and maintaining this system were 
significant. We spent about $50,000 on the initial setup. The 
system also required regular maintenance and upgrades, which 
cost us at that time about $5,000 a month.
    During the early years, our vendor continued to create new 
systems and upgrades. Every improvement resulted in some 
unintended consequence, which required a software engineer's 
time to repair. Implementing the system was particularly 
difficult on the staff. And not everyone was pleased to move to 
this new paradigm shift in our practice.
    These changes, coupled with the daily stress of working in 
a neurosurgical practice, simply proved too much. We suffered a 
30 percent staff turnover as they had difficulty in adapting to 
and learning entirely new procedures and methods. This produced 
problems with continuity of patient care and loss of 
productivity as we went the through process of hiring and 
training new staff.
    As our practice transitioned to EMR, we also had to keep 
the paper records for legal reasons. Interoperability was not 
even a concept at that point, and there was no talking between 
systems. Every paper document had to be scanned and transferred 
into the EMR.
    Notwithstanding these challenges, the physicians and our 
staff recognized the benefits of going paperless. The 
efficiency of the practice increased significantly. Staff no 
longer had to search for paper charts to answer patient phone 
calls, and they could quickly get information to the 
neurosurgeons.
    Our ability to quickly review and create new charts allowed 
us to spend more time with our patients. We improved our 
communications with other physicians since the completed 
patient record was never misplaced, always legible, and test 
results resided in a distinct folder within the EMR.
    In 1997, we converted to a Windows-based system. And we 
went through the same process again, incurring similar costs, 
down time, and lost productivity. This new system was an 
improvement and significantly expedited patient care.
    Maintaining this system for the last ten years has been a 
challenge. Hardware has failed. Servers have been hacked. 
Security requirements, particularly HIPAA, are onerous. And 
keeping a full-time IT employee in a competitive job market has 
been difficult.
    This year we are once again in the process of converting to 
yet another new program and platform and incurring all the same 
costs as before. Even with our practice's lengthy history and 
experience with EMR, this upgrade has been a costly and 
difficult process, with considerable loss of productivity. 
Furthermore and notwithstanding our experienced eyes, after we 
purchased this system, we have found flaws in the vendor's 
product.
    Madam Chairman, as you can see, our practice has been ahead 
of the curve in using EMR. Unfortunately, most physicians have 
not shared this experience. Despite the fact that EMR has the 
potential to improve the delivery of health care, most 
physicians have been slow or reluctant to adopt these systems.
    A recent study found only four percent of physicians have a 
fully functional EMR system. So we have a very long way to go. 
And a three to four-year timetable for nationwide 
implementation is optimistic at best.
    Perhaps the new prescribing provisions included in the 
recently passed Medicare bill will help encourage physicians to 
implement this entry-level mode of EMR. However, over 70 
percent of the 3 billion prescriptions written every year are 
by primary care and emergency room physicians, currently the 2 
groups with the lowest rates of EMR adoption.
    In addition, there are significant implementation issues, 
such as the pharmacy familiarity; proposed and fatally flawed 
new rigid DEA rules for Schedule II drugs, which will make 
compliance by most neurosurgical practices very difficult.
    Congress can help pave the way to widespread adoption of 
EMR by passing legislation that will standardize 
interoperability and provide financial incentives to physicians 
and practices. We cannot rush this process or force physicians 
to adopt EMR using a stick approach as this will only create 
more resentment among the physicians. It took over ten years 
for the stethoscope to become widely accepted as a medical 
tool.
    While it will take time, we are on the right path in 
promoting this. There is general agreement that HIT will 
improve patient safety, enhance quality of care, result in more 
efficient practice, and better health outcomes should follow. 
We should not deviate from this premise, nor should we rush 
launching a complex system to satisfy political or 
administrative goals.
    Thank you for the opportunity to share my experience, and I 
will be happy to answer questions at your discretion.
    [The prepared statement of Dr. Tally can be found in the 
appendix on page X.]
    Chairwoman Velazquez.  Thank you, Dr. Tally.
    Our next witness is Robert Plovnick. Dr. Plovnick is the 
Director of the Department of Quality Improvement and 
Psychiatric Services at the American Psychiatric Association. 
He oversees preparation of APA's psychiatric treatment 
guidelines, development and assessment of performance measures 
for psychiatric services. The American Psychiatric Association 
has more than 38,000 members. Welcome.
    Dr. Plovnick.  Thank you.

   STATEMENT OF ROBERT PLOVNICK, M.D., M.S., DIRECTOR OF THE 
   DEPARTMENT OF QUALITY IMPROVEMENT & PSYCHIATRIC SERVICES, 
                AMERICAN PSYCHIATRIC ASSOCIATION

    Dr. Plovnick.  Thank you, Madam Chairwoman. Members of the 
Small Business Committee, I am Dr. Rob Plovnick, Director of 
the Department of Quality Improvement and Psychiatric Services 
at the American Psychiatric Association. It is an honor for the 
APA to present this testimony to the committee regarding 
unforeseen challenges of EHRs to small specialty practices.
    The APA represents more than 38,000 psychiatric physicians 
nationwide. Our members work within a variety of systems of 
care, including emergency departments, inpatient settings, and 
small private practices.
    The development of health information technology and 
corresponding federal and state laws and regulations are a 
matter of great interest and concern to the APA, our members, 
and their patients. The APA has one committee of members solely 
focused on various aspects of EHRs and a second committee 
solely focused on privacy and confidentiality concerns.
    Carefully structured, a national HIT infrastructure has 
great potential to improve the overall quality of care provided 
to patients, inform health professionals of the latest 
standards of care, and to improve communication of health care 
information across settings.
    However, there are two significant challenges to widespread 
adoption and implementation of EHR systems that the APA would 
like to highlight in our testimony today. First, the assurance 
of confidentiality is at the core of any effective patient-
physician relationship. Electronic health information exchange 
could erode patient trust and impede clinical care if it 
facilitates dissemination of sensitive information without 
sufficient precautions to protect privacy and security.
    Second, a significant percentage of APA members operate in 
solo private practices in which the up-front costs of 
implementing an EHR system present a considerable barrier to 
adoption.
    Protecting and strengthening the confidentiality of the 
patient-physician relationship is critical to providing the 
highest quality medical care. This is particularly true with 
respect to psychiatric care because of ongoing inequity in 
insurance coverage, employment discrimination, and social 
stigma for people with mental illness.
    An unintended conscience of EHRs is that patients may be 
discouraged from seeking treatment or sharing information that 
is critical to their care due to concerns that it will be 
improperly disseminated.
    Treatment in behavioral health and other disciplines of 
medicine often require patients to share sensitive information, 
such as sexual history, drug use, pregnancy history, and HIV 
status. According to HHS, 2 million Americans, or 7 percent, of 
those with mental illness do not seek treatment specifically 
due to privacy concerns.
    A 2007 Harris interactive poll found that 17 percent of 
patients withheld information from health professionals because 
of worries the information might be disclosed. These rates are 
likely to be even greater if information exchange is 
electronically enabled and the confidentiality and security of 
health information cannot be assured.
    The trust required for a productive therapeutic 
relationship is undermined by accounts of health care workers 
who view electronic records of celebrity patients as well as by 
the loss or theft of laptops and CDs containing large 
quantities of health information.
    Apologizing and making improvements once data is lost is 
not a sufficient response. Privacy and security provisions must 
be keystones to the development of a nationally uniform HIT 
infrastructure.
    There are many approaches that could help protect the 
patient-physician relationship and optimize the advantages of 
the EHR environment. Examples include ensuring the strictest 
security protections and auditing are employed, and giving 
patients and clinicians a degree of control as to who can 
access sensitive information.
    Despite the widespread recognition of the potential HIT 
holds to increase efficiency and quality health care delivery, 
system adoption rates remain low. A recent study in the New 
England Journal of Medicine found that only four percent of 
physicians had adopted fully functional EHRs and those that had 
tended to be in larger practices. Consistently, cost is cited 
as the largest barrier to wider adoption.
    Although estimates vary widely, studies report that the 
total costs for implementing office-based EHRs range from 
$25,000 to $45,000 per physician. And subsequent annual costs 
for maintaining the system range from $3,000 to $9,000 per 
physician per year. These expenditures are amplified for 
smaller practices, where there are fewer physicians to share 
the costs.
    Psychiatrists involved in solo practice, a significant 
percentage of APA members, often have little or no 
administrative support staff, further increasing the 
physician's responsibilities with regards to selection, 
implementation, and maintenance of the system, and decreasing 
the time available for clinical care.
