[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 ---------- U.S. GOVERNMENT PRINTING OFFICE 50-468 PDF WASHINGTON : 2009 For sale by the Superintendent of Documents, U.S. Government Printing Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC area (202) 512-1800 Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001 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.] [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]