[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
                     http://www.oversight.house.gov


                     U.S. GOVERNMENT PRINTING OFFICE
45-627 PDF                 WASHINGTON DC:  2008
---------------------------------------------------------------------
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov  Phone: toll free (866) 512-1800; (202) 512ï¿½091800  
Fax: (202) 512ï¿½092104 Mail: Stop IDCC, Washington, DC 20402ï¿½090001

              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

                              ----------                              
                                                                   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

                              ----------                              


                       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:]

    [GRAPHIC] [TIFF OMITTED] T5627.001
    
    [GRAPHIC] [TIFF OMITTED] T5627.002
    
    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:]

    [GRAPHIC] [TIFF OMITTED] T5627.003
    
    [GRAPHIC] [TIFF OMITTED] T5627.004
    
    [GRAPHIC] [TIFF OMITTED] T5627.005
    
    [GRAPHIC] [TIFF OMITTED] T5627.006
    
    [GRAPHIC] [TIFF OMITTED] T5627.007
    
    [GRAPHIC] [TIFF OMITTED] T5627.008
    
    [GRAPHIC] [TIFF OMITTED] T5627.009
    
    [GRAPHIC] [TIFF OMITTED] T5627.010
    
    [GRAPHIC] [TIFF OMITTED] T5627.011
    
    [GRAPHIC] [TIFF OMITTED] T5627.012
    
    [GRAPHIC] [TIFF OMITTED] T5627.013
    
    [GRAPHIC] [TIFF OMITTED] T5627.014
    
    [GRAPHIC] [TIFF OMITTED] T5627.015
    
    [GRAPHIC] [TIFF OMITTED] T5627.016
    
    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:]

    [GRAPHIC] [TIFF OMITTED] T5627.017
    
    [GRAPHIC] [TIFF OMITTED] T5627.018
    
    [GRAPHIC] [TIFF OMITTED] T5627.019
    
    [GRAPHIC] [TIFF OMITTED] T5627.020
    
    [GRAPHIC] [TIFF OMITTED] T5627.021
    
    [GRAPHIC] [TIFF OMITTED] T5627.022
    
    [GRAPHIC] [TIFF OMITTED] T5627.023
    
    [GRAPHIC] [TIFF OMITTED] T5627.024
    
    [GRAPHIC] [TIFF OMITTED] T5627.025
    
    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:]

    [GRAPHIC] [TIFF OMITTED] T5627.026
    
    [GRAPHIC] [TIFF OMITTED] T5627.027
    
    [GRAPHIC] [TIFF OMITTED] T5627.028
    
    [GRAPHIC] [TIFF OMITTED] T5627.029
    
    [GRAPHIC] [TIFF OMITTED] T5627.030
    
    [GRAPHIC] [TIFF OMITTED] T5627.031
    
    [GRAPHIC] [TIFF OMITTED] T5627.032
    
    [GRAPHIC] [TIFF OMITTED] T5627.033
    
    [GRAPHIC] [TIFF OMITTED] T5627.034
    
    [GRAPHIC] [TIFF OMITTED] T5627.035
    
    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:]

    [GRAPHIC] [TIFF OMITTED] T5627.036
    
    [GRAPHIC] [TIFF OMITTED] T5627.037
    
    [GRAPHIC] [TIFF OMITTED] T5627.038
    
    [GRAPHIC] [TIFF OMITTED] T5627.039
    
    [GRAPHIC] [TIFF OMITTED] T5627.040
    
    [GRAPHIC] [TIFF OMITTED] T5627.041
    
    [GRAPHIC] [TIFF OMITTED] T5627.042
    
    [GRAPHIC] [TIFF OMITTED] T5627.043
    
    [GRAPHIC] [TIFF OMITTED] T5627.044
    
    [GRAPHIC] [TIFF OMITTED] T5627.045
    
    [GRAPHIC] [TIFF OMITTED] T5627.046
    
    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:]

    [GRAPHIC] [TIFF OMITTED] T5627.047
    
    [GRAPHIC] [TIFF OMITTED] T5627.048
    
    [GRAPHIC] [TIFF OMITTED] T5627.049
    
    [GRAPHIC] [TIFF OMITTED] T5627.050
    
    [GRAPHIC] [TIFF OMITTED] T5627.051
    
    [GRAPHIC] [TIFF OMITTED] T5627.052
    
    [GRAPHIC] [TIFF OMITTED] T5627.053
    
    [GRAPHIC] [TIFF OMITTED] T5627.054
    
    [GRAPHIC] [TIFF OMITTED] T5627.055
    
    [GRAPHIC] [TIFF OMITTED] T5627.056
    
    [GRAPHIC] [TIFF OMITTED] T5627.057
    
    [GRAPHIC] [TIFF OMITTED] T5627.058
    
    [GRAPHIC] [TIFF OMITTED] T5627.059
    
    [GRAPHIC] [TIFF OMITTED] T5627.060
    
    [GRAPHIC] [TIFF OMITTED] T5627.061
    
    [GRAPHIC] [TIFF OMITTED] T5627.062
    
    [GRAPHIC] [TIFF OMITTED] T5627.063
    
    [GRAPHIC] [TIFF OMITTED] T5627.064
    
    [GRAPHIC] [TIFF OMITTED] T5627.065
    
    [GRAPHIC] [TIFF OMITTED] T5627.066
    
    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:]

