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



 
 IMPLEMENTATION OF THE HEALTH INFORMATION TECHNOLOGY FOR ECONOMIC AND 

                      CLINICAL HEALTH (HITECH) ACT
=======================================================================



                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE

                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                             JULY 27, 2010

                               __________

                           Serial No. 111-149


      Printed for the use of the Committee on Energy and Commerce

                        energycommerce.house.gov




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                    COMMITTEE ON ENERGY AND COMMERCE

                 HENRY A. WAXMAN, California, Chairman
JOHN D. DINGELL, Michigan            JOE BARTON, Texas
  Chairman Emeritus                    Ranking Member
EDWARD J. MARKEY, Massachusetts      RALPH M. HALL, Texas
RICK BOUCHER, Virginia               FRED UPTON, Michigan
FRANK PALLONE, Jr., New Jersey       CLIFF STEARNS, Florida
BART GORDON, Tennessee               NATHAN DEAL, Georgia
BOBBY L. RUSH, Illinois              ED WHITFIELD, Kentucky
ANNA G. ESHOO, California            JOHN SHIMKUS, Illinois
BART STUPAK, Michigan                JOHN B. SHADEGG, Arizona
ELIOT L. ENGEL, New York             ROY BLUNT, Missouri
GENE GREEN, Texas                    STEVE BUYER, Indiana
DIANA DeGETTE, Colorado              GEORGE RADANOVICH, California
  Vice Chairman                      JOSEPH R. PITTS, Pennsylvania
LOIS CAPPS, California               MARY BONO MACK, California
MICHAEL F. DOYLE, Pennsylvania       GREG WALDEN, Oregon
JANE HARMAN, California              LEE TERRY, Nebraska
TOM ALLEN, Maine                     MIKE ROGERS, Michigan
JANICE D. SCHAKOWSKY, Illinois       SUE WILKINS MYRICK, North Carolina
CHARLES A. GONZALEZ, Texas           JOHN SULLIVAN, Oklahoma
JAY INSLEE, Washington               TIM MURPHY, Pennsylvania
TAMMY BALDWIN, Wisconsin             MICHAEL C. BURGESS, Texas
MIKE ROSS, Arkansas                  MARSHA BLACKBURN, Tennessee
ANTHONY D. WEINER, New York          PHIL GINGREY, Georgia
JIM MATHESON, Utah                   STEVE SCALISE, Louisiana
G.K. BUTTERFIELD, North Carolina
CHARLIE MELANCON, Louisiana
JOHN BARROW, Georgia
BARON P. HILL, Indiana
DORIS O. MATSUI, California
DONNA M. CHRISTENSEN, Virgin 
    Islands
KATHY CASTOR, Florida
JOHN P. SARBANES, Maryland
CHRISTOPHER S. MURPHY, Connecticut
ZACHARY T. SPACE, Ohio
JERRY McNERNEY, California
BETTY SUTTON, Ohio
BRUCE L. BRALEY, Iowa
PETER WELCH, Vermont
                         Subcommittee on Health

                FRANK PALLONE, Jr., New Jersey, Chairman
JOHN D. DINGELL, Michigan            NATHAN DEAL, Georgia,
BART GORDON, Tennessee                   Ranking Member
ANNA G. ESHOO, California            RALPH M. HALL, Texas
ELIOT L. ENGEL, New York             BARBARA CUBIN, Wyoming
GENE GREEN, Texas                    JOHN B. SHADEGG, Arizona
DIANA DeGETTE, Colorado              STEVE BUYER, Indiana
LOIS CAPPS, California               JOSEPH R. PITTS, Pennsylvania
JANICE D. SCHAKOWSKY, Illinois       MARY BONO MACK, California
TAMMY BALDWIN, Wisconsin             MIKE FERGUSON, New Jersey
MIKE ROSS, Arkansas                  MIKE ROGERS, Michigan
ANTHONY D. WEINER, New York          SUE WILKINS MYRICK, North Carolina
JIM MATHESON, Utah                   JOHN SULLIVAN, Oklahoma
JANE HARMAN, California              TIM MURPHY, Pennsylvania
CHARLES A. GONZALEZ, Texas           MICHAEL C. BURGESS, Texas
JOHN BARROW, Georgia
DONNA M. CHRISTENSEN, Virgin 
    Islands
KATHY CASTOR, Florida
JOHN P. SARBANES, Maryland
CHRISTOPHER S. MURPHY, Connecticut
ZACHARY T. SPACE, Ohio
BETTY SUTTON, Ohio
BRUCE L. BRALEY, Iowa

                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     1
    Prepared statement...........................................     4
Hon. John Shimkus, a Representative in Congress from the State of 
  Illinois, opening statement....................................     8
Hon. Lois Capps, a Representative in Congress from the State of 
  California, opening statement..................................     9
Hon. Phil Gingrey, a Representative in Congress from the State of 
  Georgia, opening statement.....................................    10
Hon. Janice D. Schakowsky, a Representative in Congress from the 
  State of Illinois, opening statement...........................    11
Hon. Joseph R. Pitts, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................    12
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, opening statement...............................    13
Hon. Joe Barton, a Representative in Congress from the State of 
  Texas, opening statement.......................................    14
    Prepared statement...........................................    16
Hon. Donna M. Christensen, a Representative in Congress from the 
  Virgin Islands, opening statement..............................    22
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................    22
Hon. John P. Sarbanes, a Representative in Congress from the 
  State of Maryland, opening statement...........................    23
Hon. Marsha Blackburn, a Representative in Congress from the 
  State of Tennessee, opening statement..........................    24
Hon. John D. Dingell, a Representative in Congress from the State 
  of Michigan, opening statement.................................    25
Hon. Kathy Castor, a Representative in Congress from the State of 
  Florida, opening statement.....................................    26
Hon. Gene Green, a Representative in Congress from the State of 
  Texas, opening statement.......................................    27
Hon. Tim Murphy, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................    28
Hon. Zachary T. Space, a Representative in Congress from the 
  State of Ohio, opening statement...............................    29
Hon. John Barrow, a Representative in Congress from the State of 
  Georgia, opening statement.....................................    30
Hon. Jane Harman, a Representative in Congress from the State of 
  California, opening statement..................................    31
Hon. Henry A. Waxman, a Representative in Congress from the State 
  of California, prepared statement..............................   155

                               Witnesses

David Blumenthal, M.D., National Coordinator, Health Information 
  Technology, U.S. Department of Health and Human Services.......    32
    Prepared statement...........................................    35
    Answers to submitted questions...............................   165
Anthony Trenkle, Director, Office of E-Health Standard and 
  Services, Centers for Medicare and Medicaid....................    48
    Prepared statement...........................................    51
    Answers to submitted questions...............................   167
Frank J. Vozos, M.D., FACS, Executive Director, Monmouth Medical 
  Center, on Behalf of New Jersey Hospital Association...........    82
    Prepared statement...........................................    86
Gregory D. Starnes, CEO, Fayette County Hospital.................    93
    Prepared statement...........................................    96
Christine Bechtel, Vice President, National Partnership for Women 
  and Families...................................................   100
    Prepared statement...........................................   102
Roland A. Goertz, M.D., M.B.A., President-Elect, American Academy 
  of Family Physicians, CEO and Executive Director, Heart of 
  Texas Community Health Center..................................   107
    Prepared statement...........................................   109
Matthew Winkleman, M.D., Physician, Primary Care Group, 
  Harrisburg, Illinois...........................................   116
    Prepared statement...........................................   118
Glen E. Tullman, Chief Executive Officer, Allscripts.............   121
    Prepared statement...........................................   124
Peggy C. Evans, Ph.D., CPHIT, Director, Washington and Idaho 
  Regional Extension Center, Qualis Health.......................   128
    Prepared statement...........................................   131

                           Submitted material

Statement of The Academy Advisors, submitted by Mr. Shimkus......   160
Statement of The Premier healthcare alliance, submitted by Mr. 
  Shimkus........................................................   162


 IMPLEMENTATION OF THE HEALTH INFORMATION TECHNOLOGY FOR ECONOMIC AND 
                      CLINICAL HEALTH (HITECH) ACT

                              ----------                              


                         TUESDAY, JULY 27, 2010

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 1:05 p.m., in 
Room 2322 of the Rayburn House Office Building, Hon. Frank 
Pallone, Jr. [Chairman of the Subcommittee] presiding.
    Members present: Representatives Pallone, Dingell, Eshoo, 
Green, Capps, Schakowsky, Harman, Gonzalez, Barrow, 
Christensen, Castor, Sarbanes, Murphy of Connecticut, Space, 
Waxman (ex officio), Shimkus, Pitts, Murphy of Pennsylvania, 
Burgess, Blackburn, Gingrey and Barton.
    Staff present: Ruth Katz, Chief Public Health Counsel; 
Purvee Kempf, Counsel; Katie Campbell, Professional Staff 
Member; Emily Gibbons, Professional Staff Member; Tim 
Gronniger, Professional Staff Member; Virgil Miler, 
Professional Staff Member; Alvin Banks, Special Assistant; Ryan 
Long, Minority Counsel; Clay Alspach, Minority Counsel; Sean 
Hayes, Minority Counsel; Brandon Clark, Minority Professional 
Staff; and Garrett Golding, Minority Legislative Analyst.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. I call the meeting of the Health Subcommittee 
to order.
    Today we are having a hearing on implementation of the 
Health Information Technology for Economic and Clinical Health 
Act of 2000, or the HITECH Act. Now, I should mention, and Mr. 
Shimkus reminded me, that this is actually in the Recovery Act, 
so we are actually talking about the implementation of the HIT 
part, if you will, of the Recovery Act. And I will recognize 
myself initially for an opening statement.
    The HITECH Act contained unprecedented funding to promote 
the adoption of health information technology among hospitals, 
doctors and health care providers through initiatives by the 
Office of the National Coordinator of HHS and through Medicare 
and Medicaid incentives. This historic investment will serve to 
modernize our Nation's use of technology to truly ensure a 
high-performing 21st century system.
    The Energy and Commerce Committee has worked on a 
bipartisan, collaborative basis for many years on health 
information technology. This hearing will examine the progress 
made so far and opportunities that will be realized in the 
future through the implementation of the HITECH Act.
    While the United States is a leader in medical technology 
and innovation, we have a curiously antiquated system today 
related to health IT. Only 20 percent of doctors and only 10 
percent of hospitals use even basic electronic health records, 
making coordination between health care providers challenging 
and leaving the burden on patients to ensure that each provider 
knows what tests have been done and what medications have been 
prescribed. Too often, this information falls through the 
cracks, resulting in wasteful, duplicative tests and preventing 
providers from having the full snapshot of a patient's medical 
profile.
    The successful adoption of health information technology 
will have a transformative effective on the quality of health 
care in the United States. The provisions of the HITECH will 
ensure that Americans nationwide have access to a truly 
patient-centered health care system with better quality, more 
affordable health care delivered in an efficient and 
coordinated manner. It also will promote the advanced use of 
electronic health records to facilitate the ordering of tests 
and medication, aid in clinical decision-making and allow for 
secure data-sharing and privacy protection among providers, 
insurers and patients.
    Now, it is timely that we have this hearing today, in my 
opinion, since CMS just announced on July 13th the final rule 
for the minimum requirements that eligible Medicare and 
Medicaid providers must meet through their use of a certified 
electronic health record technology to quality for the 
incentive payments included in the HITECH Act. This rule was 
dually released with companion final regulations on the 
standards and certification criteria needed for EHR technology 
to be successfully used by eligible professionals and 
hospitals.
    There are over 2,000 health care providers, patients and 
other stakeholders who weighed in on the proposed rule when it 
was released in January. Many changes were incorporated into 
the final rule, which preserved the goals of the HITECH Act 
while also making the requirements attainable. I look forward 
to hearing an update on these rules from our witnesses today as 
well as on other aspects of the HITECH Act.
    I will note we have two great panels of government and 
private witnesses here with us today. I am particularly pleased 
that Dr. Frank Vozos, the Executive Director of my hometown 
hospital, Monmouth Medical Center, can be with us today. I had 
the opportunity to tour Monmouth Medical Center, which is a 
community teaching hospital, over the, I guess it was the July 
4th recess or work period, and I was very pleased to see the 
work they are doing already to implement HIT adoption and to 
learn how they plan to use HITECH funds and guidelines to 
further advance their medical care, so I want to thank Frank 
Vozos, another Frank, for being with us here today.
    I have mentioned in the past sort of a personal story with 
regard to the HIT issue. My mom passed away from pancreatic 
cancer about 18 months ago now, and for the 7 months or so from 
when she was diagnosed until she finally passed, we went to 
various institutions including Monmouth Medical and Johns 
Hopkins, and it would also drive me crazy because we would 
have, I guess it was the CAT scan put on a disc--Robert Wood 
was another one that we visited--and at each place I would try 
to carry the CAT scan with me and say OK, here it is on a disc, 
you know, these are the tests she had, and without reference to 
any particular institution, I always had to have it redone, 
because they couldn't use, either there was no interoperability 
or whatever. And it drove me crazy but it just seemed to make 
no sense, and of course, I was worried because she was in a bad 
situation, that this wasn't a good thing for her to have to be 
restested all the time. So that is just my own personal 
experience that hopefully that type of thing we can guard 
against in the future.
    [The prepared statement of Mr. Pallone follows:]
    [GRAPHIC] [TIFF OMITTED] 78126A.001
    
    [GRAPHIC] [TIFF OMITTED] 78126A.002
    
    [GRAPHIC] [TIFF OMITTED] 78126A.003
    
    [GRAPHIC] [TIFF OMITTED] 78126A.004
    
    Mr. Pallone. With that, I will ask Mr. Shimkus to give us 
an opening statement.