    The APA appreciates the efforts the Small Business 
Committee has made to address confidentiality concerns while 
developing an HIT infrastructure, which offers a great 
potential to raise the overall quality of care provided to 
patients. This goal can be met without breaching privacy 
protections and can assure patient trust if privacy is made a 
cornerstone of HIT development.
    The APA further recommends the use of financial incentives 
such as grants or other support to help practitioners in solo 
or small group practices cover the costs of hardware and 
software.
    Again, we thank you for the opportunity to testify today, 
and we hope the members of the Committee will consider the APA 
as a resource as this process continues.
    [The prepared statement of Dr. Plovnick can be found in the 
appendix on page X.]

    Chairwoman Velazquez.  Thank you Dr. Plovnick.
    The Chair recognizes Mr. Johnson for the purpose of 
introducing our next witness.
    Mr. Johnson.  Thank you, Madam Chair.
    I have today the pleasure of introducing Dr. Edward 
Gotlieb. Dr. Gotlieb is a pediatrician in private practice at 
the Pediatric Center in Stone Mountain, Georgia. He is a fellow 
both of the American Academy of Pediatrics and the Society of 
Adolescent Medicine.
    He has served as the Chair of the Policy Committee for the 
Academy's Steering Committee on Clinical Information 
Technology, now the Council on Clinical Information Technology, 
on the Academy's Committee on Adolescent Centers, the past 
Chair of the George AAP Chapters Committee on Adolescents.
    The American Academy of Pediatrics is a professional 
organization of pediatricians with more than 60,000 members 
trained to deal with the medical care of infants, children, and 
adolescents.
    And we welcome you today to this Committee, sir.
    Chairwoman Velazquez.  Welcome.
    Dr. Gotlieb.  Thank you very much, Madam Chairman 
Velazquez, Ranking Member Mr. Chabot, and Members of the 
Committee.

STATEMENT OF EDWARD GOTLIEB, M.D., FAAP, THE PEDIATRIC CENTER, 
        ON BEHALF OF THE AMERICAN ACADEMY OF PEDIATRICS

    Dr. Gotlieb.  I am honored to represent the American 
Academy of Pediatrics before you. My name is Edward Gotlieb. I 
am a practicing physician, pediatrician, in Stone Mountain, 
Georgia. And you have heard my credentials.
    Let me tell you about pediatrics. Sixty percent of 
pediatricians practice in small businesses. Pediatricians are 
asked by industry to pay extra for electronic health 
capabilities to deal with the complexities of pediatric care 
that were reimbursed by the government less well to provide 
these services than our adult care colleagues. Let me explain.
    Pediatricians are different from other doctors because the 
major government program that pays for the health care of 
children is Medicaid, not Medicare. Medicaid has a major impact 
on children's care, paying for 40 percent of births in the 
United States and I believe 60 percent in Georgia.
    Medicaid faces fiscal problems but not because of the more 
than 30 million children that are covered by the program. These 
children account for more than 50 percent of Medicaid's 
population but only 25 percent of its cost.
    Pediatricians find it very costly to purchase health 
information systems. A real factor in our inability to afford 
these expensive technologies is the payment rates that 
pediatricians receive under Medicaid. Under Medicaid, payments 
for providing the same medical services average 69 percent of 
what Medicare pays. So the margins under which most pediatric 
practices operate are much more severe than those of our adult 
colleagues.
    Furthermore, if incentives for adopting health information 
technology is structured to flow through the Medicare program, 
as is now largely the case, more than 60,000 practicing 
pediatricians would be excluded from the opportunity to qualify 
for these incentives. The already inequitable system of funding 
programs for children will only be worsened. This is not a good 
investment in our future.
    Unfortunately, even if we do receive help to adopt health 
information systems in our practices, we face special 
constraints because of special needs of child care and the 
rules governing privacy for our patient population. Electronic 
medical records are frequently designed for adult care and do 
not take into account the specific needs of children.
    There are a number of special functions that a pediatric 
health record requires that must be implemented in an 
electronic medical record. In their absence, pediatricians are 
hampered in their ability to properly document care.
    Yet, the vendor community frequently asks us pediatricians 
to pay extra for these capabilities if they are willing to 
provide them at all. Major areas in which these needs arise are 
in immunization documentation, immunization registry 
management, growth tracking, medication dosing, privacy for 
special pediatric populations, and in providing normative data 
by age, body mass index, or developmental stage.
    Of particular concern in today's discussions of health 
information technology incentives are adolescent privacy 
concerns. The HIPAA privacy rule and its implementing 
regulations defer to the state and other applicable law on the 
issue of adolescent privacy. Laws about age of consent vary 
from state to state and according to the patient's presenting 
problem. The electronic health records need to be able to 
reflect this.
    As an example, in many states, adolescents who present for 
the outpatient treatment of mental health disorders may consent 
to their treatment at an earlier age before they become 18 
years old.
    Pediatric practices typically have policies with respect to 
what portion of an adolescent's care should be handled with 
special privacy protections. EHR should be flexible enough to 
handle these practice-level policies.
    The recording of patient and parental consent, child 
assent, and the permission to treat are frequently less 
straightforward for children and adolescents than for the care 
of adults. Separation of the patient's consent and the parent's 
or guardian's consent is particularly important in the areas of 
testing for drugs, screening for sexually transmitted 
illnesses, or in the case of abuse. Remember also that our 
privacy concerns are not limited to minors.
    We pediatricians continue to care for young people through 
age 21 and in some cases beyond. My written testimony also 
focuses on other special cases: children in foster or custodial 
care, consent by proxy, adoption, guardianship, and emergency 
treatment.
    Thank you for the opportunity to testify before you today.
    [The prepared statement of Dr. Gotlieb can be found in the 
appendix on page X.]

    Chairwoman Velazquez.  Thank you, Dr. Gotlieb.
    Our next witness is Ralph Hale. Dr. Hale is the Executive 
Vice President for the American College of Obstetricians and 
Gynecologists. He is a past President of the Association of 
Professors of Gynecology and Obstetrics and a past President of 
the Pacific Coast Fertility Society.
    ACOG is a professional association of medical doctors 
specializing in obstetrics and gynecology in the United States. 
It has a membership of over 49,000 and represents 90 percent of 
U.S. Board-certified obstetrician/gynecologists.
    Welcome.
    Dr. Hale.  Thank you, Madam Chairperson/woman. We actually 
like women. Actually, it is interesting that I am following Dr. 
Gotlieb--
    [Laughter.]
    Dr. Hale.  --since Dr. Gotlieb usually follows me in the 
delivery room.
    [Laughter.]

STATEMENT OF RALPH HALE, M.D., FACOG, EXECUTIVE VICE PRESIDENT, 
      AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS

    Dr. Hale.  We appreciate very much the opportunity--
    Chairwoman Velazquez.  President Bush does, too.
    Dr. Hale.  Yes. That is true. I have been the ACOG 
Executive Vice President since 1993, when I left the University 
of Hawaii to come here to Washington, D.C.
    I can tell you that our organization is strongly supportive 
of health information technology. As a matter of fact, our last 
Executive Board meeting, which was just recently held in July, 
we had an expert come in and talk to us for over an hour. And 
the main thrust is, how can we get all ob/gyns in the United 
States into health information technology?
    As part of that, our organization has made our antepartum 
record, and our women's health record free to any electronic 
vendor that would like to use them. We will prepare them. We 
will make them available to them at no cost because we feel 
this is important.
    The problem with HIT is that it has not matured to the 
level where most of our Fellows who are in small practices can 
use these systems. They are costly. They are not interoperable. 
They cannot take their health record into a hospital that has a 
different platform base and use them. This is a problem we see: 
the lack of ability for us to move across the various 
platforms.
    And while HIT will save the insurers a lot of money, it has 
yet to save our members money. The costs involved are still 
excessive, as you have heard from our previous testimony, and 
we run into problems with confidentiality. Confidentiality is 
very important because these are sensitive records. And in our 
specialty, as with Dr. Gotlieb, we deal with a lot of extremely 
sensitive issues. We need to make certain that these records, 
even though they may be transferred between providers, are 
flexible enough to accommodate state privacy laws and the 
HIPAA.
    HIPAA, of course, is extremely important. And we are very 
supportive of HIPAA because many of our women have many issues 
that they would not like to have on the latest tabloid in the 
supermarket.
    Forty percent, as you have already heard, of deliveries in 
this country are paid by Medicaid. And, yet, there is nothing 
in Medicaid that helps support an electronic medical record. 
