[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
TOO MANY COOKS? COORDINATING FEDERAL AND STATE HEALTH IT
=======================================================================
HEARING
before the
SUBCOMMITTEE ON GOVERNMENT MANAGEMENT,
ORGANIZATION, AND PROCUREMENT
of the
COMMITTEE ON OVERSIGHT
AND GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
NOVEMBER 1, 2007
__________
Serial No. 110-99
__________
Printed for the use of the Committee on Oversight and Government Reform
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
index.html
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COMMITTEE ON OVERSIGHT AND GOVERNMENT REFORM
HENRY A. WAXMAN, California, Chairman
TOM LANTOS, California TOM DAVIS, Virginia
EDOLPHUS TOWNS, New York DAN BURTON, Indiana
PAUL E. KANJORSKI, Pennsylvania CHRISTOPHER SHAYS, Connecticut
CAROLYN B. MALONEY, New York JOHN M. McHUGH, New York
ELIJAH E. CUMMINGS, Maryland JOHN L. MICA, Florida
DENNIS J. KUCINICH, Ohio MARK E. SOUDER, Indiana
DANNY K. DAVIS, Illinois TODD RUSSELL PLATTS, Pennsylvania
JOHN F. TIERNEY, Massachusetts CHRIS CANNON, Utah
WM. LACY CLAY, Missouri JOHN J. DUNCAN, Jr., Tennessee
DIANE E. WATSON, California MICHAEL R. TURNER, Ohio
STEPHEN F. LYNCH, Massachusetts DARRELL E. ISSA, California
BRIAN HIGGINS, New York KENNY MARCHANT, Texas
JOHN A. YARMUTH, Kentucky LYNN A. WESTMORELAND, Georgia
BRUCE L. BRALEY, Iowa PATRICK T. McHENRY, North Carolina
ELEANOR HOLMES NORTON, District of VIRGINIA FOXX, North Carolina
Columbia BRIAN P. BILBRAY, California
BETTY McCOLLUM, Minnesota BILL SALI, Idaho
JIM COOPER, Tennessee JIM JORDAN, Ohio
CHRIS VAN HOLLEN, Maryland
PAUL W. HODES, New Hampshire
CHRISTOPHER S. MURPHY, Connecticut
JOHN P. SARBANES, Maryland
PETER WELCH, Vermont
Phil Schiliro, Chief of Staff
Phil Barnett, Staff Director
Earley Green, Chief Clerk
David Marin, Minority Staff Director
Subcommittee on Government Management, Organization, and Procurement
EDOLPHUS TOWNS, New York, Chairman
PAUL E. KANJORSKI, Pennsylvania BRIAN P. BILBRAY, California
CHRISTOPHER S. MURPHY, Connecticut TODD RUSSELL PLATTS, Pennsylvania,
PETER WELCH, Vermont JOHN J. DUNCAN, Jr., Tennessee
CAROLYN B. MALONEY, New York
Michael McCarthy, Staff Director
C O N T E N T S
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Page
Hearing held on November 1, 2007................................. 1
Statement of:
Kolodner, Robert M., M.D., National Coordinator for Health
Information Technology, Department of Health and Human
Services; Cheryl Austein Casnoff, Associate Administrator,
Office of Health Information Technology, Health Resources
Services Administration; and Carolyn M. Clancy, M.D.,
Director, Agency for Healthcare Research and Quality....... 9
Austein Casnoff, Cheryl.................................. 26
Clancy, Carolyn M........................................ 37
Kolodner, Robert M....................................... 9
Marchibroda, Janet M., CEO, Ehealth Initiative; Dr. Winston
Price, Chair, Health IT and Transparency Advisory Board,
State of Georgia; Lori Evans, deputy commissioner for
health IT transformation, State of New York; Dr. Farzad
Mostashari, assistant commissioner, Department of Health
and Mental Hygiene, city of New York; and Dr. Neil Calman,
president, Institute for Urban Family Health............... 61
Calman, Neil............................................. 128
Evans, Lori.............................................. 98
Marchibroda, Janet M..................................... 61
Mostashari, Farzad....................................... 115
Price, Winston........................................... 75
Letters, statements, etc., submitted for the record by:
Austein Casnoff, Cheryl, Associate Administrator, Office of
Health Information Technology, Health Resources Services
Administration, prepared statement of...................... 28
Calman, Dr. Neil, president, Institute for Urban Family
Health, prepared statement of.............................. 131
Clancy, Carolyn M., M.D., Director, Agency for Healthcare
Research and Quality, prepared statement of................ 40
Evans, Lori, deputy commissioner for health IT
transformation, State of New York, prepared statement of... 101
Kolodner, Robert M., M.D., National Coordinator for Health
Information Technology, Department of Health and Human
Services, prepared statement of............................ 12
Marchibroda, Janet M., CEO, Ehealth Initiative, prepared
statement of............................................... 64
Mostashari, Dr. Farzad, assistant commissioner, Department of
Health and Mental Hygiene, city of New York, prepared
statement of............................................... 118
Price, Dr. Winston, Chair, Health IT and Transparency
Advisory Board, State of Georgia, prepared statement of.... 78
Towns, Hon. Edolphus, a Representative in Congress from the
State of New York, prepared statement of................... 3
TOO MANY COOKS? COORDINATING FEDERAL AND STATE HEALTH IT
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THURSDAY, NOVEMBER 1, 2007
House of Representatives,
Subcommittee on Government Management,
Organization, and Procurement,
Committee on Oversight and Government Reform,
Washington, DC.
The subcommittee met, pursuant to notice, at 3:10 p.m., in
room 2154, Rayburn House Office Building, Hon. Edolphus Towns
(chairman of the subcommittee) presiding.
Present: Representatives Towns, Christensen, Clay and
Bilbray.
Staff present: Michael McCarthy, staff director; Rick
Blake, professional staff member; Cecelia Morton, clerk;
Charles Phillips, minority counsel; and Benjamin Chance,
minority clerk.
Mr. Towns. The subcommittee will come to order.
I want to welcome everyone here today to what I consider to
be an extremely important hearing. Our Nation is on the verge
of a revolution in health services delivery through health
information technology, or health IT. This revolution, the
transition from paper to electronic health records, can reduce
medical errors, can enhance the security and privacy of medical
records, and can enhance the quality of care for medically
underserved communities.
I am concerned about how we are currently managing our
health IT initiatives. I am concerned that we are developing
top-down solutions and not fully connecting them to the
reduction of health disparities in the communities that need
them the most. I am worried that the programs that State and
local governments have started will ultimately be bypassed by a
one-sized Federal solution. But I am also concerned that there
is too much duplication of effort and expense as different
States start different programs.
I know that Dr. Kolodner and his team have been hard at
work, with not enough resources, I might add, in terms of
developing this health information highway. I just want to make
sure that the people from my community, Brooklyn to communities
all over the country, don't get left behind and that our State
and local and community initiatives are not discarded.
I know that encouraging innovation from our local officials
is a policy that Ranking Member Bilbray shares, so I would like
our very knowledgeable expert witnesses to tell us how to
reconcile national standards that we will ultimately need with
existing State, local and community health initiatives.
For those of you who know me, I have worked in a bipartisan
fashion regardless of who is in the majority. That's why I
hope, today, we can find some solutions that address
everybody's concerns so that we can move forward together. I am
going to announce a new House caucus within the next few days,
the Health IT Empowerment Caucus, that will focus on doing just
that. We plan to work with the administration and the 21st
Century Caucus and local and private sector groups to develop
inclusive language, programs and grant opportunities that
connect health IT with the reduction of health disparities.
In this regard, I would like to welcome other Members who
have been active on these issues. I would like to thank
Congresswoman and Dr. Donna Christian-Christensen for her work
as a leader of the Congressional Black Caucus' Health
Braintrust. I know that you have taken a leadership role in
working on the reduction of health disparities and I am proud
to be an original cosponsor of H.R. 3014, the Health Equity and
Accountability Act of 2007.
I would also like to thank Congressman Clay of St. Louis,
MO, for his efforts. He especially worked last year on the
Electronic Health Information Technology Act of 2006.
I ask unanimous consent that these Members be allowed to
participate in today's hearing. Without objection, so ordered.
I would also like to welcome those seated in the audience
who have worked long and hard to connect health IT with the
reduction of health disparities. I know that you have waited
for some time for the formal acknowledgment of your efforts,
and I hope that you will work with us and the House Health IT
Empowerment Caucus to make this happen.
[The prepared statement of Hon. Edolphus Towns follows:]
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Mr. Towns. I yield now, of course, to Congresswoman and
Doctor Donna Christian-Christensen for her remarks.
Mrs. Christensen. Thank you, Chairman Towns and Congressman
Clay. I want to thank you for holding this important hearing
today on health information technology, and I want to thank you
for the opportunity to be able to provide some comments.
Before I get into the body of my testimony, Mr. Chairman, I
wanted to just thank you for your leadership and for your
commitment to HIT and for your further commitment to ensuring
that the issue of health disparities is addressed in it and
through it. You have been at the forefront of successfully
amending HIT legislation to ensure that the issues and concerns
of minorities have been addressed, and it's been successful at
least in this House.
I am here representing the Congressional Black Caucus'
Health Braintrust, which has as its chief mission the
elimination of health disparities in African Americans as well
as in other people of color and the poor and rural populations.
Just to single out the African American community, the data
shows that we have higher rates of death and disability for
almost every disease, from heart disease and cancer to HIV and
AIDS. Our infant mortality is more than twice that of the white
population, and the life expectancy of the African American
male is the lowest of all population groups.
There are many causes for this. Among them are high rates
of poverty and social determinants that follow from it, the
lack of insurance, the lack of providers who come from the same
cultural and racial background, discrimination in health care
services, the high-risk lifestyles that are fueled by poverty
and discrimination, and a lack of sufficient political will to
change it.
Health information technology has the great potential to
improve the health of Americans and to raise our country above
that 37th WHO rating, the lowest of all industrialized
countries, many of which are far ahead of us on health
information technology. HIT reduces errors by eliminating the
illegible notes like the ones I used to write, by reducing
medication interactions and by providing relevant and timely
information. It also improves practice through protocols and
decision support for providers, and it can empower patients
through accurate and consumer-friendly health information.
The potential of HIT to improve health as well as to reduce
costs is great but not without deliberate action by this
Congress. Without that, it will fall short of the good that
could be done. It's imperative that this committee and Congress
pass provisions and funding to ensure that HIT reaches all
Americans, especially the most vulnerable populations and their
providers. It is important because of the extreme burden of
disease that these populations bear, and it's important for
their providers. Doctors treating vulnerable populations are
largely at the mercy of Medicare and Medicaid, and so they
receive the lowest reimbursements for the heroic work that they
do. Therefore, these patients and providers will require more
help from the Federal Government to ensure that the benefits of
HIT are equitably available to them.
Reports show that 98,000 deaths occur annually from medical
errors, and reports also show that they occur more frequently
in minority populations. So we in the Congressional Black
Caucus, as well as in the Tri-Caucus, clearly have a stake in
making sure that health information technology is accessible to
every community.
In the Federal Government's efforts to fund health IT,
there has been very little focus on reducing health
disparities, and we've seen the consequences of not having
health IT advancements in all communities through the natural
disasters like Hurricane Katrina. The victims then were largely
those to whom this testimony is focused and who need an extra
effort to be reached, minorities and the poor.
I would like to just highlight briefly a Tri-Caucus-
sponsored bill that takes a comprehensive approach to health
disparity elimination; and it also includes HIT provisions that
you, Congressman Towns, amended into H.R. 4157 as one of its
key provisions. That's the Health Equity and Accountability Act
of 2007, which was introduced this year by Congresswoman Hilda
Solis.
Under H.R. 3014, in addition to providing that our
communities have access to the programs that improve health
care delivery, using language lifted directly from your
amendments, Congressman Towns, emphasis is placed on,
``ensuring that health information technology and personal
electronic health records become a component in the efforts to
measure, reduce and ultimately eliminate racial and ethnic as
well as geographic health disparities.''
The bill also has provisions to increase racial and ethnic
minority providers, to bolster data collection and to bolster
accountability in Federal agencies that have health and health
care oversight. It's a much-needed bill, but it's a bill that
we will need your support to pass.
