[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]


 
                            SUBCOMMITTEE ON 
                       REGULATIONS AND HEALTHCARE 
                   HEARING ON HEALTH IT ADOPTION AND 
                        THE NEW CHALLENGES FACED 
                        BY SOLO AND SMALL GROUP 
                         HEALTH CARE PRACTICES 

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

                                HEARING

                               before the


                      COMMITTEE ON SMALL BUSINESS
                             UNITED STATES
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                              HEARING HELD
                             June 24, 2009

                               __________

                 [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
                               

            Small Business Committee Document Number 111-032
Available via the GPO Website: http://www.access.gpo.gov/congress/house

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50-468 PDF                       WASHINGTON : 2009 

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                   HOUSE COMMITTEE ON SMALL BUSINESS

                NYDIA M. VELAZQUEZ, New York, Chairwoman

                          DENNIS MOORE, Kansas

                      HEATH SHULER, North Carolina

                     KATHY DAHLKEMPER, Pennsylvania

                         KURT SCHRADER, Oregon

                        ANN KIRKPATRICK, Arizona

                          GLENN NYE, Virginia

                         MICHAEL MICHAUD, Maine

                         MELISSA BEAN, Illinois

                         DAN LIPINSKI, Illinois

                      JASON ALTMIRE, Pennsylvania

                        YVETTE CLARKE, New York

                        BRAD ELLSWORTH, Indiana

                        JOE SESTAK, Pennsylvania

                         BOBBY BRIGHT, Alabama

                        PARKER GRIFFITH, Alabama

                      DEBORAH HALVORSON, Illinois

                  SAM GRAVES, Missouri, Ranking Member

                      ROSCOE G. BARTLETT, Maryland

                         W. TODD AKIN, Missouri

                            STEVE KING, Iowa

                     LYNN A. WESTMORELAND, Georgia

                          LOUIE GOHMERT, Texas

                         MARY FALLIN, Oklahoma

                         VERN BUCHANAN, Florida

                      BLAINE LUETKEMEYER, Missouri

                         AARON SCHOCK, Illinois

                      GLENN THOMPSON, Pennsylvania

                         MIKE COFFMAN, Colorado

                  Michael Day, Majority Staff Director

                 Adam Minehardt, Deputy Staff Director

                      Tim Slattery, Chief Counsel

                  Karen Haas, Minority Staff Director

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

                                  (ii)

  


                         STANDING SUBCOMMITTEE

               Subcommittee on Regulations and Healthcare

               KATHY DAHLKEMPER, Pennsylvania, Chairwoman


DAN LIPINSKI, Illinois               LYNN WESTMORELAND, Georgia, 
PARKER GRIFFITH, Alabama             Ranking
MELISSA BEAN, Illinois               STEVE KING, Iowa
JASON ALTMIRE, Pennsylvania          VERN BUCHANAN, Florida
JOE SESTAK, Pennsylvania             GLENN THOMPSON, Pennsylvania
BOBBY BRIGHT, Alabama                MIKE COFFMAN, Colorado

                                 (iii)

  













                            C O N T E N T S

                               __________

                           OPENING STATEMENTS

                                                                   Page

Dahlkemper, Hon. Kathy...........................................     1
Westmoreland, Hon. Lynn..........................................     2

                               WITNESSES

Blumenthal, Dr. David, National Coordinator for Health IT, U.S. 
  Department of Health and Human Services........................     4
Fetzner, Mr. Jim, CEO, Comfort Care, Erie, PA....................    12
Jackson, Mr. Rob, CEO, Grove City Medical Center, Grove City, PA.    15
Kressly, Dr. Susan, American Academy of Pediatrics, Warrington, 
  PA.............................................................    17
Stuckey, Dr. Charles, Executive Director, Pennsylvania Optometric 
  Association, Harrisburg, PA, On behalf of the American 
  Optometric Association.........................................    18
Edwards, Dr. Carladenise A., Chief of Staff, Georgia Department 
  of Community Health, Atlanta, GA...............................    20

                                APPENDIX


Prepared Statements:
Dahlkemper, Hon. Kathy...........................................    34
Westmoreland, Hon. Lynn..........................................    36
Blumenthal, Dr. David, National Coordinator for Health IT, U.S. 
  Department of Health and Human Services........................    38
Fetzner, Mr. Jim, CEO, Comfort Care, Erie, PA....................    46
Jackson, Mr. Rob, CEO, Grove City Medical Center, Grove City, PA.    50
Kressly, Dr. Susan, American Academy of Pediatrics, Warrington, 
  PA.............................................................    56
Stuckey, Dr. Charles, Executive Director, Pennsylvania Optometric 
  Association, Harrisburg, PA, On behalf of the American 
  Optometric Association.........................................    61
Edwards, Dr. Carladenise A., Chief of Staff, Georgia Department 
  of Community Health, Atlanta, GA...............................    65

Statements for the Record:
Association for Healthcare Documentation Integrity / Medical 
  Transcription Industry Association, Modesto, CA................    74
American Academy of Ophthalmology................................    92
Rural Hospital Coalition, Inc., Pride, LA........................    95
Lousiana Rural Health Information Exchange, Bunkie, LA...........    97
National Rural Health Association, Kansas City, MO...............    99
Rural Wisconsin Health Cooperative, Sauk City, WI................   103
National Center for Policy Analysis, Washington, DC..............   105
PDX, Inc., Fort Worth, TX........................................   109

                                  (v)

  


                            SUBCOMMITTEE ON
                       REGULATIONS AND HEALTHCARE
                   HEARING ON HEALTH IT ADOPTION AND
                        THE NEW CHALLENGES FACED
                        BY SOLO AND SMALL GROUP
                         HEALTH CARE PRACTICES

                        Wednesday, June 24, 2009

                     U.S. House of Representatives,
                               Committee on Small Business,
                                                    Washington, DC.
    The Subcommittee met, pursuant to call, at 10:05 a.m., in 
Room 2360, Rayburn House Office Building, Hon. Kathy Dahlkemper 
[chairwoman of the Subcommittee] presiding.
    Present: Representatives Dahlkemper, Altmire, Westmoreland, 
and Thompson.
    Chairwoman Dahlkemper. This committee hearing is now called 
to order. Good morning.
    With Congress and the administration prepared to modernize 
our health system, today's hearing is especially timely. In 
crafting health care reform, it is important to not only find 
ways to provide coverage to more Americans, but also to 
identify ways to reduce costs.
    During a roundtable discussion and previous hearings, this 
committee heard how spiraling health care costs are squeezing 
small businesses. New technology in the form of health IT and 
electronic health records, or EHR, can go a long ways towards 
reducing these costs. Some experts estimate that wide-scale 
adoption of health IT would lead to an annual saving of $77 
billion.
    By streamlining data flow and increasing communication 
between providers, health IT reduces errors, increases 
efficiency, and can save patients' lives. However, 
implementation of health IT has not occurred as rapidly as we 
would have hoped. Smaller and solo health care providers have a 
particularly hard time when it comes to adopting health IT. 
Fifty-seven percent of physicians who are in practices with 
more than 50 doctors utilize electronic health records. By 
contrast, only 13 percent of solo practitioners are putting 
this new technology to use. This health IT gap is particularly 
significant when you consider that most treatment occurs in 
small practices. Eighty percent of all outpatient visits take 
place in medical practices with 10 or fewer doctors. Given 
these facts, it is clear we need to find ways to make this 
technology accessible for small doctors' offices.
    Most physicians recognize that health IT is a critical 
investment. They know that HIT and EHR will not only save money 
in the long term, but help them better meet patients' needs. 
The main problem is that integrating health IT and EHR into a 
medical practice is so expensive up front. The starting price 
tag on health IT system is $32,000 per doctor. This means the 
typical medical practice with three doctors pays close to 
$100,000. That is a big investment for any business, and for 
many physicians it is enough of a hurdle to stop them from 
purchasing health IT.
    Like any new product, the price of health IT will drop as 
it becomes more mainstream and more practices purchase it. 
However, it is unclear when we will reach this tipping point 
and see prices dip to affordable levels. With the President and 
Congress moving forward swiftly with health care reform we 
cannot wait for the market alone to solve this problem.
    The American Recovery and Reinvestment Act took some 
important steps to spur health IT adoption. Through Medicare 
and Medicaid payments, the new law rewards physicians who start 
using this technology. However, even with these incentives, 
many small practitioners will find it difficult to make the 
necessary initial investment.
    That was why I am proud to be introducing the Small 
Business Physicians Access to Capital Act of 2009. This bill 
will establish a new loan program at the Small Business 
Administration, designed specifically for doctors who want to 
invest in health IT.
    Ultimately, small and solo health care practitioners are 
small businesses. Similar to small businesses everywhere, one 
of their biggest challenges is accessing affordable capital. 
This legislation will help them find that capital.
    It is my hope that we can explore solutions like these 
during today's hearing. If we can make health IT more 
affordable for physicians, we can make health care more 
affordable for everyone.
    I would like to thank all of today's witnesses in advance 
for their testimony. I know that you are taking time away from 
your businesses to be here, and I look forward to hearing from 
you.
    With that, I would like to yield to the ranking member, Mr. 
Westmoreland, for his opening statement.
    Mr. Westmoreland. Thank you, Madam Chairwoman, and I thank 
you for convening this timely hearing on health information 
technology and small health care practices.
    I would like to extend a special welcome to all of our 
witnesses and especially Dr. Carladenise Edwards, a fellow 
Georgian, whom I will introduce later.
    As Congress considers health care reform legislation, 
health information technology will be an important component of 
that effort. This is a critical issue for the medical 
profession and particularly small medical providers. Some 
studies estimate that 75 percent of practices in the United 
States have five or fewer physicians.
    Health IT is a useful tool for the management of medical 
information and its exchange among patients and providers. This 
technology can help to reduce errors, better manage chronic 
diseases, decrease paperwork and increase efficiency. Despite 
these benefits, fewer than one out of ten small medical 
practices have fully electronic health records.
    Barriers to small practices adopting health IT such as cost 
and the risk of purchasing systems which may become obsolete 
remain. This year's stimulus legislation included ambitious 
goals for the adoption of health information technology. It 
established Medicare incentives to providers who demonstrate 
meaningful use of health IT and penalties for those who do not, 
strengthened the HIPAA privacy rule--which, by the way, is one 
of the biggest reasons that health care is so expensive, 
according to a lot of providers I have talked to--and created a 
new patient right to be notified in the event of a breach. The 
Department of Health and Human Services will issue regulations 
regarding that law.
    As we move forward, we hope that small manufacturers of 
health IT systems and their users, as well as small-practice 
physicians and hospitals, will be included in that dialogue.
    The National Coordinator for Health IT, in consultation 
with the Hit Standards Commission, has been drafting standards 
in the certification for health IT. We are awaiting a 
definition of "meaningful use," as this definition is 
critically important to those people providing.
    In addition, while I believe that health IT has many 
benefits and we should encourage its adoption, small providers 
are concerned about interoperability, privacy, and security 
standards, and the fact that the HIT funding has not yet begun 
to be distributed. It is important that these concerns be 
considered.
    Finally, I want to add a word about health care reform 
generally. Small companies are struggling. In a difficult 
economy, they are doing their best to stay in business. A 
mandate that employers must offer health insurance will simply 
add to their already stretched bottom line.
    I feel strongly that exempting even some small firms will 
be an invitation to Congress to go back at some future point 
and include more of them in the mandate; and I am concerned 
that a national, government-run health care system could drive 
private insurers out of the market, reducing competition and 
raising costs.
    Everyone in this room has been a patient, and everyone 
understands that for privacy and for respect of medical 
information, the most important issue for health care reform 
should remain the doctor-patient relationship. I would hope 
that health care reform will acknowledge this fact.
    Madam Chairwoman, I appreciate you calling this important 
hearing, and I look forward to hearing the testimony of these 
witnesses.
    Chairwoman Dahlkemper. Thank you.
    I would like to introduce our first witness, Dr. 
Blumenthal.
    Welcome.
    Dr. David Blumenthal is the National Director for Health IT 
in the U.S. Department of Health and Human Services. As the 
National Coordinator, Dr. Blumenthal leads the implementation 
of a nationwide health information technology infrastructure. 
HHS is the government's principal Agency for protecting the 
health of all Americans and providing essential human services.
    We look forward to your testimony.