    [GRAPHIC] [TIFF OMITTED] T5627.067
    
    [GRAPHIC] [TIFF OMITTED] T5627.068
    
    [GRAPHIC] [TIFF OMITTED] T5627.069
    
    [GRAPHIC] [TIFF OMITTED] T5627.070
    
    [GRAPHIC] [TIFF OMITTED] T5627.071
    
    [GRAPHIC] [TIFF OMITTED] T5627.072
    
    [GRAPHIC] [TIFF OMITTED] T5627.073
    
    [GRAPHIC] [TIFF OMITTED] T5627.074
    
    [GRAPHIC] [TIFF OMITTED] T5627.075
    
    [GRAPHIC] [TIFF OMITTED] T5627.076
    
    [GRAPHIC] [TIFF OMITTED] T5627.077
    
    [GRAPHIC] [TIFF OMITTED] T5627.078
    
    [GRAPHIC] [TIFF OMITTED] T5627.079
    
    [GRAPHIC] [TIFF OMITTED] T5627.080
    
    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:]

    [GRAPHIC] [TIFF OMITTED] T5627.081
    
    [GRAPHIC] [TIFF OMITTED] T5627.082
    
    [GRAPHIC] [TIFF OMITTED] T5627.083
    
    [GRAPHIC] [TIFF OMITTED] T5627.084
    
    [GRAPHIC] [TIFF OMITTED] T5627.085
    
    [GRAPHIC] [TIFF OMITTED] T5627.086
    
    [GRAPHIC] [TIFF OMITTED] T5627.087
    
    [GRAPHIC] [TIFF OMITTED] T5627.088
    
    [GRAPHIC] [TIFF OMITTED] T5627.089
    
    [GRAPHIC] [TIFF OMITTED] T5627.090
    
    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:]

    [GRAPHIC] [TIFF OMITTED] T5627.091
    
    [GRAPHIC] [TIFF OMITTED] T5627.092
    
    [GRAPHIC] [TIFF OMITTED] T5627.093
    
    [GRAPHIC] [TIFF OMITTED] T5627.094
    
    [GRAPHIC] [TIFF OMITTED] T5627.095
    
    [GRAPHIC] [TIFF OMITTED] T5627.096
    
    [GRAPHIC] [TIFF OMITTED] T5627.097
    
    [GRAPHIC] [TIFF OMITTED] T5627.098
    
    [GRAPHIC] [TIFF OMITTED] T5627.099
    
    [GRAPHIC] [TIFF OMITTED] T5627.100
    
    [GRAPHIC] [TIFF OMITTED] T5627.101
    
    [GRAPHIC] [TIFF OMITTED] T5627.102
    
    [GRAPHIC] [TIFF OMITTED] T5627.103
    
    [GRAPHIC] [TIFF OMITTED] T5627.104
    
    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:]

[GRAPHIC] [TIFF OMITTED] T5627.105

[GRAPHIC] [TIFF OMITTED] T5627.106

[GRAPHIC] [TIFF OMITTED] T5627.107

[GRAPHIC] [TIFF OMITTED] T5627.108

[GRAPHIC] [TIFF OMITTED] T5627.109

[GRAPHIC] [TIFF OMITTED] T5627.110

[GRAPHIC] [TIFF OMITTED] T5627.111

[GRAPHIC] [TIFF OMITTED] T5627.112

[GRAPHIC] [TIFF OMITTED] T5627.113

[GRAPHIC] [TIFF OMITTED] T5627.114

[GRAPHIC] [TIFF OMITTED] T5627.115

[GRAPHIC] [TIFF OMITTED] T5627.116

[GRAPHIC] [TIFF OMITTED] T5627.117

[GRAPHIC] [TIFF OMITTED] T5627.118

[GRAPHIC] [TIFF OMITTED] T5627.119

[GRAPHIC] [TIFF OMITTED] T5627.120

[GRAPHIC] [TIFF OMITTED] T5627.121

[GRAPHIC] [TIFF OMITTED] T5627.122

[GRAPHIC] [TIFF OMITTED] T5627.123

                                 