A 2005 Minority Health Disparities Report coming out of the
Office of Minority Health stated, ``Life expectancy and overall
health have improved in recent years for large numbers of
Americans due to an increased focus on preventative
medicine''--and I don't know where that was''--and by making
new advances in medical technology.''
However, not all Americans are benefiting equally. There
are continuing disparities in the burden of illness and death
experienced by African Americans, Hispanic Americans, Asian
Americans, Pacific Islanders, and American Indian/Alaska
Natives as compared to the U.S. population as a whole.
The expansion of health information technology is vital for
our communities, and it will require efforts from the Federal,
State and local government levels as well as from the
university and private sectors. And, it will require an
investment, but it's an investment that will pay and will
reduce future costs through better health.
I am proud to say that my alma mater of George Washington
University is a longtime leader in health information
technology and that my district, the Virgin Islands, has also
begun its own HIT initiative, but it is the Federal Government,
through its programs and in having the responsibility for more
than 115 million Americans, that must be placed in the lead. So
we need to continue to work with you, Congressman Towns, and
others to ensure that we can get meaningful HIT legislation
signed into law, which will improve health care, reduce costs
and eliminate health disparities. It's necessary for the health
of all of us and for the economic health and continued
competitiveness and strength of our Nation.
So thank you again for the opportunity to make comments,
and I look forward to hearing from your witnesses.
Mr. Towns. Thank you very much for your statement. I also
thank you for your involvement in this issue.
At this time, I would like to yield to Congressman Clay
from St. Louis.
Mr. Clay. Thank you, Mr. Chairman.
Let me begin by thanking you and your staff for your
leadership on this important issue.
I firmly believe that the Federal Government must take the
lead in the development and adaptation of a nationwide Health
Information Network that can improve the quality of care
provided to all citizens.
During the 109th Congress, I introduced H.R. 4832, the
Electronic Health Information Technology Act of 2006. H.R. 4832
sought to codify the current Office of the National Coordinator
for Health Information Technology at HHS. In addition, the bill
partnered with the private sector by providing grants and
incorporating a direct loan program that would offer key
economic assistance for institutions seeking to expand their
electronic health record capability.
Mr. Chairman, our effective pursuit of health IT standards
will dramatically reduce the significant health care
disparities that Dr. Christensen mentioned are facing many
minority and rural populations. I look forward to today's
testimony and in working with you on this issue.
I yield back.
Mr. Towns. Thank you. Thank you for your involvement as
well.
At this time, I would like to yield to the ranking member
of the committee, Congressman Bilbray from California.
Mr. Bilbray. Thank you, Mr. Chairman.
Mr. Chairman, let me just say that I appreciate your
holding this hearing.
As I have stated before, in my previous life, I was the
chairman of San Diego County, an area of 3 million people and
we provided the health care safety net for the working class
people of that region; and health data assessment and
information were critical components there.
Also in my previous life, when I served 6 years here in the
House before the voters gave me a 5-year sabbatical, I was
actually working on a telecommunications bill and the big issue
of how much Federal standards should be imposed, how much
flexibility has to be encouraged is a legitimate argument in
every one of these discussions.
A good example was the fact that if we did not have a
minimum standard, we would never be able to get to the issue
that you and I had a hearing about last week. It was about
making sure that all drivers' licenses in the United States are
held to a minimum standard, something the 9/11 Commission
wanted to do. There, the DMVs came forward and asked us, as a
Federal agency, to create a minimum standard so that we had
uniformity there, at least with the standard, even though we
had a State-by-State application of those standards.
On the other side, when we were working with
telecommunications, we were saying we want to have a network--
which is important--that the Federal Government leads on, but
we didn't want the Federal Government to set a standard for it.
You know, if we'd set a standard for computers back when they
came out, none of us would ever have seen Windows. It wouldn't
have been legal to have Windows. So just think about how far
we've been able to go because the Government wasn't in the way,
blocking it.
So, as they say, politics is the art of the possible.
Contrary to what the college professors say, it is not a
science. It's still an art. You still have to finesse it, and
you still have to have that delicate touch of trying to respond
to reality.
So I hope as we discuss this today, we look at that balance
between the ability for information to be transmitted and read
but still the ability for systems to be able to be upgraded
with innovation improvement being allowed in the process.
Because I'll tell you one thing as somebody who has been in
government since I was 24 years old--I was a city council
member--so often we legislate our way into dead ends, and some
of the greatest challenges we have with technology in America
is not to get the technology online but get it legally to go
online. So I hope we look at this with the innovation of let's
just have just enough guidance to make the system work but keep
enough flexibility to where innovation and improvement can go
on there.
I think all of us agree that there were a lot of people
scared when we busted up the monopoly of Ma Bell, but I don't
think any of us are really pining for the days when we had
rotary phones and our kids couldn't walk around the house with
a cordless phone, and so I hope that we look at it that way. We
learn from our successes of the past and from our mistakes of
the past and, hopefully, this panel will help set that
foundation to make sure that the consumer will be served, the
``consumer'' being the patient who needs to have this
information made available.
I would just like to close by saying, I serve on the
Veterans' Committee, Mr. Chairman, and we are looking at this
issue from the veteran's point of view, and I would strongly
urge that we work with my old friend Bob Filner--and I say
``old friend'' because we've been working together since the
1970's--at maybe using the Veterans' Committee as a stalking
horse here and the Federal Government should get its medical
records in order and straight as we move forward in talking
about a minimum standard for the rest of the country.
I yield back, Mr. Chairman.
Mr. Towns. Thank you very much. I look forward to working
with you in every way to try and see if we can move this
forward.
At this time, we will ask our first panel to come forward.
Will you continue to stand? It's a longstanding tradition
that we swear our witnesses in.
[Witnesses sworn.]
Mr. Towns. Let the record reflect that all three answered
in the affirmative.
Let me introduce our first panel, the three leaders in the
area of health IT. We are delighted to have you.
Dr. Robert Kolodner is the National Coordinator for Health
IT, reporting to the Secretary of Health and Human Services. He
has served in a number of executive positions in Health IT,
including that of Chief Health Informatics Officer in the
Department of Veterans Affairs; and, of course, he is
responsible for the development of the VA's electronic health
records system.
Of course, Cheryl Casnoff manages the Office of Health
Information Technology for the Health Resources Services
Administration. She oversees the awards of $40 million in new
telehealth and health IT grants. She previously directed the
State Children's Health Insurance Program at HHS.
Welcome.
Dr. Carolyn Clancy is the Director of the Agency for
Healthcare Research and Quality, one of the Nation's most
important health research agencies. Dr. Clancy is one of the
Nation's leading authorities on health quality and access to
care, and she has served in a number of senior academic
positions.
Your entire statements will be included in the record. So,
if I could, I'll ask each of you to summarize within 5 minutes,
which will allow us an opportunity to raise questions.
So, Dr. Kolodner, why don't you start?
STATEMENTS OF ROBERT M. KOLODNER, M.D., NATIONAL COORDINATOR
FOR HEALTH INFORMATION TECHNOLOGY, DEPARTMENT OF HEALTH AND
HUMAN SERVICES; CHERYL AUSTEIN CASNOFF, ASSOCIATE
ADMINISTRATOR, OFFICE OF HEALTH INFORMATION TECHNOLOGY, HEALTH
RESOURCES SERVICES ADMINISTRATION; AND CAROLYN M. CLANCY, M.D.,
DIRECTOR, AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
STATEMENT OF ROBERT M. KOLODNER, M.D.
Dr. Kolodner. Thank you.
Good afternoon, Chairman Towns, Ranking Member Bilbray and
members of the subcommittee.
I am Dr. Robert Kolodner, as you heard, and I am pleased to
testify before you today on the administration's vision for
interoperable health IT and how we are working with agencies
and stakeholders to meet the needs of our Nation's medically
underserved.
Three years ago, President Bush established the position of
the National Coordinator, reporting to the Secretary of HHS, in
order to provide leadership and strategic guidance to advance
the national health IT agenda in America with the goal that
most Americans have access to electronic health records by
2014.
From my 29 years of experience as a physician and as an
administrator at VA, I know that information technology is
absolutely necessary to be able to improve quality of care, to
reduce medical errors, to increase efficiency, and to provide
better information to patients and clinicians.
HHS is aggressively working to address the five critical
components necessary to achieve widespread use of health IT
across the Nation. These are a collaborative decisionmaking
process, a secure Nationwide Health Information Network, health
IT standards with a certification process to confirm they are
incorporated into health IT products, the adoption and use of
interoperable health IT products and solutions, and clear,
strong privacy and security and other health IT policies.
The first critical component, a collaborative
decisionmaking process, had been served initially by the
American Health Information Community [AHIC], which was
chartered in 2005 as a time-limited Federal advisory committee
to make recommendations to the Secretary of HHS on ways to
accelerate the development and adoption of health IT. We are
now transitioning this collaborative function to an independent
public-private partnership based in the private sector with the
Federal Government continuing as an active member and
participant. We have taken specific steps to ensure the
involvement of consumers, including medically underserved
populations, as we transition to the AHIC successor.
The second critical component is the Nationwide Health
Information Network to allow health information to be
appropriately available in a secure and reliable manner
anywhere in the United States. In fiscal years 2006 and 2007,
the ONC led a project that confirmed the feasibility of
exchanging electronic health information nationwide. In
September 2007, we funded multi-stakeholder health information
exchanges [HIEs], in nine communities across the country to
work together to identify and implement the best solutions for
exchanging health information. These nine HIEs will include
safety net providers in their communities.
The third critical component is the identification of
health IT standards and the incorporation of them into health
IT products and services. This activity has been extremely
successful. Since May 2006, 93 ambulatory electronic health
record products, accounting for 75 percent of those in use in
this country, have been certified by CCHIT as meeting their
functionality, interoperability and security criteria. The
first certified inpatient EHRs will be announced very soon.
The adoption and use of interoperable health IT products
and services is the fourth critical component. Today, only
about 10 percent of all doctors and hospitals in the United
States use EHRs that have even a minimum set of functionality.
We have been working across the Federal Government as well as
with the private sector to remove barriers and to promote the
use of EHRs by health care providers. Actions have included
regulatory changes to allow hospitals to donate EHRs to
physician practices in collaboration with HRSA regarding their
grants to safety net providers. This week, Secretary Leavitt
announced a 5-year CMS demonstration project designed to learn
how we can most effectively promote EHR adoption by physicians
in small to mid-sized practices where the current adoption rate
is even lower, being under 5 percent.
The fifth critical component relates to Federal and State
health IT policies, including privacy and security policies.
HHS is carefully exploring options to address these issues. As
part of this activity, ONC and AHRQ have worked collaboratively
to bring together a broad range of grassroot stakeholders in 34
States and territories to assess current variations in State-
level privacy and security practices and develop State-based
solutions and implementation plans. In at least 11 of these
States, there have been specific representation for medically
underserved populations who participate in the working groups
and steering committees. ONC is also working with the National
Governors Association to address cross-State health IT issues
and challenges to interoperability.
In summary, the widespread use of health IT is a
fundamental change that must occur in order to improve the
quality and efficiency of health care and to enable consumers
to manage their health and to promote individual and population
health. Moreover, the use of health IT has the potential to
help decrease significantly disparities in health care quality.
We are pleased that over the past 3 years there has been
substantial progress in coordinating multiple Federal and State
health IT initiatives to ensure that all populations get
benefit from advancements in health IT.
Mr. Chairman, thank you for the opportunity to appear
before you today.
Mr. Towns. Thank you very much.
[The prepared statement of Dr. Kolodner follows:]
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Mr. Towns. Ms. Casnoff.
STATEMENT OF CHERYL AUSTEIN CASNOFF
Ms. Austein Casnoff. Good afternoon, Mr. Chairman and
members of the subcommittee. Thank you for the opportunity to
meet with you today on behalf of the Health Resources and
Services Administration [HRSA], to discuss the health
information technology programs we administer. I appreciate
your support and awareness of the importance of health
information technology in underserved communities.