     STATEMENT OF DAVID BLUMENTHAL, M.D., M.P.P., NATIONAL 
COORDINATOR, OFFICE OF THE NATIONAL COORDINATOR FOR HEALTH IT, 
          U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

    Dr. Blumenthal. Thank you, Madam Chairwoman.
    Madam Chairwoman, ranking member Westmoreland, members of 
the subcommittee, I am David Blumenthal. I am the National 
Coordinator for Health Information Technology in the Department 
of Health and Human Services, and I am very pleased to testify 
before you today on the administration's health information 
technology activities and specifically how they impact small 
health care practices.
    Health information technology, or HIT, allows comprehensive 
management of medical information and its secure exchange 
between health care consumers and providers. Broad use of 
health information technology has the potential to improve 
health care quality, to reduce unnecessary health care costs 
and to improve population health.
    The American Recovery and Reinvestment Act of 2009 included 
the Health Information Technology for Economic and Clinical 
Health Act, or HITECH act. The HITECH Act includes $2 billion 
in funding to the Office of National Coordinator to lay the 
groundwork for the adoption and meaningful use of HIT through 
infrastructure programs. It also includes an estimated $44.7 
billion in incentive payments from Medicare and Medicaid to 
providers who are meaningful users of certified electronic 
health record technology.
    Many physicians in small practices want to adopt HIT, but 
do not have the ability to invest upwards of $40,000 in the 
technology systems. By providing physicians and other health 
care providers with financial assistance for adoption and use 
of interoperable HIT, we will help reduce this burden.
    Physicians, including those in solo or small practices, can 
receive up to $44,000 under Medicare in incentive payments for 
being meaningful users of certified electronic health records. 
The HITECH Act includes grant programs, as well as education 
and technical assistance opportunities, to health providers, 
especially those in small practices, to overcome barriers to 
adoption.
    Meaningful users will become eligible for incentive bonuses 
in 2011. Beginning in 2015, the Recovery Act authorized 
penalties under Medicare for eligible professionals and 
hospitals that fail to demonstrate meaningful use of certified 
electronic health records. The qualification criteria for 
incentives are still in development and will be defined through 
regulation.
    The HIT Policy Committee, which is the Federal advisory 
committee that provides recommendations to the National 
Coordinator, met on June 16th, 2009 to discuss proposed 
objectives and measures of meaningful use. This discussion 
focused on a vision of health care that outlined a progression 
from process measures in 2011 to outcome measures in 2015 for 
improved population health.
    ONC and CMS are hosting listening sessions targeted at 
small health care practices so that HHS is informed of their 
questions and unique concerns as HITECH is implemented. The 
definition of "meaningful use" is a key step toward 
transforming our health care system.
    In addition to the incentive payments, the HITECH Act 
authorizes grant programs that ONC can implement as health 
providers and communities adopt and become meaningful users of 
electronic health records. Two of these include regional 
extension centers and State grants to promote health 
information exchange, or HIE.
    Currently, 21 percent of physicians have adopted an EHR. 
The adoption rate among small health care practices is 
significantly lower at about 13 percent. This discrepancy in 
the rate of adoption for the Nation and for small practices 
highlights the need for focused technical assistance for small 
health care practices.
    The HITECH Act authorizes an HIT extension program to make 
assistance and education available to all providers with 
priority given to select providers, including individual or 
small practices and small group practices that are focused 
primarily on primary care.
    HHS is actively working to get programs planned and 
implemented this year to support hospitals and eligible 
providers in becoming meaningful users of EHRs. The HITECH Act 
provisions of the Recovery Act provide a historic opportunity 
to improve the health of Americans and the performance of the 
Nation's health system through an unprecedented investment in 
HIT.
    This initiative will be an important part of health reform 
as professionals and health care institutions, both public and 
private, will be enabled to harness the full potential of 
digital technology to improve and increase the efficiency of 
our health care system.
    Madam Chairwoman, thank you for the opportunity to appear 
before you today. I would be glad to answer any questions.
    [The statement of Dr. Blumenthal is included in the 
appendix.]
    Chairwoman Dahlkemper. Thank you, Dr. Blumenthal.
    I yield myself 5 minutes for questioning.
    Dr. Blumenthal, you talked about the meaningful use 
requirements as this was defined obviously in the stimulus-- 
well, it isn't defined; that is why we are looking to defining 
it--and you state in your testimony that you expect to publish 
a rule by late 2009.
    This is midway, through June, now. How has your office 
approached defining this issue? What steps will you take if you 
are unable to make that deadline? Will you make that deadline 
by the end of this year?
    Dr. Blumenthal. The regulation will actually be a CMS 
regulation, because CMS is tasked with providing the incentive 
payments to physicians and hospitals under the law. So CMS will 
actually run the regulatory rulemaking process.
    Their plan right now is to have that regulation ready to 
put in the form of a notice of proposed rulemaking by the end 
of this calendar year, and we will be advising them on that 
definition and helping them come to a conclusion about it.
    We have a continuing process that we have outlined. We are 
going to hold another hearing of our Health Information 
Technology Policy Committee on July 16th. That group heard from 
a working group on a definition of "meaningful use" on June 
16th. We are still in the process of a public comment period on 
that definition, which I want to make clear was a definition 
proposed by a working group of our advisory committee, not by 
the Department; and that advisory committee, after the July 
16th hearing, we hope will make some recommendations to the 
National Coordinator.
    There will then be a period of open comment on that 
definition, and then the process of rulemaking will begin 
formally; and we hope that that a notice of proposed rulemaking 
will be available by the end of the calendar year.
    Chairwoman Dahlkemper. Who is involved in the working 
group? Can you give me a few examples?
    Dr. Blumenthal. The working group was actually created by 
the Recovery Act. Its membership was very explicitly defined. 
GAO appointed the large bulk of the members, Members of this 
body, and the Senate appointed additional members and the 
Secretary appointed three members. And it represents a broad 
group of stakeholders, hospitals, physicians, insurance 
companies, consumers, so it is a very broad and very clearly 
defined membership in the law.
    Chairwoman Dahlkemper. Okay.
    Since the certification process can be slow, some providers 
will be unable to adopt certified EHR systems when the 
incentives for the Recovery Act become effective.
    What steps is HHS taking to encourage the Commission on 
Health Information Technology to develop and implement 
standards more quickly?
    Dr. Blumenthal. We are comprehensively reviewing the 
certification process. We were asked to do that under the law. 
We will be making recommendations concerning what the 
certification process should be. The Certification Commission 
For Health Information Technology has been tasked with doing 
certification in the past. We will be looking at its role going 
forward. We certainly hope that that process will be capable of 
certifying very many--certainly more than sufficient number of 
records, so that physicians and hospitals will have ample time 
to adopt certified records. That is certainly the goal of our 
office. And we hope to be able to design a process that allows 
innovation, the certification of new and innovative products, 
as well as the certification of products that already exist on 
the market.
    Chairwoman Dahlkemper. The Recovery Act did not extend HIT 
funding to a large number of health professionals who operate 
in the Medicare and Medicaid program. However, many expect HHS 
to compel these providers to adopt HIT if they are going to 
continue offering Medicare and Medicaid services.
    If HHS takes this step, should there be some relief or 
financial incentives for these providers as well?
    Dr. Blumenthal. I hear in your question an assumption as 
some point we may compel the adoption of health information 
technology. I want to make clear that that is not contained in 
the Recovery Act right now. And so I think it is somewhat 
speculative to talk about what would happen if that were to 
happen in the future. That is not a plan on the books right now 
in the Department.
    Chairwoman Dahlkemper. There is no--you are not looking at 
compelling others to do this at this point?
    Dr. Blumenthal. No. No.
    Chairwoman Dahlkemper. My 5 minutes is up. I will now 
recognize the ranking member, Mr. Westmoreland, for 5 minutes.
    Mr. Westmoreland. Thank you, Madam Chair.
    Dr. Blumenthal, when this legislation was signed and put 
into effect, how long had this legislation been in the system, 
the HITECH legislation? Or was this something that was just 
created?
    Dr. Blumenthal. Well, Congressman, there were a number of 
bills that had been close to passage in the past. As a matter 
of fact, bills similar to this legislation had passed the 
Senate and had actually passed the House and had failed to get 
agreement in conference. So many of the provisions were 
familiar to the health committees that had jurisdiction over 
this area.
    Now, my history is not authoritative in this regard, so I 
can only tell you what I observed at that time as a 
nongovernmental--
    Mr. Westmoreland. How long have you been with the 
Department?
    Dr. Blumenthal. Since April 20th, sir.
    Mr. Westmoreland. So not that long?
    Dr. Blumenthal. Not that long.
    Mr. Westmoreland. The HIT policy committee, what is the 
makeup of that? I don't know if you were talking about the 
advisory committee a while ago or the HIT committee.
    Dr. Blumenthal. Well, we would be glad to get you the 
roster of that group if you would like to see it.
    Mr. Westmoreland. Is it 10 people?
    Dr. Blumenthal. Twenty-three people.
    The great bulk of that membership was specified in law. The 
process of appointment was specified in law, and 20 of those 23 
were appointed either by the GAO or by the leadership of the 
House and the Senate.
    Mr. Westmoreland. And the membership, what is it made up 
of? I mean, what professions? What backgrounds?
    Dr. Blumenthal. Physicians, consumers, nurses, people who 
run neighborhood community health centers, people who are 
members of the health insurance community, people who are 
experts on privacy and security, and people who are experts in 
public health. There are some members of the Federal 
Government, representatives of the Department of Defense, the 
VA, the Office of Science and Technology Policy.
    It is designed to be broadly representative of the 
stakeholders who are playing a role, who have to be part of the 
process of health information technology adoption.
    Mr. Westmoreland. How about any people from the IT 
community?
    Dr. Blumenthal. Yes, we have people who have developed and 
sold health information technology--the chief executive officer 
of a company called EpicCare and another gentleman who has 
started and run and sold two HIT companies.
    Mr. Westmoreland. How many companies provide the IT service 
to physicians and hospitals and providers?
    Dr. Blumenthal. I don't have an exact number for you. I can 
get you that number.
    But I can tell you that the certification commission in the 
past has certified well over 100 ambulatory care products, so 
there are at least 100 discrete providers of health information 
technology. It is a very competitive market.
    Mr. Westmoreland. And I am assuming that the goal of this 
is that all of it will be interoperable.
    And with over 100 different companies providing the 
service, have we got any committee or anything that is looking 
into how they are working together to try to do that, and is 
that something that they are going to willingly do? Because you 
know that will take some information trading, I guess, to be 
able to do that.
    Dr. Blumenthal. Well, Congressman, the House and Senate 
equipped us with two committees to advise the Office of 
National Coordinator. One is the policy committee which we have 
been discussing. There is another called the Health Information 
Technology Standards Committee.
    The critical element in communicating between different 
software are the standards that the software has to meet so 
that the information in both is recognizable to each system. 
And the Health Information Technology Standards Committee is 
tasked with advising the office on the standards that are 
required for interoperability.
    They have met twice as well. They have to, by statute, 
provide--not they, but the office, with their advice. The 
Department has to provide an interim final rule by the end of 
the year on the standards that are required for certification. 
So we are under considerable time pressure to get those 
standards up and ready.
    We held a meeting of the standards committee yesterday and 
they are providing invaluable advice. It is a complex, 
difficult undertaking, but we are hoping that the fact that the 
"meaningful use" definition that was outlined by the Congress 
does require interoperability will focus the vendors on that 
requirement and also focus the purchasers, small practices and 
large, hospitals, both individual hospitals and groups of 
hospitals, on the interoperability provisions and capabilities 
of their software that they are purchasing.
    Mr. Westmoreland. I see my time is up and I hope the 
chairlady will allow us to have one more round of questioning.
    Chairwoman Dahlkemper. I now recognize the gentleman from 
Pennsylvania, Mr. Altmire.
    Mr. Altmire. Thank you. I wanted to follow up on Mr. 