  OPENING STATEMENT OF HON. JOHN SHIMKUS, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF ILLINOIS

    Mr. Shimkus. Thank you, Mr. Chairman, for holding this 
hearing to update us on the progress of implementing the HITECH 
Act. This issue has shared bipartisan support as we seek to 
modernize and create efficiencies in our health care delivery 
system.
    Despite the enthusiasm and promises of HIT, concerns have 
been voiced from the provider community as we move forward. 
Some issues have already been addressed such as loosening the 
number of requirements in the first year to comply with 
meaningful use and allowing critical-access hospitals 
eligibility for certain payments under Medicaid. However, other 
roadblocks remain and we must ensure providers across the 
country are able to meet the requirements in the timeline set 
out.
    The hearing today is a chance for us to review where we 
stand and ask ourselves if we are trying to make providers run 
before they can walk when it comes to HIT. I particularly want 
to thank a few of our witnesses for being here today from my 
district back in Illinois. First, Mr. Gregory Starnes is here 
from Fayette County Hospital, which is a critical-access 
hospital. Mr. Starnes lends a voice to rural hospitals and the 
unique challenges they face in trying to implement their 
systems without the budget and attention of some larger urban 
hospitals. I also want to thank Dr. Matt Winkleman from 
Harrisburg, Illinois, for making the trip here today, and of 
course everyone knows Harrisburg, Illinois--and that is 
supposed to be a joke. My staffer is fired. That is a good 
joke. It is all in the delivery, he says.
    I look forward to hearing from Dr. Winkleman on his 
practice was able to rise to the challenge of implementing HIT 
while working off the small margins that come from serving a 
rural working-class community.
    Despite the promising future the HITECH Act holds, it is 
difficult to look past the failures of the so-called stimulus 
bill it was part of. The American people paid the tab on what 
they were told would create jobs, keeping unemployment at below 
8 percent and to stimulate the economy. The country has lost 
over 3 million jobs since the stimulus passed and unemployment 
hovers at 9.5 percent, even higher in my district in Illinois, 
all this at a cost of $1.2 trillion to the American taxpayer, 
an enormous failed policy continued with the health reform law. 
We have been in session 15 weeks since the health care bill was 
signed into law by the President in March, 15 weeks and 15 
hearings on health, not on the law. In what is likely our last 
hearing before recess, the majority has never responded to 
numerous requests to hold hearings on implementation of the new 
law. On several occasions we have asked for the Administration 
to come before the committee, to no avail. Yet with ease we 
were able to have representatives of both HHS and CMS to 
discuss the HITECH Act today, and we appreciate them coming.
    It has been over four months and the majority won't even 
acknowledge problems exist with the new law and they aren't 
going away. According to CBO, premiums in the individual market 
are going to increase 10 to 13 percent as a direct result of 
this law. Nearly all small businesses will see no relief from 
the tax credit in the law. Many small businesses will opt to 
pay fines rather than buy health insurance because they can't 
afford the cost. Instead, they will raise prices to customers 
and stop hiring new employees. High-risk pools that were 
supposed to provide immediate coverage uninsurable are going to 
have to have waiting lines and use preexisting conditions to 
limit those who enter the new pools. We were told the 
President's Executive Order would prevent federal dollars from 
being spent on abortion services yet we already know in 
Pennsylvania and New Mexico, millions of new federal dollars 
will go toward coverage of abortion services through their 
high-risk pools. The President promised the pro-life community 
and pro-life Democrats in the House his executive order would 
prevent this from happening. Will the President now make good 
on the promise or is this evidence of what many of us feared 
all along, that the health reform law lacks critical 
protections to prevent taxpayer-subsidized abortions.
    Millions of Americans will be forced into a Medicaid 
program that is going broke. At the same time, half of all 
seniors with Medicare Advantage will lose their coverage. Those 
lucky enough to keep them will see increases in cost while 
losing dental coverage and other benefits they rely on. For 
those in traditional Medicaid, the billions of dollars in cuts 
are unsustainable and will cause problems and reduce quality of 
care for seniors. Leading the charge will be Dr. Donald 
Berwick, CMS Administrator without any Congressional approval, 
and we need to talk to the new CMS Administrator. He is a big 
supporter of the British health system which has just reported 
that it has failed and they were moving to a decentralized 
process in system. The list continues to go on.
    We have a responsibility to hold hearings on the 
implementation of the new health care law just as we are doing 
here today when it comes to the HITECH Act. Madam Chairman, 
with the law that will touch every American life, I hope we 
will at least have an explanation for the majority to the 
American people on why this request is being ignored, and I 
yield back the balance of my time.
    Mrs. Capps [presiding]. The Chair recognizes herself for an 
opening statement.

   OPENING STATEMENT OF HON. LOIS CAPPS, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Mrs. Capps. I am so pleased that today we are exploring the 
beginning stages of the HITECH Act and our Nation's considered 
effort to move toward a more efficient and effective system of 
health care. Like many of my colleagues, I was here for some of 
the earliest conversations we had in this committee about HIT 
and I am really proud of what we have accomplished. This 
includes Chairman Dingell's bill last Congress, the Protecting 
Records, Optimizing Treatment and Easing Communications through 
Health Care Technology Act of 2008, and that bill is actually 
the one that laid the groundwork for many pieces of the HITECH 
Act.
    I hope that today we will be able to explore the 
implementation of the HITECH Act to date including both the 
successes as well as the challenges that have been encountered, 
but I also hope to discuss the future implementation steps of 
this bill as our Nation's health care system moves from paper-
based recordkeeping to a dynamic electronic system. The promise 
of health information technology for both patients and 
providers is, I believe, remarkable, and as the public 
understands how it is so beneficial, it is going to make a 
difference in the way we accept the changes in health care that 
will come about as we see that they are very cost-effective.
    I am a nurse by background and I am also a mother and a 
grandmother, and I know firsthand the logistical challenge that 
paper-based systems pose. That is one I have been familiar with 
as a nurse most of my professional life. Every parent knows how 
you struggle to find the proper records of their child's 
vaccinations when they start back to school in the fall. 
Medical specialists unsure of a senior's medical regimen from 
their primary care provider, the senior maybe can't remember 
all of the things that have happened since. Moving to a new 
town, trying to fill out one's medical history at the doctor 
for the very first time, or even when you go back and you are 
asked to re-fill the form and you can't remember all the things 
that have happened. Electronic health records can follow the 
patient and can flag potential issues while at the same time 
enhancing the medical provider's practice by reducing 
inefficiencies in recordkeeping and frustration in collecting 
an accurate medical history. And while HIT is not a silver 
bullet to all of our health care problems, it is a key step in 
modernizing our health system.
    So I look forward to the testimony of our witnesses and I 
yield back.
    At this time I will recognize Mr. Gingrey for an opening 
statement.

  OPENING STATEMENT OF HON. PHIL GINGREY, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF GEORGIA

    Mr. Gingrey. Madam Chair, thank you so much.
    Health information technology has the potential to improve 
the quality and reduce the cost of health care in this country. 
In fact, according to the Rand Corporation, the potential 
savings for both inpatient and outpatient care could average 
$77 billion annually if most hospitals and doctors actually 
adopted HIT, health information technology. The study found 
that the largest savings would come from reduced hospital stays 
and administrative time as well as more-efficient drug 
utilization and not having doctors order the same test two 
weeks apart, expensive scanning and that sort of thing.
    Therefore, Madam Chair, I am interested to hear the 
witnesses, Mr. Blumenthal's and Mr. Trenkle's thoughts on how 
providers will achieve the broader information exchange 
requirements specified under stage 2 in light of the relaxed 
requirements that the final rule has under stage 1. In 
addition, I look forward to hearing from our second panel of 
witnesses and their thoughts on how we move forward.
    Madam Chair, if there were silver bullet solutions for our 
health care system, information technology would surely be one 
of them, maybe the main one. This technology has the potential 
to improve the quality and the efficiency of our health care 
system while ensuring that tax dollars are spent wisely. With 
it, we can better identify and we can cut waste, fraud and 
abuse out of the system. Once implemented, we will be better 
able to protect patients' privacy and eliminate the 
inefficiency of a system based on paper charts. I know of what 
I speak. I practiced medicine for 31 years.
    Therefore, a series of targeted bills based on silver 
bullets, medical liability reform, increased transparency, 
electronic medical records, health insurance reform for sick 
and low-income Americans could have passed in a transparent and 
bipartisan manner. Instead, what did we do? We passed a 2,400 
page omnibus bill that few members could read and understand. 
Madam Chair, I have repeatedly used my opening statement in 
this committee over the past few months to support my ranking 
member, John Shimkus's call for a hearing on Obamacare, Patient 
Protection and Affordable Care Act of 2010. Why? Well, because 
on March 9th, Speaker Pelosi said that the bill is, and I am 
going to quote her now, ``going to be very, very exciting but 
we have to pass the bill so you can find out what is in it away 
from the fog of controversy.'' Now, that is a direct quote. 
Speaker Pelosi was successful and this Democratic majority did 
pass Obamacare, but the fog of controversy still exists in 
spite of her promise. It turns out that a large majority of 
workers won't be able to keep the health care they like today 
and they may even lose their jobs because of the law. The cost 
projections for patients, employers and our government continue 
to rise. Health insurance will not be available or affordable 
to hundreds of thousands of sick Americans. These problems all 
represent broken promises made by the President to the American 
people. Where the President's rhetoric has not lived up to his 
product, Congress indeed needs to investigate. The American 
people deserve to know what is in this law, and I fear that 
unless we hold hearings immediately to investigate the new law, 
our constituents will find out the hard way.
    Madam Speaker, I have gone a little bit over. Thank you for 
your patience. I would like to submit three things for the 
record as I yield back. One is a statement in regard to 
electronic medical records by the American Medical Association, 
another by the United Health Group, and finally, by Electronic 
Health Records Association.
    Mrs. Capps. Without objection, so ordered.
    [The information was unavailable at the time of printing.]
    Mr. Gingrey. And I yield back. Thank you so much, Madam 
Speaker.
    Mrs. Capps. The Chair now recognizes Ms. Schakowsky for 5 
minutes--for 3 minutes.