And we fear that within the next couple of years, Fellows who 
do not use Medicaid electronic medical records will be 
punished.
    While there is an increased need for HIT, physicians have 
less ability to afford these systems. This is a compelling 
reason for physician assistance in paying for HIT.
    We all know that the clinical benefit of the electronic 
medical record is great. In one of our groups at the 
Massachusetts General Hospital they have an outstanding medical 
record which they have put together, which allows patients to 
be seen in any office related to their physicians.
    And we need to bring that record into the hospital so if 
the patient has a problem in pregnancy, this record is there. 
The physician who sees the patient in the emergency room or 
sees the patient in the hospital can immediately pull up this 
record and can take care of the patient for her care and for 
the care of her infant. Unfortunately, this is not true 
throughout the medical system and among all the electronic 
medical record vendors.
    Representative Shuler has identified the problem. And all I 
can say is amen to what you ran into because that is what our 
Fellows see. The records are not adaptable across many, many 
areas. This is a problem.
    I would like to say that H.R. 2377 is a good start to guide 
us forward in this as we develop incentives for physicians to 
purchase HIT and to seek consensus on important privacy issues. 
This is a massive undertaking that requires physicians to trust 
their investment in HIT and for the patients to trust that 
their sensitive health information is protected.
    Thank you very much for the opportunity to testify. And 
ACOG is more than willing to assist you in any way that we can.
    [The prepared statement of Dr. Hale can be found in the 
appendix on page X.]
    Chairwoman Velazquez.  Thank you, Dr. Hale.
    And now the Chair recognizes Mr. Chabot for the purpose of 
introducing our next witness.
    Mr. Chabot.  Thank you very much, Chairwoman.
    Dr. Bort is a fellow Cincinnatian, as I mentioned before. 
He is also a Board-certified family physician and a fellow of 
the American Academy of Family Physicians.
    He is Chairman of the Board of Directors of The Family 
Medical Group of Cincinnati. And after completing his residency 
at the University of Cincinnati in the Department of Family 
Medicine, he commenced private practice in 1986 with a 
physician partner. Since then, the Family Medical Group, which 
is a partner-owned practice, has grown to 12 physicians, 5 
other health care professionals, and 86 employees overall, with 
over 28,000 patients, including me and my family, in 3 
different Cincinnati locations.
    One of Dr. Bort's major areas of interest is headache 
diagnosis and treatment as well as diabetes and other areas as 
well, but those are two of his special areas of interest.
    Two years ago, the group implemented a fully integrated 
technology platform. Today every person in the group utilizes a 
computer.
    Dr. Bort is a volunteer Assistant Professor of Family 
Medicine at the University of Cincinnati. He also serves on the 
Advisory Board of Crossroads Health Center in Cincinnati, which 
treats substance abuse.
    Cincinnati Magazine included Dr. Bort in their summer 
edition this year, in 2008, as best doctors in Cincinnati 
edition. We welcome him here today and look forward to his 
testimony.
    And all the other doctors have set a very high standard 
here, Dr. Bort. So we know you won't let us down.
    [Laughter.]
    Dr. Bort.  Thank you very much.

 STATEMENT OF THADDEUS BORT, M.D., CHAIR, BOARD OF DIRECTORS, 
                      FAMILY MEDICAL GROUP

    Dr. Bort.  Chairwoman Velazquez and members of the 
Committee, I am honored to be here today on behalf of family 
physicians; my partners at The Family Medical Group of 
Cincinnati; Ohio; and, most importantly, our patients.
    I am a Board-certified family physician and member of the 
American Academy of Family Physicians. I commenced practice, 
private practice, in 1986 with my partner, Dr. Timothy 
McCarren. Since then, as Congressman Chabot was kind enough to 
say, we have grown to 12 partners and 5 mid-level providers, 
and 86 employees. We have over 28,000 patients.
    After waiting for years for the perfect EMR system, we 
decided in 2006 that it was time to invest in one. After 
investigating a number of systems, we purchased the Misys EMR 
system but found that converting our practice from paper to 
electronic records was an arduous process. Only our integrity 
and our desire to help our patients kept us on task. The report 
from the Institute of Medicine on the unacceptable number of 
avoidable medical errors stimulated our resolve.
    During the first year of installing the EMR, we actually 
had to decrease our patient load by 20 percent until we became 
more comfortable with the system. Now, with two years 
experience, we realize that we deliver health care on a 
technology platform. Every employee uses a computer. And every 
patient encounter involves entering data into our EMR system. 
The experience has provided us some perspective on the cost, 
benefits, as well as the challenges associated with the use of 
EMRs.
    Costs. When we decided to convert to EMR, we didn't 
anticipate the ongoing cost of developing and maintaining a 
system. We purchased our system at an initial total cost of 
over $228,000, which did not include the transfer of existing 
paper files to an electronic format, nor did not include the 
time and effort required for the entire staff to become 
proficient and lost revenue while in training.
    However, we found that there is not only the up-front cost, 
as in the past year we paid over $258,000 to the EMR vendor. 
This is an annual expense that is not based on volume but the 
reality of maintaining a system.
    One of the largest expenses was converting 25,000-plus 
paper charts to a format the EMR could use. This required 
scanning of important documents of each chart. We tried to do 
this on our own but then resorted to shipping the remaining 
charts to North Carolina to be scanned professionally, at a 
total cost of $80,000.
    Benefits. Convenience, accuracy, efficiency, and 
completeness are among the benefits of the system. For example, 
our patients can schedule appointments or request a 
prescription refill, which is then sent directly to their 
pharmacy. When I am with my patient in an exam room, I am able 
to access lab results or check past history all with a click of 
a mouse. This fosters better patient care because of our 
ability to track measures, benchmarks, and standards.
    We find privacy and confidentiality are enhanced with EMRs. 
With paper charts that were all over our office, there was no 
way to know who looked at the chart. Thus, it was near 
impossible to monitor HIPAA compliance. Now it is necessary to 
log on using password protection, and an audit trail is 
recorded down to the second.
    Finally, one of the most important roles that effective 
HIT, like an EMR, can play is to implement what is called a 
``patient-centered medical home.'' This is a team-based health 
care model that emphasizes coordination of care that is 
particularly important for patients with chronic conditions, 
such as diabetes. The EMR is central to the operation of a 
primary care practice that serves as a patient-centered medical 
home.
    Challenges. Our EMR uses an encrypted system to transmit 
information. While this acts to insure patient security, it 
also poses a great challenge. When our doctors visit patients 
at some of the hospitals, we are unable to access the patient's 
information in our office because the hospital system and our 
office system are not compatible.
    Moreover, as family physicians, we interact with a variety 
of providers, such as my colleagues at this table: 
laboratories, radiology, consultants, hospitals, nursing homes, 
et cetera. Each of these providers has their own computer 
system, but because they are not interoperable, communication 
from these various providers still requires paper.
    While I would like to say that we have achieved a paperless 
office, we continue to be inundated with paper. All day long 
our fax streams hundreds of prescription refill requests to us 
since there is no direct electronic communication between our 
system and the pharmacy or other providers.
    The hospitals as well fax us reams of paper reports since 
thus far there is no standard for hospitals to electronically 
communicate with EMR. This amounts to several hundred sheets of 
paper, which we must scan into the EMR, then pay to shred.
    Based on our EMR experience, I would like to offer two 
recommendations. Number one, due to the potential benefits but 
in recognition of the substantial cost associated with the 
EMRs, the investment and the utilization of HIT should receive 
some form of tax incentive or system of reward.
    Number two, Congress should foster an environment that 
provides incentives for the private sector to hasten the 
interoperability of EMR systems, work flow, and clinical data 
to promote low-cost solutions to enable quality measurement and 
improvement.
    In closing, both despite and because of our experience, I 
believe the benefits of EMR over paper charting are numerous 
and profound. But because of the substantial costs and time 
barriers, it is quite difficult for a small practice to convert 
to EMR. Yet, we recognize how EMRs can improve the quality and 
efficiency of our care.
    We all share the goal of better outcomes at lower costs. 
Widespread use of health care information technology and 
electronic medical records is central to achieving that goal.
    Thank you for inviting me to testify. And I look forward to 
your questions.
    [The prepared statement of Dr. Bort can be found in the 
appendix on page X.]

    Chairwoman Velazquez.  Thank you, Dr. Bort.
    Believe me, this has been quite a learning experience. And 
if there is something that I can say, it is that there is no 
easy answer. We all want to produce savings when it comes to 
the health care system and to produce and integrated system and 
the benefits of health IT. Everybody talks about it. But how do 
we get there? That is the real challenge.