Consistent with the President's goal of the adoption of
electronic health records for most Americans by 2014, HRSA has
a number of grant programs already in place to assist safety
net providers in accomplishing this important goal. HRSA
promotes the adoption and effective use of HIT, including
telehealth, to meet the needs of people who are uninsured,
underserved and/or have special needs. HRSA also provides
technical assistance to health centers and to other HRSA
grantees in adopting model practices and technologies, in
promoting grantee HIT advances and innovations as models and in
ensuring that HRSA HIT policy and programs are coordinated with
those of other U.S. Department of Health and Human Services'
components and those of other Federal programs.
HRSA is working with many different stakeholders.
Collaboration and coordination is key to the successful
implementation of HIT. At HRSA, I'd like to give a few examples
of how we're doing this.
We are working with internal and external partners to make
sure the medically underserved and the safety net providers are
a part of every component of the HIT agenda. Reducing health
disparities is a key goal of our agency. To this end, we have
formed a coordinating group with the Office of Minority Health
specifically to address the potential of HIT to reduce health
disparities. We are translating and customizing priorities of
the National Coordinator's Office and standards for our
grantees. We serve on several coordinating committees to help
ensure that the medically underserved will benefit from the
promises of HIT. We participated in AHRQ's ambulatory safety
and quality grant application review process as well as in
their contract for Medicaid HIT technical assistance. We are
working closely with CMS and with State Medicaid agencies that
receive Medicaid transformation grants, and we are linking our
grantees to these opportunities.
At this point, I would especially like to thank Dr.
Kolodner for all of his support and the support of the National
Coordinator's Office in recognizing the special goals of our
agency to provide quality care to vulnerable populations. He
has worked with us to establish a new grant program, and he
took the time personally to visit some of our health center
sites.
HRSA's Office of Health Information Technology was formed
in December 2005, as the principal advisor to the HRSA
Administrator in developing in an agency-wide HIT strategy.
OHIT, as we're called, was specifically created to promote the
adoption and effective use of HIT in the safety net community.
Our office awards planning and implementation grants for
telehealth, electronic health records and other HIT
innovations, while encouraging market-based solutions and while
encouraging providers to incorporate HIT as a normal cost of
doing business. Our office also provides leadership and
representation for HRSA grantees with other Federal and State
policymakers, researchers and other stakeholders.
For fiscal year 2007, we funded four new types of grants
targeted specifically to health centers for a total of $33
million. These grants were based on specific comments that we
received from the safety net community about how we could best
support HIT in that community.
Implementing HIT innovations and transforming health care
through HIT is a huge undertaking that should not be
underestimated. Some of the barriers that safety net providers
face are the scarcity of funding, expert staff and resources,
sorting through the flood of information on HIT, selecting
software, hardware, appropriate tools, partners, and vendors
and, perhaps most significantly, using HIT to achieve real
change in clinical practice operations' staff and duties.
HRSA is continually looking for ways to overcome these
barriers for our grantees. We have compiled and shared lessons
from grantees with others and have provided technical
assistance.
In partnership with AHRQ, we have established an HIT
community specifically for HRSA grantees. It serves as a
virtual community for health centers, our health center
networks and State primary care associations, as well as other
grantees, to collaborate around the adoption of technologies
that are promoting patient safety and high-quality care. This
portal creates a central hub for communication across
geographic areas, and it allows our grantees to talk about and
to gain information about HIT advances.
We have also developed a toolbox, which is a compilation of
HIT planning, implementation and evaluation resources, to
support our grantees, and it will be expanded to include rural
health, maternal and child health, HIV/AIDS, and telehealth. We
will be releasing that shortly.
In conclusion, the Department of Health and Human Services
has identified furthering the use of HIT as a key priority.
This focus supports the President's goal of the adoption of
electronic health records for most Americans by 2014. We are
diligently working with our grantees and with our partners in
ONC, in CMS, in AHRQ, and other Federal and State public and
private organizations to meet this important goal. We are very
proud of our efforts and progress to date.
Thank you for giving me the opportunity to come here today
to update you on the progress of our agency in the area of HIT
and for your dedication and interest in underserved
communities. I will be very happy to answer your questions.
Mr. Towns. Thank you very much.
[The prepared statement of Ms. Austein Casnoff follows:]
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Mr. Towns. Dr. Clancy.
STATEMENT OF CAROLYN M. CLANCY, M.D.
Dr. Clancy. Good afternoon, Mr. Chairman and members of the
subcommittee. I am Dr. Carolyn Clancy, the Director of the
Agency for Healthcare Research and Quality [AHRQ], a component
of the Department of Health and Human Services. I, too, would
like to thank you for the opportunity to discuss the role that
health IT can play in improving the quality of health care for
underserved populations across the Nation.
It is an understatement to say that health care quality in
this country is nowhere near as good as it could or should be
and we also have wide racial, socioeconomic and geographic
inequities in health care and how it's delivered.
So, according to research from RAND, partially funded by
AHRQ, Americans have a little bit better than a 50 percent
chance of receiving the recommended care they need when they go
to a doctor's office and serious problems with health care
quality exists in all areas of health care. These problems are
pretty pervasive across communities.
It actually doesn't matter where you live, we have quality
challenges. In fact, according to data from our annual
congressionally mandated National Healthcare Quality Report and
our National Healthcare Disparities Report, health care quality
improved just 3.1 percent in 2006, the same rate of improvement
as the previous 2 years. At that rate, it will take us about 20
years to close the gap between best possible care, and care
that's routinely provided.
From these reports, we know that we have wide racial,
ethnic, economic, and geographic disparities in health care.
For example, rural Americans are more likely to be elderly,
poor--in fair or poor health--and to have chronic illnesses.
They are less likely to receive recommended preventative care
and report, on average, fewer visits to health care providers.
Unfortunately, we don't have data specific to urban underserved
Americans.
So the good news here is that we're working to resolve
these quality problems, and we are making some progress. The
bad news here is that the pace is slow, and we could move a
whole lot faster.
So the big question then is: How do we accelerate the
change that we need? How do we engage all stakeholders so that
we can make sure that everyone, every American in this country,
receives the highest quality and safest health care possible?
Well, first, we have to recognize, as Secretary Mike
Leavitt often says, ``We don't have a health care system. We
have a health care sector that's rapidly growing and is
increasingly fragmented.'' Health IT becomes a critical
connector for the multiple parts of this system that, today,
are not very nicely connected.
It is very important to note, though, that health IT is not
a magic bullet. It alone will not transform the health care
system, but it's impossible to envision how the transformation
could occur without the capacities that it brings. So AHRQ's
health IT initiative includes more than $166 million in grants
and contracts to 41 States to support and to stimulate
investment in health IT with a particular focus on rural and
underserved areas. Through this initiative, we are working to
ensure that the promise and potential of health IT is available
to all Americans.
More than 50 percent of our health IT funding has targeted
rural populations. So, from 2004 to 2006, the amount spent for
rural health IT projects totaled $75 million. Under our more
recently funded ambulatory safety and quality initiative, we're
spending $6.5 million for health IT grants targeting priority
populations, out of a total of $21 million in these grants in
fiscal year 2007.
Mr. Chairman, we recently awarded one such grant to the New
York City Department of Health and Mental Hygiene to enable the
meaningful measurement of the quality of care with a focus on
public health priority issues, disadvantaged populations and
small office practices.
We are very pleased to be collaborating with Dr. Kolodner's
office on the funding of a report to review and analyze the
best clinical evidence on the use of health IT by the
underserved, elderly and disabled. We believe the findings from
this analysis will give us critical information that we need to
ensure that these populations reap the benefits of health IT.
We have also just recently funded a $3 million contract to
provide technical assistance to up to 20 States on the best use
of health IT to improve the quality of health care for Medicaid
and SCHIP beneficiaries.
Technical assistance is critical to the successful adoption
and implementation of health IT and we take this so seriously
that, from the outset, we have created a national resource
center for health IT. This resource center leverages our
investments by offering help where it's needed most in real-
world clinical settings that may feel ill-equipped, as my
colleague described, to meet the implementation challenge. So,
by way of example, this resource center has assisted States in
their initiating Statewide clinical data-sharing and these
include New York, Wyoming, Montana, Maryland, Georgia, and
others. As my colleague noted, the resource provides a Web
portal with capabilities to convene practitioners, to encourage
collaboration and to disseminate best practices.
Through our collaboration with HRSA, we have a special
portal for the Nation's community health centers. We've also
supported providers in the Medicare health IT initiative and
the Indian Health Service, and we've seen some dramatic
improvements in care in the IHS.
So, Mr. Chairman, I'd like to conclude by offering just a
few brief observations on our work to date.
First, health IT alone cannot improve our health care
system unless it is integrated and embedded in the very fabric
of how we provide care.
Second, for most health care settings, health IT is not
likely to be an out-of-the-box solution. Effective use of
health IT has to be linked with a very careful examination of
how care is delivered and so that the power of health IT can be
harnessed to enhance the effectiveness and the efficiency of
care.
Third, accelerating the pace of adoption and implementation
requires the sharing of both knowledge and experience through
opportunities for voluntary peer-to-peer learning. It's a
fairly local phenomenon.
Finally, the development of interoperable health IT can
accelerate the pace of innovation and the speed with which
patients will benefit from new medical breakthroughs.
So I'd like to thank you for the opportunity to be here
today. I am confident that, in working together, we can ensure
that all Americans receive high-quality, safe health care
services.
[The prepared statement of Dr. Clancy follows:]
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Mr. Towns. Thank you.
Let me first thank all three of you for your testimony.
Again, I apologize for our lateness. There were votes on the
floor and, you know, you have to vote around here. You know, if
you don't vote, they talk about you so that delayed us. So I
wanted to just sort of apologize for that.
Let me begin with some questions. You know, I'm concerned
that the communities that need health care, better health care,
are generally the communities that will probably last be
connected. I mean, these are the communities that will sort of
be left out.
What can we do to try and make certain that the communities
that have been neglected for so long are not neglected this
time around? What can we do to prevent that from happening?
Ms. Austein Casnoff. Well, certainly that is the population
that we target, and those are the providers who we work with.
Obviously, the majority of the patients we serve are uninsured.
Over two-thirds are minority populations, so HRSA's mission is
very much geared toward addressing the needs and in providing
the highest quality care to those populations.
We do believe, as my peers today have talked about and as
I've talked about, that HIT is a very powerful tool to help
move that agenda forward; and I think you will hear as well
from the next panel some very specific examples, including one
of our grantees who is moving that forward and who is using HIT
to accelerate the pace of quality care in those kinds of
communities. That's specifically what our grants are targeted
to do.
Mr. Towns. Any other comments?
Dr. Kolodner. Mr. Chairman, as you know, we do have this
national awareness of the need to move forward in health IT.
And, really, there have been fairly early efforts to move
forward, and there have been attempts to do this over the last
15 years. I would say that the activities that have occurred in
the last 3 years, actually, have made more progress than in the
decade or two before that.
What we need to do, as I'd mentioned, is to make sure that
in every aspect that we're looking at, whether that's the
electronic health record or the funding for resources there or
the network and how it is addressed or privacy and security
policies and in understanding that there are difficult cultural
biases and preferences, that we need to take into account, to
make sure, that as we do each of these activities that we
involve the community, that we involve those who are members of
the medically underserved communities or those who are taking
care of them.
Mr. Towns. Do you want to add anything, Dr. Clancy?
Dr. Clancy. The only thing I'd add is, when I think about
some of the really dramatic successes we've seen, they include
a number of underserved communities; and I think our collective
challenge in working together and with you is to make sure that
we can scale this up as rapidly as possible. It is absolutely
not a given that we have to have a digital divide and that we
can't bring everyone along together.
So, in New York City, you know, the Health and Hospitals
Corp. has been using a registry for the past few years, which
is the specific application or functionality of an electronic
health record to track people with diabetes; and it makes a big
difference. You can't do that on paper.
So that's the kind of advance that I think we can insist on
and will continue to do so.
Mr. Towns. How about establishing an HIT empowerment zone,
a health empowerment zone?
You know, I'm looking at these empowerment zones around the
country and in other areas that have really done some
remarkable things. You know, I was in Harlem just recently, a
place that was just written off. They now have an empowerment
zone there, and it's the place to be now. You know, people are
fighting to get in there, and they're saying that the
empowerment zone really made the difference.