       OPENING STATEMENT OF HON. JANICE D. SCHAKOWSKY, A 
     REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS

    Ms. Schakowsky. Thank you, Madam Speaker.
    I just want to respond briefly to the ranking member, who 
rather than addressing the potential for reducing costs and 
improving care of health IT decided as usual to restate the 
talking points of the insurance industry including saying that 
this historic and important piece of legislation is the cause 
of higher costs. Instead, what we have seen is excessive 
premium increases--see Well Point--and higher profits--see 
United Health Care, who at the same time as their profits went 
up the amount of health care they actually provide for each 
dollar has gone down. And a part of this bill is talking about 
the advantages that we can reap from taking advantage of health 
IT, which is vital for this country.
    The development of a nationwide interoperable health 
information technology system is a critical component of 
improving health care quality, promoting care coordination and 
reducing medical errors. I have been in the record rooms of 
clinics and hospitals, rooms overflowing with files taking up 
space that could be put to significantly better use. These 
clinics need health IT, and the $2 billion provided in the 
American Recovery and Reinvestment Act will go a long way to 
upgrade and improve this Nation's health care system. As 
someone who recognizes the substantial rewards of moving our 
health care system toward health IT functions, I also know that 
we must ensure complete security and privacy for consumers.
    Through the chairman's leadership, the HITECH Act 
strengthened federal privacy and security laws to protect 
personal identifying information from misuse. Without critical 
privacy and security guarantees, consumers will simply not be 
willing to utilize electronic records. As we move forward with 
greater utilization of electronic records, this is an area 
where we have to remain diligent.
    I would also like to thank the witnesses today for their 
testimony, in particular, those from the Administration. 
Congress tasked HHS with a large job when we passed the HITECH 
Act, and they have worked quickly to implement this program. 
They have also been responsive, addressing concerns with 
implementation. I was one of several members that urged HHS to 
reevaluate their first consideration of meaningful use, and 
they have subsequently taken many of those concerns into 
account during rulemaking. I look forward to working in the 
months and years ahead as we implement the full promise of 
health IT.
    So I thank you, Madam Chairman, and I yield back the 
balance of my time.
    Mrs. Capps. The Chair now recognizes Mr. Pitts for his 
opening statement.

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Mr. Pitts. Thank you, Madam Chairman.
    On February 17, 2009, the President signed the American 
Recovery and Reinvestment Act, also known as the stimulus bill, 
into law, promising that the $787 billion bill would create or 
save 3\1/2\ million jobs over the next 2 years. We were also 
told that the stimulus would hold unemployment under 8 percent. 
At this point in the recovery, unemployment would be at 7.5 
percent. No one, not the White House, not Congressional 
leadership, can tell us with any degree of accuracy how many 
jobs have been saved or created. In fact, it is impossible to 
calculate how many jobs were not lost due to the passage of the 
stimulus or any other bill, for that matter. As for jobs 
created, we have an ever-expanding federal workforce, not a 
thriving private sector, and as we all know, unemployment is 
currently at 9.5 percent after peaking at 9.9 percent earlier 
this year.
    One of the provisions included in the stimulus was the 
Health Information Technology for Economic and Clinical Health, 
or HITECH Act. While I would question how the HITECH Act is 
stimulative or how many jobs it has saved or created, we all 
see the promise of health information technology from reduced 
errors, greater efficiencies to being able to share information 
across the country with the click of a mouse, and I support the 
goals of the HITECH Act. Many of us have been contacted, 
however, by providers from back home who panicked when the 
proposed rule came out earlier this year, and it seemed that 
few hospitals and doctors' offices could meet such an 
aggressive implementation timetable or stringent criteria.
    I hope that our Administration witnesses will discuss how 
the final rule has been changed to address some of these 
concerns, and I look forward to hearing from our witnesses. 
Thank you, Madam Chairman. I yield back.
    Mrs. Capps. The Chair now recognizes Ms. Eshoo for her 
opening statement.

 OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Ms. Eshoo. Thank you, Madam Chairwoman. It is nice to see 
you in the chair, and thank you for holding this important 
hearing on the implementation of the HITECH Act.
    The legislation we included in the American Recovery and 
Reinvestment Act to promote health information technology was 
adopted to revolutionize the health care delivery system in our 
country. I have been so often struck by this: we live in the 
Information Age and yet our health care system has really been 
mired in the pen-and-paper past, and so the money that is 
directed toward a comprehensive, interoperable and nationwide 
HIT system is one that really meets what the 21st century is 
all about, and I don't think that there is a doubt that this 
will have a salutary outcome in terms of enhancing patient 
safety, reducing medical errors, improving the overall quality 
of care, and of course, having a system that protects the 
privacy of patients as well.
    I have been concerned for a long time about this issue. I 
introduced comprehensive legislation, HIT legislation, in 2007. 
We spent months meeting with doctors, with hospitals, with 
technology companies, which I think everyone knows, many of 
them make their home in my Congressional district, as well as 
HIT vendors, and I am proud to say that the work that my staff 
and myself did on that legislation really became the basis of 
the legislation that Mr. Dingell introduced and now we are 
going to be reviewing it.
    So I am really pleased that Dr. Blumenthal, the National 
Coordinator for HIT, and Anthony Trenkle from the Office of E-
Health at CMS are going to share with us their experiences in 
implementing the legislation. I know that there are bumps in 
the road. There always are. When constituents ask me about 
legislation, I always say well, understand that legislation is 
shaped by human beings and that legislation bears the mark of 
humanity. It is less than perfect. But what is exciting to me 
is that we have launched the effort. We have placed significant 
resources next to it, $2 billion, and so today is a good chance 
to hear about how we are doing on this very important journey. 
So I look forward to hearing from our friends that are here to 
be witnesses and also to the second panel that will instruct us 
as well.
    So I thank the chairwoman, I thank the chairman of the 
subcommittee for scheduling this and I thank the witnesses and 
look forward to hearing from you.
    Mrs. Capps. I thank my colleague.
    Now we turn to the ranking member of the full committee, 
Mr. Barton, for his opening statement.

   OPENING STATEMENT OF HON. JOE BARTON, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Barton. Thank you, Madam Chairwoman. I thank you and 
Ranking Member Shimkus and Subcommittee Chairman Mr. Pallone 
for holding this hearing. We thank our witnesses on this panel, 
and I know we have several on the second panel. We thank them 
for participating, especially the witness from the Heart of 
Texas Community Health Center down in Texas. We are glad that 
he is here.
    Obviously the Republicans are not against health 
information technology. Last year we worked on a bipartisan 
basis to pass a bipartisan health IT bill. Unfortunately, that 
bill did not become law. Instead, at the start of this 
Congress, our friends in the majority passed their version of 
health IT as part of the so-called stimulus bill. I would like 
to hear from the witnesses later this afternoon just how 
stimulative that has been. The unemployment rate is about 9\1/
2\ percent around the country. This bill that we are looking at 
today didn't do much in the private sector. It focused more on 
spending federal dollars while ignoring the less-expensive 
avenues for health IT deployment. I think it would have been 
better to allow hospitals and physicians to donate health IT 
systems to each other, for example. It has been over a year 
since this bill became law, the stimulus bill, that is. That 
package is going to cost about $1\1/2\ trillion. Numbers that I 
have been given indicate that according to the Bureau of Labor 
Statistics, we have lost over 3 million jobs in that time, so I 
think it is a fair question: where are these jobs and how has 
this particular bill helped create jobs.
    While it is not the focus of the hearing, last week myself 
and several other Republicans asked for a hearing on the recess 
appointment of Dr. Berwick to head the new CMS. Dr. Berwick was 
appointed without being approved by the Senate, which I think 
is a bad precedent, although not unprecedented. Obviously other 
Presidents have done recess appointments. As we try to 
implement the new health care law, the bigger law, I think 
people have a right to know how Dr. Berwick plans to implement 
that law and make all those cuts in Medicare in the 
neighborhood of $145 billion.
    So in any event, Madam Chairman, again, we are not opposed 
to health IT, we are not opposed to the federal government 
being involved, but we didn't have much say in this particular 
bill, so it is going to be an interesting dialog as we go 
forward.
    With that, I will put the rest of my statement in the 
record. And again, we do thank our witnesses and we look 
forward to their testimony. Thank you.
    [The prepared statement of Mr. Barton follows:]
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    Mrs. Capps. Thank you, Mr. Barton.
    And now we turn to Mrs. Christensen for her opening 
statement.

       OPENING STATEMENT OF HON. DONNA M. CHRISTENSEN, A 
       REPRESENTATIVE IN CONGRESS FROM THE VIRGIN ISLANDS

    Mrs. Christensen. Thank you, Madam Chair, and I want to 
thank you and Chairman Pallone and the ranking member for 
holding this hearing on implementing of HIT, an issue that has 
been of particular importance for me. Of course, it is 
important to all providers, but providers of color, those in 
minority and poor and rural neighborhoods in my district have a 
particular interest in how it is going to be implemented.
    The Health Information Technology for Economic and Clinical 
Health Act holds out great promise for improving medical care, 
and although a few would disagree, reducing health care costs 
in the future. But I also want to make sure that it eliminates 
disparities, not exacerbate them. I appreciate the response of 
the public comments on what constitutes meaningful use, but if 
some of the big guys like Partners in Health Care, Kaiser 
Permanente and others have concerns about being able to meet 
the standards, certainly the smaller, poorer, understaffed, 
overworked providers will definitely have problems. I can 
imagine that OMC has in balancing the need to get this 
implemented, ensuring privacy and bringing all providers in. On 
the other hand, I know the challenge of providers like I was 
would have getting this implemented while trying to take care 
of patients. We will be looking to the regional extension 
centers like the one at the University of Ponce in Puerto Rico 
with the Virgin Islands Medical Institute for their help in 
getting this done. Dr. Blumenthal, in your testimony you say 
that we should look at this not as investments in technology 
per se but as efforts to improve the health of Americans and 
the performance of their health care system, and of course key 
to improving the health of all Americans is to ensure that 
those who are disproportionately affected by health inequities 
are able to access and take full advantage of the provisions of 
the HITECH Act.
    So I look forward to the testimony and thank and welcome 
our witnesses for being here today.
    Mrs. Capps. The Chair now recognizes Mr. Burgess for an 
opening statement.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE 
              IN CONGRESS FROM THE STATE OF TEXAS

    Mr. Burgess. I thank the Chair for the recognition. Welcome 
to our witnesses. We are grateful that you are here. I am 
grateful that our committee is exercising proper oversight to 
see if the HITECH provisions of the stimulus bill are being 
implemented as intended. After all, the United States Congress 
put $20 billion on the table with the goal of increasing and 
ultimately achieving universal electronic medical record 
adoption.
    For the record, I did not support the stimulus bill and I 
continue to believe that some of the provisions relating to 
health information technology contained within that bill have 
actually been inhibitory toward their adoption. I am still 
uncertain whether providing financial incentives such as grants 
will be effective. I continue to believe that claims-based 
incentives ultimately make more business sense.
    In addition, our lack of addressing safe-harbor issues is a 
flaw, and early in an early iteration of a health IT bill, H.R. 
1031, I introduced such a concept but unfortunately it was not 
part of the language that was adopted by the majority when the 
stimulus bill was passed. I would also like to be certain that 
new federal guidelines are working in coordination with the 
quality improvement initiatives that many in the industry are 
already undertaking and certainly not work at cross purposes to 
those efforts.
    We need to focus on implementation. Even if I didn't agree 
on how, I am committed to ensuring that the taxpayer dollars 
are now used responsibly to establish the goal that was set 
forth. Even if $1 doesn't go out the door, penalties for 
providers are coming no matter what, and guess what? They are 
coming pretty darn fast. They will be here in just a couple of 
years. I have been committed to see that the rules set up by 
the federal government encourage adoption and allow providers 
to avoid the proverbial sword of Damocles hanging over the head 
of every doctor and every hospital in the country in just a few 
short years. I have certainly been fearful that federal 
regulations might bog down the normal and routine medical 
treatment by requirements that are unnecessary and that I 
imagine both patients and doctors will have some difficulty 
with complying. Unfortunately, the draft regulations put out in 
February were, in a word, unworkable. I authorized with 
representatives Space, Stearns and Engel a letter pointing out 
several issues with the proposed rule. These were so 
intuitively obvious that 250 Members of Congress agreed to sign 
on to the letter. Dr. Blumenthal, to his credit, has always 
taken my calls, always listened to my concerns and did address 
many of the issues that were raised. I do remain concerned 
about the multi-campus issue which has been mentioned and on 
certification of existing systems as qualified to receive 
incentive payments, and Madam Chairwoman, I would like to 
insert into the record a statement by the Premier Health Care 
Alliance addressing that issue.
    So we will continue to work in Congress on legislation to 
address these issues as they come up. We hope we can achieve a 
bipartisan consensus with our members in this committee on both 
sides of the dais and with committee members of Ways and Means. 
I certainly look forward to hearing the testimony today and I 
will yield back the balance of my time.
    Mrs. Capps. Hearing no objection, the Chair will insert the 
letter that is recommended by the gentleman.
    [The information appears at the conclusion of the hearing.]
    Mrs. Capps. And now turning to Mr. Sarbanes for an opening 
statement.