    We hear about the costs of adopting EHR systems and the 
lack of benefit, of direct benefit, especially true for small 
practitioners.
    Dr. Plovnick, I would like to ask you, in your estimation, 
what barriers to EHR implementation do psychiatrists face? And 
what are the unique challenges to the mental health profession?
    Dr. Plovnick.  A few barriers that come to mind offhand, 
there is not wide breadth of software options to choose from 
that are specific to mental health care in psychiatric 
treatment settings. So selecting a system that will work for 
the solo practice psychiatrist is a challenge.
    As I mentioned, psychiatrists often have very small offices 
and little administrative support. So all of the work involved 
in selecting a system, putting it together, and then 
maintaining it falls disproportionately on the physicians 
themselves, which takes away from the time for clinical care.
    The cost, as has been discussed by most people at the table 
today, has a particular impact on psychiatry, the solo practice 
in terms of the overall revenue. And the number of patients 
that psychiatrists see tends to be fewer than some other 
clinicians, which provides less opportunity to make up the cost 
savings for the expense of the system.
    Chairwoman Velazquez.  Do you have any specific 
recommendation in terms of your profession in terms of what we 
can do here in Congress that will alleviate?
    Dr. Plovnick.  It is a hefty question. I think that the 
issue of standards that has been raised is true with 
psychiatry, as with any other profession.
    Right now every system works on its own. And there is 
little opportunity for connecting between clinicians or within 
the inpatient setting. So assistance in providing 
interconnecting systems would be quite advantageous.
    Chairwoman Velazquez.  Thank you.
    Dr. Tally, I heard you loud and clear. The cost, the 
preliminary cost, $15,000, the $5,000 monthly maintenance fee, 
the 30 percent turnover, how we comprise continuity of care, 
the loss of productivity, not having systems interact with, 
communicate with each other. So the question of obsolescence is 
of particular concern to small practice specialists, who rely 
on fairly sophisticated systems.
    Have vendors responded to this concern? And what steps in 
the health IT industry would help to alleviate this problem of 
investing in a system that may not be useable in five years?
    Dr. Tally.  Madam Chair there is obsolescence and we are no 
different than any other industry because there are continual 
upgrades. We have to keep up with the technology.
    We are not using a CT scanner that was developed in 1988. 
Now what used to take 30 minutes can take 12 seconds. EMR and 
all electronics must continue to evolve, which dictates that 
parts of it will become obsolescent. This includes the 
Internet, and that is the reason we actually chose to go on an 
entirely new platform.
    It is a matter of how to adapt to this at an affordable 
cost. Our situation, in particular, is hampered by the fact 
that there is no company that would be willing to invest the 
amount of time to develop a specific neurosurgical program. 
There are not enough practitioners to make it financially 
viable and we have complex templates that one would have to 
construct.
    The Congress can act as a convener to orchestrate those 
involved to adapt certain standards. We are doing this 
currently with MRIs so that all MRI information has basic 
platforms that all of us can read. Currently that is not the 
case.
    If we had a basic platform that we could all read, such as 
what we would now call interoperable, then, as progress 
develops and technology improves, then industry could simply 
tack on an additional feature. But the basic system would still 
be there.
    And that is where I think that your role would be very 
helpful.
     Chairwoman Velazquez.  Okay. Thank you.
    Dr. Gotlieb, you point out that the average pediatrician's 
Medicaid payment is about two-thirds of what is received by 
adult care doctors for the same service. And this would seem to 
place pediatricians at a distinct disadvantage when it comes to 
health IT adoption.
    What is needed from us, Congress, to encourage greater 
adoption of health IT by pediatricians?
    Dr. Gotlieb.  Well, I think, first of all, if there were 
incentives, they need to pass through something other than 
Medicare because we have no access to those funds. The only 
funds that I have seen come through Congress recently is with 
the S-CHIP program, which could get us as much as $200 million 
over 10 years. And you guys have passed that. That has been 
vetoed twice. And it is sitting somewhere. So finding some way 
for us to get funds to do it would be a real help.
    Another thing that is not an Academy position but an idea 
that I would like to suggest is you have done it with drugs, 
where you have given benefits to drug companies, to include 
pediatric research for medications. Maybe you could do the same 
thing with health information technology people and say, ``If 
you have the functionality that pediatricians require, there is 
some benefit to you.''
    Chairwoman Velazquez.  Okay. Dr. Hale? No. Dr. Bort, let go 
with you first. Health IT security poses a significant 
challenge to physicians trying to access their patients' 
information outside of their office. You suggest standardizing 
electronic health record systems as a possible solution.
    What steps at the federal or state level could create this 
standardization and ensure the security of records?
    Dr. Bort.  I guess the way I would approach this is that 
looking at the cell phone industry as an analogy, what is so 
frustrating to us, Madame Chairman, is that we have, all of us 
in the room have, a cell phone. And there is a multiple number 
of carriers. But if they did not communicate, it would be so 
frustrating because we couldn't talk to one another, even 
though we had the cell phones, et cetera.
    And that is what we are living with, I believe, in HIT at 
this point because the security is not--I believe they are all 
encrypted in ways that I don't entirely understand. So it is 
not a safety as much as a communication problem that we are 
encountering that leads us back to resorting to endless faxes 
and defaulting to paper, which is the lowest common 
denominator.
    I believe this was mentioned earlier that HIT has lagged 
far behind the rest, for example, the business sector, where 
everybody lives on a Blackberry. We are not using that 
technology at this time in health care.
    I have a couple of thoughts, that, first of all. It is a 
paradigm shift because we have all been on paper. And we have 
our work flow issues. So it is easy to do different paper 
patterns in that regard. But now we are bringing a paradigm 
shift with the computers. And that is a big step.
    Now, if we would give computers, electronic prescribing, 
for example, to medical students, they would never have a paper 
pad or understand that. Since they have all been weaned on Game 
Boys, et cetera, that is no big step for them. They actually 
expect it.
    So we are dealing with problems of what to do with those of 
us who have been used to paper for years and then the new 
generation, which I think is where the answer lies: the medical 
students. For example, we see students and residents from the 
University of Cincinnati. And when they come to us, we have 
asked for them to have a computer so they could access our 
medical record. That has not been possible.
    As to your original point on the privacy and 
confidentiality, I have great confidence that the software 
managers know how to program that stuff aide make it safe. And, 
as I mentioned in my testimony, we have audit trails in our 
office.
    Chairwoman Velazquez.  Okay. Now I recognize the ranking 
member. Thank you.
    Mr. Chabot.  Thank you very much.
    Chairwoman Velazquez.  Yes.
    Mr. Chabot.  Dr. Tally, if I could just ask you a quick 
question? What year did you initially start your--
    Dr. Tally.  We started the process in 1992.
    Mr. Chabot.  '92. And the cost was $50,000 I think at that 
time?
    Dr. Tally.  Back then.
    Mr. Chabot.  That is what I was thinking because I know Dr. 
Bort said it was $228,000 in his practice. So we are basically 
talking '92 versus 2006.
    And I think both of you mentioned that one of the initial 
things that you either hadn't anticipated or didn't appreciate 
was the maintenance of this system, monthly payments and 
upgrading it, and that sort of thing. Would you both like to 
just touch on that briefly maybe, Dr. Tally and Dr. Bort?
    Dr. Tally.  Well, upgrading it is no different than the 
similarity which many people are familiar with, like opening up 
a Word document, Word 2003 versus Word '97. We all know that a 
Word 2003 will not decode a '97, which is why the Library of 
Congress is having so much trouble.
    So innovation is great, but you have to keep up with it. 
And as you keep up with that, again, there has been no 
standardization.
    As I was talking about with the Chairwoman, if you have a 
basic function, then you can add features on such as the cell 
phone analogy. You may have all of these features in the cell 
phone, but you still use a number. Even it has a voice 
recognition, it is a number that transmits. So you have that 
basic function. You can add on any other ``gee whiz'' features 
that you choose.
    But we should have all the vendors come to a common 
agreement that there is a platform with which we will persist. 
And then that will be the interoperable platform.
    Mr. Chabot.  Dr. Bort, did you want to touch on that?
    Dr. Bort.  Well, it was a shocker to us because of the 
sticker shock of the initial outlay. But then the ongoing 
upkeep and enhancements as we got further into the system and 
dependent, to be honest, where we depend upon it. So we are 
obligated to upgrade it and make sure that we have the latest 
version because, for example, there are drug interactions.
    Well, there are no drugs coming out monthly. So we have to 
make sure that our software when we are prescribing, eventually 
when we hope to do that via voice, that will help us to know 
that we are catching all of the possible reactions for patient 
safety.