Westmoreland's question on interoperability.
    One of the problems, as I am sure are aware, with health IT 
with regard to government entities is the VA and DOD. 
Completely interoperable. When somebody completes their 
military service and goes to the VA, the VA receives a PDF file 
by e-mail that is--you cannot manipulate the data in any way; 
someone has to actually sit down at the computer and type in 
what might be 30 years of medical data, because they can't 
transition over.
    And one of the concerns I have with implementing health IT 
across the country is that there are a lot of hospital systems 
providers in this country that are doing the right thing now 
without government money; they are spending their own money and 
resources to get health IT off the ground. And I am concerned 
about having a situation develop across the country that will 
be similar to what the DOD and VA have. Where you have systems 
that cannot communicate with each other.
    I am wondering if you have commentary on how we can prevent 
that from happening. I don't want to be in the position where 
this money gets rolled out, and we penalize the people who have 
already done this on their own by saying, Sorry, you are not 
compatible with the system that we want you to use.
    Dr. Blumenthal. We don't want that to happen either, 
Congressman. And our view is, if we can provide the standards 
that allow interoperability and the models of working 
interoperable systems--which we have been doing through work 
that we are doing on the National Health Information Network--
that if we can provide that, then providers will be motivated 
to take advantage of those standards and also those mechanisms 
to achieve interoperability.
    There have been in the past some technical obstacles. We 
think those can be overcome, that vendors could overcome them 
if purchasers demanded that they provide the capability.
    There has not been an incentive of the kind that we now 
will have under Medicare and Medicaid for individual physicians 
or institutions to demand that interoperability be a feature of 
the electronic health records that they purchase.
    Some of those vendors will be able to retrofit or add on 
interoperability capability. Some may not. And in the latter 
case, it may be necessary for some providers to seek an 
alternative vendor. But they will have funding from Medicare 
and Medicaid to help them to do that.
    Mr. Altmire. How far away do you think we are and how 
realistic is it that in the near future--my district in 
Pittsburgh, Pennsylvania--that someone from my district on 
private insurance will be able to travel to Portland, Oregon, 
show up at the hospital and have their records pulled up?
    How far away in the future is that?
    Dr. Blumenthal. Well, I wish I had a crystal ball to be 
able to answer that question, and I don't. It is our goal to 
develop that kind of interoperable health system as soon as we 
possibly can. And I think that that capability will be in 
existence in a matter of a few years for some types of 
providers, especially large institutions.
    But to say that it will be universally available in a 
particular number of years, I think would be hard to speculate 
about.
    Mr. Altmire. Thank you.
    And it is not much time, but I would be happy to yield my 
remaining minute or so to Mr. Westmoreland if he has another 
question.
    Mr. Westmoreland. Thank you very much.
    And I wanted to go to the "meaningful user," the 
definition. You mentioned that you all had a meeting, I think 
on June 16th. I think you mentioned an open comment period?
    Dr. Blumenthal. Yes.
    Mr. Westmoreland. Okay. And so when is that up? When is the 
comment period--
    Dr. Blumenthal. The 26th of June. It has been open for 10 
days, from June 16th to June 26th.
    Mr. Westmoreland. And this was an open comment period on 
the definition or what the definition should be?
    Dr. Blumenthal. It certainly could involve that.
    The explicit invitation was to comment on the working 
document that the committee produced, which outlined a set of 
"meaningful use" definitions.
    Mr. Westmoreland. Okay.
    Now, who all was--I mean, you are getting this input from 
all the medical community--IT providers, hospitals?
    Dr. Blumenthal. Well, sir, we don't know yet all of who 
will comment, as we are collecting that input. And if you would 
like to know more about who has commented, we would be glad to 
get you that information.
    [The information is included in the appendix.]
    Mr. Westmoreland. I think that is interesting, because that 
is so critical a term to this whole process. And for a 10-day 
period--you know, that is not a long time.
    Dr. Blumenthal. That is not the only time they will have, 
Congressman. After our next meeting on July 16th there will be 
another open comment period; and then when the notice of 
proposed rulemaking is listed, there will be a 60-day comment 
period. We want this to be an open and responsive process.
    Mr. Westmoreland. That is like the old "Once the horse is 
out of the barn, it is too late to close the gate." From my 
experience with these comment periods, once the committee gets 
into their mind what they are going to do, you can comment 
about anything and it is not going to change the fact.
    The best time to get in is at the front, rather than the 
end of it. But thank you.
    Chairwoman Dahlkemper. I will open up for another round of 
questions, so that we can continue this. There are some 
important issues to bring up here.
    I wanted to ask you, Dr. Blumenthal, for many physicians--
and I get this complaint all the time from physicians in my 
area--the Medicare and Medicaid reimbursements are already low. 
And the penalties could further diminish these payments for 
practices that do not transition to electronic health records.
    I am afraid in my home State we are going to see physicians 
turning away from treating anyone who is on Medicaid or 
Medicare and avoid that financial burden.
    So, has HHS examined how these penalties will affect 
patient care and access to care?
    Dr. Blumenthal. Well, Madam Chairwoman, I think that the 
first point I would like to make is that the American 
physicians and hospitals now have available $45 billion to 
support the adoption of health information technology that they 
didn't have before the Recovery Act. So that is an enormous new 
investment by the American taxpayer in making this technology 
possible to adopt.
    In 2015, those who have not could be the subject of 
penalties. That is true. It is 1 percent the first year, 2 
percent the second year, and 3 percent the third year. It is 
certainly our hope that those penalties will never go into 
effect and that the great majority of providers will have 
become meaningful users by 2015.
    Chairwoman Dahlkemper. But 1 percent, 2 percent, 3 percent, 
do you have any idea whether those will be physicians from 
small practices versus physicians from larger practices? I 
think the testimony and some of this questioning going forward 
is that those who are in single practice or two or three docs 
in practice have a much more difficult time financially.
    Dr. Blumenthal. Sure. I understand that.
    We obviously don't know 6 years from now exactly who will 
have become a meaningful user and who will not. And we will, of 
course, be examining that as time goes on.
    I do want to point out that the law makes special provision 
for technical assistance to small practices and through the 
extension center mechanism that we are planning to implement in 
the near future. This is very real, hands-on support and help 
for adopting electronic health records and learning to be a 
meaningful user of that record.
    So that is part of the $2 billion that we have available to 
provide technical assistance to small practices and small 
hospitals. And we are working very hard figuring out how best 
to use that money right now.
    Chairwoman Dahlkemper. Is there any provision for more of 
the funding going towards those practices percentage wise?
    Dr. Blumenthal. It is certainly possible that we could do 
that. The law draws attention to small practices and primary 
care physicians.
    Chairwoman Dahlkemper. Who would make that decision?
    Dr. Blumenthal. The Secretary would.
    Chairwoman Dahlkemper. Is there any talk of that currently?
    Dr. Blumenthal. I think we are looking at all the options, 
Madam Chairwoman. And that is certainly on our mind; we 
understand that small practices carry an extra burden.
    Chairwoman Dahlkemper. Okay. I am going to yield at this 
point to Mr. Westmoreland.
    Mr. Westmoreland. Thank you.
    Dr. Blumenthal, I know you have only been there a short 
period of time and didn't have any input into the language of 
the bill, but why would 13 members of this HIT policy committee 
be appointed by the Comptroller General?
    Dr. Blumenthal. Sir, I really can't get into the minds of 
the folks who wrote this legislation.
    Mr. Westmoreland. I can't either. I don't know of anybody 
in this room who could, really. I guess the interesting part is 
just the makeup of this board and exactly what is going on.
    But each State, I am assuming, is going to get some money 
to help them communicate with these health records also; is 
that right?
    Dr. Blumenthal. That is correct. The Appropriations 
Committee directed us to spend $300 million--at least $300 
million on grants to States to encourage health information 
exchange.
    Mr. Westmoreland. And then the 44,000 that will go to the 
physicians or the health care providers, when do you see that 
money--how long do you think it is going to take to get the 
program started?
    Dr. Blumenthal. The first incentive payments become 
available in 2011. So we are devoting ourselves to laying the 
groundwork so as many physicians and hospitals as possible can 
be eligible for those funds in 2011.
    Mr. Westmoreland. And your Department will be the one 
administering that? They are actually apply to your Department?
    Dr. Blumenthal. They actually will apply to the Center for 
Medicare and Medicaid Services because they will be eligible 
for incentive payments in Medicare and Medicaid funding, and 
that is the authority of CMS, rather than my office which is 
devoted to developing policy and programs around health 
information technology.
    We don't control the Medicare and Medicaid programs.
    Mr. Westmoreland. And as far as the security goes, you 
know, we have foreign countries hacking into our grid system 
and doing things. And, you know, with the few HIPAA 
requirements and stuff, who is going to be responsible if 
somebody hacks into this system and people's medical records 
get out?
    Because, you know, if somebody drops a chart off of a cart 
or leaves it laying open in a hospital, that is one person. You 
hack into a system, you are talking about millions of people.
    Who is going to bear that responsibility? Is it going to be 
the doctor? Is it going to be the person that wrote the IT 
program? Is it going to be the government? Who is going to be 
responsible for that?
    Dr. Blumenthal. Well, that is an excellent question; and we 
are very, very committed to making this system as private and 
secure as possible. We are exploring ways to increase its 
privacy and security, and the liability for any breaches falls, 
as I understand it, to the organization that holds the 
information.
    And we are going to have a very diverse information system 
in this country, as we have a very diverse health care system. 
So I imagine that it will depend on who is responsible in the 
particular case for collecting and holding that information.
    But if you would like more information on that, I would be 
glad get back to you.
    Mr. Westmoreland. Your Department is going to be 
responsible for the rules and regs, right? I mean--
    Dr. Blumenthal. We are going to be responsible for some of 
the rules and regulations. A lot of what we are going to be 
doing is giving guidance to the States who often develop 
privacy and security laws. That is--in this country, HIPAA puts 
a floor under this, but the States can supersede HIPAA 
regulations and create additional regulations, and they often 
do.
    Mr. Westmoreland. If they do, then I could see where they 
could be responsible for the difficult thing, but if they just 
go with the Federal Government's HIPAA regulations, who is 
going to bear the responsibility for these--
    Dr. Blumenthal. Congressman, I would like to get back to 
you on that because I would like a legal opinion on that.
    Mr. Westmoreland. That is fair enough.
    Dr. Blumenthal. I have to apologize, but I have a 10:45 
obligation on the Senate side. I informed your staff of that as 
we were preparing for this hearing.
    So with your permission, I will leave a little bit early. 
If there are other questions that you would like me to answer, 
I am sure that we could get back to you in writing.
    Chairwoman Dahlkemper. Dr. Blumenthal, I thank you for 
being here today, and I thank you for your time. And I am sure 
you will be available, and if anyone on this committee has 
further questions that we could contact you and your staff.
    Dr. Blumenthal. Certainly.
    Chairwoman Dahlkemper. Thank you.
    We have been called for a vote, and it looks like it is 
going to be one vote. And so I think we are going to--we can 
run over and vote and come right back and then we will resume 
the hearing with the second panel when we return from voting.
    The committee stands in recess.
    [Recess.]
    Chairwoman Dahlkemper. We want to thank the second panel 
for your patience.
    Chairwoman Dahlkemper. We will reconvene the hearing. And I 
would ask the witnesses to please watch your clocks; you will 
have 5 minutes to deliver your prepared statements. The time 
begins when the green light is illuminated. When 1 minute 
remains, the yellow light will come on, and the red light when 
the time has expired. You have a button that says "Talk"; make 
sure that you hit your button and shut it off with your 
statement.
    I would like to introduce our first witness, and it is Mr. 
Jim Fetzner, the CEO of Comfort Care and Resources in Erie, 
Pennsylvania, my hometown. Mr. Fetzner is working on service 
innovation and health care IT initiatives in his company. 
Founded in 1997, Comfort Care is a home-based care provider 
that offers flexible, cost-effective solutions so that elders 
may live in their homes regardless of physical and social 
needs.
    Welcome to Washington. Thank you for being here Mr. 
Fetzner.