OPENING STATEMENT OF HON. JOHN P. SARBANES, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF MARYLAND

    Mr. Sarbanes. Thank you, Madam Chair. I look forward to the 
testimony from the witnesses today.
    The search for the tipping point on health information 
technology has sort of been for some like the search for the 
Holy Grail. I don't think when we get there that is what it 
will turn out to be but I do think it is going to make a huge 
difference, first for patients and then for the costs of the 
system in terms of reducing cost, promoting more efficiency and 
so forth.
    I always have every head in the room nod when I talk to an 
audience about how frustrating it is when a patient goes to a 
provider and has to have the baseline medical record recreated 
for them because it is so difficult for the provider to put 
their hands on tests and other records that have been done and 
are available out there somewhere but they somehow can't get 
hold of those, the result being that the patient is then 
subjected to more tests, more pushing and prodding when that 
information that we give the provider a baseline picture of the 
person's health and condition is available, it is just not at 
their fingertips. And HIT has the potential to solve that 
problem. When it does so, it is going to make a tremendous 
advance forward for patient care and obviously, as I said, 
improve efficiency and reduce cost.
    So I think the investment in this both in the stimulus bill 
and in the health reform law was a smart investment. I am 
looking forward to hearing from you today as to how we are 
making progress on that investment, and I yield back my time. 
Thank you.
    Mrs. Capps. The Chair now recognizes Mrs. Blackburn.

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF TENNESSEE

    Mrs. Blackburn. Thank you, Madam Chairman, and we do 
welcome our guests and we thank you for being here.
    We do want to keep tabs on what is happening with the 
HITECH Act, with health IT as it moves forward. We are 
concerned about the funds that were provided in the stimulus 
bill, what was included there and we are also concerned with 
the rules. I am glad that CMS has finally published the final 
rules for the electronic health records and we know that our 
doctors and our hospitals are working diligently to try to 
comply with these rules because we are hearing from them, and 
while we know that the EHRs are going to hold tremendous 
promise, we also know that we have got some hurdles out there 
if we are going to reach the goal of everyone having an 
electronic health record by 2015.
    I think that everyone is concerned with this deadline of 
January 1, 2011. We will have some questions about that because 
that is the time for provides to have in place a certified EHR 
to qualify for those Medicare health IT incentive programs, and 
between now and then our providers and vendors are going to 
have to ramp up very quickly. I will say, Madam Chairman, I 
think that when Congress does not engage in putting some of 
these items in statute and leaves it to agencies to put in 
place, we see unworkability and having to do some revisits. It 
also appears that CMS had lowered the bar in some areas in the 
recent rule while remaining overly prescriptive in others. An 
example, Tennessee hospitals are extremely concerned about the 
financial implications on multi-campus hospitals that share a 
single Medicare provider number. That is another area we will 
want to discuss with you today.
    What we must keep in mind that government excels at 
regulation, not innovation, and we are going to need to listen 
to the private sector on this and we will look forward to some 
questions there for our second panel, and as this rush is 
taking place to build this nationwide network very quickly, I 
am concerned that CMS could end up building a national but 
suboptimal system, and I hope that we are going to continue to 
see working through these problems together.
    Tennessee is a leader in the health IT innovation and 
implementation and we are hopeful that this can be put on the 
right direction and some of these concerns and stumbling blocks 
addressed as we move along the way.
    I thank you for the time. I yield back.
    Mrs. Capps. The Chair is now pleased to recognize the 
chairman emeritus of the full committee, Mr. Dingell, for his 
opening remarks.

OPENING STATEMENT OF HON. JOHN D. DINGELL, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF MICHIGAN

    Mr. Dingell. Madam Chairman, thank you, and thank you for 
holding this important hearing.
    Health information technology has the ability to modernize 
and improve our entire health care system by allowing for more 
informed decision-making, by reducing duplicative and 
unnecessary paperwork, by speeding up diagnoses and by reducing 
medical errors. The Health Information Technology for Economic 
and Clinical Health Act, HITECH, that was passed as a part of 
the American Recovery and Reinvestment Act of 2009, created an 
unprecedented investment in health information technology. In 
fact, the Congressional Budget Office noted the adoption of 
health IT would reduce Medicare spending by $4.4 billion over 
the 2011-2019 period and create federal savings in Medicaid 
over $7 billion in the same timeframe. Given this potential, we 
must ensure that we get a good return on that investment and 
vigorously move forward on the implementation of the statute.
    These resources will put us on the path to a more 
coordinated health care system, which is why the topic of 
health information technology has long been a focus of this 
committee. I would like to note that not only has this 
committee spent many years studying and legislating on the 
matter but that we have done so in a bipartisan fashion. For 
example, in the last Congress, this committee passed the 
bipartisan health information technology bill, H.R. 6357, the 
Protecting Records, Optimizing Treatment and Easing 
Communication through Health Care Technology Act of 2008. This 
bill included language to codify the Office of National 
Coordinator for Health IT and to provide grants designed to 
stimulate the spread of HIT. It also included strong privacy 
protections. This bill became the basis for the HITECH Act.
    The Administration recently issued rules, final in 
character, to support meaningful use of electronic health 
records. I am delighted that the Office of National 
Coordination for Health IT and Centers for Medicare and 
Medicaid Service have worked with all interested parties to 
develop standards that are attainable but also propel our 
health technology systems forward. They have had to thread a 
very fine needle, and overall they have done a commendable job. 
However, we all understand that a few concerns remain. I am 
confident the Administration will continue to hear and respond 
to the legitimate concerns. I am also aware that the work of 
the Congress may not be totally done on this issue.
    I want to thank both of the panels of our witnesses today 
for joining us and look forward to their updates on the 
implementation process. We will find that the testimony today 
will be in front of a group of people that has a real interest 
in ensuring that HITECH Act moves forward in a way that 
fulfills the intent of the legislation.
    Again, Madam Chairman, I thank you and I yield back the 
balance of my time.
    Mrs. Capps. The Chair is pleased to recognize for an 
opening statement Ms. Castor.

  OPENING STATEMENT OF HON. KATHY CASTOR, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF FLORIDA

    Ms. Castor. Thank you, Madam Chair, for calling this 
hearing on how we improve health care through modern 
technology. You know, the health care investments that have 
been made through the Recovery Act have really been a godsend 
to communities all across the country and created thousands and 
thousands of jobs including in my hometown of Tampa and the 
Tampa Bay area.
    One of the initiatives that I am most proud of was made 
possible by the HITECH Act included in the Recovery Act and it 
is the Paper-Free Florida Collaborative Regional Extension 
Center. In April, Paper-Free Florida was awarded nearly $6 
million for its initiative developed by the University of South 
Florida in my district. It is one of more than 70 regional 
extension centers authorized by the Office of National 
Coordinator. I notice that Glen Tullman from Allscripts is 
here. He gave us great advice and encouragement from the get-
go, so I am glad you are here, Glen. Paper-Free Florida will 
effectively implement electronic health records in more than 
1,000 priority clinical practices, and I heard from the other 
side of the aisle where are the jobs. Well, I am grateful that 
a number of the jobs are right in my hometown in Tampa because 
what we are going to be able to do is recruit and train and 
employ over 100 e-health ambassadors as HIT extension agents in 
20 countries. We are going to avoid costly medical errors for 
patients, and you should have seen the young doctors when we 
made the announcement. They are already there. They know this 
technology and they just can't wait to get started, and it is 
exactly what we intended by the Recovery Act, creating these 
high-wage jobs that communities like mine need in this economic 
downturn. So thank you.
    While I am proud that one of the many success stories made 
possible by the HITECH Act comes from my community, there are a 
few roadblocks that we need to address to ensure that more 
health care providers are able to coordinate care, and one area 
of improvement I think I am hearing consensus across the board 
here is the meaningful-use rules, and I think you for granting 
additional flexibility as you took comments from folks and 
providers all across the country, but we have more work to do 
here. Dr. Blumenthal, you have worked hard to make sure that 
certain entities that are eligible for HIT incentive payments 
are going to be eligible, but as many of the members today 
mentioned, the hospital systems with multiple campuses remain 
in a tough spot under these new rules. And I was with a chief 
medical officer in Florida for a big hospital system yesterday, 
they were singing your praises, but this is giving them real 
heartburn. The decision to allow only one payment per provider 
number, even if that provider number is used for more than one 
facility, puts multi-campus hospitals at a real disadvantage. 
Meanwhile, they have great potential to deliver results, the 
results that we need.
    Nevertheless, the overall benefit of the HITECH Act is 
among the most exciting components of the Recovery Act and 
alongside the Affordable Care Act, we will continue to make 
great strides to improve the health for American families.
    So thank you, Madam Chairman, and I look forward to hearing 
from our witnesses today. I yield back.
    Mrs. Capps. The next opening statement will be by Mr. 
Green.
    Mr. Green. Thank you, Madam Chairman. Before I begin I 
would like to ask unanimous consent to include a written 
statement for the record. This is written testimony of Dan 
Hawkins of the National Association of Community Health 
Centers.
    Mrs. Capps. Hearing no objection, so ordered.
    [The information was unavailable at the time of printing.]

   OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Green. Like my colleagues, I thank you for holding this 
hearing to check on the implementation and progress of the 
Health Information Technology for Economic and Clinical Health 
Act of 2009. For many years, this committee and Congress has 
the goal of encouraging large-scale implementation of 
electronic health records. The passage of the Health 
Information Technology for Economic and Clinical Health Act of 
2009, HITECH, in the American Recovery and Reinvestment Act of 
2009 demonstrated Congress's commitment to improving and 
coordinating patient care as well as streamlining and updating 
our medical records system. In a high-tech world, the days of 
paper records should be well behind us.
    With integrated information technology, patients can manage 
their own electronic records and avoid having to haul multiple 
records to various physicians. The lack of coordinated care in 
the country is startling, but if we can coordinate our care 
systems through health IT, we have a potential to change our 
health care system.
    We are all aware of the benefits improved IT will bring the 
health care sector and the patients it serves. If implemented 
correctly, health IT will improve patient safety and garner 
cost savings. That is why I am glad we are having the hearing 
today to discuss the status and the implementation of the 
HITECH Act. As we know, no legislation is perfect and Congress 
has a history of revisiting legislation many years after its 
passage. The HITECH Act is no exception. I am particularly 
interested in discussing potential changes that need to be made 
to assist community health centers and mental health providers 
adopt health IT.
    The implementation of health IT has dramatically improved 
the community health center coordination of care in our 
district and we are excited about the potential this has to 
improve quality of health care for medically underserved in the 
district. I do want to discuss how payments to health care IT 
are made to individual providers at the community health 
centers rather than the actual health center, which is a more 
common practice in allowing recurrent funding for health 
centers.
    With regard to mental health providers, I sponsored the 
Community Mental Health Services Improvement Act for many 
years. This legislation contains funding for the establishment 
of grant programs to improve health IT for mental health 
providers. I recently began working with Representative Patrick 
Kennedy and Representative Tim Murphy on H.R. 5040, the Health 
Information Technology Extension for Behavioral Health Services 
Act, which would amend HITECH to give mental health providers, 
substance-abuse providers and psychiatric hospitals in parity 
with other health care providers for medical use of health 
information technology and electronic health. This legislation 
clarifies the definition of health care provider to include 
mental health professionals, substance-abuse professionals, 
psychiatric hospitals, behavioral mental health clinic and 
substance-abuse treatment facilities. The legislation requires 
HHS through the National Coordination of Health Insurance 
Technology to award grants for mental health treatment 
facilities not eligible for meaningful-use incentives through 
the HITECH Act. The grants would allow for purchase of 
certified electronic records training of medical staff and the 
use of electronic records and improve the exchange of health 
information between mental health providers and other health 
care providers. I am hopeful these issues can be discussed in 
the future the community health centers and mental health 
providers are an integral part of our health care system.
    Again, I want to thank the witnesses for appearing. I want 
to welcome Dr. Roland Goertz, CEO and Executive Director of 
Heart of Texas Community Health Center in Waco on the second 
panel, and I yield back my time.
    Mrs. Capps. Thank you.
    Mr. Murphy is now recognized for his opening statement.

   OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Mr. Murphy of Pennsylvania. Thank you, Madam Chairman.
    We all know that electronic medical records hold enormous 
potential for the practice of medicine but tools like IT with 
health are only valuable if we know how to use them and if we 
have them, and that process began with more than $20 billion in 
federal resources allocated. Today, only 6 percent of hospitals 
and 2 percent of physicians rely on these health records.
    These incentives no doubt are going to increase 
participation but as I have heard from many doctors and 
hospitals in my district, that initial requirement for 
incentive payments seems to be too complex and unobtainable. 
Now with CMS cutting back on the scope of HIT mandates, it has 
given providers more time to adopt records that will collect 
essential patient data, and I look forward to hearing what 
providers can do before being financially penalized for 
noncompliance.
    HIT will be an essential component of medicine, or as Dr. 
David Blumenthal has put it aptly, as accepted in the daily 
lives of health professionals as the stethoscope and the exam 
table. Well said. Health IT is most valuable when it is 
available to providers across all disciplines, and as it 
advances, we want to make sure government is not a barrier but 
a team member to work better, effectively, efficiently and 
economically.
    I also believe that health IT needs to be integrated, 
interactive, interoperable and intelligent in order to provide 
great patient outcomes, and that is where I am afraid sometimes 
we may fall short in terms of integrating care, and let me give 
two quick examples. Patients in skilled nursing homes are 
extremely ill on average and take eight different kinds of 
medication. Eighty percent of this population comes from a 
hospital, but there is little exchange of patient data 
electronically, so a hospital may discharge a patient to a 
skilled nursing facility on Friday, the paper records are sent 
to the skilled nursing facility via fax a day or two later. If 
it was electronic, that facility could do a better assessment 
upon admittance and know the patient's medications immediately.
    Second, we need to be thinking about the overall health of 
an individual. Unfortunately, the incentives exclude mental 
health providers. As my colleague, Mr. Green, said, Congressman 
Patrick Kennedy and I have put in a bill, the HITECH Extension 
for Behavioral Health Services, H.R. 5040, to make mental 
health providers eligible for the federal incentive payments. 
This is a critical bill, and it would extend Medicare and 
Medicaid reimbursements for meaningful use of electronic health 
records to mental health professionals across a spectrum.
    So as Congress continues to support advances in technology, 
I look forward to working with this committee to secure passage 
of this bill and others. Keep in mind that those with chronic 
illness run the risk twice that of the population for having 
depression and other mental illnesses. We have to make sure 
that all these records are integrated together so that whatever 
medical problem they have, whatever complications people with 
chronic illness have, the key feature of electronic medical 
records is to make sure we can use them and provide the 
incentives and provide the facilities for us to be able to make 
better medical decisions.
    With that, I yield back.
    Mrs. Capps. Thank you, Mr. Murphy.
    Mr. Space, you are now recognized for your opening 
statement.

OPENING STATEMENT OF HON. ZACHARY T. SPACE, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF OHIO

    Mr. Space. Thank you, Madam Chairman.
    Thank you for holding the hearing on an issue that of 
considerable important to all of us. When it comes to health 
IT, there does seam to be a great deal of agreement on both 
sides of the aisle with very good cause. Both Democrats and 
Republicans, providers and consumer groups by and large seem to 
agree that improving the adoption of health information 
technology around the country will be beneficial to the 
practice of medicine, reduce redundancies, save money, provide 
a safer environment for patients and I certainly include myself 
in this support. How we achieve the adequate adoption of health 
IT is what has brought us here today. Ensuring that every 
hospital, doctor and clinic in this country have high-quality 
record systems that ensure patient safety is not an easy task 
and there is no simple answer to how we reach that destination.
    The HITECH Act included as part of H.R. 1 earlier this year 
offers a promising framework for accomplishing this goal, 
establishing an Office of the National Coordinator and 
developing a structure for incentive payments has created a 
framework for pushing the adoption of health IT in a strategic 
and meaningful way. However, the meaningful-use rule provided 
by CMS 2 weeks ago holds some troubling provisions that I fear 
may steer us away from adoption, and I would like to touch on 
two of those issues today. First, the multi-campus issue that 
was brought up earlier I think during Mr. Burgess's statement. 
I believe firmly that it was the intent of this body in passing 
the HITECH Act to ensure that each hospital would be entitled 
to its own incentive payments. The rule offered by CMS denies 
those payments to hospitals that have chosen to structure 
themselves with multiple campuses under a single provider 
number, and I am disappointed in this decision, particularly 
after we worked with Representatives Burgess, Engel and Stearns 
to send a letter to CMS that was signed by 240 members of this 
body. My staff will continue to work with those members and 
their staffs along with the staff of this committee and the 
Ways and Means Committee so that this issue can be resolved.
    And the second concern we have is what this rule will mean 
for smaller rural hospitals, like the 13 that we have in Ohio's 
18th Congressional district. Most of those hospitals, indeed, 
all of those hospitals, see an exceptionally high caseload of 
Medicare and Medicaid recipients with an ever-growing number of 
self-pay cases. That is a euphemistic term for charitable 
cases. We see these cases increasing with the economy. For 
these hospitals, investing in the needed capital to purchase 
health IT systems that meet the criteria spelled out today is 
especially challenging. Even with the promise of incentive 
payments, these investments are costly and difficult. I still 
have concerns about what these requirements will mean for our 
hospitals and I certainly hope to learn more about how HHS and 
CMS intend to help small rural hospitals in accessing this 
vital technology.
    Thank you, Madam Chair.
    Mrs. Capps. Thank you.
    The Chair recognizes Mr. Barrow for an opening statement.

  OPENING STATEMENT OF HON. JOHN BARROW, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF GEORGIA

    Mr. Barrow. I thank the Chair for the opportunity to 
explore this topic.
    In getting ready for this hearing, I reached out to some of 
the folks on the ground back in my district and some of the 
folks who represent them up here, and there still seem to be a 
lot of unknowns and unanswered questions out there. We spent a 
lot of time poring over legislative language and debating the 
definitions of legislative terminology. I would like to bring 
to the attention of the committee some of the more fundamental 
challenges that I am talking about.
    I represent areas that don't even have access to reliable 
broadband services. I represent counties that are at least an 
hour's drive away from the nearest IT professional. I am 
concerned that even if we do everything right up here, we make 
grant funding available, we offer technical guidance, we 
provide reasonable rewards for proper implementation, many 
providers out there are still going to be left behind because 
we still don't have the proper technological infrastructure in 
place to take full advantage of this. So my concern is that we 
make great leaps forward in all other kinds of places with 
information technology that we don't forget those folks who are 
still struggling to get on board the IT bandwagon in the first 
place, and I hope that can be addressed in the course of the 
hearing.
    Thank you, Madam Chair, and I yield back the balance of my 
time.
    Mrs. Capps. Ms. Harman, the Chair recognizes you for an 
opening statement.
    Ms. Harman. Thank you, Madam Chair. It is nice to have a 
school nurse in the chair, and the quality of school nursing 
care matters to this committee, and I think electronic IT will 
be helpful even at that level, and I am sure you agree with me.
    Mrs. Capps. Absolutely.

  OPENING STATEMENT OF HON. JANE HARMAN, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Ms. Harman. Most of our colleagues have described what is 
in this legislation, which is absolutely essential. I just 
wanted to add a couple of things that haven't been said. One is 
that a firm in my district makes dog tags, electronic health 
dog tags for soldiers, and has had some success in selling 
these to the Pentagon. I have no idea, and probably others 
would know better than I, whether these could have a civilian 
application, but the notion that a soldier hit on the 
battlefield would have all of his health records in this tiny 
little chip that he wears around his neck is an exciting idea 
and it might really be useful to people who for any number of 
reasons could get into problems and urgently need one health 
provider to be able to download their history. There would 
obviously be some notion of choice here. I don't assume 
everyone would be compelled to wear these things, but I just 
put it out there as something that I think may have promise.
    The other thing I would want to mention that has been said, 
I am sure, before but not while I have been sitting here is the 
issue of both privacy and accuracy of records. I mean, once we 
consolidate and integrate health data, and boy, do I think 
``integration'' is a critical word, it has to be accurate. The 
goal here is obviously to reduce errors and duplication, but 
what is on those records really matters and so while our 
legislation goes a long way in that direction, I just mention 
to our witnesses that this is something that will need renewed 
focus.
    And I congratulate this committee for legislating on a 
bipartisan basis in an area that is absolutely critical to the 
quality and cost of health care for Americans including school 
kids who go to excellent school nurses like our friend Lois.
    Thank you very much. I yield back, Madam Chair.
    Mrs. Capps. And on that note, we conclude our opening 
statements by members of the subcommittee and we turn now to 
our witnesses. I want to welcome you both and thank you for 
your patience in listening to all of us. We have on our first 
panel Dr. David Blumenthal, National Coordinator of Health 
Information Technology for the U.S. Department of Health and 
Services, also joined by Mr. Anthony Trenkle, Director of the 
Office of E-Health Standards and Services, Centers for Medicare 
and Medicaid Services. Welcome to you both.
    Dr. Blumenthal, you may begin your testimony.

  STATEMENTS OF DAVID BLUMENTHAL, M.D., NATIONAL COORDINATOR, 
 HEALTH INFORMATION TECHNOLOGY, U.S. DEPARTMENT OF HEALTH AND 
  HUMAN SERVICES; AND ANTHONY TRENKLE, DIRECTOR, OFFICE OF E-
HEALTH STANDARD AND SERVICES, CENTERS FOR MEDICARE AND MEDICAID

                 STATEMENT OF DAVID BLUMENTHAL

    Dr. Blumenthal. Chairwoman Capps, Ranking Member Shimkus, 
distinguished subcommittee members, thank you for the 
opportunity to submit testimony on behalf of the Department of 
Health and Human Services regarding the implementation of the 
Health Information Technology for Economic and Clinical Health 
Act.
    The provisions of the HITECH Act are best understood not as 
investments in technology per se but as efforts to improve the 
health of Americans and the performance of their health care 
system. Three interdependent rulemakings were required to 
implement the provisions of the HITECH Act generally and the 
Medicare and Medicaid EHR incentive programs in particular. The 
first rulemaking establishes the requirements that eligible 
health care providers will need to satisfy in order to qualify 
for incentive payments. The second specifies the technical 
capabilities and standards that certified EHR technology will 
need to include to support these health care providers, and the 
third creates the processes for EHR technology to be tested and 
certified, thus providing confidence and assurance to eligible 
health care providers that certify the EHR technology they 
adopt will perform as expected.
    On July 13th, with the issuance of the Medicare and 
Medicaid EHR incentive programs' final rule and the initial set 
of standards, implementation specifications and certification 
criteria final rule, a 17-month effort was capped to publish 
the three rulemakings necessary to implement meaningful use, 
stage 1. These rules cumulatively reflect over 2,000 public 
comments from stakeholders across the health care system and 
illuminate the initial pathway to achieving an integrated and 
electronically connected health care system. Our health 
information technology policy committee and health information 
technology standards committee played vital roles in advising 
me and the Secretary on these rules and many other matters.
    With the adoption of these three rules, attention now turns 
to their implementation. The ONC, the Office of the National 
Coordinator, is now ramping up the development of other 
processes that will need to be in place to enhance 
interoperability. Many of these processes will be components of 
a comprehensive standards and interoperability framework 
developed by the Office of the National Coordinate to expedite 
standards harmonization as well as their adoption and use.
    I am also pleased to report that in the approximately 4 
weeks since the temporary certification program rule was 
finalized, ONC has already distributed 32 applications to 
organizations seeking to become authorized testing and 
certification bodies to test and certify EHR technology. I am 
highly encouraged by the strong interest shown thus far and I 
am optimistic that multiple organizations will be granted ONC-
authorized technology and certification body status and thus be 
authorized to test and certify complete electronic health 
records and EHR modules under the temporary certification 
program. Such a result should create a competitive market and 
would provide EHR technology developers with multiple options 
and could lower the costs to EHR technology developers that are 
associated with testing and certification.
    ONC has engaged in a number of cross-cutting activities 
related to administering the provisions of the HITECH Act. The 
major program investment established to date with the $2 
billion appropriated to ONC under ARRA include the Health 
Technology Extension program, the State Health Information 
Exchange Cooperative Agreement program, the Beacon Community 
Cooperative Agreement program, the Health IT Workforce program, 
and the Strategic Health IT Advanced Research Projects program.
    The Health Information Technology Extension program 
includes the establishment of a national health IT research 
center and a nationwide network of regional extension centers. 
Regional extension centers will be dedicated to ensuring that 
providers have all the necessary resources to meet the 
challenges ahead to adopting and becoming meaningful users of 
certified electronic health record technology. They will place 
a special emphasis on providing technical assistance to 
clinicians furnishing primary care services from individual and 
small group practices.
    The State Health Information Exchange Cooperative Agreement 
program has the overall aim to advance appropriate, secure and 
sustainable health information exchange within and across 
States and other jurisdictions. Over $500 million has been 
obligated to 56 States, eligible territories and qualified 
State-designated entities to support health care providers, 
demonstrate the meaningful use of certified electronic health 
record technology and to leverage the additional efficiencies 
and quality improvements gained from health information 
exchange.
    The Beacon Community Cooperative Agreement program provides 
certain communities with funding to build and strengthen their 
health IT infrastructure and health information exchange 
capabilities. These communities will demonstrate the vision of 
a future where hospitals, clinicians and patients are 
meaningful users of health information technology and together 
the community achieves measurable improvements in health care 
quality, safety, efficiency and population health.
    The HITECH Act provides for an unprecedented level of 
funding to improve the quality and efficiency of health care 
through HIT and its historic investment will undoubtedly help 
transition our current antiquated paper-dominated health care 
system into a high-performing 21st century health care system.
    It is my privilege to testify before you today and I look 
forward to continuing to work together in answering any 
questions you might have.
    [The prepared statement of Dr. Blumenthal follows:]
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    Mrs. Capps. Thank you very much, Dr. Blumenthal.
    Now Mr. Trenkle for your testimony.