    Mr. Chabot.  And, Doctor, let me follow up, if I can. You 
had mentioned about what you believe Congress should do, how we 
can be helpful. And you had mentioned--and this goes along with 
the cost--perhaps some tax incentive that would help those that 
are doing it now and maybe those that are anticipating it in 
the future, maybe make it more likely for them to modernize.
    I would assume that at this point in time the equipment 
that you purchase, you know, depending on how many years it is 
going to be good for, you can deduct that from the tax of the 
partnership or if you are a Sub. S or whatever you are 
individually, whatever.
    What you would prefer to have, something that would be more 
of an incentive, a tax credit or something. Have you thought 
about that?
    Dr. Bort.  Well, I can't speak specifically as to tax 
credits, but I will say this, that, for example, what you all 
in Congress have done with the Medicare D incentives for 
encouraging us to go for E prescribing, I believe that is a 
step in the right direction. I think it is a small step, but 
that is, for example, an incentive that will help us with the 
costs that we are incurring.
    As to the tax incentives, we are just struggling with the 
overhead. We are drowning in overhead. And this was one that we 
didn't foresee. It is one thing to deal with the overhead with 
our staff and salaries, benefits, et cetera. But now with the 
upkeep costs--and once we are down the road with this EMR 
system and committed to it, when they say that, you know, 
``This version is going to be necessary if we want to get 
results'' down the road from the hospital, then we are 
obligated to take that step.
    Mr. Chabot.  Thank you, Doctor.
    Let me go to Dr. Plovnick and Dr. Hale next, if I could. I 
guess in the fields that you are in, both psychiatry and 
obstetrics and gynecology, you emphasize the privacy issues and 
the sensitivities that might be there if personal information 
gets out. And that would seem obvious.
    I know up here, just as a member of Congress, I can tell 
you I was one member whose computer system got hacked into by 
the Chinese. And there were other committee chairs who got 
hacked in. We think the Chinese probably chose us because I am 
one of the Co-chairs of the Congressional Taiwan Caucus. And we 
have also been pretty outspoken on human rights abuses in 
China. So we were one of the ones that got hacked in.
    We had the incidence of an IRS agent recently who was 
snooping into the IRS returns of celebrities and things. So 
there is always a concern out there about information.
    Are there any suggestions that the two of you might make to 
us or anything that we can do to improve the concerns that 
might be out there about privacy issues relative to the 
electronic records in the medical fields and your fields?
    One or both.
    Dr. Plovnick.  Offhand there are two types of situations, 
where information could be disseminated. One is a security-
related issue with hacking, as you mentioned, where an outsider 
gets into the system and accesses information. And there are a 
variety of technological solutions to prevent that in terms of 
encryption and password protection and protecting the 
information as it goes online. Any system with sensitive health 
information needs to have that level of protection.
    Another situation where information can be accessed is 
actually be somebody who may have legitimate access within a 
system. That is in the situation of celebrity records being 
accessed. Those are often by people who do have access to the 
system, hospital staff or IRS staff, in the situation you 
mentioned.
    So in that situation, having as strict a control over 
information as possible, having more than just all or none 
access to records but really limiting access to those who are 
authorized to use it and standards built in from the start that 
allow that level of protection really help protect sensitive 
information.
    Mr. Chabot.  Thank you.
    Dr. Hale?
    Dr. Hale.  Yes. Thank you, Representative Chabot.
    Obviously externally you can have firewalls. You can have 
coded entry protection. One of the problems our fellows see is 
that, with no ability to transfer records from one platform to 
another platform the greatest breach of security happens when a 
contractor goes into the record to move it to another platform. 
You can't always say that that individual, who is transferring 
records from one platform to another will retain the 
information's privacy.
    Just as you said, there are people out there who, even 
though they talk about how secure their record is, when they 
get to another platform, somebody has had to breach that 
security.
    That is one of the problems we face with this lack of 
ability to move medical records. I hadn't originally thought 
about it, but I think the cell phone analogy is very true. Let 
me just give you an example that we have found.
    As I indicated earlier, we have made our record available 
free of charge. We have an outstanding antepartum record for 
pregnant women. It is used by hundreds of thousands of 
pregnancies every year. We have said we will make it available 
to any electronic vendor that wants to use that record.
    Yet we have a few vendors who are actually using it. We 
have others that are using part of it and want to use it. And 
why will they not use it? They don't want to make certain that 
anybody else could use it or that it is compatible with other 
groups because it ultimately compromises their ability to 
retain business and threatens their profit margin. That is 
where we see the greatest difficultly.
    If we had a consistent platform, our records could go to 
Dr. Bort's physicians. Obviously with Dr. Gotlieb, our records 
need to be compatible. And, yet, they are not. So every time 
you have to share that record with some other system, you run 
the great risk of loss of security. That is where one of our 
biggest problems is today.
    Mr. Chabot.  Thank you.
    Dr. Gotlieb, did you want to respond? Then maybe I will ask 
a question.
    Dr. Gotlieb.  Could I, please?
    Mr. Chabot.  Yes. Okay.
    Dr. Gotlieb.  For pediatrics, there are state jurisdiction 
issues on privacy. So if I have to send a record to Alabama, 
which has privacy protections for the adolescents in my 
practice, the things are different in Alabama. So my computer 
would not only have to be interoperable, but it would have to 
take in specific legislation in a different jurisdiction. And 
once you start doing that, you get into great trouble.
    Our trouble for a lot of folks is not trying to worry about 
whether the Chinese are going to break in but whether the 
parents are going to break in. You know, if I have a patient 
who comes to me with abdominal pain because her boyfriend is 
yelling at her a lot and I find out that she actually has 
appendicitis, I have to deal with the reality with an 
electronic health record, within a note, of protecting the 
psychiatric information in that visit with the physical 
information in that visit. I have to deal with the interface 
between the parents' right to know and the adolescent's right 
to privacy.
    Mr. Chabot.  Thank you very much, Doctor.
    I yield back, Madam Chair.
    Chairwoman Velazquez.  Mr. Gonzalez?
    Mr. Gonzalez.  Thank you very much, Madam Chair.
    I am going to make some observations so that there is kind 
of a frame of reference. The medical profession I think needs 
to understand where this is legislatively and where it is all 
going so that you can become part of it so that your voices are 
heard, so that your considerations and your observations and 
your input are part of the final product.
    I will put it this way. I believe that health information 
technology, electronic medical records, whatever you want to 
call it, that the train has left the station. And let me 
explain why.
    One, I think the government has determined that it is an 
effective way of saving money. And for government, budgets are 
big things. And because the government has such a state 
financially in providing health care services, it will be 
heard.
    Number two, I think the private sector is already on it. I 
think you all have your own experiences in dealing with private 
insurance companies of what they may insist in the way that you 
may submit for your billing and so on and what information. It 
is happening. You have got Google out there now that is 
providing some sort of a service regarding an individual who 
may want to create some sort of an electronic medical record 
file.
    All these things are moving forward. It is just a question 
of whether we are going to take your real life experiences and 
factor them in. And I think that is totally essential or it is 
not going work. So you are needed. That is one thing that I 
want you to understand.
    In my discussions with members of the medical profession 
and teachers and such, I don't know if it is generational. It 
is in a lot of other professions. I came from the legal one. 
And when we went from hard copy and my big law books and my CD-
ROM, I went nuts. My mind wasn't even--I couldn't even digest 
the information. I was so used to the way that it was already. 
I mean, you all probably would shake your heads in agreement. 
It is the same thing.
    I know that in medical schools and such, these recent 
graduates are pretty savvy when it comes to what is going on 
out there in the electronic world. They are fully embracing it. 
It is just a matter of whether you have the systems for these 
entering doctors to utilize.
    The other observation, let us not confuse privacy with 
security. That is so important because, as members of Congress, 
we have a problem with that when we discuss legislation. We 
will always have concerns about privacy. Medical records 
privacy in the hierarchy of privacy concerns is at the very top 
because of the nature of it. I mean, we understand that.

    But let us not go--security is another thing. That is the 
other component. We understand privacy and the precautions we 
are going to take and the policies. And we will have federal 
standards for that.
    I also believe that in due course--and it is going to 
happen much sooner, and the medical profession has to be more 
nimble than other professions. I think electronic records are 
actually going to be part of a standard of care.