                 STATEMENT OF JAMES P. FETZNER

    Mr. Fetzner. Thank you Chairwoman Dahlkemper, Ranking 
Member Westmoreland and members of the committee for allowing 
me the opportunity to testify today regarding health care 
information technology and Title XIII of the American Recovery 
and Reinvestment Act of 2009. I consider it an honor to be a 
part of the process of moving our health care system into a new 
and critically important generation of technology and service 
delivery.
    My name is James Fetzner, Chief Executive Officer of 
Comfort Care and Resources. Currently, we serve three counties 
and hundreds of patients, enabling them to age in place. Our 
company was started in 1997 by my mother, Beverly Fetzner, with 
only a pager, a passion, and a belief that there is nothing 
that is done in a nursing facility that cannot be done better 
at home. At that time, and unfortunately still, in some places 
this philosophy is a radical idea; however, it has informed my 
vision as CEO.
    As a result, we continue to push the forefront in long-term 
care, working with multiple technology incubators, university 
centers, State departments and local agencies. With these 
partners, we will create an integrated and interoperable HIT-
enabled service delivery system that will drastically reduce 
the cost of long-term care.
    It is from this perspective as an entrepreneur, not as a 
clinician or practitioner, that I offer my testimony on HIT.
    While Title XIII makes mention of additional settings and 
is intent on facilitating standards for these settings, the 
clear emphasis and investment is focused on the adoption and 
meaningful use of certified EHR. While this is certainly 
necessary, it is not sufficient. Meaningful use will not be 
realized until new, high-value information is incorporated into 
work flow and decision-making.
    When a cardiologist can see a trend analysis for daily 
vitals of a congestive heart failure patient living 
independently at home is when meaningful use will exist. This 
type of meaningful use does not occur by investing in certified 
EHRs alone. This occurs when an entire provider network is 
connected and coordinated around that patient's plan of care. 
For information to be delivered to and from the front lines of 
care in our homes and communities a seamless ecosystem must 
emerge. Enterprise integration will be critical as information 
will need to pass to and through multiple providers.
    Providers such as skilled home health agencies, nonmedical 
home care agencies, area Agency on Aging case management and 
others will need to utilize and contribute to that information 
before it comes to rest in EHR at a primary care physician's 
office. Additionally, triggers and alerts will need to be 
designed for each individual patient to allow anomalies to jump 
out from the steady stream of data that will be created.
    If we simply digitize information that exists through EHRs, 
the margin of value from HIT will be limited. Significant value 
will be achieved when new high-value information can be 
delivered, assimilated and leveraged for clinical and 
operational decision-making.
    The most valuable information will be delivered from the 
front lines of care where we did not have access to it before 
from our nurses and from our nursing assistants. This is more 
challenging by the day as the front lines of care are becoming 
dispersed and disintegrated.
    Nearly every person's home is part of the health care 
system at some point and the home's role will only increase 
with cost containment measures requiring early discharges and 
less institutionalized care.
    It is clear to me that if we look to the future of the 
health care system, the entry and exit points will no longer be 
our hospitals and doctors' offices, but rather they will be 
individual homes. Whether that be a patient utilizing the 
Internet to check and update their personal health information 
or clients for whom we monitor and deliver information to their 
doctors and families, the starting point will be home. Therapy, 
recovery, and end-of-life care will continue to shift towards 
home to match patients' desires in a more cost-effective, high-
quality way.
    With advances in technology, we can confidently move 
forward to redefine the health care system knowing that the 
past insurmountable problems of time and distance will be 
overcome. No longer will patients need to adjust their lives to 
fit our health care system, but rather our health care system 
will conform to each individual. For long-term care, this will 
mean long overdue deinstitutionalizing of seniors.
    I am honored to be a part of the solution and thank you for 
your time; and I look forward to your questions.
    Chairwoman Dahlkemper. Thank you, Mr. Fetzner.
    [The statement of Mr. Fetzner is included in the appendix.]
    Chairwoman Dahlkemper. Our next witness is Mr. Rob Jackson, 
who is the CEO of Grove City Medical Center in Grove City, 
Pennsylvania, also in my congressional district.
    And welcome to Washington.
    Mr. Jackson is responsible for the oversight and 
development of an integrated health system in the center. The 
Grove City Medical Center currently is licensed to operate 95 
acute-care beds and 20 skilled nursing beds.
    I appreciate you coming down from the Third District and I 
look forward to your testimony.

              STATEMENT OF ROBERT C. JACKSON, JR.

    Mr. Jackson. Good morning. I am Robert Jackson, Chief 
Executive Officer of Grove City Health System. Grove City 
Health System is composed of Grove City Medical Center, which 
is a 95-bed community hospital; Wolf Creek Medical Associates, 
which is a multispecialty physician group practice; and a 
charitable foundation called Grove City Health System 
Foundation.
    We are the nearest health care facility to the intersection 
of Interstate 79 and Interstate 80 in northwestern 
Pennsylvania. From a geographical perspective, we are 1 hour 
due north of Pittsburgh and 1 hour and 15 minutes due south of 
Erie. Our hospital serves a primary service area of 55,000 
people containing the communities of Grove City, Mercer and 
Slippery Rock, Pennsylvania. About 100 physicians have 
privileges at our hospital with 35 of them considered to be 
active members of the medical staff.
    In order to provide a framework to analyze my testimony, I 
need to explain where we are as far as our journey towards 
electronic medical records. Our health system has spent close 
to $2 million in software, hardware and training costs to 
accomplish an integrated system among our facility and our 
medical staff. I would like to explain briefly some of the pros 
and cons that we see related to the adoption of an electronic 
medical records in the semirural and smaller provider 
environment.
    Not everything is made better with automation; however, 
EMRs offer physician offices the opportunity to streamline 
office procedures and share information among staff members in 
an incredibly efficient manner. Use of an EMR brings a higher 
level of patient safety and regulatory compliance to a 
practice. For example, with its ability to review a drug 
through volumes of information to identify any potential 
pharmaceutical interactions or other allergies that the patient 
may have, the patient and the physician can have greater 
confidence in the prescribing of that pharmaceutical for their 
condition.
    The documentation capture with an EMR is more detailed and 
provides a easily searchable repository of information and 
patient's history at the physician's fingertips. Hospitals and 
physicians have begun sharing information electronically at the 
local level, but what is astounding to consider is the 
potential of the information that can be exchanged and how it 
can improve the health of our Nation.
    However, that is not to say there is not a downside. The 
introduction of EMRs to the hospital and physician practice 
environment adds cost to patient care. A private practice 
office is potentially looking at $50,000 for initial investment 
in hardware and software, group practices in the neighborhood 
of $200,000, and as I mentioned, the hospital and its 
affiliates have spent close to $2 million. This is just to get 
started. It does then also require monthly maintenance and 
service contracts, which again adds cost without additional 
revenue.
    Initial implementation of an EMR has the potential to 
reduce the throughput of a practice up to 50 percent in some 
cases. Considerations need to be made for those staff that may 
not be able to learn how to use the EMR or may choose not to.
    The use of EMR also affects the sacred relationship between 
the physician and the patient. Patients need to feel like they 
have been heard when they have a visit with their physician. 
The introduction of this technology into the patient care 
relationship can be disruptive to that relationship.
    Incentives make sense when you begin to think about what a 
physician practice would have to give up in order to have an 
EMR. As physician practices grow in the number of providers 
their employ, the use of an EMR increases efficiency and makes 
it a worthwhile endeavor. However, as a one- or two-physician 
practice, you would think long and hard before making this 
decision.
    I would like to touch briefly on where this all may be 
going. The physicians and hospitals that care for me on a 
regular basis both have EMRs. The question is, how does that 
help me when I need emergency services when I am visiting 
Washington, D.C.? Providing incentives through the ARRA is a 
great step to move those physicians and other health care 
providers, who may have been on the fence, forward. 
Nevertheless, at the end, what we have we created? There will 
be physicians on a myriad of systems, and in some cases they 
will be able to transfer information with the hospitals they 
work with.
    As EMR adoption is a central tenet of cost savings in the 
redesign of the health care system, there needs to be a plan on 
how this will actually improve the health of individuals and 
not just provide another mechanism to penalize the 
reimbursement of health care providers. The impact of EMR 
adoption is significant regardless of the size of the health 
care provider. The group that has the greatest risk is the 
small, independent physician practice.
    As we travel along our journey through to an EMR 
environment--and eventually, we hope, an EHR environment--the 
incentives will help us get there. However, the plan for health 
care redesign happening concurrently with this initiative needs 
to be considered as the implementation of an EMR cannot be only 
a cost savings strategy and not one to help patient care.
    Chairwoman Dahlkemper. Thank you, Mr. Jackson.
    [The statement of Mr. Jackson is included in the appendix.]
    Chairwoman Dahlkemper. I would like to introduce Dr. Susan 
Kressly, a Board Certified pediatrician and a Fellow of the 
American Academy of Pediatrics. She has a private practice in 
pediatrics in adolescent medicine in Warrington, Pennsylvania.
    The American Academy of Pediatrics was founded in June 1930 
and has approximately 60,000 members. Another fellow 
Pennsylvanian; it must be Pennsylvania day here.
    Welcome.