So when I look at areas that have all of these health
disparities, what about the possibility of creating an
empowerment zone to deal with the health issues in these areas?
Because the traditional fashion--you know, for some reason,
they have just not gotten service, and so I just think that if
we continue down the road--and you mentioned in terms of 20
years. See, those communities might be 40 years; they might be
no years, you know. So I'm just wondering, what is your
reaction to a possible empowerment zone that would take this
information and would come in and would make certain that they
get everything and get it first and then move forward?
Dr. Clancy. Well, I guess, Mr. Chairman, I'm not exactly
sure what an ``empowerment zone'' is. We'd like to followup
with you on that.
Let me say that I think one terrific aspect of the work
that Dr. Kolodner's office has launched, particularly in the
Nationwide Health Information Network, is the potential to
connect public health with clinical care. We know that we've
seen as a result of reporting on quality of care that we are
starting to see improvements overall and a reduction in
disparities for those activities that take place in a
clinician's practice--so were the right tests ordered?--and so
forth.
Where we're seeing slower improvements are in those areas
that require chronic, ongoing care to achieve, for example, the
optimal control of diabetes, the control of risk factors for
heart disease and so forth. We believe that in order to
actually advance those areas of quality, we are going to need
good connections between clinicians' practices and resources in
the community, and I think health IT could be very powerful
there. And I think that's one of the potential, powerful
applications of the Nationwide Health Information Network; it's
that kind of connectivity that you need.
Mr. Towns. Right.
Dr. Kolodner, is there a written policy office that ties
the implementation of health IT and grants to the reduction of
health disparities? Is there a written policy?
Dr. Kolodner. There is not a specific written policy.
What we have done is, as I've mentioned, in each of the
activities that we've undertaken, we have specifically written
in language. For example, on the grant contract agreement that
we put out for the AHIC successor, we specifically wrote that a
consumer sector would need to address the needs of healthy
populations as well as those of vulnerable, disadvantaged and
chronically ill populations.
In the NHIN network contracts that we put out, when we put
out the first contract language, we said that to be considered
as an eligible health information exchange the applicants would
need to include different types of provider organizations, two
of which must include independent physician practices and
safety net providers.
So, while we don't have a single specific policy written in
the office that says what we're going to do, we actually have
been embedding it in all of the activities that we've
undertaken.
Mr. Towns. You know, let me ask, is there any coordination
of these programs? I'm just concerned about that. I mean, do
agencies talk to each other about what's going on and about
what needs to go on?
You know, I was just listening to the comments made earlier
by Dr. Christensen when she was talking about it in terms of
disparities and in terms of the numbers. Are the agencies
talking to each other as we move forward?
Dr. Kolodner. Yes. Actually, if you had asked me that
question 3 or 4 years ago, I think you would have found kind of
spotty collaboration. What we have, in fact, been doing,
especially in the last few years, is increasing that.
I think one of the reasons that you might have a question
about that is we probably haven't done as good a job of
communicating the activities that we have been doing, but we
have, for example, a Health IT Policy Council that is across
the Federal agencies and departments, and we have a Federal
health architecture group that involves 26 different agencies
and departments. So we actually do have collaboration going on,
and we connect the appropriate levels and the appropriate types
of people in each of the departments and agencies. And, as I've
mentioned, not only across the Federal sector but also with our
activities with AHRQ and with others, we're actually
facilitating collaboration across the States and between the
Federal and the State entities.
So we are doing our very best. There are a lot of things
that are going on. I'm sure there's opportunity for
improvement, but I think we actually have been doing a great
deal of the collaboration in the last couple of years.
Ms. Austein Casnoff. If I may, collaboration is absolutely
key to what we do. We spend a very large part of our energy in
working with other agencies and in finding partners to help the
safety net providers.
For example, next week, we're having our first-ever HRSA-
HIT grantee meeting with over 600 attendees--the title is
Success through Collaboration and we are very pleased that AHRQ
is represented there--the National Coordinator, every Federal
agency as well as public and private sector organizations.
So we believe it is absolutely critical to not only HRSA's
activities but particularly to our grantees, and we are trying
to educate our grantees about collaboration with potentially
nontraditional partners as well, working with States, working
with the Governors and their legislatures, working with their
Medicaid agencies. So we absolutely emphasize that as critical
to the movement of HIT in the safety net community.
Mr. Towns. At this time, I yield to the ranking member,
Congressman Bilbray.
Mr. Bilbray. Thank you.
Dr. Clancy, you made a reference that 50 percent of your
funds are going to rural, 50 percent.
Dr. Clancy. Yes.
Mr. Bilbray. Off the top of your head, generally, what
would that be in comparison to the general population? 10
percent?
Dr. Clancy. Do you mean what proportion of the U.S.
population is rural?
Mr. Bilbray. Yes.
Dr. Clancy. About 25 percent.
Mr. Bilbray. You know, I grew up in a working class
neighborhood where, without the Navy hospital, you had the
clinic, and that's about it; you had the neighborhood. With the
underserved community, it was so easy for us to use race and to
use ethnic background, but, overall, the common denominator in
my neighborhood was that we were working class people who were
below the average income. That's pretty consistent. The
economic status is the largest determining factor with the
underserved. Is that fair to say?
Dr. Clancy. What I can tell you is, from our annual report
on health care disparities, we see big gaps associated with
individuals' race and ethnicity, and we also see very large
gaps for poor compared to high-income Americans.
Mr. Bilbray. But don't those ethnic groups tend to fall
into the same category as the ethnic? I mean, I find it hard to
believe that a lot of our Californians who live in Hollywood
and who happen to be African American are not going to be
falling into the underserved population in their neighborhoods.
You know, the poor tend to be underserved no matter who you
are. Do we move up into the middle class and upper middle class
where the minorities are getting hit pretty hard with it?
Dr. Clancy. Both race or ethnicity and income turn out to
be important and independent predictors of getting even poorer
quality of care than everyone else. They are, as you note,
often closely associated, but they are independent. So there
are members of racial and ethnic minorities who have done much
better, in terms of income, who still experience disparities.
Mr. Bilbray. But the community base tends to be served,
generally, substandardly in both areas?
Dr. Clancy. Yes.
Mr. Bilbray. The VA had a success story with Hurricane
Katrina in recovering the records. Why were you able to be so
much more effective at recovering records than the private
sector in New Orleans?
Be careful. You've got to remember that my wife is from New
Orleans, so I lived through that. We had a house hit by
Katrina.
Dr. Kolodner. For about 20 years, the VA started investing
in health IT, and it was an effort that was led by the
frontline clinicians, not just a top-down type of process. So
the issue of top-down/bottom-up, for example, is something I do
not see as an either/or. It has to be at both ends. Leadership
has to say that we want to do it, but the real innovation and
creativity and motivation is going to come from the frontline
commissions. So the VA had, over that period of time, been able
to put in an information system that was extensively used.
In many places, such as New Orleans, it was essentially
paperless. When the power went out in New Orleans and the
veterans were trapped in the VA hospital, they did have
emergency power, and the electronic health record actually
continued to run up until the time that the last person was
evacuated. And they were able to take that information and
within 24 hours have it loaded so that wherever those people
went, their information was there and available. And I think
that's the kind of experience that confirms the value of having
the information electronically and the tremendous improvement
in the continuity of care not only in crises, but in other
times as well, and improving the quality of care that
electronic health records allow.
Mr. Bilbray. Doctor, the private sector for decades now has
been trying to get away from paper records and trying to go to
electronic, and they haven't been doing it because of some
lofty vision of fairness. They've basically been doing it
because they feel it's cost-effective.
Is that fair enough to say that we should be able to
implement an IT system that, in the long run, will be more
cost-effective than maintaining the paper structure we have
today?
Dr. Kolodner. Yes, I think that would be very fair.
Mr. Bilbray. The question will be then, where are we going
with the VA? Can the VA lead the Federal family by setting an
example for the rest of the Nation and lead through example
rather than through mandate?
Dr. Kolodner. Well, we are working--with the collaboration
I mentioned, we actually have the VA, the Department of Defense
and the Human Health Service all at the table and helping with
the national health IT agenda, both connecting into the
Nationwide Health Information Network as well as at the table,
advancing the standards and embracing the standards themselves.
I think one of the things that those agencies have had as
an advantage is that there's a perfect alignment between the
funding and the incorporation of health IT. Right now, one of
the challenges we have is, with the disparate funding
mechanisms we have and with some of the perverse incentives
there, that what we are working to do is to get not only
solutions in place, but we are working to align those adoption
incentives so that we can move forward.
Mr. Bilbray. You know, sadly, so often those who would be
the best served are the most scared of new technology. I mean,
the real scare tactics out there are people being scared of new
technology being used. It astonishes me the people who will
talk about and be worried about privacy, and then they'll have
a cell phone on their hip or in their purse and they'll have a
credit card in their wallet. Any one of us who uses either one
of those devices can be extensively tracked even when the phone
is turned off.
I always like making my constituents feel really
comfortable with that.
What are we doing about security with the IT issue? Any one
of you can answer that, but I know the VA has been pounded on
this for a while.
Dr. Kolodner. The VA has been pounded on it. Although, if
you look at the instances, the electronic health record that is
used for the delivery of care isn't where the breaches have
occurred. We know, as we roll out the national health IT
agenda, that the security and the privacy of that information
is absolutely fundamental. I would not put my information on a
system that's not secure and that's not honoring the privacy in
the way that I might want it. So we're building that into the
foundation.
As to the certification of the products--of the electronic
health records--for example, security is one key factor for
that certification criteria. With the Nationwide Health
Information Network, the security is a key part, and what we
actually have done in the trial implementations of the nine
contracts that we've just let is we've built in consumer choice
as a requirement for participating, where the individuals get
to say whether or not they want their information to flow over
the network at all or how they might want it to flow.
So we believe that those are critical capabilities. We are
still learning how to balance those and how to make sure that
we honor those without actually causing an increased chance of
giving them bad care. So those are the kinds of things that we
need to pursue.
Mr. Bilbray. But isn't it true that with cooperation and
with the biometric confirmation that IT has the potential, if
done properly, to substantially increase the security and
privacy with documentation as opposed to the existing system
where you have clerks going through it and you have paper
needing to be shredded and that kind of issue?
Dr. Kolodner. When done properly, health IT actually is
much, much better than the paper record.
Mr. Bilbray. Ladies, do you have any comments to either one
of those issues?
Dr. Clancy. I agree.
Mr. Bilbray. Thank you very much.
I yield back, Mr. Chairman.
Mr. Towns. Thank you very much, Congressman Bilbray.
Congresswoman Christensen.
Mrs. Christensen. Thank you, Mr. Chairman. I thank you and
the ranking member for allowing us to join you in this hearing.
I would just like to say, on the health empowerment zones,
I know Dr. Clancy has heard me talk about them, the part of
H.R. 3014 that have been part of our minority health bill going
back two Congresses. I think it's a very good concept, and it
goes beyond what you may know as REACH, the REACH Program, to
allow communities to have priority access for programs at any
agency that can help them meet their health care goals. So, in
3014, you'll see a little of what a ``health empowerment zone''
is.
Dr. Clancy, I guess I'll start with you. We've been working
together for a long time, so you probably can anticipate my
first question, which is, are any grants going to territories
or are they precluded from having some of these grants, the
$166 million worth of grants that are going to 41 States?
Dr. Clancy. I was just checking with my experts here who
are closer to the actual detail. We do have a collaboration
with Puerto Rico. This was part of the collaboration we did
with ONC, which looked at information security and privacy
policies and actually----
Mrs. Christensen. The territories are eligible and can
apply competitively?
Dr. Clancy. Yes. Yes.
Mrs. Christensen. With regard to community health centers,
how many community health centers do we have in the country?
Ms. Austein Casnoff. I believe there are over 1,000.
Mrs. Christensen. Was that ``18'' number for community
health centers that have gotten grants? Are those all that have
gotten--I can go back to your testimony, Dr. Casnoff: Eighteen
health centers were awarded high-impact EHR grants in 2007.
My question really is, since these are so central to the
delivery of health care in underserved communities, is there a
long-term plan to have all of them hooked up to HIT, all of
them electronically, to have all of their medical activities
electronic?