    I think, Dr. Tally, you said it took ten years for doctors 
to finally say, ``We are going to have stethoscopes.'' Maybe 
the stethoscope of the Twenty-First Century or something is 
electronic medical records, but it is going to be part. It is 
going to be a factor and a component as to say whether you are 
truly practicing state-of-the-art medicine in today's society 
because the question will always be posed, ``Well, if you had 
had electronic medical records and you had had access to this 
because every other doctor does but you don't,'' I think there 
is a very, very serious question that we are going to have 
there.
    I will agree with each and every one of you about 
interoperability, about federal standards. We are working on 
that. We are not just going to go in there and mandate or 
reward or punish someone for the lack of utilizing electronic 
medical records.
    Without understanding the cost of it--and I am going to get 
into the cost in a minute. Yes, we will have standards. And 
then, of course, you can fine-tune it regarding what is the 
specialty. But I think also there is tremendous education that 
is lacking as to what you really need basically to probably 
comply with what the federal government is going to require.
    Now, there are two ways of doing this: you know, positive 
or negative incentives. And we have been talking about it. 
There are all sorts of these bills out there. One of them is 
mine with Dr. Gingrey. We have got tax incentive. We have got 
grants. We have got loans. We understand that. And we need to 
be providing that.
    The other is obviously enhancing how we reimburse 
physicians when it is a federal dollar being paid for the 
health care that is being delivered. I believe in positive 
incentives, but you need to understand that there are those in 
government that believe that the negative incentive works just 
as well.
    And we can go over if the Chairwoman would just give me 
some additional time to come back visit this, about how we are 
going to do that, the negative incentives are basically being 
punished for not complying with some sort of a standard in 
having electronic records.
    And we have people in very high positions that believe that 
is the way to go. I disagree, but we really need for you to be 
part of this debate and removing all obstacles because it is 
coming, it is happening. Believe me, it would just be part of 
your practice. There is nothing you can do to delay it much 
because it is going to be implemented.
    I know that I have gone over time, and I haven't asked the 
one question I want. So I will just yield back and see if the 
Chairwoman will give me--
    Chairwoman Velazquez.  We will have a second round.
    Mr. Gonzalez.  We will have a second round?
    Chairwoman Velazquez.  Sure.
    Mr. Gonzalez.  Thank you.
    Chairwoman Velazquez.  Mr. Buchanan?
    Mr. Buchanan.  Thank you, Madam Chair.
    I got in late, had another meeting, but I want to recognize 
Dr. Tally is from our congressional area. And I appreciate your 
effort, energy coming up here because I know all of the doctors 
are busy.
    Again, I don't want to be redundant. Maybe it was said. But 
what is did you find your return on investment in terms of 
energy and time and the investment? I am sure you probably 
talked about it, but I hear so much about these electronic 
records. And it is going to save us a lot of money.
    I am sure I agree with the congressman. That is the future. 
I was just curious as it relates to your practice. What have 
you found the efficiencies? Have you been able to have less 
employees or what has happened, in essence, as a result of 
putting your system in?
    Dr. Tally.  Sure. Thank you.
    I was just discussing this with my administrator, who has 
been through this process with me, this tripled process over 
the last 12 years. ROI, and even when I give some of the 
seminars on teaching it, is very difficult to link to a 
financial number because it is an ongoing cost of doing 
business. We just made the commitment years ago that this was 
going to be a better way to deliver health care.
    ROI is more physician satisfaction. Are there cost savings? 
Clearly when we first did this system, our transcription costs 
dropped 90 percent. But, as someone pointed out, it is a 
paperless system, not a paper-free system. So you still have a 
lot of the world who sends you paper, even if you are 
electronic.
    Now with voice recognition--and we are in the up front with 
doing voice recognition. This is going to give us some cost 
savings, even off the last ten percent. Technology has gone 
forward.
    Am I going to get an ROI on that when you then calculate in 
the upgrade cost and cost of doing business, such as was 
mentioned when it was sort of a shock figure? It is going to be 
very difficult for me to tell any physician ``Oh, this is how 
much it is going to save you'' because, as costs of staff and 
everything else goes on, it may just keep you from going under 
faster in today's current market.
    Mr. Buchanan.  Yes. I think it is inevitable. I think the 
other thing that has been brought up just since I have been 
here is the whole generational thing. I know a lot of doctors 
in their 50s. And they are just hoping to get their retirement. 
They don't have to get involved. They know it is coming. But I 
am just interested to see how that is going to play out over 
time.
    You know, it is one thing to have electronic records. It is 
more efficient. Then it is another thing to force people or 
encourage people, however you are going to do that, to change 
the way they have been doing things for 25-30 years. And we 
have a lot of physicians you know in our area that are in their 
50s thinking about retirement in 10 years, 5 years. And I know 
it has been touched on a bunch here today.
    What are your thoughts? Any additional thoughts on that?
    Dr. Tally.  Our current thinking is if you are not thinking 
about practicing more than five years, don't bother because the 
transition of the costs and then trying to make it proficient 
enough for you in a small practice is probably not worth that 
with one exception. And that would only be that if you intend 
to sell your practice someday. Whoever buys your practice is 
going to want an electronic format, absolutely.
    The unusual thing about who is willing to adopt and who is 
not is typical even among the neurosurgeons across the country. 
It has been somewhat of a dichotomy. I find just as many of 
those who are in their 45 or 50-year age group who want to 
embrace electronics and their junior partners do not want them 
to invest.
    And, as someone said, we have all of these residents coming 
out who are used to the electronic format. They may well be 
because they were trained on one system, and they are used to 
that. But as soon as they get out into a regular practice, they 
are going to suddenly find a plethora of systems that won't 
cross-talk. And they will be experiencing the same frustrations 
that you have heard here today.
    It is going to be just a gradual paradigm shift. And, 
unfortunately, it is going to take a lot longer than the vast 
majority of any of us would prefer.
    Mr. Buchanan.  Yes. I have been in business myself 30 
years. We have implemented a lot of systems. It usually takes 
longer, costs more, but eventually it works its way in and 
becomes part of the culture of the business. So I think it is 
inevitable.
    Thanks for coming. I don't want to take any more time of 
the Committee. Thank you, Madam Chair. I yield back.
    Chairwoman Velazquez.  Thank you.
    Dr. Hale, the Director of the Congressional Budget Office 
recently testified that withholding Medicare payments or 
creating some other financial levy are efficient ways to 
encourage EHR adoption. He went on to say that if you want to 
get to near universal health IT in the next five years, it has 
got to be the stick.
    Do you agree that tying Medicare payments to EHR adoption 
is the best approach?
    Dr. Hale.  Interesting question. I read what the 
Congressional Budget Office said. And I think if you look at it 
from the bigger perspective, yes, the only way sometimes that 
you are going to get the carrot is when you have the stick.
    The small practitioner is going to look at it just the 
opposite. They are going to say, ``It is a cost factor which I 
cannot afford. And my only recourse to that is I will see no 
more Medicare patients.'' And I don't think we want that.
    One of the issues, though, that we have not talked about 
with the electronic medical record--we have talked about the 
cost, we have talked about the efficiency--is patient safety. 
We have seen in our own specialty that those people who have 
adopted an electronic medical record, patient safety becomes a 
very critical issue and is very important because written 
notes, things like that that are not easily seem--we all know 
that it is easy to misstate what a prescription is. Patient 
safety is a big issue.
    That is what we have tried to push in our own emphasis. We 
haven't tried to push penalties because doctors don't respond 
well to penalties and to forcefulness. We have tried to push 
patient safety in the office, patient safety in the hospital. 
The management of the patient, that is what is going to benefit 
you. And yes, it is going to cost more at first.
    Wwhen I read what the CBO said and at least the Washington 
Post adaptation of what the CBO said, I think that many doctors 
would get their hackles up immediately and say, ``Wait a 
minute. You are going to punish me for not having a record when 
I would like to adapt to something that is reasonable and cost 
efficiency'' because I understand the young people like the 
record. But let me give you an example outside of patient care.
    In our organization with our Executive Board, most of the 
physicians are at my age, maybe a little younger. But we have 
instituted totally paperless meetings. Everything is done by 
the computer. We thought people would object to it.
    We recently decided to hold a meeting outside of 
Washington, D.C. And we were going to have to go to paper. And 
what was the biggest complaint we got? ``It is not electronic. 
We want to go back to the electronic. We don't want all of 
those papers. We don't have to carry a folder.''
    So I think physicians are willing to adapt. As Mr. Buchanan 
said, I think physicians will adapt to it. I think they are 
willing to put it in. I think it is the factor of costs given 
the already reduced Medicare payment. Fortunately, the 10.6 
percent didn't go into place.