           STATEMENT OF SUSAN KRESSLY, M.D., F.A.A.P.

    Dr. Kressly. Thank you very much, Chairwoman Dahlkemper and 
members of the committee. Thank you for your leadership and 
representation of the Third District of Pennsylvania. Many 
children in northwest Pennsylvania have been helped by the 
votes you have cast in favor of the reauthorization of SCHIP 
and ARRA. The Academy also applauds your attempts to find 
innovative solutions to help IT funding.
    My name is Susan Kressly. I am a practicing pediatrician in 
Warrington, PA. I am honored to represent the American Academy 
of Pediatrics before you today.
    On behalf of nearly one-third of America's population who 
cannot vote, I would like to express my gratitude to this 
committee for allowing me the opportunity to give children a 
voice. After 15 years in a large group practice, in 2004, I 
started my own small business convinced that there had to be a 
better way to create a medical home using technology. I wanted 
to increase practice efficiency, so I could spend more time 
listening to my patients.
    My desire to provide higher quality medical care was 
enabled by the ability to collect and analyze meaningful data, 
such as patients who are overdue for preventive or follow-up 
care. My HIT allows me to practice medicine in a way that I 
always envisioned I could. I know what is possible. More 
pediatricians need help implementing similar technology.
    Currently, pediatricians are the lowest adopters of HIT of 
all physician groups. Sixty percent of pediatricians practice 
in small businesses like mine. Many of us have found it 
difficult to purchase health IT systems on our own. A big 
factor in our inability to afford expensive technology has been 
the reduced Medicaid payments that most pediatricians receive. 
According to AAP surveys, Medicaid payments average around 70 
percent of Medicare rates and vary widely from State to State. 
If a typical Medicare provider sees 20 patients per day, a 
Pennsylvania Medicaid provider must see 30 patients to earn the 
same amount.
    And Congressman Westmoreland, Atlanta is the same.
    In New York, the Medicaid provider burden jumps to 40 
patients and my exhausted colleagues in Chicago must see 50. 
With Medicaid now covering more than 30 million children, this 
pace is simply unsustainable.
    The Academy greatly appreciates the funding included in 
ARRA for pediatricians to purchase health IT. Unfortunately, 
the statute creates disparities between practices that are paid 
by Medicaid versus Medicare. First, ARRA funds flow differently 
for the two programs. ARRA requires practices to maintain a 
minimum percentage of Medicaid patients in order to qualify for 
incentives under that program. This requirement is not imposed 
on practices receiving Medicare payments. The Academy believes 
that this requirement should be repealed so that the Medicaid 
and Medicare incentives are comparable.
    Second, the definition of "meaningful use" is treated 
differently for Medicare versus Medicaid programs. Medicare is 
defining a single national standard under which a practice will 
qualify for ARRA incentives. On the Medicaid side, it appears 
that States can create their own definitions. As a result, 
within a brief time there could be 56 different definitions of 
"meaningful use" in the various State and territorial Medicaid 
programs.
    One-third of doctors practice near State lines. Under the 
current statute they might need to qualify under two or more 
States' meaningful use rules. I cannot imagine a single EHR 
vendor who will be willing to write 56 different meaningful use 
reports for medical practices to submit to their States.
    The Academy believes that a single national standard for 
pediatric meaningful use is not only achievable, but essential 
for measuring and improving the equality of health care for all 
children. We stand ready to work with the appropriate agencies 
to create such a uniform definition.
    We would also urge you to consider one other issue that 
could have immediate impact on the advancement of child health 
IT. There had been much talk about HIT interoperability. Every 
State maintains a central immunization registry, and the CDC 
has defined robust interchanged standards for these systems. 
Yet only a small handful currently offer real-time 
interoperability with EHRs and almost none of them talk to each 
other. Why? Because States lack resources to upgrade their 
systems and implement those standards.
    As a result, my pediatric colleagues and I have limited 
access to this critical public health information. The 
collected data sits in massive repositories just beyond our 
reach, when it could be put to meaningful use in short order.
    This shovel-ready project has significant value to each and 
every practicing pediatrician as well as promoting public 
health goals by improving immunization rates and preventing 
misuse of health care dollars due to inappropriate or duplicate 
immunizations.
    Thank you very much for the opportunity to testify before 
you today. We appreciate this committee's efforts to help small 
pediatric practices continue our vital mission to provide high-
value medical care to the Nation's children. I will be happy to 
entertain any questions.
    [The statement of Dr. Kressly is included in the appendix.]
    Chairwoman Dahlkemper. We have been called over for another 
vote. We will have time to get two testimonies in and then we 
will go vote and then we will come back for the questions.
    So I would like introduce Dr. Charles Stuckey. Dr. Stuckey 
is the Executive Director of the Pennsylvania Optometric 
Association in Harrisburg, Pennsylvania. The Pennsylvania 
Optometric Association is the professional organization for 
over 1,250 doctors of optometry in Pennsylvania. He is 
testifying on behalf of the American Optometric Association. 
The AOA represents 36,000 doctors, students, assistants and 
technicians in the optometry industry.
    Welcome, Dr. Stuckey.

           STATEMENT OF DR. CHARLES J. STUCKEY, O.D.

    Dr. Stuckey. Thank you and good morning.
    My name is Charlie Stuckey. I practiced as an optometrist 
for 23 years in Pennsylvania, and I am currently the Executive 
Director of the Pennsylvania Optometric Association 
representing more than 1,250 Pennsylvania doctors of optometry. 
Today, it is my honor to testify on behalf of the American 
Optometric Association and its 36,000 members nationwide, many 
of whom have traveled to Washington, D.C., today to participate 
in the AOA Congressional Advocacy Conference.
    We appreciate this opportunity to provide the House Small 
Business Subcommittee on Regulation, Health Care and Trade with 
our views and recommendations regarding the challenges to 
greater adoption and use of health information technology 
facing physicians, specifically doctors of optometry, and other 
health care providers.
    AOA agrees with many analysts and policymakers that health 
IT is an important ingredient for improving the efficiency and 
quality of health care in the United States. The electronic 
health record, or EHR, is the central component of health IT, 
and when used effectively, can enable providers to better 
organize patient data, replace lengthy record processes, help 
deliver better coordinated care among a patient's team of 
health care providers, prevent errors, and cut overall health 
care costs.
    AOA was pleased that optometrists were included when 
Congress incorporated a provision of the American Recovery and 
Reinvestment Act of 2009, or ARRA, to spur greater adoption of 
health information technology by providing substantial 
financial incentive to help physicians purchase and implement 
health IT. AOA members appreciate the valuable opportunity to 
obtain this unprecedented assistance; however, significant 
barriers to widespread adoption and use remain.
    ARRA explicitly states that for a physician to be a 
meaningful user of health IT and be eligible for incentives, 
the EHR that he or she uses must be certified. Yet, to date, 
the only federally recognized certification body is the 
Certification Commission for Health Care Information and 
Technology, CCHIT, which has not developed a certification for 
eye care EHRs. While AOA's concerns focus mostly on eye care, 
we believe that our situation will not be unique as other 
medical specialties with specialized EHR systems seek to 
develop certification through CCHIT.
    The AOA and others lobbied for a path to certification 
which led CCHIT to place eye care on the road map for a 2011 
launch. We continued to argue that it was essential for the eye 
care specialty to have an accelerated time line for launch so 
that eye care professionals would be able to adopt certified 
EHRs and be able to use them meaningfully by 2011. We were 
delighted to learn earlier this month that the Commission is 
open to an eye care EHR certification launch in 2010, but the 
limiting factor to add specialty areas of certification was 
resources.
    Today, the AOA would strongly recommend that the Office of 
National Coordinator endorse and support the expansion of areas 
of CCHIT certification to ensure that ARRA incentives serve 
their intended purpose of spurring widespread adoption of 
health IT. In addition, we would urge that as policymakers and 
certifying organizations move to define meaningful use; we 
would caution against a one-size-fits-all approach. Just as 
different providers need different types of EHRs, the 
meaningful use of EHRs can vary. The bottom line should be 
improved results for patients.
    In addition to certification concerns, the AOA is troubled 
that some provider colleagues are not currently eligible for 
HIT adoption incentives and may be left behind as the 
nationwide HIT system develops. While ARRA provides incentives 
to doctors of optometry and other Medicare physicians, the 
legislation does not address the need to ensure the inclusion 
of a large and diverse group of providers which comprise a 
significant part of our health care delivery system.
    AOA fosters a multidisciplinary team approach to care. The 
AOA urges the leaders in Congress to ensure that all clinicians 
are included as we get to work on developing a nationwide 
health IT network. This is particularly important for 
optometrists and other clinicians who are small businesses and 
need to be able to plug into local and regional networks.
    Thank you for the opportunity to represent the concerns of 
thousands of owners of small business optometric practices 
before you today. Thank you.
    Chairwoman Dahlkemper. Thank you, Dr. Stuckey.
    [The statement of Dr. Stuckey is included in the appendix.]
    Chairwoman Dahlkemper. And now I would like to recognize 
Mr. Westmoreland to introduce our last witness.
    Mr. Westmoreland. Madam Chairwoman, it is my pleasure to 
introduce Dr. Carladenise Edwards, who is the chief of staff of 
the Georgia Department of Community Health. DCH is the Georgia 
State agency responsible for health care planning, financing 
and regulation, and provides health care for approximately 2 
million people. Dr. Edwards serves as a principal advisor to 
the Commissioner of Community Health on health care policy.
    Prior to her current position, Dr. Edwards was the 
Executive Director of the South Florida Health Information 
Initiative, a regional health information organization designed 
to improve health care quality, access, and efficiency through 
technology.
    She also served as the first Executive Director of the 
Florida Governor's Health Information Infrastructure Advisory 
Board. Dr. Edwards earned a B.A. In sociology and an M.S. In 
education from the University of Pennsylvania. She holds a 
doctorate in medical sociology from the University of Florida.
    Welcome to the subcommittee, Dr. Edwards. We look forward 
to your testimony.