                  STATEMENT OF ANTHONY TRENKLE

    Mr. Trenkle. Thank you, Chairwoman. Chairwoman Capps, 
Ranking Member Shimkus and other members of the subcommittee, 
thank you for the invitation to discuss the CMS incentive 
program for electronic health records, which is part of the 
American Recovery and Reinvestment Act of 2009. Certified EHR 
technology use in a meaningful way is one piece of a broader 
health information technology infrastructure needed to reform 
our Nation's health care system and improve the quality and 
safety of care for both Medicare and Medicaid beneficiaries.
    On January 13, 2010, we published a proposed regulation 
that defined meaningful use and described the eligibility and 
payment methodologies for the EHR incentive programs. This NPRM 
was developed through close cooperation between CMS and the 
Office of National Coordinator and also allowed for extensive 
stakeholder input and recommendations from several federal 
advisory committees, in particular the HIT policy committee. 
The NPRM laid out three stages of meaningful use with stage 1 
covering the first 2 years of the program. We received more 
than 2,000 comments on the proposed rule from interested 
stakeholders including health care providers, associations and 
patients. Most of the commenters felt that the proposed set of 
objectives was too difficult for stage 1 and asked for some 
flexibility in meeting them. The agency carefully reviewed and 
considered all submitted comments and took them into account in 
making policy decisions for the final rule. Our goal was to be 
as inclusive and flexible as possible within the bounds of the 
statute. We continued to work closely with ONC and received 
additional recommendations from the HIT policy committee. It is 
important that this program provides payment incentives for 
both Medicaid and Medicare. The programs have different 
statutory requirements but we tried to harmonize the 
meaningful-use requirements as closely as possible for stage 1. 
Both the CMS rule and the ONC certification standard rule, 
which sets out the functionality requirements for EHR, were 
displayed the Federal Register on July 13, 2010, and will be 
published in the Federal Register tomorrow, July 28, 2010.
    I will now discuss some of the key areas of the final rule. 
Eligible professionals, the major change in that was to expand 
the definition of ``eligibility'' to hospital-based physicians 
who work primarily in outpatient departments. This is made 
possible by a change to the original statutory language made in 
the Continuing Education Extension Act of 2010. Most Medicare 
Advantage-affiliated eligible professionals will also quality 
for this incentive if they are able to show meaningful use, and 
on the Medicaid side we provide additional flexibility for 
determining patient volume in order to quality more EPs.
    Eligible hospitals--we have received, as was noted by a 
number of the committee members, much comment and request that 
CMS recognize each campus of a multi-campus hospital for the 
incentive payments. We understand that this issue of importance 
to Members of Congress, the hospitals and the public. However, 
from the agency's perspective, we believe it is important to 
treat hospitals consistently, and the decision to deviate from 
longstanding policy in this particular instance without clear 
statutory direction to do so would have made CMS vulnerable to 
legal challenges asserting our policies are being implemented 
in an arbitrary manner. We intend to remain consistent with 
other payment policies and make incentive payments based upon 
how hospitals have organized themselves under provider numbers. 
There is a more detailed discussion of this issue in my written 
testimony and I am happy to respond to questions on this. We 
will continue to work with all interested stakeholders in 
future rulemaking related to the implementation.
    The other major hospital issue was with the Medicaid 
program, and in response to public comments on the proposed 
rule, we added critical-access hospitals to the definition of a 
Medicaid acute hospital in order to allow CAHs to quality for 
both programs. The major changes we made in the rule were with 
the meaningful-use definitions. As we mentioned in the NPRM, we 
received a number of comments that asked for more flexibility, 
and we decided to make some changes based on these comments 
that I will address in the next few moments.
    Some of the major changes were modifying the all-or-nothing 
approach to objectives that must be met for meaningful use and 
reducing this requirement to a required set or a core and a 
menu set or optional set. Eligible hospitals and professionals 
have the flexibility to defer up to five of the menu set 
objectives. Where appropriate thresholds to meet meaningful-use 
requirements were reduced in the final rule in response to 
comments. We also removed the administrative transaction 
requirements in the final rule in response to comments these 
transactions are often done through practice management 
software as opposed to EHRs. We also modified the States' 
ability to impose more-robust requirements that would have made 
it more difficult for Medicaid providers to achieve elevated 
targets. We believe it is important for States to have some 
flexibility so we preserved the flexibility. However, in 
response to the concerns raised, it was limited to four public 
health measures. We also added additional objectives for 
patient-specific education resources and advanced directives 
for hospitals were added in response to numerous requests in 
the comments and the HIT policy committee recommendations.
    It is important to note that Medicaid providers are not 
required to meet meaningful-use criteria in their first 
participating year. Instead, they may qualify for an incentive 
payment if they adopt, implement or upgrade certified EHR 
technology. In subsequent years, Medicaid providers must 
demonstrate meaningful use in order to receive the EHR 
incentive payments. The meaningful-use definition described for 
Medicare will also be the minimum requirement for the Medicaid 
EHR incentive program. Unlike the Medicare program, however, 
there are no Medicaid penalties for EPs and hospitals that will 
unable to demonstrate meaningful use.
    Finally, I want to mention that Congress recognized the 
critical importance of reporting quality measures through EHRs 
in the HITECH legislation. We support this requirement but 
recognize that the infrastructure to support the reporting of 
quality measures through EHRs is not yet available. In response 
to comments, CMS limited CQMs to only those which have 
electronic specifications. Eligible providers will now be 
required to report on three core measures from a set of 41 
measures. Hospitals will be required to report on 15 measures 
as applicable to their population.
    In conclusion, the CMS and ONC final rules lay the 
groundwork for establishing a robust national health care 
infrastructure that supports the adoption of EHR technology 
that can help providers practice safer, more effective 
medicine. CMS understands the scope of these programs is vast 
and the doctors and facilities across the country have varying 
awareness of EHRs and of the program. We are working closely 
with ONC to conduct wide-scale outreach to educate those 
eligible for the program as well as working with the States and 
provider stakeholders. We look forward to working with Congress 
and our many stakeholder partners as we implement this rule and 
future rules and advance the use of HIT in our health care 
system.
    Thank you very much for allowing me to testify.
    [The prepared statement of Mr. Trenkle follows:]
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    Mrs. Capps. Thank you, Mr. Trenkle. And the statements of 
both of our witnesses in the first panel will be made a part of 
the hearing record. Each witness may also submit additional 
pertinent statements in writing and at the discretion of 
committee be included in the record, and now I recognize myself 
for 5 minutes of questioning.
    My first question is for you, Dr. Blumenthal. Dr. 
Blumenthal, I believe that health information technology will 
benefit all of us but it can also be particularly important in 
improving the health of individuals with complicated 
comorbidities such as people with severe mental illness. I am 
aware that mental health providers are not authorized to 
participate in Medicaid and Medicare reimbursement under the 
HITECH Act. Because of that omission, I am a cosponsor of a 
bill I want to acknowledge by our colleague here, Mr. Murphy, 
and our colleague in Congress, Mr. Kennedy, H.R. 5040, to 
correct that situation. I do worry that without health 
information technology it will becoming increasingly difficult 
for behavioral health providers to provide the necessary 
coordinated care for people with serious mental disorders. They 
cannot receive reimbursement for adopting HIT. Can behavioral 
health providers participate in any part of the HITECH Act 
technical assistance regional extension center program and will 
you describe that for us?
    Dr. Blumenthal. Sure. Thank you, Madam Chair. Well, as a 
long-term primary-care physician, I well understand the value 
of behavioral health information. I treated many patients with 
dual diagnoses, that is behavioral health and problems or 
substance-abuse problems as well as so-called physical 
problems. So it is absolutely vital that that information be 
available for accurate and careful management of patients. 
There is no question that the regional extension centers can 
serve any physician who is using electronic health record and 
intends to become a meaningful user of that electronic health 
record. There are certain priority providers that we have 
outlined in order to achieve the intent of the law and we have 
focused on primary-care physicians, critical-access hospitals, 
physicians in small groups and in underserved areas but there 
is no restriction that prevents a regional extension center in 
addition from serving mental health providers.
    Mrs. Capps. And you are reaching out to these communities?
    Dr. Blumenthal. Yes, we are.
    Mrs. Capps. OK. So that they know about what services they 
can be eligible for?
    Dr. Blumenthal. We certainly are making every effort to 
make those services known.
    Mrs. Capps. May I also mention another topic? The HITECH 
Act provided $2 billion to the Office of the National 
Coordinator for Health Information Technology, partly to build 
an infrastructure that promote the electronic exchange and use 
of health information. Can you describe how the health 
information network and the health information exchanges are 
critical to this effort?
    Dr. Blumenthal. Well, exchange is absolutely essential to 
good health-care management. Knowing what your patients' 
experiences have been in other locations is a great benefit, 
potential benefit of health information technology. At the same 
time, we need to make it possible for exchange to occur. It is 
not something that is under the control of individual 
providers. Exchange is in many ways a team sport. You need to 
have someone out there to get your pass when you throw the pass 
and you need to be able to take the pass when it comes back to 
you. So the health information exchange cooperative agreement 
programs that provide funds to the States are meant to empower 
the States and encourage the States to lead in the development 
of health information exchange capabilities within state 
jurisdictions and across state jurisdictions. Similarly, the 
Office of the National Coordinator has undertaken an aggressive 
program for the development of new standards and technologies 
that can provide a tool kit for exchange that the States can 
use and that local service providers can use.
    Mrs. Capps. One final question to you. Your office, I know, 
has been in touch with the providers that are required to start 
exchanging health information electronically but once they have 
begun that, is there the national infrastructure to allow it to 
continue to work forward? In other words, are you building a 
network? I have just a half a minute left for you to respond.
    Dr. Blumenthal. We want very much for this to be an ongoing 
feature of the health-care system and of health information 
technology so we are working hard with our health information 
exchange groups at the State level to make them sustainable 
over time.
    Mrs. Capps. So there is a network that is building within 
the State and then will that filter----
    Dr. Blumenthal. Absolutely. That network has to be created 
or else exchange will not continue.
    Mrs. Capps. Thank you very much.
    Mr. Shimkus.
    Mr. Shimkus. Thank you, Madam Chair.
    First, I want to segue into and follow on the line of 
questioning that Mrs. Capps talked about. Also, there is a 
provision on the absence of physical therapy as part of being 
not eligible to receive and I just want to throw that out 
there. I think your answer would be very similar in the 
response. But I think it is worth noting that there are some 
gaps there and there will be a debate on who is eligible and 
who is not eligible.
    Dr. Blumenthal, what happens to eligible professionals and 
hospitals that fail to meet the meaningful-use requirements? 
Are they penalized? Will they be penalized?
    Dr. Blumenthal. Well, Congressman, the law specifies what 
will happen for failure to meet meaningful use.
    Mr. Shimkus. And since you are implementing that law, what 
would that be?
    Dr. Blumenthal. Well, as of 2015, eligible providers that 
have not implemented, not become meaningful users would be 
potentially penalized in their Medicare and Medicaid----
    Mr. Shimkus. When? When will that start? When will the 
penalties start?
    Dr. Blumenthal. Twenty fifteen.
    Mr. Trenkle. Yes, 2015 is specified in the legislation.