Ms. Austein Casnoff. Well, we are still exploring how to
get to complete coverage for all of the health centers.
Obviously, they need to be part of the broader movement toward
electronic records.
What we are doing is, in a sense, we are seeding; we are
demonstrating; we are getting started and are helping each of
our networks' grantees move to more and more health centers. So
we are continuing to expand the number of health centers that
are getting HIT support, and we believe very strongly they need
to do it together and not necessarily as individual health
centers. So we think they can learn from each other, benefit,
reduce the risk of purchasing. Each of our grants requires
these networks to take on new health centers and not continue
to fund the same ones, so we are moving in that direction.
Mrs. Christensen. As the different agencies under Health
and Human Services collaborate, do you try to make sure that--
because HRSA has grants and Dr. Clancy's agency has grants and
there are other grants in the department, do you try to
coordinate so that they are fairly spread across the country,
so that one State isn't getting one from the agency for health
care quality and research grants and also getting yours? Are
you spreading it around in your collaboration?
Dr. Kolodner. Many of the grants and contracts are a
competitive process; and so, depending on whether it's a
contract or a grant, we may be actually locked into what the
ranking of the applicant is. But we do, in fact, sit down and
look at where those different activities are occurring so that
we can get as broad a spectrum as possible.
Mrs. Christensen. Well, our communities don't necessarily
have a lot of grant-writing expertise. I wonder how you
accommodate for communities that have high need but don't
really get the high grades on the grant applications.
Ms. Austein Casnoff. That was a very large priority of Dr.
Duke's, the Administrator of HRSA, which was to make sure those
communities that, in a sense, were left behind in the grant
process received grants. So there was a whole special
competition this year for those areas that have never received
a health center grant before, and we also work very closely--we
have something called ``planning grants,'' because we heard
from the communities that not everybody was ready to move into
a more sophisticated HIT, so we actually did a special
competition of relatively small grants to get people started.
We certainly recognize that not everyone is at the same point.
Mrs. Christensen. Dr. Kolodner, you said in your testimony
that the agency has taken specific steps to include medically
underserved populations as you transition to the AHIC
successor. Could you tell us something about the steps that
you've been taking?
Dr. Kolodner. OK. That's what I mentioned a little bit
earlier.
The process that we're doing right now is--we actually put
out a cooperative agreement type of grant. The applicants sent
in their applications by the end of September, and we are in
the process of selecting, but the messaging that we sent out to
anybody who was considering that application was, as I
mentioned, the need to take into account and to include a broad
spectrum of consumers, including those who are from the
vulnerable populations.
In addition, because it's a cooperative agreement, we will
be working with the awardee to make sure that they, in fact,
have at the table, as part of the participating group, members
from a variety of rural, underserved and medically vulnerable
populations.
Mrs. Christensen. Go ahead.
Ms. Austein Casnoff. I was just going to add that any time
there is a public notice as Dr. Kolodner is referring to, we
get that out specifically to our HRSA grantees to make sure
that they're aware of these public comment opportunities and to
offer them the opportunity to make sure that they do respond.
Dr. Clancy. One other point. I'm sorry. When you were
asking about how we try to create a coherent portfolio and to
make sure that we're reaching out, one of the ways that we do
that--as a matter of fiscal responsibility, there are very
specific checks and balances--for example, to make sure that
we're not funding the same person in four different agencies to
do the same work. In addition to that, you heard Cheryl say
that she served as a reviewer for our grants. We also use set-
aside mechanisms.
So, this year, in a portfolio of $21 million of grants that
we were going to make, we said we are going to set aside a few
million dollars. Actually, we ended up investing more in
underserved communities. We had about twice as much as we had
set aside, which I thought was actually a very good sign. So
there is a fair amount of outreach. I think we could do more,
but we are working very hard.
Mrs. Christensen. Just as I'm going through--I'll hold on
any other questions I might have for right now.
I wanted to just point out that some of you are familiar
with the minority AIDS initiative and the fact that when funds
were to be targeted to indigenous communities and faith-based
groups, a lot of other groups came in and started to change the
board around. They hired a new executive director and presented
themselves as minority organizations.
So as you reach out to make sure that minorities are
sitting at the table, I just want to make sure that you're
aware of that and that you try to get organizations or groups
that are really from the community.
Mr. Towns. Thank you very much.
Congressman Clay.
Mr. Clay. Thank you, Mr. Chairman.
Let me start off with some questions for the entire panel.
Is there any consideration given to reducing health
disparities in either your grant deliverables or your grant
strategy? And this is along the same line of questioning as Dr.
Christensen. In other words, what health-policy objectives are
you attempting to meet, in terms of your agencies' overall
goals?
Ms. Austein Casnoff. If I may begin, we actually asked
anyone applying for money this year to have a baseline set of
core quality measures. HRSA's moving toward a consistent set of
measures, and we have built some of those specifically into our
grants. And then we will be monitoring; they will be required
to report on those as well.
So we absolutely are committed to quality measurement,
because, again, HIT is not the end. It's improving the quality
of care in a very quantitative, measurable way.
Mr. Clay. OK.
Dr. Clancy.
Dr. Clancy. Because we have the opportunity, which I would
like to thank you all for, to report annually to all of you on
both quality and disparities in care, what that means is that,
for the first time in this country, we actually have a
consistent set of metrics, and we can report our progress in
terms of how we are doing.
And for each group, in some areas we are doing better, in
other areas we're about the same, and in some areas we're doing
worse. We use that very specifically to frame a lot of
priorities for our initiatives.
So, by way of example, our recent disparities report found
some pretty glaring problems for Hispanic elders. So that has
resulted in a collaboration with the Administration on Aging
specifically targeting preventative services for Hispanic
elders, because the rates were so strikingly different.
So we've got the framework to be able to do that, and my
colleagues will tell you that we're not shy about sharing these
results.
Mr. Clay. Very good.
Anything to add, Doctor?
Dr. Kolodner. Well, the activity of our office is actually
fairly small, in terms of the grant. It's really trying to get
the infrastructure in place. But, as I've mentioned, it is
important that we make sure that infrastructure be informed by
the needs of all of the communities. And we have done the very
best that we know how to get that input and to make sure that
those communities are involved. We will continue to work in
that direction.
Mr. Clay. Thank you for that.
Another panel-wide question: The implementation of health
IT can be expensive, in terms of large-scale enterprise-type
solutions. Have you looked into smaller-scale technologies like
smart cards, cellular phones, to interconnect community health
facilities?
Ms. Austein Casnoff. One of the things we heard from our
community, again, when we put out a Federal Register notice,
was it was not just about electronic health records, as you
say, so we created something called the innovations grant. And
we had, in a sense, low-hanging fruit and heavy lifting. And it
was just as you said, for our health centers serving the
populations in need, what best serves their needs?
And you will hear on the next panel from one of the
recipients of that, about how personal health records or kiosks
or e-prescribing or linking oral health or mental health to
medical records. So it is not always the biggest solution.
Sometimes it is those intermediate solutions or building on
something that is already in place.
So that's absolutely a priority for our awards.
Dr. Clancy. I mean, I'm sure you're aware that in the
health care industry, generally, there is a lot of innovation
going on, in terms of using cell phones and other technologies
to reach people for disease management and other interventions.
We have funded a fair amount of work in this area.
In addition to that, we now have a clearinghouse where
people can share these innovations. And we are reaching out
very broadly so that people know about this, so they know about
potential promising practices that will help them.
So it is not the full enterprise solution or paper, you
know, that there is steps on the way.
Mr. Clay. Doctor.
Dr. Kolodner. Well, the idea of having standards is that it
actually breaks you free of a particular technology solution so
that, really, innovation can occur. And by making sure that the
standards are there and not proprietary but are really open, I
think it fosters a tremendous amount of creativity and movement
forward for just the type of opportunities you are talking
about.
Mr. Clay. Thank you.
Mr. Chairman, is the clock malfunctioning? That 5 minutes
went awfully quick. Oh, it's 3 minutes. I'm sorry.
Mr. Towns. Yes, yes, but if you need another half a minute,
I'd be delighted to give it to you.
Mr. Clay. Thank you. I'm touched.
Just real quickly from all of you, are you using small or
disadvantaged business vendors to supply your grantees with any
technological capability?
Ms. Austein Casnoff. Well, we award grants to our health-
center networks, and then they have to follow proper procedures
to do competitive purchasing. We do not get involved at all in
their selection of products. But they do have to follow
Government rules in terms of competitive purchasing.
Mr. Clay. But you do monitor who they award the contracts
to?
Ms. Austein Casnoff. Correct.
Mr. Clay. And do you know if they use small or
disadvantaged-owned business?
Ms. Austein Casnoff. I am not aware of that, but we can
certainly get that information for you.
Mr. Clay. Would you provide this committee with that,
please?
Ms. Austein Casnoff. Sure. OK.
Mr. Clay. Thank you. I yield back.
Mr. Towns. Yeah, on that note, let me just say that--do
other agencies outside of HHS have health IT grants?
Dr. Kolodner. I think the grants to the communities--USDA
has some grants. I don't know that their communities--they do
have grants for electronic health records. FCC has some things;
in fact, they have a grant program that I think they will be
announcing the results of shortly, that are medical broadband
connectivity to rural and underserved areas. And that is not
just rural, but also inner-cities.
There are others that do have related technologies but not
usually for the kinds of health IT that HHS entities fund.
Mr. Towns. All right. How can we get a list of these
grants? Is there any way that we can--I will definitely be
delighted to hold the record open to get it--a list of all of
these grants, because I think the question raised by my
colleague from Missouri, in reference to minority vendors, you
know, I think that is something that we need to really look
into.
Dr. Kolodner. I think we have a partial list. I can go see
whether we can refresh that and get that back to you.
Mr. Towns. I appreciate that. Thank you so much.
Any other questions?
Let me thank all three of you for your testimony. I really
feel that this is a very important issue. I think that this is
a way that we can address some of the concerns that are out
there. And I appreciate your honesty and the fact that there is
a disparity in a major kind of way, and we feel that through
this process, maybe we can correct some of these things. But in
order to do it, you will have to be flexible and to make
certain that the areas that are not served are served. And I
think that's key. You know, we don't want to leave them out
again.
So thank you so much for coming. I look forward to working
with you in the days and months ahead.
And you will hear more about this empowerment zone. You
know, we think that has a lot of potential; we think that will
help us with the disparities. And, of course, we will be
working on it.
And I want to thank Dr. Christensen for her efforts in this
area. I want to thank Congressman Clay and my colleague,
Congressman Bilbray.
And I say about this committee, you know, in the Congress,
we have a lot of people that do not work together and do not
work in a bipartisan way. But I tell you now, this committee is
a bipartisan committee, and we work together.
Thank you so much.
Mr. Bilbray. Because we fear the chairman; that's why.
[Laughter.]
Mr. Towns. Thank you so much.
[Witnesses sworn.]
Mr. Towns. Let the record reflect that all five have
answered in the affirmative.
So I want to start with you, Ms. Marchibroda, and then sort
of just move right down the line.
STATEMENTS OF JANET M. MARCHIBRODA, CEO, EHEALTH INITIATIVE;
DR. WINSTON PRICE, CHAIR, HEALTH IT AND TRANSPARENCY ADVISORY
BOARD, STATE OF GEORGIA; LORI EVANS, DEPUTY COMMISSIONER FOR
HEALTH IT TRANSFORMATION, STATE OF NEW YORK; DR. FARZAD
MOSTASHARI, ASSISTANT COMMISSIONER, DEPARTMENT OF HEALTH AND
MENTAL HYGIENE, CITY OF NEW YORK; AND DR. NEIL CALMAN,
PRESIDENT, INSTITUTE FOR URBAN FAMILY HEALTH
STATEMENT OF JANET MARCHIBRODA
Ms. Marchibroda. Good afternoon, Chairman Towns, Ranking
Member Bilbray, honorable subcommittee members, Dr.
Christensen, distinguished panelists and guests.
My name is Janet Marchibroda, and I am the chief executive
officer of the eHealth Initiative. It is an honor to offer my
testimony before you today on Federal, State and local efforts
to transform health and health care using health information
technology.