   STATEMENT OF CARLADENISE ARMBRISTER EDWARDS, Ms.Ed., Ph.D.

    Ms. Edwards. Thank you and good morning, Chairwoman 
Dahlkemper and Ranking Member Westmoreland. Thank you for the 
opportunity to testify on a subject that I am exceptionally 
passionate about, health information technology.
    My name is Carladenise Armbrister Edwards, and as the Chief 
of Staff for Georgia's Department of Community Health, as the 
ranking member has said, I am responsible for the health care 
for over 2 million Georgians.
    Our department provides health care through the Medicaid 
program, the State employee program; and we ensure compliance 
with health care regulations across the State. On July 1, we 
will also assume responsibility for public health, emergency 
preparedness and health care regulations.
    Prior to serving as the Chief of Staff for Georgia's 
Department of Community Health I actually founded my own 
business, The BAE Company. My father, Lieutenant Colonel 
Anthony Armbrister, Marine Corps, Retired, and I built the 
business with the intention of helping other small businesses 
achieve their strategic goals through business development, 
implementation of technology, change management and system 
redesign strategies. So, therefore, I come before you not only 
with some knowledge and experience in health information 
technology implementation, the impact on State government, but 
also with some experience in small business ownership.
    First, I would like to talk to you a little bit about the 
impact of health information technology on health care 
providers and the benefits and drawbacks of the Recovery Act 
from the perspective of a large government employer who 
contracts with health care providers for the Medicaid and State 
health benefit plan.
    As you can imagine, the State of Georgia has a vested 
interest, a $12 billion interest, in ensuring health care 
services are provided in the most cost-effective and efficient 
manner possible. We want to make sure that our employees have 
access to quality health care so that we have a strong, 
productive work force; and we want to make sure that 
beneficiaries have access to health care at the lowest possible 
cost to the State. Therefore, we are strong proponents of 
health IT.
    Georgia's Department of Community Health is actively 
participating in the advancement of health information 
technology and transparency projects in several ways. First, we 
have established a health transparency Web site that provides 
health care consumers with information that allows them to 
identify providers by location, cost and quality. It also gives 
them the opportunity to evaluate health plans. We think it is 
critically important that consumers actively participate in 
understanding the opportunities that come from health 
information technology and managing their own health care.
    The Department is also providing grants to large and small 
health care providers to implement health information 
technology systems in their practice. However, due to State 
budget constraints, this program is at risk of being 
discontinued, despite the fact that we have seen the financial 
benefit to implementing interoperable health information 
exchange that can reduce duplication, improve patient safety, 
and increase access to care through the use of telemedicine and 
electronic prescribing.
    Thirdly, Georgia's Medicaid program is in the process of 
creating a technological solution that will be Web based and 
allow Medicaid providers secure access to an electronic health 
records system in a virtual environment. We are hoping that 
this will help avoid or eliminate some of the challenges that 
the previous panelists have spoken about relating to the cost 
of purchasing, hosting, and maintaining a hardware and software 
solution. In many cases, that is not viable for a small 
physician practice.
    And lastly, but not finally--I just don't have time to tell 
you about everything that we are doing--DCH is working 
collaboratively with private and public partners to sustain 
Georgia's electronic health record partnership. We are trying 
to position ourselves to serve as one of the regional extension 
centers that the coordinator spoke of earlier through the 
HITECH Act.
    We also look forward to being able to disseminate loans to 
small physician practices and grants to providers through the 
HITECH Act, as well as creating the opportunity for training 
and technical assistance which is so very much needed in order 
to assure compliance with the rules and regulations as well as 
the new HIPAA provisions.
    Georgia is looking forward to the opportunities presented 
in the HITECH Act, but we are aware of the drawbacks--primarily 
the drawback being failure. Frederick Douglass once said that 
power does not concede without demands. The failure will come 
from consumers' inability to advocate on their own behalf. And 
those consumers are consumers of health care as well as the 
providers and the small businesses who consume the resources 
that our health care industry provides. So we think it is 
critically important that we provide the incentives and that we 
are able to advocate for consumers as well as small businesses 
at the State and Federal level.
    Thank you for this opportunity.
    Chairwoman Dahlkemper. Thank you, Dr. Edwards.
    [The statement of Ms. Edwards is included in the appendix.]
    Chairwoman Dahlkemper. And I appreciate your patience and 
the committee now stands in recess.
    [Recess.]
    Chairwoman Dahlkemper. The committee is now called to 
order. Thank you for your patience.
    We will get through the questioning. I am going to yield 
myself 5 minutes now, and we will yield each member 5 minutes. 
And if we have time, we will go through a second round, if 
needed. But that will help us get through the questions in case 
we are called back for another vote shortly.
    Dr. Edwards, I wanted to talk to you a little bit about 
your experiences there in Georgia. And you testified that your 
government's role has been addressing barriers that prevent the 
use of health technology. From your experiences in Georgia, do 
you find that cost is generally the greatest barrier?
    What barriers are you seeing in Georgia? I want 
perspectives on how you see what you have done in Georgia, how 
your experiences could be utilized in our looking at a system 
that would cover the entire country.
    Ms. Edwards. Thank you for the question.
    Finance for small physician practices is one of the 
significant barriers. Many of the practices say that it is cost 
prohibitive to adopt. But the initial investment is not so much 
the fear as it is the long-term sustainability and then the 
fear of reduction in service and their ability to provide 
services in an economical way.
    So cost is defined in several ways. One, you have to come 
up with the money to invest in the system, and two, you have to 
sustain that system. But then you also have to change your 
business practices to accommodate a new way of practicing 
medicine.
    So the second barrier really comes from whether or not 
there is a desire or willingness to have an interoperable 
system that shares information and ultimately, in some cases, 
reduces duplication and utilization of unnecessary health care 
services.
    And so the fight, or the tension, between making a system 
more efficient and then being able to make money creates this 
conflict and, sometimes, a barrier to adoption.
    And so we found both in Georgia where, for small physician 
practices, it could simply be the upfront cost; but for larger 
health systems, it is a lack of a desire or willingness to want 
to share information that creates the efficiencies that 
ultimately reduces health care spending.
    Chairwoman Dahlkemper. Right now we have a fee-for-service 
system. So the more service you can give, the more money you 
can make. And let me ask you then, as you look at that, being 
one of the barriers, do you see the barriers at all broken down 
by maybe age of the practitioner or do you see it broken down 
by specialties? Are there any differences there?
    Ms. Edwards. Age is interesting. I have actually had in my 
small business practice where I am helping them implement 
technology, providers say, I will either retire or die before 
you make me use a computer. So I say, Okay, I don't know which 
one is going to come first, but your business manager has 
already made the investment.
    So I have had older physicians say they are just not 
inclined to want to use technology as part of their practice. 
So that is a barrier in some cases, although that is a 
stereotype.
    There are some who are more than willing and able to do 
that.
    On the other end, as it relates to specialty--and Dr. 
Stuckey spoke to this very, very well and profoundly--the EHR 
companies and the vendors have been focused on ambulatory care 
in a comprehensive way, but failed to recognize that different 
doctors practice medicine differently. And what they chart and 
record and the information they need varies from one specialty 
to the next.
    And I have had with my practices that I have worked with 
barriers to adoption because the system doesn't accommodate OB/
GYN charting, pediatric growth charts or any other specialty. 
Oral screenings, they don't have the capacity to chart that 
information in the system and therefore the physicians are less 
likely to adopt.
    So both of those, age as well as specialty, have been 
barriers to universal adoption.
    Chairwoman Dahlkemper. But then there are also some 
intrinsic problems with how we are developing these systems 
that is not user friendly to all the different specialties that 
you might be dealing with?
    Ms. Edwards. Correct. It is not one-shoe-fits-all.
    Chairwoman Dahlkemper. Do you think we are going to be able 
to achieve that in what you have seen so far? You have been 
working on this for a while Georgia.
    Ms. Edwards. I am an optimist, and I think we can. If you 
think about banking and cell phones there are a gazillion 
different types of cell phones and we are still all able to 
talk to each other. There could be that many different types of 
EHR systems that are able to talk to each other if the demand 
is there. If we, as consumers, demand to have a more efficient 
system that is interoperable, that allows us to travel and have 
access to our information when we need it and where we need it.
    Chairwoman Dahlkemper. Mr. Jackson, you are one of the 
early adopters of HIT. How much time and money do you estimate 
it takes you to train an employee? You did bring up that there 
are some staff that you don't think will be able to utilize 
these systems once they are in place.
    Mr. Jackson. Yes, our experience has been that there have 
been staff members in some of the offices that we have 
integrated that have elected not to learn the new system 
because it was so different from what they had spent the 
previous 20 years doing.
    In terms of training, I think you are looking, from a 
dollar and cents wise, minimally probably $2,500 to $3,000 per 
individual to have them functional on a system such as we are 
using within our hospital.
    Chairwoman Dahlkemper. Are smaller practices going to be 
able to overcome those kinds of financial challenges as you 
look at that?
    Mr. Jackson. I am concerned about that, as I view it from 
the standpoint that--as I mentioned in my testimony--you are 
talking really about asking small practices to disrupt their 
operation. So not only are you going to lessen their 
throughput, you are going to put additional burden of hardware 
and software acquisition and the opportunity costs of training 
both from the time you take the individual out of being able to 
assist the physician and the actual hard dollars in training 
where you have to buy that, most likely, from the HIT company 
that you contracted with.
    Chairwoman Dahlkemper. What do you think could be something 
that we could do here in government to help assist that?
    My father, who lives in Erie, traveled to Detroit to see my 
sister, had some medical issues there; went to Ft. Worth to my 
brother's, had some medical issues there; stopped in Memphis to 
see my daughter, had some medical issues there; and ended up in 
the hospital in Indianapolis on his way back through Detroit on 
his way back to Erie.
    Obviously, we have a person like him, who is 85 and still 
traveling around the country. Obviously, when we are talking 
about controlling costs and not having to have different tests 
in every city he goes to is going to be a huge saver in the 
end.
    I see the value of this, but what do you think we could be 
doing here?
    Mr. Jackson. From a government standpoint, I think there 
needs to be standardization of the information, how it is 
stored, how it is transmitted. And I think we have to explore 
at some point the thought of a central repository and that, 
instead of making it all individually based on the individual 