    Mr. Shimkus. We don't have any idea based upon where people 
are in a survey of projection of how many providers may be 
penalized?
    Dr. Blumenthal. I think it would be premature to speculate 
about that.
    Mr. Trenkle. We put some estimates in the impact analysis 
as part of the regulation, but----
    Mr. Shimkus. And what would those analyses show?
    Mr. Trenkle. We had both a high- and a low-end projection 
for that.
    Mr. Shimkus. I will give you a chance to look for that.
    Mr. Trenkle. No, I have got them right here, actually. The 
projection we had on the low end was by 2015, 21 percent of EPs 
would be meaningful users, and on the high end, 53 percent 
would be meaningful users, but keep in mind that that 
represents numbers based on previous studies that our actuaries 
used to come up with these numbers. They don't take into 
account what the effects of outreach and other activities that 
will be done under this Act will do.
    Mr. Shimkus. You know, and I think from colleagues on both 
sides of the aisle, especially those of us who represent rural 
communities, I think, you know, our one of many concerns would 
be major institutions have the capital or the foundations to 
move in the aggressively upfront cost. Poor, rural hospitals do 
not, and our concern is the timeline and our concern would be 
then when they are servicing in poor areas that they will then 
have a penalty when they are still trying to comply. So that is 
part of the question.
    Mr. Trenkle. Excuse me just a second, but the numbers I 
gave you were for the professionals, not for the hospitals.
    Mr. Shimkus. Well, it is true for them too.
    Mr. Trenkle. Right. I understand.
    Mr. Shimkus. What about the other issue that we have heard 
of is interoperability between the family practitioner and 
maybe the hospital, and the question would be, and it deals 
with the incentive payment issues. Who would pay if you have 
two systems that are not compatible and then you have to 
develop a compatibility software system? The family 
practitioner may balk and say well, that is our deal. The 
hospital may say well, that is not our deal. How are you going 
to take into consideration those issues?
    Dr. Blumenthal. Well, one of the reasons why we put back to 
stage 2 some of the more complete exchange capabilities was to 
give the local providers a chance to work those things out, 
come to agreements locally on who is going to do what to create 
exchange. I think the two key factors at work here are the 
incentives which will be available if exchange occurs, and 
perhaps for some the avoidance of penalties. And the second, 
the availability of good tools for exchange including open 
source free software, which we are developing.
    Mr. Shimkus. And my time is real short, but I want to just 
ask, in your testimony, Mr. Trenkle, you have a range of 
estimates between $9.7 billion and $27.4 billion over the next 
10 years, and that is a pretty large range. Can you explain why 
that is the case and that can't be narrowed down a little bit 
more?
    Mr. Trenkle. For the purpose of the impact analysis, we did 
both a high- and a low-end scenario. As I mentioned a few 
moments ago, those are based on studies and actuarial 
projections. We also changed some of the numbers based on input 
we received from a number of organizations including the 
American Hospital Association, which allowed us to actually we 
had to lower the lower end because some of the cost projections 
and projections of getting up to speed had to be lowered 
because of the longer implementation lead time they projected.
    Mr. Shimkus. Thank you, Madam Chair.
    Mrs. Capps. Mr. Waxman, the chairman of the full committee, 
is recognized for his questions.
    The Chairman. Thank you, Madam Chair.
    The gathering of health IT should not be a goal in itself. 
It is a worthy goal, but that is not the only reason we want 
it. The lack of timely clinical information is a contributor to 
our Nation's well-documented problems with uncoordinated care. 
Health IT is a tool that can help deal with that problem right 
at the time of the patient's visit. The health reform 
legislation contains numerous policies to improve the delivery 
system such as establishing accountable care organizations, 
reducing hospital readmissions and moving towards greater 
bundling of services.
    Dr. Blumenthal and Mr. Trenkle, what role will health IT 
play in making sure these kinds of delivery system reforms are 
successful?
    Dr. Blumenthal. Well, Mr. Chairman, you can't have 
accountable care organizations without knowing how to make them 
accountable, and to be accountable you need to know what you 
are doing, and health IT is the best possible source of good 
information about performance in real time quickly. Once you 
have a system up and going, the system should generate 
information about quality and efficiency and cost in real time 
as a product of the work, not post-retrospectively through 
chart review, which is costly, lengthy, and by the time it is 
available often no longer relevant to the performance of the 
organization. So it is really I think enormously empowering for 
enabling providers to take responsibility for their 
performance.
    Mr. Trenkle. I would follow up on what Dr. Blumenthal with 
the fact that we are actually building infrastructure over the 
next several years that will support much of the health reform 
from the electronic specifications for the quality measures to 
the health information exchanges and the other work we are 
doing will allow us to have the infrastructure, that will allow 
the flow of data and support many of the objectives of health 
reform, so we feel this is a critical first step in moving 
towards some of the goals set out in the legislation.
    The Chairman. Is it fair to say that without health IT we 
wouldn't be able to have the reforms be as successful as we 
hope them to be?
    Dr. Blumenthal. Well, I would certainly agree with that, 
Mr. Chair.
    The Chairman. Now, there is another value in electronic 
health records. The availability of information in these 
records has the potential to support population research to 
better understand disease and treatment patterns. What plans 
are underway with other agencies to make use of the information 
for public health planning and what role do you think this can 
play in improving the quality and efficiency of health care 
delivery?
    Dr. Blumenthal. That is an excellent question. We are 
working with our sister agencies to try to define how records 
can privately and securely capture and make available 
information that is relevant to the missions of other agencies 
like the Food and Drug Administration or the National 
Institutes of Health or the Agency for Health Research and 
Quality or the Centers for Disease Control and Prevention, how 
we can, for example, in real time learn about the occurrence of 
influenza-like illness so that we can keep track of influenza 
epidemics and know where vaccine needs to be administered or 
keep track of foodborne illness outbreaks though real-time 
availability of information on related types of illness. So 
there is an enormous public health benefit and there is 
enormous value with patient consent and agreement recruiting 
patients into clinical trials for relevant new experiments 
whether it is in cancer or heart disease or diabetes, patients 
who want to be part of these experiments but who might 
otherwise be located without the benefit of the information 
that is available in electronic form.
    Mr. Trenkle. Let me also mention that under the meaningful-
use objectives, one of the major goal areas was to improve 
population in public health and we included a number of 
objectives that provide for the capability to exchange public 
health data, and as I mentioned in my testimony earlier, we are 
also allowing States to have the flexibility to make some of 
these objectives core measures and core objectives for the 
purposes of meeting the meaningful-use criteria for the 
incentive program.
    The Chairman. Thank you. I yield back my time.
    Mrs. Capps. Thank you, Mr. Chairman.
    The Chair recognizes Mr. Gingrey for 5 minutes of 
questioning.
    Mr. Gingrey. Madam Chair, thank you very much.
    I don't know who to ask this so I will ask both of you. The 
HIT policy committee adoption certification work group recently 
recommended that ONC work with the FDA and representatives of 
patient clinician vendor and health care organizations to 
determine the role that the FDA would play to improve the safe 
use of certified electronic health record technology. Recently 
the FDA has suggested that direct-to-consumer genetic tests--we 
had a hearing on that just last week--that those should be 
classified as medical devices for the purpose of oversight. Do 
either of you believe that the FDA should consider electronic 
medical records as medical devices for the purposes of 
regulating these records?
    Dr. Blumenthal. Congressman, our concern and the concern of 
the policy committee that you cited was to take maximum 
advantage of health information technology and electronic 
health records to improve the safety of concern, and what 
actually the committee focused on in addition to the FDA was 
other alternatives for collecting information about the 
implementation of electronic health records to make sure that 
those implementations are as safe as they could possibly be. So 
we also discussed using patient safety organizations and using 
our new certification to collect post-market, post 
surveillance, post-certification surveillance information. So I 
think that the mandate to us, the recommendation to us, not a 
mandate, was to develop and look at all the ways we could 
collect information to make sure that our work was doing 
everything it possibly could to enhance patient safety.
    Now, whether or not the Food and Drug Administration takes 
any action beyond what it already has I think is premature to 
speculate about. They have no plans right now that I am aware 
of to do anything further than what they have already done. So 
we are right now at the Department looking at these information 
collection opportunities that we already have and have created 
and not looking at anything else beyond that.
    Mr. Gingrey. Mr. Trenkle, do you have any further comments 
on that?
    Mr. Trenkle. No, I agree with what Dr. Blumenthal said.
    Mr. Gingrey. I thank you. I hope that I understood 
correctly your response, Dr. Blumenthal, that you really don't 
think that the FDA should treat electronic medical records as a 
medical device.
    Dr. Blumenthal. Well, there are issues, there are legal 
issues which I am not qualified to speculate about as to what a 
device is or isn't. From the standpoint of policy, I would say 
there is no plan right now for the FDA to do anything of that 
sort.
    Mr. Gingrey. Thanks. I have got about 2 minutes left.
    Technology companies have told me, and we have a very good 
one in my district, the 11th of Georgia, in Carrollton, 
Georgia, I won't mention the name of the company but they are 
very good and they have been out there doing this for a while, 
that is, providing electronic medical record hardware and 
software to specialty-specific groups, general surgery, OB/GYN, 
et cetera, and they have told me how critically important it 
will be to have 12 to 18 months of lead time in order to align 
their products with the stage 2 criteria. Understanding how 
critically important quality products are to the viability of 
our future nationwide network, can you give these companies 
like the one in my district some public reassurance today that 
the development of stage 2 criteria will allow these companies 
a 12- to 18-month window in order to bring their products into 
compliance?
    Dr. Blumenthal. We are going to do everything we can to 
give companies as much warning as we can about what the 
criteria will be, and we want to have time to learn from stage 
1 about what the experience has been of providers and vendors 
and others, patients, with the new rules and implementation 
efforts. So we want to wait a while before we get that 
experience. Then we also want to get the rules done as early as 
possible.
    Mr. Gingrey. Well, I don't want to interrupt you, but I 
definitely want to ask Mr. Trenkle a question before my time 
runs out. I have 10 seconds.
    You said to one of my colleagues that the issue of the 
final rule on the hospitals that have multiple campuses, that 
they would just be eligible for one meaningful-user incentive 
payment for Medicare and Medicaid. How about physician groups, 
let us say a family practice group of five individual 
physicians, they are affiliated in some way, how would you deal 
with them? Would that group only be eligible for one payment, 
$44,000 or $77,000, whatever it is, or multiple payments for 
each individual doctor?
    Mr. Trenkle. I just want to add one thing to the previous 
question on the meaningful use stage 2. We have, in addition to 
what David mentioned, we have also signaled in the preamble for 
this particular rule that we were going to move the menu items 
to the core objectives for stage 2 and also signaled our intent 
to add administrative transactions in stage 2 as well as 
increasing the percentage measurement for computerized 
physician order entries. So we have given some signals.
    But to answer your second question, we have--for this 
particular rule, we have payments are made to individual 
eligible professionals so they are not made by group, they are 
made by professionals, and we made that decision very much 
after listening to some of the comments, reading some of the 
comments that came in and listening to some of the concerns 
that people had on both sides where they felt the way the 
legislation was written and the ability to track the dollars 
spent in the performance to meet the criteria, we have 
determined that we would go with the individual eligible 