    So I think they are willing to do it, but they want to be 
able to show that it does work, that they can continue to see 
their patients, and that they have a compatible record. They 
don't want to pay for have a record today, spend the $40,000 to 
$50,000, and next year be told ``That record is obsolete. You 
have got to put another 40 to 50 thousand.''
    That is not only difficult for the physician. It is 
difficult for the patient. And it is extremely difficult for 
the staff.
    Chairwoman Velazquez.  And, Dr. Hale, for this Committee, 
that is basically the most important issue. How can we help 
solo and small practitioners to adopt IT? And we will be 
looking into legislation that will provide ways to be able to 
provide affordable financing for the adoption of IT for small 
practitioners and solo practitioners. And we are going to be 
working to see if we could craft legislation that will provide 
the mechanism where we can use the Small Business 
Administration loan programs to help achieve that goal.
    With that, I would like to ask Dr. Gotlieb, under the 
Medicare physician fee fix bill that passed here in Congress, 
are those physicians offered incentives to purchase if 
prescribing systems. Like most health IT funding if prescribing 
incentives are structured to flow through the Medicare program. 
This funding structure does not apply to Medicaid payments.
    As a result, do you see pediatricians moving more slowly 
towards e-prescribing?
    Dr. Gotlieb.  I don't think pediatricians are moving slowly 
toward it. It is an Academy policy that we approve of and urge 
our members to go to e-prescribing. Most of the things 
pediatricians do don't have a whole lot to do with money or we 
wouldn't be in pediatrics. We do it because it is the right 
thing to do. And e-prescribing would really be a help for us 
and others.
     So we would certainly like to find some way to enhance the 
income to the practices. And e-prescribing would be a method to 
get it to us.
    You know, if you went to the adult community and tried to 
drop Medicare by ten percent, you would have an insurrection. 
If you tried to give us 90 percent of Medicare, we would be 
dancing in the aisles.
    [Laughter.]
    Chairwoman Velazquez.  Okay. Thank you.
    Dr. Bort? Dr. Bort, despite the challenges your practice 
has encountered implementing its system, you remain a strong 
supporter of health IT adoption. How did your previous 
experience as a health IT vendor make adoption simpler for your 
practice?
    Dr. Bort.  I believe you are referencing my experience with 
Pocketscript--
    Chairwoman Velazquez.  Correct.
    Dr. Bort.  --that Steve Burns and I started, actually out 
of our pain. One day I was realizing that most of my day, a 
great part of my day was spent scribbling prescriptions on 
pieces of paper that flew out of the office. I wasn't sure how 
legible they were and how they were interpreted, drug 
interactions and so forth and so on.
    So I have a passion for e-prescribing because the second 
largest paper transaction in our economy happens to be 
prescriptions, upwards of 4 billion. I know the number 3 
billion was mentioned earlier, but I have seen data up to 4 
billion pieces of paper with scribbles floating around 
sometimes. Hopefully they make it to the pharmacy and they are 
filled properly.
    Well, I think that, unfortunately, perhaps we are ahead of 
our time, as we were told. We were unable to sustain that back 
in 2000. But going from that step back into full-time practice, 
I was convinced that we had to draw a line in the sand 
sometime, we would never have the perfect EHR system out there 
that we had to start.
    And amongst our group, there are 12 of us. And it has been 
somewhat of a bell-shaped curve. There are some early adopters, 
as was mentioned earlier by Congressman Chabot. A few of the 
partners surprisingly--and this was referenced earlier--some 
older, some younger, were really gung-ho for it. And that 
really drove the passion in our office to follow through with 
it. Others were less likely and less comfortable. We sort of 
had to drag them along.
    But we looked at different options, such as voice 
recognition software, that one of my partners, middle-aged, two 
middle-aged and one younger doc, who preferred dictating and 
have voice recognition. So that has helped the adoption. I 
think once you make the commitment, there is no turning back.
    One of the problems we have faced is what happens when the 
power goes down. What we have found has happened a few months 
ago, that we were helpless, that everything depended from the 
phone systems in our office to the front office, back office. 
And that was a big impairment. For a day or two, we had to 
resort to paper. And it was so archaic to fall back to that. 
And we realized that there is absolutely no turning back.
    Chairwoman Velazquez.  Thank you.
    Now I recognize Mr. Chabot.
    Mr. Chabot.  Thank you, Madam Chair.
    I, first of all, want to once again commend you for holding 
this hearing. This is really very important. It has been very 
enlightening to me and I am sure the staff that is here and the 
other members.
    It is such an important issue. And most of the doctors that 
we are talking about really do fall right in the small business 
category, which is the jurisdiction of this Committee. And so 
it is a perfect thing for us to be talking about.
    I also wanted to mention I can certainly relate to what Mr. 
Gonzalez said before relative to when practicing law, the 
challenge that there was when we went from paper and books and 
Westlaw and all of that to the computer. And then it was just 
sort of mind-boggling.
    I had to sort of laugh when somebody hit McCain recently 
because he was sort of mystified by the Internet and 
technologies. And it might be to some degree an age thing, but 
you can sort of relate to it.
    Rather than us moving forward with this, I think we would 
probably be wise to get input from our fellow colleagues who 
happen to have been medical doctors and practicing medical 
doctors before they got here, both the House and the Senate, 
both Republicans and Democrats, because we have quite a few. 
And I think we ought to also rely upon some of the things they 
have experienced and their instincts in this area.
    Finally, rather than ask a specific question, I would just 
ask anyone who would like to comment, is there anything ``I 
wish I would have made this point when I was testifying'' or, 
you know, ``I wish they would have asked me this. One thing we 
really didn't touch on, you know, that we probably should have 
in afterthought''? If there is any one thing that you just want 
to suggest that perhaps we look into if you want to comment? If 
we have covered everything, that is fine, too, because this has 
been a pretty comprehensive hearing.
    And I will just go down the line. So, Dr. Tally, if there 
is anything you want to sum up with or bring up that we didn't 
talk about, for that matter?
    Dr. Tally.  Thank you.
    I think there are two issues. One, you just addressed, 
which is, unfortunately, right now a lot of comments are being 
made by those who neither build systems or actually have to 
operate them.
    I liken this to the fact that I may enjoy the benefits of 
air travel, but Boeing is not asking me how to build a plane, 
and I am not telling the pilot how to fly or asking every pilot 
to be in a 747.
    The second issue--and so asking those of us, the people who 
are going to build the systems and the people who have to use 
them, how to get--as you have said, that is critical to making 
sure we have some type of accepted usage throughout the nation.
    The second thing is what has just become available, which 
is still going to be a huge stumbling block. And that is e-
prescribing. It looks very good from the top down. The 
pharmacies and some of the big companies have done a great job 
establishing the freeway, but getting everybody a car on it 
right now is going to be the real challenge.
    And right now one of the things that has held us back, as 
is many specialties, is because we do have to do a lot of 
prescribing of narcotics. What we do involves that a lot, the 
Schedule II drugs. And the DEA finally because of your efforts, 
you all managed to get the DEA to say, ``Okay. We will allow 
you electronic prescribing.''
    They just established some rules, which are in my 
estimation right now a poison pill. There is in my estimation 
no way that under the current proposed rules that the vast 
majority of doctors will undergo the details and rigid rules 
that the DEA has proposed in order to do what they are already 
doing for other non-Schedule II drugs. We do this every day. 
And to get us to allow that rule or those types of encryption 
and onerous procedures when most of us would spend ten seconds 
writing a prescription, it will force many people to get off of 
it entirely.
    So I know that this is a proposed rulemaking, but I would 
just ask you to look very closely at that process.
    Mr. Chabot.  Thank you, Doctor.
    Dr. Plovnick, anything?
    Dr. Plovnick.  Thanks for the opportunity.
    Just to emphasize that a lot of concerns about protection 
of sensitive information have been raised at the table today. 
And the earlier the infrastructure is built in to protect that 
information, the easier it will be to incorporate it in a 
system.
    If you have a wider degree of adoption than we currently 
have trying to plug in privacy protection of sensitive 
information at a later stage, it will make the matter a lot 
more difficult. So now is an excellent opportunity to address 
those issues.
    Mr. Chabot.  Thank you.
    Dr. Gotlieb?
    Dr. Gotlieb.  Since you asked, care of children in this 
country shouldn't be a partisan issue. In the last fiscal 
budget, when you remove military kinds of fundings and stuff 
and you look at what has happened, one percent of the budget 
went to children's issues of new spending. And I can get you 
the reference.
    If we are really serious about taking care of the next 
generation, we need to start finding some ways to take better 
care of kids.
    Mr. Chabot.  Thank you, Doctor.