physician, either base it on the individual consumer or give a 
large repository where multiple nodes have access to 
centralized records.
    Chairwoman Dahlkemper. I said I was going to limit myself 
to 5 minutes. I have gone over, but I wanted to give everybody 
a chance in case we are called back for votes.
    I want to yield to Mr. Westmoreland.
    Mr. Westmoreland. I thank the chairlady for that.
    Just a quick--have any of you filed anything to what 
"meaningful use" is? Okay.
    That is an interesting point that was brought up about the 
chairlady's father; and I want to ask Dr. Kressly this:
    I know you are a pediatrician, but say somebody comes in 
that is from another State, and we have this up and running and 
there is a problem getting the information off or maybe they 
can't locate a different system or whatever they are trying to 
compile, all of this information, and it takes a while to do 
it.
    And this person is in the emergency room, and they need 
immediate care, and that care is given to them or whatever. An 
hour later all of these records come in, and they find out that 
they did something totally wrong, but they had to do a quick 
assessment of what was going on.
    You know, I think it is hard for everybody to get their 
heads around this and what is going to be involved to get these 
records down to something that can actually be very beneficial 
for the use.
    Mr. Fetzner there was talking about, it is going to start 
in the home. It is going to eventually get down to the home, 
somebody being monitored there. So what are the complications 
that could arise from these medical records and what kind of 
care a doctor may be hesitant to give without these records, 
his having these records, if the system was in place?
    I know now he basically just has to work from what tests he 
can do immediately and that. But if these records were 
available, how hesitant would a doctor be to go in and try to 
do something--acute care--without these records?
    Dr. Kressly. It is an interesting question. I believe, 
first of all, that physicians always act with whatever 
information they have in front of them at the time. I don't 
think that the electronic record makes any difference than the 
paper record. In my experience, if you are in the emergency 
room and someone comes in and you call for their old records, 
they come up a half an hour later--
    Mr. Westmoreland. This is somebody that has no old records.
    Dr. Kressly. You are at an disadvantage even in your own 
hospital if somebody is looking for the paper record that is 40 
feet deep.
    I am hoping that physicians will not alter the way they 
think, in that providing care with the best information they 
have at hand.
    The other thing that everyone should be aware of we talk a 
little about interoperability and exchange of information. 
There are actually some pretty good basic standards written 
already that the leading vendors are starting to implement.
    And physicians really do not want everything. I mean, I 
don't have time, whether it is on paper or in an electronic 
record, to sift through a lot of data. There are couple of hot-
ticket items--problem lists, current medications, history of 
surgeries, things that don't take a sophisticated amount of 
data exchange--that would affect how we treat medically.
    And I am not sure that you do that different electronically 
than you do with a phone call to the physician who might have 
seen them before, or whether a patient brings a thumb drive 
with their personal medical record and we can get it that way.
    Mr. Westmoreland. Now you are the doctor, you have got the 
medical records, and I don't know how long it is going to take 
you to go through them.
    Do you depend on what you observe or what the medical 
records and what other physicians have said about the different 
conditions that the patient may have?
    Dr. Kressly. You do it multifactorily. You take every 
information into consideration and you act as quickly as you 
need to, based upon the information that you have at hand. And 
sometimes you look back and you alter what you have already 
done and there are things that probably not implicated.
    But we have a better chance with the hot-ticket mistake 
items as far as medication interactions and medication 
allergies, a problem list, if we can condense them and get them 
quickly electronically, I do believe that has potential to save 
care, and physicians would act in the patient's best interest 
with more data than we have now.
    Mr. Westmoreland. Thank you.
    Dr. Edwards, given your unique perspective on the State 
level, and also being a small business provider level, what do 
you see the proper role of the Federal Government versus the 
State being in this case for our citizens?
    Ms. Edwards. I see the role of the Federal Government as 
being one that knocks down barriers or tries to create 
opportunities that would allow State government as well as 
local practitioners to advance the adoption and utilization of 
EHR.
    We typically say health care is local. Most people do 
receive health care in their community by their local provider, 
and so that individual, as well as that community, should be 
able to make decisions about what is in its best interest.
    The Federal Government, I think, has an obligation to 
create standards and ensure compliance, but at the same time 
not create barriers or inhibitors to us moving forward with 
systems and processes that really serve the interests of the 
consumers and the constituents in the community.
    And so I would look to the government to ensure that there 
are standards, to ensure that there is compliance as well as 
safety; and then create opportunities that will increase 
adoption and utilization.
    In Georgia, we are actually looking forward to the 
opportunity to participate in some of the high-tech related 
initiatives because we think that that we will, as a Nation, 
get more bang for our buck if we do use a centralized system of 
training or technical assistance for those providers who can't 
afford to go out and do that on their own.
    So if the money is available, I think it does make sense 
for the State to participate, to help provide training, to help 
provide technical assistance, as well as to ensure that the 
incentives that are provided actually meet the needs of those 
providers in their community.
    Mr. Westmoreland. Thank you.
    We will go another round if you want to.
    Chairwoman Dahlkemper. I now recognize Mr. Thompson for 5 
minutes.
    Mr. Thompson. Thank you, Madam Chairwoman, ranking member. 
This is a very important topic in terms of health care.
    Actually, a number of the witnesses--I represent that part 
of Pennsylvania adjoining Mrs. Dahlkemper up in the rural part 
of Pennsylvania; and having come out of health care--working 28 
years in health care, actually--my health system engaged in a 
somewhat painful process years ago with health information 
technology as a beta program.
    I wouldn't recommend that to anyone, actually; this is 
where you work out all the bugs. But it certainly has been a 
good move.
    I have some questions. I was interested, representing a 
very rural area, what has your experience been with 
interconnectivity? It is one thing to invest in infrastructure 
within the facilities, within the bricks and mortar, for the 
practices that you represent or the hospitals or the health 
care facilities. But networking them for the greatest 
efficiency in terms of communication, especially in rural 
America? Any thoughts, reflections on how prepared are we with 
interconnectivity?
    I will open that up to anyone on the panel.
    Ms. Edwards. Chairwoman Dahlkemper, if you don't mind--and 
Mr. Thompson--I would like to respond.
    The stimulus, the ARRA provisions actually have language in 
there and opportunities for increasing broadband activities. 
And in Georgia one of the things that our Governor, Sonny 
Perdue, has done is require all of the agencies that are 
eligible for stimulus funding to meet and meet and meet on a 
weekly basis, to make sure that we drive any dollar towards an 
end point that can be sustained by the State once these funds 
are no longer available, and then meet the best interests.
    One of those work groups is around broadband adoption, 
ensuring that if we have a broadband initiative, that it is 
used to expand the bandwidth for rural providers who want to 
adopt HIT from the HITECH Act. He has almost required us to say 
that if you are going to do this, we want to make sure that we 
get the bandwidth for the communities and maximize that 
opportunity.
    One of the opportunities that all the States should look at 
is how you intersect and force collaboration between education, 
health, and technology so that you are not building five or 
six--we call them T-1 lines--when you only really need one to 
meet the needs of the people who are out in the rural 
community, whether it is health or education or safety.
    Mr. Thompson. Anyone else with a perspective or experience 
with interconnectivity?
    Mr. Fetzner. Yes, from the perspective of home- and 
community-based care, which is about as dispersed as it gets, 
interconnectivity to me is the key issue in all of this. What 
we are really trying to create is a network where every user 
who joins benefits the whole. If, as long as we are just simply 
digitizing little silos--a doctor's office here, a hospital 
here--and they don't talk to each other, we really are not 
accomplishing all that much.
    And so, establishing standards--as Dr. Kressly pointed out, 
there are some standards that are existing already. Continua 
Health Alliance has recently published their standards; that is 
a great first step to creating that interconnectivity. So 
anything that the Federal Government can do to push standards 
quicker to get that groundwork laid will help with the 
adoption.
    Dr. Kressly. One of the things I wanted to say, being from 
rural PA, the standards and implementation are there, but there 
also have to be resources. Because the small businesses and the 
rural practices, the primary care physicians, don't have a lot 
of resources to help write the other piece of the interface.
    For example, my local hospital offered to help with health 
information technology for the primary care people in the 
region. But they decided that they would pick the vendor that 
was not friendly for pediatricians and other resources.
    And so some people went out and got their own EMR that 
actually is pediatric friendly. But the hospital won't turn on 
the spigot to let the information flow both ways even though I 
have the technology to do it. And there is no way a 
pediatrician can afford to add that additional cost of 
interoperability.
    So I would say that greasing the wheels between the two 
interoperable sites needs to come from funding from somewhere 
else, whether it is at the State level or used at--the 
interoperability that Dr. Blumenthal was talking about this 
morning.
    It needs to come from somewhere else because it is going to 
make it much harder for the smaller, independent physician 
groups when there are big players in the arena who can afford 
their end and decide they want to push what they want as their 
agenda, but it freezes out some of the smaller uses of 
technology which need to be supported.
    Believe it or not, in Warren, PA, a colleague of mine just 
bought an EHR, and he was able to input all the data from the 
Pennsylvania State registry as part of a pilot project, so all 
the immunization data he has been entering the last 15 years 
came back to him in electronic format. But that is a pilot and 
Pennsylvania State doesn't have the resources to make that a 
more statewide global initiative.
    So we are starting pilot projects but we need resources. 
The standards are being written. We can't wait for standards to 
all be finalized to start implementing. Again, the horse is out 
of the barn and the technology is moving ahead. We need to make 
sure that the resources put a level playing field for the 
small, independent practices and people in specialties who are 
not represented nationally in all the work groups.
    Mr. Thompson. And I think you hit on a real practical 
issue.
    My most recent experience before coming here was electronic 
medical records, specifically in a skilled nursing setting, 
which was great for nursing, but had absolutely no application 
for the physician part or rehabilitation part or other aspects. 
I think that is a challenge as we are now spending a lot of 
money--investing, and I look at it as investing.
    But there are not a lot of products out there that will 
handle the comprehensiveness, the continuum, in all the health 
care settings.
    Chairwoman Dahlkemper. We will do another round of 
questions for 5 minutes each.
    Mr. Fetzner, as you talked about the state of HIT adoption, 