Chairman Towns, I greatly appreciate your invitation to
address this subcommittee, and I commend you for your
leadership in furthering the use of health IT to improve health
outcomes, enhance access to care for medically underserved
communities, and reduce health disparities. We at the eHealth
Initiative look forward to working with you and the Health IT
Empowerment Caucus.
The eHealth Initiative [eHI], is a nonprofit independent
organization whose mission is to improve the quality, safety
and efficiency of health care using information and information
technology. We are a diverse group representing every sector of
health care, both nationally and locally. We serve as a key
bridge between national policy and local initiatives through
our work in States and communities, and actually helped 20
States in our country develop road maps for using health IT and
are working with a number of regions to drive sustainability of
health information exchange.
As my written testimony indicates, concerns about quality,
safety and disparities in care and rising health care costs
have driven the Federal Government and national and local
leaders alike to look for solutions to these challenges.
Because of the highly fragmented nature of our health care
system, clinicians often don't have the information they need
to better serve patients, those that are responsible for
population health also don't have that information, and then,
most importantly, patients can't easily engage in their own
health and health care, view their own health records or choose
to share their health information across clinicians who treat
them.
And so, a lot is going on at the Federal level--that is in
my written testimony--as well as the State level, and it's very
interesting. A number of States are now moving forward with
great vigor around moving the health IT agenda. While there was
no legislation prior to 2005, actually in 2005 and 2006, 38
States introduced 121 bills related to health IT, and 36 were
passed in half of our country's States.
Since January 1 of this year, 217 bills have been
introduced across all 50 States in the United States related to
health IT, and also Governors are playing a significant role,
with 20 Executive orders having been issued.
In addition, if we go one more level down, there are a
number of community-based initiatives--and we counted 165 back
in 2006--that are bringing multiple stakeholders together to
mobilize data to improve health care quality and safety.
But, despite all of this activity, adoption has been slow
for a number of reasons. There is a lack of standards adoption
that would enable interoperability. There is a misalignment of
incentives that often drives volume and fragmentation as
opposed to sharing information. There are some concerns about
privacy and confidentiality, and not to mention the significant
workflow issues within the small physician practice.
We put together, working with 200 organizations from every
sector of health care, the ``eHealth Initiative Blueprint:
Building Consensus for Common Action,'' which is a shared
vision and a set of common principles, strategies and actions
for improving health through information technology.
We were able to achieve consensus on a number of issues,
but there were two areas where more work, more dialog is
needed. We got to consensus on principles, but in the areas
around policies for information-sharing, and specifically
financing, more work is needed, and a public-private sector
dialog and partnership will be needed in order to move that
work forward.
You asked us, top-down or bottom-up? Are there too many
cooks in the kitchen? And which approach will work best? We
believe that leadership needs to come from both but needs to be
coordinated.
Clearly, a need for Federal leadership for moving this
agenda, particularly around adopting standards for
interoperability, getting harmonization in adopting, providing
guidance on policies related to information-sharing, and then,
of course, stimulating the private-sector investment by
providing necessary seed funding and aligning incentives.
At the same time, much work is also needed at the State and
local level, and we are actually not going to get there just
with the top-down approach. And I will be very brief, as we
watch the time.
We did some research, and we released it back in June 2007.
And what did it tell us? It said there are no incentives for
sharing information, or actually disincentives across the
country for doctors and hospitals and plans to share
information, given our current payment system. So those that
have been successful have been able to do so because they've
built social capital, a radius of trust among folks that don't
ordinarily work together, in order to move that forward. And
you've got to do that locally, where health care is delivered.
And you really need it in order to address those difficult
policies for information-sharing. How do we address the privacy
issues?
The other thing is just logistical. If you look, and our
survey shows, that the clinical data that you need to exchange
to deliver health care, most of it, a lot of it, resides
locally, within the doctor's office, within the hospital,
within local pharmacies. So, as a result, the Nationwide Health
Information Network will need to be built from the ground up,
but also linked with national networks, because there are many
actors working at the national level.
So, in closing, some suggested actions for national and
Federal leadership.
First thing, we need to drive standards adoption. We need
to harmonize and drive adoption for interoperability. And this
is critical. The Federal Government has made significant
progress in the area of standards so far. We believe that the
transition of the AHIC over the next several months will
support the continuation of this work.
We believe that this transition, however, will require an
independent convener that engages every sector of health care
in an inclusive, transparent and balanced process that is
designed to listen, engage, synthesize and deliver a common
path forward.
Second, the Federal Government should continue to lead and
expand upon its efforts to develop a framework for privacy and
security, leveraging things like the HISPC as well as the FACA
committee under AHIC 1.0. We need to focus on aligning
incentives, of course, and that is a complicated problem that
we'll need to address, and a public-private sector dialog is
needed.
But we think, in addition, much progress can be made today
through a public-private partnership that can provide guidance
on and stimulate shared action for how the field might move
forward on some short-term actions or business cases for the
use of information, whether it is around quality, drug safety
or consumer access for information.
The Federal Government is playing a leadership role in
addressing disparities, but opportunities exist for more
leadership in this area. Health IT offers great promise for
helping clinicians deliver equitable care through evidence-
based decision support, chronic care management tools and
population health functions.
But targeted resources must be provided to those clinicians
who serve minority and other underserved communities to ensure
they are not left behind in the drive to accelerate health IT
adoption. The Federal Government can play a strong role in
ensuring that the providers have the resources they need,
whether it's grants, loans or hands-on help, to support this
process.
In addition, the Federal Government----
Mr. Towns. If you could sum up. Yeah, the lighting is not
working.
Ms. Marchibroda. OK. Should I stop?
Mr. Towns. Sum up. Just sum up.
Ms. Marchibroda. OK, I'll sum up.
So around the areas of disparities, there are a number of
areas that need more Federal involvement in order to move this
work forward.
Finally, and we heard earlier, providing technical
assistance is very important and particularly States and
communities, as you deal with sustainability, we need to focus
on that area.
Thank you for the opportunity, and I look forward to
answering any questions you may have.
[The prepared statement of Ms. Marchibroda follows:]
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M. Towns. Thank you very much.
Dr. Price.
STATEMENT OF WINSTON PRICE
Dr. Price. Thank you very much, and I hope you're using the
same hearing timing technology.
Mr. Chairman, members of this committee, Members of the
House of Representatives, ladies and gentlemen, good afternoon.
I am Dr. Winston Price, a board-certified pediatrician
working both in New York and Georgia. I am also a past
president of the National Medical Association and the current
chair of the Georgia Health Information Technology and
Transparency Board. On behalf of the NMA and the Georgia HIT
Board, I would like to thank you for the privilege of
testifying before you at this time on this vital subject.
Mr. Towns and your staff deserves special mention in light
of your role in the preparation of this important hearing.
Throughout the 112-year history of the National Medical
Association, we have been a leading voice in the struggle
toward eliminating health disparities that affect not only our
members but also the millions of minority patients that we
serve. As we embrace the innovations of the 21st century, we
remain committed to the notion that all Americans should have
access to health care of the highest quality. It is in this
context that I have framed my remarks.
As the Nation addresses this subject, we must ask
ourselves, are vulnerable populations at the crossroads of a
health care evolution, or are they in someone's cross-hairs
during a health care revolution?
I think we can all agree that health care has evolved. The
United States leads the world in health care innovation, as
noted, for example, by the many Nobel Prizes Americans continue
to win in medicine. The whole world seems to want to come to
American hospitals, especially our teaching hospitals, for
cutting-edge treatments and cures. Our pharmacy industry is the
world's most innovative and profitable.
But be that as it may, our health outcomes do not speak to
that same degree of advantages. Unfortunately--and you've heard
from the honorable Dr. Christensen, so I won't belabor that
issue again--but America's vulnerable populations do not
display the same high quality that we see in terms of the
innovations that bespeak our health care system.
So is it a revolution? Well, many of us are now convinced
that America's health care is in need of a revolution. If
health care innovators are the leading revolutionaries, then
the concerns of the Nation's underserved populations must be
their vox populi that informs their manifesto.
Our strategy for ensuring that this revolution efficiently
addresses the needs of all Americans is that we must understand
the heavy weight as impacted by each of the following five
factors and I will be very brief with those.
Standards: And you heard the description about the
importance of standards in moving this health care HIT agenda
forward.
Electronic health records: And you will hear from the other
members of this panel, so I won't go into detail about that.
But let me emphasize the fact that electronic health records is
a key component of this HIT initiative. We have lessons learned
from Katrina, but I want you to not lose sight of the more than
a half-million children in foster care who suffer from a
perennial Katrina every day. These unfortunate individuals,
similarly like the individuals in Katrina, are separated from
their family historians who could fill in the health care
history gaps and they, many of them, received fragmented,
episodic and oftentimes substandard care without the benefit of
available and continuous medical record.
Let me delve into pay-for-performance, very briefly, as the
third category. Now, many facets of determining the return on
investment for HIT is centering around the fact that it's going
to improve the quality of health care for Americans. But I must
impress upon you the fact that these initiatives, while well-
intended under the guise of improving quality, aim many times
to position themselves in such a way to redefine methodologies
for physician reimbursement. We must ask ourselves, how will
pay-for-performance affect physicians' practice patterns as
they relate to sicker minority groups? And given the sicker
caseload of minority physicians, how will pay-for-performance
affect the viability of these physicians?
Now, we certainly believe that health disparity speaks for
itself, but we know that the main reason for minority
physicians not getting involved with health information
technology is the fact of funding. Indeed, the Medical Records
Institute's survey in 2006, reported that the top two reasons
for not engaging in health information technology was lack of
adequate funding and lack of support by the medical staff.
Process and outcomes is certainly important, as well.
And because time is up, I'm going to summarize in the last
30 seconds that we have between Brooklyn folks.
And that is, in Georgia, where I chair the Health
Information Technology Transparency Board, we recognize the
importance of addressing a number of the issues that we talked
about earlier. We have instituted a $1 million demonstration
pilot project that we targeted specifically to rural
communities and some of the issues that you raised earlier, in
terms of making sure that minority vendors are involved in the
engagement in those particular grants, are things that we look
at very consciously.
And, recently, we were awarded a $3.9 million grant from
CMS to look at the development of a transparency Web site. A
transparency Web site to bring the quality and cost to the
consumer are two of the cornerstones of Secretary Leavitt's
initiatives to make sure we move that health care agenda.
So I'm just going to tell you the broad categories. I
promise I'm only going to read the categories of the AMA
recommendations to move this forward: bridge the digital
divide; amend the charter of the American Health Information
Community to make sure that there is adequate representation by
the minority community; create HIT empowerment zones, something
that you've been discussing already; implement a Medicare and
Medicaid demonstration project to identify payment
methodologies that encourage participation and make sure the
underserved communities are part of the mix; and, last, to
coordinate the Federal data-collection process.
Mr. Chair, I want to thank you for the opportunity to speak
with you on this particularly important topic and we stand
ready, at the National Medical Association, to assist you in
your movement forward. And I commend you on the selection of
your committee members.
Thank you.
[The prepared statement of Dr. Price follows:]
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Mr. Towns. Thank you very much, Dr. Price.
Ms. Evans.
STATEMENT OF LORI EVANS
Ms. Evans. Good afternoon, Mr. Chairman, Ranking Member
Bilbray, Dr. Christensen. Thank you very much for inviting me
here today.
My name is Lori Evans. I am deputy commissioner at the New
York State Department of Health, responsible for our new Office
of Health Information Technology Transformation. I also had the
fortune of helping launch the first national health IT office
with Dr. David Braylor, so I am especially excited about the
topic of the hearing today.
And I'm also thrilled to have two co-cooks with me, Doctors
Mostashari and Calman, who you will be hearing from as well.
In New York, we are currently investing approximately $150
million in health information technology to support our
progress in improving health care quality, affordability and
outcomes for all New Yorkers.
The most important aspects of health IT is not software and
computers; it is clinicians being able to make better treatment
decisions and coordinating care more effectively. It's about
nurses and pharmacists delivering safer therapies, and
consumers and patients making better choices from different
health care options. It's the way people connect together
across a fragmented delivery system, from community health
centers to physician offices, hospitals to skilled nursing
facilities, and even to the consumer's home. It's the way
information is retrieved and used to realize value from health
information technology.