    Dr. Hale?
    Dr. Hale.  Thank you very much.
    I would just like to reemphasize again the Gingrey-Gonzalez 
bill, H.R. 2377, that I think that is a very good first step 
because it increases the IRS tax deduction for HIT purchase. 
And it also doubles the depreciation in the first year. That 
will be a big help.
    I would also like to say that my own personal health care 
is given to me by the Medical Faculty Associates at George 
Washington University, which is here. They have a very strong 
integrated HIT program. And if you need to see a program where 
doctors can write a prescription and you can walk down to the 
hospital pharmacy and pick it up or to the physician's office 
and pick it up and when you go in for your routine colonoscopy, 
which I did not too long ago, and have all of your record just 
routinely transferred over, they have a very good system, which 
is I think the type of thing we would like to see all of 
medicine have.
    Mr. Chabot.  Thank you very much, Doctor.
    And last, but not least, Dr. Bort?
    Dr. Bort.  Thank you.
    First and foremost, I am a small business. And I live small 
business. I love small business. I think that is what drives 
our country. So bless you all for doing this important work.
    One thing that was not mentioned earlier, it was told to me 
that we would be able to decrease the number of employees in 
our office when we went electronic. The good news is we got rid 
of 28,000-plus charts. We have some more space. But we have not 
been able to decrease full-time equivalents, which, again, is 
affecting our overhead.
    I do believe voice-activated software programs are--that is 
the easiest thing that we are all used to. And there are a 
number of platforms out there that are being developed. And I 
believe that will be the most user-friendly personally. And I 
had mentioned earlier about putting this software and these 
devices in the hands of medical students and residents because 
that is the future for the children that we are hearing about 
and so forth in going forward, I believe. They are used to that 
technology, as was just mentioned by Dr. Hale.
    Another example where this is being done well, I believe, 
is the VA system. Now when I get records from the VA on a 
patient, they are very concise and legible and very well done.
    Thank you.
    Mr. Chabot.  Thank you very much, Doctor.
    I yield back, Madam Chair.
    Chairwoman Velazquez.  Sure. Mr. Gonzalez?
    Mr. Gonzalez.  Thank you very much, Madam Chair. And you 
don't know how much we welcome your input on this because I say 
if it is going to be successful, can't do it without the person 
on the ground that deals every day with the patient in how to 
best meet those needs.
    I will give you a real quick example of something. And I 
don't know how we get past this other than we are going to set 
some minimum standards and such so that when you do make that 
investment, you are getting something that basically is 
understood by everybody, interoperability,--that is a given--
and so on, but I have a small application software vendor in 
San Antonio. She is absolutely brilliant. She is wonderful and 
made quite an investment. So I go, and I get briefed by what 
she has to offer the medical profession in San Antonio.
    I go to my cardiologist. And I am sitting there. And his 
wife is the office manager. So I just said, ``Where did you 
purchase your electronic medical records?'' And they tell me 
about this big, giant national firm.
    So I said, ``Well, do you know about'' so and so ``who is 
here locally?'' And she is a local leader and everything else.
    So ``Yes.'' And they had made their presentation, and they 
considered it.
    So I asked the officer manager, who is the real boss, the 
wife. And I asked her, ``Why didn't you all buy that system?''
    She said, ``Well, because my husband,'' the cardiologist, 
``wanted something with all the bells and whistles.''
    I said, ``But did the local vendor, what they offered, meet 
the needs?''
    And she said, ``Yes. We don't really use all the bells and 
whistles that my husband wanted, but that is the way he is 
about cars, too.''
    [Laughter.]
    Mr. Gonzalez.  So I am just saying that I think there are 
some basic systems out there. And I know they need special 
tweaking because of cardiologists, just like a neurologist. It 
is going to be different from the family practitioner and so 
on. But I think that it is out there.
    The question that I have is, how are you making your voices 
heard? Each of you who is in a specialty obviously has an 
organization, an association. Are they coming together and 
identifying the special needs of your specialty in making sure 
that that is being reflected?
    I don't know. Look, the American Medical Association is 
engaged. Don't get me wrong. And that is the big umbrella. But 
I am just talking about something that Dr. Tally has made 
reference to a couple of times. And that is, again, tailoring 
things to make sure that they meet your needs.
    So just quickly if you will tell me what efforts are being 
made within your own specialty, with your own group, within 
your own association to be able to communicate your special 
needs?
    Dr. Tally.  Well, as you said, every specialty is 
different. It is somewhat based on size. The American 
Association of Family Practice has done a fabulous job. They 
have a very intense IT department that has done a great job of 
promoting them. I am strongly in favor of that because that is 
where you, the congressmen and the government, need to work. 
And it is primary care.
    People like me, we are one percent of the physicians. 
Getting us up and running is a challenge for our association. 
And we have our own internal committees. And, as you have seen, 
I am also working with the AMA for this. The bulk if you can 
get anything to do 90 percent of the work, our challenge is to 
get 90 percent of the people who give 90 percent of the care. 
And that involves family practice, ob, pediatrics. The rest of 
us will come along in time.
    So the time and the effort to be spent by Congress, 
vendors, associations is where the vast majority of health care 
is being given, just like for the areas where we spend most of 
our money in Medicare: CHF, MI, diabetes, pneumonia. That is 
where the bulk of the savings has to come. And that is where 
HIT will deal its greatest benefit.
    Mr. Gonzalez.  Good point.
    Dr. Plovnick.  At the American Psychiatric Association, we 
have a committee of members specifically focused on electronic 
health records. They are early adopters who picked this up now. 
And a part of what they do is articulate some of the needs that 
they have for software in their various psychiatric practices. 
And this information is made available to members on the Web 
site and in other forums.
    And we actually have members who have adopted software. 
They have an opportunity to share their experiences with 
software on their Web site so that members can learn from other 
psychiatrists who have already adopted the systems. That is 
some of the activity of the APA.
    Dr. Gotlieb.  The American Academy of Pediatrics has many 
policy statement, position papers on what we need. We are not 
talking about pie in the sky stuff. We have specific issues 
that can be dealt with with such a small part of what the 
vendors considered to be their market, that they have a real 
interest in not listening to us sometimes.
    We are required in the State of Georgia to report 
immunizations to the immunization registry. I was on a 
committee with the State American Academy of Pediatrics going 
to the vendors one by one and them telling us ``Yes, we will do 
this. Give us yet another $100,000 per practice just to 
integrate your EHR or your practice management system into 
that. And we will be glad to think about it in the next 
iteration of the software.''
    We have things that we can offer. It is out there. I would 
be glad to present it.
    Mr. Gonzalez.  Thank you.
    Dr. Hale.  I am fortunate at the American College of 
Obstetricians and Gynecologists, I am the one that makes the 
decision as to where we are going. And our Executive Board has 
directed that one of our top priorities is to have all of our 
Fellows using an electronic health record.
    At our annual clinical meeting, we now bring in as many as 
24 different vendors and make them available so our Fellows 
have the opportunity to meet them.
    We are pushing it very hard. We would like to see by the 
year 2015 that every ob/gyn in the country is using electronic 
health records. I don't think we will succeed, but that is our 
goal. Unless you have a goal to reach for, you will never get 
there.
    Dr. Bort.  As a family doc in the trenches of primary 
care,--as I like to say, that is where I live and work,--I know 
how important it is to our small business.
    When I think back, I can't recall any edition of the 
American Academy of Family Physicians that hasn't had some 
article, either encouraging us, instructing us, or putting 
together guidelines to help us implement EHR into make us 
realize that it is imperative that we embrace these standards.
    The most important concept that is developed is that of the 
medical home. And for the medical home concept to work where 
you see your family physician for your health care needs, the 
EMR is actually mission-critical to having that come to 
fruition.
    Mr. Gonzalez.  Thank you very much, Madam Chair.
    Chairwoman Velazquez.  Okay. Well, again let me take this 
opportunity to thank all of you for taking time to come before 
this Committee.
    And let me say that we know that there are different 
legislative proposals moving through different committees. Just 
Wednesday the Energy and Commerce Committee reported out the 
H.R. 6357. And the Ways and Means also is considering 
legislation as it pertained to IT. And I just want to make sure 
that this Committee plays a role in making sure that the 
perspective and the challenges faced by small practitioners are 
heard. And we will do everything that we can.
    So, with that, let me just say I ask unanimous consent that 
members will have five days to submit a statement and 
supporting materials for the record. Without objection, so 
ordered.
    This hearing is now adjourned.
    [Whereupon, at 11:50 a.m., the foregoing matter was 
concluded.]

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