maybe you could talk about the state of HIT adoption and 
integration in the long-term care industry, an industry that 
obviously continues to grow. All of us baby boomers will 
eventually be at that point. How will the provisions in the 
stimulus bill improve that adoption?
    This goes to the conversation we were just having. The 
integration and the people that go in and out of those 
facilities or in and out of those care sectors, if you could 
address that.
    Mr. Fetzner. Well, as part of the state of HIT adoption in 
home- and community-based care, it is pretty limited. You have 
providers implementing telehealth and telemonitoring, but again 
that information is being reported back to that single service 
provider, and it is not interconnected with the different 
aspects of the health care delivery system.
    With regards to the stimulus bill, one of my concerns in 
the stimulus bill is what I might consider an overemphasis on 
EHRs in that entire system. It is an important backbone, but 
not necessarily sufficient.
    So from the stimulus perspective, it would be nice to see a 
more balanced investment across the entire network of providers 
where you would lay many different seeds of investment with 
pilot projects and things across many different settings. I 
think that would help to create that tipping point of adoption 
where physicians who never had the information before will now 
have different information and will begin to realize that is 
useful to me for X, Y or Z or whatever that might be.
    Chairwoman Dahlkemper. Thank you.
    Dr. Stuckey, how much success has the eye care community 
had in working with CCHIT to establish criteria for certified 
HIT systems? And what are the unique challenges that you see 
your community facing on this front?
    Dr. Stuckey. Well, after giving testimony, I was fortunate 
enough to have a conversation with Dr. Kressly and her husband; 
and the amount of positive feedback that I got, we are going to 
be--we feel fairly assured that we are going to be successful 
relative to the results coming out of CCHIT.
    And the second part of the question was?
    Chairwoman Dahlkemper. What are the unique challenges that 
you see the optometric community facing on this front?
    Dr. Stuckey. It is very similar to what was previously 
said. I mean, basically the industry, being somewhat fragmented 
as it is, presents itself with the HIT issue--for it to be 
fragmented also. So as far as the challenges that were spoken 
to in terms of interoperability and interconnectivity, those 
are the challenges that we see in the future.
    So I would say everybody is really speaking the same 
language here, and I think if you look at it across the segment 
of the different health care representatives that we have, I 
think it is very similar.
    Chairwoman Dahlkemper. Dr. Kressly you brought up several 
different points that I found interesting in terms of the 
immunizations--I think that is what you are referring to when 
you talk about this physician in Warrington and being able to 
download that.
    Obviously, as a mother of five--and even myself, if I went 
to the doctor and they said, When is the last time you got a 
tetanus shot, most of us have no idea, so we get it anyway.
    The other point I wanted you to expand a little bit on is 
the States' ability to define "meaningful use." I am from the 
northwest corner of Pennsylvania, there is a 45-mile difference 
between New York State and Ohio in my area, so we have got 
physicians and patients sometimes going back and forth. So 
maybe if you could address that a bit.
    Dr. Kressly. I would be happy to. I think that presents a 
big problem.
    The way--it appears as if the ARRA funding under Medicaid 
is going to allow States their own State Medicaid programs to 
define "meaningful use." And I think that poses a problem for, 
especially, physicians practicing on borders. And the panel was 
actually speaking at the break; we would like to see government 
try to make the "meaningful use" definition as broad as 
possible.
    The more you hone down and try to make it specific, the 
more you are going to exclude people from adopting technology. 
And what we want to do here is actually promote increased 
adoption, not exclude people or give them reasons not to adopt. 
And so the broader those "meaningful use" definitions are that 
could cross State lines and apply to different Medicaid 
programs across State lines, the more easy this will be to 
implement and, I would expect, more easy for the government to 
actually be able to certify that people are using things 
meaningful.
    So I would urge everyone to consider that "meaningful use" 
should be broad and easily implemented in broad categories so 
we can catch as many people and promote as increased adoption 
as possible, widespread among different users with different 
needs.
    Chairwoman Dahlkemper. Thank you. And I would actually ask 
those in the panel and anyone else in this room who is 
interested to look at the open comment period here now, and 
when they have one in the future, and put your input here. You 
obviously have some great things to say.
    I will yield to Mr. Westmoreland. You are really 
outnumbered; Pennsylvanians all around. Luckily you brought in 
Dr. Edwards.
    Mr. Westmoreland. She has a Pennsylvania tie, too. I don't 
know how that worked out.
    Mr. Fetzner, you made a statement saying: When a 
cardiologist can see a trend analysis for daily vitals of a CHF 
patient living independently at home, meaningful use will 
exist. This type of meaningful use does not occur by investing 
in certified EHRs alone. This occurs when an entire provider 
network is connected and coordinated around a patient's plan of 
care. And I understand that.
    So you are looking at this "meaningful use" term as a 
living term that is going do evolve; is that true?
    Mr. Fetzner. Yes, that is correct. We are going to have a 
difficult time nailing down one specific meaning, which is why 
I would completely agree with Dr. Kressly, the broader you make 
it to be inclusive, the more you are going to stimulate 
adoption.
    Mr. Westmoreland. I agree with that. I just don't want to--
you know, once we come up with a definition, I think that this 
is something that you all need to put into this time of input, 
that this term, as the system progresses, may change--you know, 
how it is looked at.
    I think that is a linchpin to how successful this is going 
to be and how many people are going to participate.
    Mr. Fetzner. I think the pace of adoption, as it speeds up 
it is going to be incredibly difficult to put definitions 
around with regard to regulations and things like that. The 
more we allow the entrepreneur, the individual, the small 
business line of sight into what the goal of that regulation is 
and create a generous and efficient waiver process where they 
can say, Hey, I am meeting this in a different and alternate 
method, I think that is going to go a long way to promoting the 
adoption.
    Mr. Westmoreland. I think that is a good point. I think Dr. 
Edwards alluded to that, that the Federal Government needs to 
get out of the way--I know you didn't say that.
    Dr. Edwards, I will ask you one other question about 
meaningful use. Is it possible for these small group private 
physicians to meet the HHS health IT information goals without 
"meaningful use," without that term?
    Ms. Edwards. Boy. Honestly, yes, Mr. Westmoreland. It is 
possible for small physician practices, large physician 
practices to adopt and to utilize technology in a meaningful 
way without Federal Government having defined "meaningful."
    I agree with Dr. Kressly. The definition of "meaningful" 
needs to be broad enough to incentivize and encourage the 
adoption and utilization; however, you need to have some 
guidance in terms of how you would distribute those funds.
    If I ruled the world, I would ensure that the distribution 
of those funds met the needs of the small business practice, 
the small physicians, the entities that have the greatest 
challenge in adopting due to perhaps the age of their practice, 
their revenue stream or their access to technology, based on 
their location, being in a rural environment. If we can make 
sure that we drive the available resources to increase adoption 
among those who are least likely to adopt, I think we would 
make the best use of those funds.
    "Meaningful" will mean different things to different 
people. It is not just adopting it and having it sitting on a 
shelf; it is actually utilizing it for the benefit of the 
patient and the consumer.
    Mr. Westmoreland. Right.
    And let me say, you made a point, I think, when the 
chairlady asked you about age or specialty or whatever. Every 
time I go to a doctor, I ask them about the IT and the 
electronic health records.
    My wife--and thank the Lord, she doesn't have cancer and 
she had to go to an oncologist. And one of the reasons that 
they had not gone, or at least attempted to, is because the 
system that they looked at did not meet their needs for what it 
took to input the information.
    I went to my doctor and I asked him about it too. It just 
happened to be a urologist. He made--I don't guess I am 
violating any HIPAA laws or anything--but he said the same 
thing.
    And so I think this is something that we are going to have 
to get down and take into consideration when we are looking at 
"meaningful use" to make sure that the Federal Government 
doesn't have a one-size-fits-all kind of thing and that they 
have to look at each of the individual specialties and 
professions and health care providers; whether it be long-term 
health care or at home or wherever it is, that they look at 
this and take this under consideration when they are coming up 
with this term that is going to be so vital to who is going to 
be able to have accessibility to the funds.
    With that, I yield back.
    Chairwoman Dahlkemper. I now recognize Mr. Thompson and we 
have 4 minutes and 45 seconds left.
    Mr. Thompson. Mr. Jackson, Grove City has overcome some 
significant hurdles to institute your IT system, but many of 
your rural neighbors in Pennsylvania have not had the same 
opportunities or foresight.
    The stimulus package included $18 billion of information 
technology. It is a large dollar amount, but really it is only 
a drop in the bucket of the realistic need. Included with it 
were some strings that a 3 percent cut in Medicare payments 
would occur after 2015 without implementation of a system.
    What advice would you give Congress when looking at rural 
health providers that, frankly, are going to face, I think, 
more barriers than perhaps other areas in implementing this; 
and how can we provide further incentives for rural hospitals 
and doctors?
    Mr. Jackson. Mr. Thompson, the part that I am most 
concerned about is the collision of the health care redesign 
with the EMR implementation.
    The incentives out there will provide the ability to move 
some providers off the fence, but ultimately you are looking at 
an investment that is going to be a recovery not unlike when 
you install new windows in your home. There is a large 
investment up front, knowing that over 20 years you will have 
an incremental savings that will exceed the initial investment.
    Somehow we need to get the money into the hands of the 
rural providers to make that initial investment--not just use 
it, but be able to acquire the technology. Most of the 
incentives are in place for use of the technology.
    Mr. Thompson. You talked about a large investment up front. 
I would also encourage--my own involvement with information 
technology, this technology is turning over very rapidly. It 
used to be 7 years, it is closer to 3 years now. And the folks 
who design this--it is a good thing, but this initial 
investment of billions of dollars, it is going to require 
billions that will have to come out of your operations--maybe 
every 3 years at a minimum; at the most, maybe 7 years right 
now.
    And I don't put that in the form of a question because we 
have to go vote. So thank you.
    Chairwoman Dahlkemper. Thank you, Mr. Thompson.
    I want to thank the panel today for your--first of all, for 
your patience with us as we have to go vote. I thank you for 
traveling here and for your testimony and for your answers to 
our questions. I think you brought up a lot of good points.
    I will be dropping my Health Information Technology 
Financing Act of 2009 today, which is a loan guaranty program 
that will help small group practitioners find the funding they 
need to implement HIT.
    So, with that, I ask unanimous consent that members will 
have 5 days to submit statements and supporting materials for 
the record. Without objection, so ordered.
    This hearing is now adjourned.
    [Whereupon, at 12:25 p.m., the subcommittee was adjourned.]

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