Reforming our health care system will require many things,
which are under way in New York such as universal coverage,
such as long-term care and hospital restructuring and many
other things and it must also include vastly improved
availability in use of health information. Our success in New
York and our success across the country will be defined by
whether or not we use information to improve patient care and
to reduce health care costs and to support different ways of
paying for health care in different models of delivering care,
especially in our most underserved areas.
In my written testimony, I provided a high level of
discussion of our approach in New York related to the funds
that we have the good fortune of spending. And there are really
three foundations that we are trying to realize in New York,
that we are trying to set in New York. And one is the
technical, one the clinical, and one is organizational.
And the technical foundation is about enabling the
technical interoperability and transformation of today's
largely paper-based system to an electronic interconnected
system and being able to measure and report on quality in
population health information.
The clinical foundation is about clinical adoption to
attract the sufficient demands for health IT from clinicians
and the supply of it from the industry. So we ensure that the
health IT tools increase the likelihood of success and are able
to deliver value to those that are using them and to result in
patient care improvements.
And the organizational foundation is also crucial. It's
about governance and public trust and how health care
clinicians can use health information technology to succeed in
patient care improvements, and for them to know that there
their issues will be resolved in a reasonable way.
The successful adoption of health information technology
must emerge from these three intertwined capabilities. For
example, interoperability is as much a function of trust as
technology or clinical participation, and it is achieved
through policy and governance.
Regional health information organizations become very
important in this context. RHIOs working with other RHIOs, the
Government and others, are about creating this collaborative,
multi-stakeholder environment that assures effective
interoperability and quality in population health improvement.
Another critical component of the organizational foundation
is an organization called the New York eHealth Collaborative.
That is a public-private statewide partnership in New York that
is helping to drive a lot of our work there.
Turning to the role of health information technology in
improving health outcomes and decreasing health disparities, I
think this agenda really starts with access to care. But I
think this is also where access to insurance and access to
information go hand-in-glove, because simply having health
insurance is no guarantee that there will be access to the
right high-quality care at the right time by the right
clinician.
This requires a health care system that is restructured to
create a patient-centered model that emphasizes primary and
preventive care. In New York, we believe these reforms start
with the Medicaid program. This requires changing our
reimbursement system from a system that rewards volumes of
services to a system that recognizes quality and improved
outcomes and encourages the delivery of preventive care.
Creating this quality-based or outcomes-based reimbursement
system will require the widespread adoption of health
information technology, and that is the foundation that we are
trying to lay through our grant program.
Integrating prevention and quality measurement enabled by
health information technology offers tremendous potential in
addressing and eliminating health disparities caused by a lack
of prevention and access to the most effective health
interventions.
Regarding the interplay of Federal and State government--
and I wish our Federal colleagues were still here--I think the
interplay is crucial to advance the socially optimal level and
type of health information technology adoption we need in New
York and across the United States. We don't have too many
cooks. We have too few cooks. We need a solidification in
funding of a coordinated structure and process comprised of
Federal and State leadership, as well as the health care
community. And I think the three panelists from New York today
really symbolize that quite nicely.
Mr. Towns. Could you sum up?
Ms. Evans. Sum up.
In the Congress, you know, we think that the lack of
funding has been significant. And to just have as bit of fun
with the analogy today, I think we have been served a small
plate of lima beans. We need many cooks contributing to a well-
defined meal plan with all food groups and proper nutritional
levels. This, with the proper funding, will lead to a feast of
health information that will feed the Nation's health reform
efforts.
Thank you.
[The prepared statement of Ms. Evans follows:]
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Mr. Towns. That is why we are having this hearing, trying
to get you a balanced diet.
Ms. Evans. Thank you.
Mr. Towns. Dr. Mostashari.
STATEMENT OF FARZAD MOSTASHARI
Dr. Mostashari. Good afternoon, Chairman Towns and Ranking
Member Bilbray. I am Dr. Farzad Mostashari. I am assistant
commissioner in charge of the Primary Care Information Project
at the New York City Department of Health and Mental Hygiene.
We heard that our current health care system does not
deliver health efficacy, efficiency or equity. Our system is
rife with redundant, unnecessary and sometimes harmful
interventions, while evidence-based, life-preserving measures
are delivered only about half the time. Health disparities are
not addressed, or even exacerbated by unequal delivery of
services.
We, at all levels of government, as purchasers of health
care and as guardians of the health and safety of the public,
now have a responsibility and an opportunity to create a new
landscape for health care.
Extension of electronic health records and establishment of
policy and standards for health information exchange are
critical building blocks, but they are not sufficient. A recent
study in the Archives of Medicine found that patient encounters
conducted with electronic medical records, as currently
designed and implemented, had the same low quality of chronic
disease management and preventive care as those conducted with
paper records.
This may seem paradoxical but should not come as a
surprise. Consumers, purchasers and payers do not have the
information needed to recognize and incentivize providers who
deliver better prevention. So our reimbursement system rewards
providers who deliver more services, not prevention. It
therefore follows that the health care IT market and physician
office workflows are also not oriented toward prevention in
chronic disease management.
In order to break this logjam, we need to simultaneously
support a restructuring of health IT, office workflows and
reimbursement systems. Once established, these new structures
will be mutually reinforcing, and market forces can finally be
aligned to deliver improved health and value.
We believe that we have created a local model for this
transforation through the New York City Primary Care
Information Project. Anchored by a city commitment of $27
million and approximately 40 staff members, we are implementing
electronic health records for over half of all high-volume
Medicaid providers in the city; establishing standards-based
data transmission between practices in laboratories,
pharmacies, health plans and hospitals; integrating prevention
into EHR software and practice workflows and enabling pay-for-
prevention. Let me briefly describe each of these
interdependent pieces.
We are assisting more than 1,500 New York City primary care
providers to adopt prevention-oriented EHR systems over the
next 2 years. This includes all 29 of the city's federally
qualified health center networks. This group alone comprises
648 providers and half a million patients, 50 percent of whom
are on Medicaid and 20 percent of whom are uninsured.
We are also focusing on Medicaid providers among solo and
small practices, which provide most of the primary care in this
country but don't have the financial, technical and quality-
improvement resources of larger practices and the lowest rates
of EHR adoption.
Bringing interoperability and health information exchange
to this community of safety-net providers has required a great
deal of effort on our part. As the Institute of Medicine's
recent report describes, the absence of a strategic plan and
the lack of clear decisionmaking processes have hindered
national progress on interoperability. They also suggest
process and a commitment to evaluation and updating of
standards based on experience in the field.
In our experience in the field, these Federal efforts have
had a measurable impact in some areas, but well-established and
agreed-upon standards are still not widely implemented. The
absence of policy guidance has resulted in slow standards
developments in some priority areas and the risk of overly
hasty standards-setting in other areas, including quality
reporting in biosurveillance.
The impact of the planned transformation of the American
health information community is unknown, but in our opinion, it
is unlikely that an industry-led entity will be able to provide
the credible policy leadership to this process, as has been
done in New York through the work of the State Department of
Health and the New York eHealth Collaborative.
The policy leadership requirement extends to EHR
functionality as well as interoperability. Several features
critical for improving prevention are not consistently or
effectively implemented in products meeting Certification
Commission for Health Information Technology's standards. These
include structured data collection for a minimal set of
required clinical items, like smoking status; registry tools
for examining entire patient panels and generating lists of
patients for recall or anticipatory care; automated clinical
quality measurement, including the ability to view and analyze
health disparities in every measure; and real-time, bilateral
connections to the public health system for immunization and
disease reporting.
Unfortunately, practices are also not structured to
effectively deliver or monitor preventive care. As part of our
community initiative, we are working with safety-net providers
to maximize the productivity of support staff, the completeness
of necessary documentation, improve patient satisfaction. In
some cases, we need to design new workflows.
We believe that interoperable EHRs with registry functions
implemented by practices that focus on quality of care can
finally produce reliable metrics of actual clinical outcomes.
And this platform can be the basis for pilot physician
recognition and paper-prevention incentive programs.
In conclusion, although I would like to gratefully
acknowledge the support we have received from CDC and ARC for
research and evaluation, New York City's Primary Care
Information Project is an example of a community-led project
with local innovation and resources.
Healing our health care system using interoperable health
information technology will require the resources and energy of
all of us at the Federal, State and local levels. There is a
need for a common policy framework at the national level, but
we cannot afford overly prescriptive or premature policies or
standards that would thwart State and local innovation and
stifle local investments.
We, and other communities like ours, could realize a great
public benefit from Federal legislation that provided funding
and a comprehensive policy framework for EHR extension, health
information exchange, and quality-based recognition incentive
programs if such legislation included an explicit and pervasive
emphasis on prevention, a concern for disadvantaged
communities, support for community-based projects as the action
arm for these activities, and a commitment to fund and support
the rigorous evaluation and optimization of these initiatives.
Thank you for the opportunity to testify. I'll be happy to
answer questions.
[The prepared statement of Dr. Mostashari follows:]
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Mr. Towns. Thank you very much.
Dr. Calman.
STATEMENT OF NEIL S. CALMAN
Dr. Calman. Chairman Towns, thank you for inviting me to
provide testimony on this very critical issue of health
information technology and health information exchange. I am
going to focus my remarks very specifically on issues related
to the care of those who are traditionally underserved by our
current health care system: the poor, the uninsured, the
homeless, new immigrants, people of color, folks whose primary
language is other than English, those who are covered by
Medicaid, in many cases, and other vulnerable groups.
I am a family physician still practicing in the Bronx and
Manhattan for the past 31 years. I am also president and
cofounder of the Institute for Family Health. We are a Reach
community; we are a federally qualified health center. We
operate 29 practices in New York City and up in the mid Hudson
Valley. We were founded in 1983 with the specific goal of
serving the underserved.
We serve 75,000 patients at our sites; 67 percent are black
or Hispanic; 12 percent are uninsured; 40 percent receive
Medicaid; 65 percent are below 200 percent of the Federal
policy level; and 18 percent require services in a language
other than English.
In 2006, we had a thousand patients served who were
homeless and more than 600 with HIV/AIDS.
The institute is similar to over a thousand other community
health centers in this country. What is different about us is
that, in 2002, we made the investment to become one of the
first community health center networks to implement a fully
integrated electronic medical record and practice management
system throughout our entire network.
This has allowed us to enhance our services, significantly
improving patient care through improved record keeping,
tracking systems, alerts to providers at the point of care,
visit summaries, which we give to our patients after each
visit, and a vast library of health educational material that
are available in multiple languages.
The motivation for this project, interestingly, came out of
our work with REACH and our work with over 40 diverse
organizations including 20 faith-based organizations whom we
work with to try to eliminate racial disparities in diabetes
and cardiovascular disease. We were recently named a National
Center of Excellence in Health Disparities.
I want to give you four very specific examples of how
health information technology works in this safety net.
First of all, alerts to providers, to our providers
reminding them to give pneumonia vaccine to patients over 65
brought the number of vaccine dosages that we give a month from
23 to 395 a month.
An alert which asks nurses to ask a two question depression
screening questionnaire brought our rate of depression
screening from 4 percent to over 90 percent within 4 months of
implementing this technology.
Talking about recall systems, there was a recent study
which showed that 7 percent of all people taking a blood
pressure medicine called ace inhibitors, if they take it in the
first trimester of pregnancy, will give birth to a baby with
severe cardiac or respiratory birth defects. Within a day of
the study being released, we identified 225 people in our
practice who were taking this medication, women of child
bearing age, and reached out to every single one of them to
warn them that if they were going to become pregnant, that they
needed to stop the medication.
These kinds of activities were completely unable to be done
before the implementation of health information technology.
We also provide data to the New York City Department of
Health and Mental Hygiene every day on the symptoms and
findings in our patients in the city.
This resulted in putting our information into their
syndromic surveillance system of identifying the onset of the
flu epidemic in 2004, 13 days before the data from any of their
other data sources.
There are dozens of other examples of how health
information technology and information exchange in service to
our most vulnerable and needy populations is a worthwhile
investment.
I would like to end with some very specific recommendations
for this as we move forward.
We have to ensure that all legislation and funding that
supports the implementation of electronic health records
targets the patients at highest risk in our society. All of the
developments must have organized ways for community
participation in planning and execution. This is something
that, to date, has been sorely lacking.
We need to make sure that providers in the health care
safety net are included as primary targets for funding.
Two, we need to make sure that in health information
exchange networks that community health centers and other
safety net providers are required to be participants in these
networks and in order to participate in them, they need
electronic health records. So you can't participate in health
information exchange if you don't have the core fundamentals of
electronic health records in your system.
Three, we need to fund the integration of electronic health
records into systems like those run by the city department of
health so that we become part of a monitoring system that
monitors the care of vulnerable populations, and that can only
be done if we aggregate our information and send it to our
local health departments.
Four, we have to mandate that all electronic health record
systems capture data on race, ethnicity, primary language
because otherwise we have no mechanism for determining whether
people being cared for in the big academic medical center in
New York City are being cared for the same irrespective of race
or their insurance coverage.
Five, we have to encourage electronic health record vendors
to find mechanisms to help flag people who are eligible for
clinical trials. Underrepresented--minorities are vastly
underrepresented in clinical trials, and so the data that comes
from those trials turns out to be of very limited usefulness in
treating those populations.
There are only a few more.
Six, we have to require that EHR certification requires
that information that is produced by electronic health records
for patient consumption, such as health education materials,
visit summaries, portals that allow patients internet access,
all have to be made available in multiple languages and in a
fourth grade literacy level.
We have to ensure that all rural areas and all public
housing projects are wired, that all rural areas deploy
broadband technology and that broadband access is provided in
all newly funded public housing, and we need to set a date when
all existing public housing needs to have broadband technology;
otherwise we are not going to have access in those places.
Finally, we have to require input of communities of color
in planning privacy and security requirements. Dr. Price
mentioned this before, but privacy and security mean different
things in communities of color than they mean for the rest of
our society.
There have been enough examples of abuses that people do
not trust when information is shared without adequate
protections.
We have to provide resources for health information
technology in places where the most vulnerable patients are
served in prison, in our foster care agencies, in homeless
health care sites, migrant health care providers. We have to
create a national system for specifically monitoring the impact
of health information technology, and I believe one of you
asked, but every single grant program should be required to
report on the impact of the dollars that are being spent on
disparities in the communities that they serve.
I have provided the subcommittee a complete analysis of
these issues as well as detailed examples of how our institute
has achieved substantial success in some but not all of these
areas. And I make myself available to you as you explore this
issue further to work with the subcommittee or any Members of
Congress who seek to further understand and address the
important issues of health information technology in our most
vulnerable communities.
Thank you.
[The prepared statement of Dr. Calman follows:]
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Mr. Towns. Let me thank all five of you for your
statements. I really, really feel you were very helpful in
terms of sharing.
Let me just move to you, Dr. Price.
Are there any issues that African American doctors may have
adopting this technology, and what can we do to facilitate them
if there are able to be helped? What can we do?
Dr. Price. Well, I think some of those points were raised
by a number of the speakers. Cost is the No. 1 issue in terms
of implementation. I think that many of the programs that you
heard about from the Federal agencies have all of the right
rhetoric and nice touchy-feely sounds about getting into
communities, but physicians are facing decreasing
reimbursement, increasing liability costs, and the expense of
health information technology is just not a priority right now,
even though they recognize the benefits, such as Doctor Calman
explained.
So I think the best things that can be done are similar to
what CMS just announced, getting the systems in as a basic
course of business for doing good medical care and in the
territories as well to make sure the Virgin Islands and Puerto
Rico and Guam are also covered.
Mr. Towns. Let me ask this question. I really should have
dealt with the Federal agencies on this.
This is an area that I am really concerned about.
You know, now we have physicians that are in private
practice and, of course, still single practice and you know,
when they expire, nobody comes into that practice. That is a
thing of the past.
What happens with those records of those doctors that have
been practicing for 40, 45 years, have a room full of records
that are now there? What happens? Because in many instances,
these are people that have had, you know, serious kinds of
operations and all kinds of things, these records are going to
be there and nobody wants to be responsible, you know, for them
in bringing them. So what do we do with a case like that?
Dr. Price. There are technologically possible ways to
integrate that by scanning and digital archiving those records,
but for the most part, those records sit dormant in damp
basements unbeknownst to anyone.
I think as we move forward--I think one of the key issues
is that the health care of the future is going to be improved
as we get more people to enter their data into electronic
health records and also as we improve the issue of personalized
health records so individuals can carry their information with
them.
Mr. Towns. Because in the old days, somebody would come buy
the practice.
Dr. Price. Someone would buy the practice but wouldn't want
to decipher the scribbly notes that are on 3-by-5 index cards.
Mr. Towns. I yield to my colleague.
Ms. Christensen. Thank you, Mr. Towns.
Thank you all for being here.
Dr. Calman, and maybe you said it in your testimony, if you
did, I missed it. Did you have problems getting your patients
in the health center and the community that you are serving to
accept the electronic medical records?
Dr. Calman. Actually, they love it. What we did when we set
it up, we based it on the focus groups that we had done with
our REACH colleagues, and what we found out was that trust was
one of the biggest issues that our community faced. So when we
set it up, we used that as sort of a framework for everything
from how we designed the exam rooms to how we designed the
electronic health records. I'll give you two examples.
We put flat panel monitors in the exam room so the patients
can watch when the doctors are recording the visit on the
screen. They can also look at their health education materials,
diagrams of different health education, things that the doctors
can bring up when they are seeing the patient.
We also created what is called an after-visit summary. So
far only available in English, but we are now working on ways
to see if we can translate it into other languages so that
literally at the end of a visit in our center, we hand a
patient a copy of everything that was written about them that
day, including new lab reports, new X-ray reports and even
though people can't necessarily read this, there is something
incredibly symbolic when you say to the patient, there is
nothing that I have about you, there is nothing that I know
about you that I don't feel comfortable sharing with you.
This was more of a transformation for our providers than it
was for the patients. The patients were anxious to get their
information. The providers were initially reluctant to give it
to them. But now have basically complied.
Ms. Christensen. Thank you. So the concerns we have that
people are going to be afraid for their privacy and everybody
knowing their medical history, you were able to overcome this?
Dr. Calman. We have taken a slightly different approach in
that we believe that before we can share information about
patients in a network, whether it is a national network or a
State-wide network, patients have to have access to that
information themselves. They need to know what is in their
record before we go putting it out on the airwaves, and I think
that is critically important. So that it will be years before
we are all connected, but we have already, for the last 5
years, started to transform that process. And hopefully by this
fall--one of the grants we got from HRSA was a grant to
implement a patient portal into our electronic health records.
So patients will be able to, either through the Internet or
through kiosks in our waiting room, look at their own records
with the help of an assistant who will teach them about that,
and we are looking at that as a way of both bridging their
health literacy issues but also their technology literacy
issues as kind of a double win.
Dr. Price. I know you are familiar with the discrimination
that disproportionately affected African American and Latinos
when health information was inadvertently shared, particularly
in the light of sickle cell disease and early on in the game
with HIV.
I think we are going to need in the medical community to
turn back to the legislature to put some real teeth behind the
inappropriate gathering of health information by hacking into
health systems and sharing or using that information to
discriminate. We don't need that kind of a negative throwback
on some of the innovative projects that are going on, like Dr.
Calman described, but without those teeth, those things will
happen. And they must be dealt with appropriately for our
community to have real trust and not be concerned about
Tuskegee coming back again.
Ms. Christensen. While you're at your mic, Dr. Price, do
you have any ideas, just in MNA membership, how many MNA
physicians are using electronic medical records now?
The USA Today says under 35, 44 percent; 65 and older, 18;
55-64, 18 and the rest somewhere in between that. Do you know--
do we have any idea?
Dr. Price. It is 35 percent of those who are in hospital
based systems. It is probably closer to 10 percent for
individual practitioners and the ones that are using practices.
We are in the process of finalizing a survey that we are
going to do electronically and by fax of our entire membership
to be able to give you those numbers, so hopefully within the
next couple of months.
Ms. Christensen. Do you think that it is possible to do
pay-for-performance across the board without having electronic,
you know, electronic medical records in a fully network system?
Dr. Price. Absolutely not. Not effectively, and it is pay-
for-performing for many of our physicians. We are concerned
about the methodology that is used. As many of you are well
aware, if the right data is not being used to set up the
metrics for pay-for-performance, with a sicker population we
suffer in any of those schemas, in particularly if they use as
a method of reimbursement.
Ms. Christensen. Ms. Evans and Dr. Mostashari, I am sorry
that I had to step out and take a call during part of each of
your testimony. You may have talked about this before. But what
specific outreach was made to ensure that providers in poor--
your poor communities in New York City were able to
participate?
Dr. Mostashari. I am very happy to answer that.
Our target population are Medicaid providers in New York
City. We also--so our first group of outreach was community
health centers, and that was a group of community health
centers, a consortium that we brought together of every single
community health center network in New York City. So that was
the first kind of the backbone of our safety net system that we
worked with.
Then we started looking at the small providers, and we
actually have a program in Harlem, South Bronx and Central
Brooklyn, and we went to every single practice in Harlem, South
Bronx and central Brooklyn, every single one. We visited them,
we talked to them, we developed this brochure that talks about
readiness for adopting electronic health record system,
protecting patient data, the small practice economics, health
information exchange; what does it mean to the practice?
So we actually get more time with the providers than the
pharmaceutical companies do.
And we are also, you know, continuing to put the word out
there to hospital affiliated providers, to the ethnic IPAs and
others to say this is exactly the--if you care for medically
underserved populations, we want to sponsor you to get in the
electronic health record.
And I think an important point I want to add here, I am not
sure if I made that point clearly in my testimony was, you
can't support people getting electronic health records by just
giving them cash. To effectively create a cocoon of services
around EHR adoption and quality improvement, we need boots on
the ground. Mailing a check from Washington isn't going to do
it, and that is what we have built. That is what we found; we
need to have in our community and every community that the
Federal Government wants to see the entire EHR adoption really
happen and really have gains for prevention and gains for
population health, we need that local presence, that community
network.
Ms. Christensen. Thank you.
Mr. Towns. Let me ask you, one question to you, Ms.
Marchibroda.
I'm sure you know that people of color can be less trustful
of the Federal Government and of the Federal agencies and, of
course, technology, too. Since you are one of the primary
health IT collaborators, how do you intend to address these
concerns?
Ms. Marchibroda. Chairman, getting to agreement on policies
for information-sharing is probably one of the most important
things that folks at the State and local levels engage in. What
we tell them and what they're doing--and those who are
successful are having those hard conversations about building
trust and what policies will work for us, whether we're in New
Hampshire or in Oklahoma City or in Los Angeles, around what
rules or policies will we put in place to protect privacy and
confidentiality. What are we comfortable with among us? How do
patients and consumers feel about this?
There are a number of tools out there that are actually
helping State and regional leaders, including one delivered by
Connecting for Health with the Markle Foundation and with
support by the Robert Wood Johnson Foundation that is providing
a toolkit, if you will, for having those tough conversations.
But you can't shortcut it. You can't get to the technical
aspects of this, until you begin to have those tough
conversations about what policies will be put in place to build
trust.
Mr. Towns. Let me thank all of you for your testimony, and,
of course, we really appreciate your sharing with us. And we
are convinced we have a long way to go, no ifs, ands or buts
about it.
Dr. Calman, I am really impressed with what you're doing,
and I know it has not been easy because of the fact that, at
times, the support system has not really been in place or has
been cooperative. But we really realize, in order to really
deal with the health care disparities that this is one thing
that we need to try and fix and try and fix it as soon as
possible.
So you can be assured that we will be working on this side
to try and get the resources out and to try and highlight how
important it is to move forward in this direction. And we'll be
recognizing that there will be problems as we move forward, but
in working together, I am sure we'll be able to solve them.
Thank you again for your testimony.
The subcommittee stands adjourned.
[Whereupon, at 5:15 p.m., the subcommittee was adjourned.]
[Additional information submitted for the hearing record
follows:]
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