professionals. So if there are five members of a group 
practice, each one of them would have to show meaningful use to 
meet the requirements to get an incentive.
    Mr. Gingrey. But they would each be eligible if they did 
for the bonus payment?
    Mr. Trenkle. That's correct.
    Mr. Gingrey. Mr. Chairman, thank you. I thought that was 
very important. I am glad you let him answer.
    Mr. Pallone. Thank you.
    Our chairman emeritus, Mr. Dingell, is recognized.
    Mr. Dingell. Thank you, Mr. Chairman.
    Dr. Blumenthal, would you agree that lack of certified EHR 
technology has the potential to hinder our progress and 
discourage physicians from participating in the EHR incentive, 
yes or no?
    Dr. Blumenthal. I don't think that is going to be a 
problem, Mr. Dingell.
    Mr. Dingell. It does have the potential, though, does it 
not?
    Dr. Blumenthal. If certified technology were not available, 
yes, it would have that.
    Mr. Dingell. Now, if eligible providers don't know which 
technology will eventually pass the test, they will be slow to 
go out and buy it. Isn't that correct?
    Dr. Blumenthal. I don't think that is going to happen, but 
yes, that is correct.
    Mr. Dingell. It is a possibility. So it is critical that we 
have a strong certification program in place as soon as 
possible to provide some level of certainty for providers. Do 
you agree with that?
    Dr. Blumenthal. I agree with that.
    Mr. Dingell. And I don't want you to be defensive about 
this. I just want you to understand, I have the apprehension if 
we don't make these things flow, there is going to be trouble.
    Now, while the Medicare/Medicaid incentive programs begins 
next year, the permanent certification program is not expected 
to be fully operational until early 2012. Is that correct?
    Dr. Blumenthal. That is correct.
    Mr. Dingell. Now, what has the Administration done to 
remove the potential uncertainty surrounding certification to 
ensure that we have as much as early participation for 
providers as possible?
    Dr. Blumenthal. Well, we have already published in mid-June 
a final rule creating a temporary certification process which 
will be in existence until the final permanent process is 
available. That process can certify records, will certify 
records, will certify them by the fall, so that we believe 
there will be ample time for eligible providers to have not 
only installed a record but have some time to look them over, 
think about what they want to install, and then some time to 
install them, and still qualify for the full payments available 
under the incentive plan.
    Mr. Trenkle. Congressman Dingell, can I make a comment 
also? One of the things we took into account when establishing 
the criteria for meaningful use is to have a 90-day reporting 
period in year one in recognition of the fact it will take some 
time to set up the certification program and also to allow the 
providers and hospitals additional time to sign up for the 
program and demonstrate meaningful use.
    Mr. Dingell. Thank you. I think you are both telling me 
then that the temporary program is necessary but that it is not 
going to be sufficient over the long haul. Is that correct?
    Dr. Blumenthal. The temporary program will be, we hope, a 
high-quality program but it won't meet all the criteria that 
certification bodies should meet in order to meet international 
standards.
    Mr. Dingell. Now, will the technology certified through the 
temporary program be subjected to additional certification 
under the permanent program?
    Dr. Blumenthal. It will continue to be certified for stage 
1 until additional criteria come into play.
    Mr. Dingell. Now, Dr. Blumenthal, I note that HITECH has 
made substantial program investments including funding for 
support of the Beacon Community Cooperative Agreement program. 
The first round of awards were announced, and I understand that 
there were strong applications from Michigan, but I also 
understand that none of the Michigan applications were 
selected. Am I correct that you plan to announce two additional 
awards?
    Dr. Blumenthal. You are correct, sir.
    Mr. Dingell. And am I to assume that Michigan will be most 
sympathetically considered?
    Dr. Blumenthal. We will give it every sympathetic 
consideration, sir.
    Mr. Dingell. I will be looking forward to that. What will 
be the timeline for this announcement?
    Dr. Blumenthal. Middle of August, I believe.
    Mr. Dingell. Beg your pardon?
    Dr. Blumenthal. Mid-August, I believe.
    Mr. Dingell. Now, I would like to get your assessment of 
the current EHR marketplace. HITECH included a provision that 
would require your office to make certified EHR technology 
available if the marketplace fails to do so. Is that correct?
    Dr. Blumenthal. That is correct.
    Mr. Dingell. Now, what is your current assessment of the 
marketplace? Do you feel that there is adequate innovation 
currently going on so that I don't need to be apprehensive 
about the prior point?
    Dr. Blumenthal. I do believe so.
    Mr. Dingell. Mr. Chairman, I note my time has expired and I 
thank you for your courtesy.
    Mr. Pallone. The gentleman from Texas, Mr. Burgess.
    Mr. Burgess. I thank the chairman.
    Dr. Blumenthal, the American Medical Association in the 
brief that was submitted by Dr. Gingrey for the record makes 
note about the need for small physician practice representation 
on your policy committee. How are you addressing that?
    Dr. Blumenthal. I think that is a fair point. We certainly 
want to make sure that we have heard from the full spectrum of 
physician practices and perspectives so we would be, I think, 
open to that suggestion.
    Mr. Burgess. Another thing that I have encountered, I don't 
know if it has come up----
    Dr. Blumenthal. Congressman, if I could just make one 
amendment to that?
    Mr. Burgess. Yes.
    Dr. Blumenthal. The membership of that committee is 
actually determined by the GAO and the Congress and then 
specified by law as to who else the Secretary can appoint. The 
only way we could appoint small physician practice 
representatives would be as a member of a working group, not as 
a member of the policy committee per se. That is just a matter 
of the way the law is written.
    Mr. Burgess. How many of those working groups do you have?
    Dr. Blumenthal. We have several, so it would be quite 
possible to include them.
    Mr. Burgess. I would also then ask you to consider, I know 
I have heard from a number of physicians who practice 
orthopedics that they face a particular challenge in 
instituting this technology from their offices and that the 
packages that are available to them, the products that are 
available to them that also include digital imaging, the 
broadband requirements are so high, the storage requirements so 
high that they are sometimes looking at systems that cost in 
excess of several hundreds of thousands of dollars which 
obviously is a barrier to entry. So I would encourage you to 
hear voices from across the spectrum of the real world in 
practice because ultimately these are the individuals you are 
going to count on to make this work, and if it is not workable 
for them, clearly we will have a problem.
    What happens to professionals who fail to meet the 
meaningful-use requirements?
    Dr. Blumenthal. Well, in the period between 2011 and 2015, 
they fail to accumulate the incentive payments that are 
available. In 2015 and beyond, they are subject to the 
penalties that were placed in the law with respect to Medicare 
reimbursement.
    Mr. Burgess. So if a practice elects to do nothing, it is 
not that they will just ultimately be left alone, they 
ultimately would be penalized by the provisions of HITECH and 
ARRA?
    Mr. Trenkle. Yes, if they are under the Medicare program if 
they qualify.
    Mr. Burgess. And what----
    Mr. Trenkle. And that was legislatively mandated. That was 
part of----
    Mr. Burgess. But what are the penalties that they are 
looking at?
    Dr. Blumenthal. I will let Mr. Trenkle answer that.
    Mr. Trenkle. The penalties are as they were put into the 
legislation. It is 1 percent in 2015 and then it goes upward 
beyond that, but we implement them as they were put into the 
legislation.
    Mr. Burgess. And just for the record, I argued strenuously 
against that type of punitive approach to this because I don't 
know if we have allowed ourselves enough time to ramp this up. 
Dr. Blumenthal, you have worked a Herculean effort this past 
year to get where you are right now. Imagine putting that 
effort on top of a small physician practice working 16 hours a 
day just to take care of their patients and pay their bills and 
keep their doors open with all of the other stipulations we 
have put up them. This one does seem onerous. For either of 
you, how many providers are going to be penalized? Do you have 
some notion as to how extensive this is going to be?
    Dr. Blumenthal. There are estimates that were made by the 
Office of the Actuary which I will let Mr. Trenkle summarize, 
but I will add a prior comment to say that all those estimates 
were based on experience prior to the availability of 
incentives and prior to the availability of the regional 
extension center program, the Beacon community program, our 
workforce training program and all the other efforts we are 
making to assist providers in becoming meaningful users.
    Mr. Trenkle. As I had mentioned earlier in a similar 
question, we had scenarios both high and low in the impact 
analysis that were compiled by our actuaries using data from 
studies and other information that they had.
    Mr. Burgess. Maybe you could get back to me with that in 
writing because I am going to run out of time and I would be 
interested in your response to that.
    Mr. Trenkle. OK.
    Mr. Burgess. But I guess one of the other follow-up 
questions I have is, obviously there are going to be people who 
have these systems for sale. Now, the people who have the 
systems for sale, the vendors, are they under any sort of 
punitive aspects under this law or do they just simply present 
their wares for sale and that is that?
    Mr. Trenkle. No, they are not under any penalties. The only 
issue with the payment adjustments was what was in the 
legislation.
    Mr. Burgess. Let me just see if I have this right. The 
doctors are under penalty, under threat of penalty if their 
practices are not compliant, but the doctors technically don't 
really make any money off of having an electronic medical 
records system. It may be good practice and it may be important 
for patient safety but they don't actually benefit on the 
bottom line from these systems and yet the vendors are going to 
significantly benefit from the forced sale to practices of 
these systems. Are you doing anything to mitigate that 
discrepancy?
    Dr. Blumenthal. Well, the provisions of the law are the 
provisions of the law, Mr. Congressman, as you well know, so we 
have limited--what we are doing is working very hard to make 
sure that every well-intended provider who wants to be a 
meaningful user has the opportunity to become a meaningful user 
and that--but they won't fail through any lack of effort on our 
part. So that is I think our commitment at the Office of the 
National Coordinator and from the federal government.
    Mr. Burgess. But with all due respect----
    Mr. Pallone. The gentleman's time is a minute and a half 
over.
    Mr. Burgess. I will follow up with this in writing because 
this is an important point, and we have already seen how your 
rulemaking has progressed since the beginning of the year, and 
it is going to affect practices all over the country.
    Mr. Pallone. Thank you. Let me mention that you will get 
additional questions from us in writing, and any member is 
entitled to do that.
    The gentlewoman from the Virgin Islands, Mrs. Christensen.
    Mrs. Christensen. Thank you, Mr. Chairman, and thank you 
both, Dr. Blumenthal and Mr. Trenkle.
    My first question is to you, Mr. Trenkle. The territories 
are not included in the EHR program under Medicare and 
Medicaid. It is just the 50 States and the District of 
Columbia. Is the reason because we don't use a prospective 
payment program? I don't see why that should make a difference 
but you can explain if it does. And Medicaid is different in 
the territories, and while I don't agree with that either, 
Medicare is not. And in the territories, Medicaid can only be 
used in public hospitals and public clinics. So why are we 
excluded?
    Mr. Trenkle. In determining eligible professionals and 
hospitals, we followed what was in the statute.
    Mrs. Christensen. OK. So we did it?
    Mr. Trenkle. Right, so you did it.
    Mrs. Christensen. We will try to see what we can do about 
that because it really shouldn't--in the territories, Medicare 
beneficiaries and Medicaid beneficiaries should benefit from 
the same benefits of HIT as everyone else. Don't you agree?
    Mr. Trenkle. Yes, I agree. As I said, we followed what was 
in the statute, so----
    Mrs. Christensen. Thank you.
    Dr. Blumenthal, on the Beacon Community Cooperative 
Agreement program, and we heard that the first round has been 
awarded, certain communities are provided with funding to build 
and strengthen the HIT infrastructure and HIT capabilities. 
Could you describe briefly the criteria for other communities 
that are chosen? I am trying to get at--and if you know this, 
if you would help me to understand, what proportion of racial 
and ethnic minorities and low-income communities were served in 
the first round?
    Dr. Blumenthal. Well, I would like to get back to you with 
specific numbers. I can tell you that my memory is that the 
communities' populations are representative of the underserved 
populations in the country as a whole. The beacon community 
program was awarded, vendors were chosen through an objective 
review competitive process. As a matter of fact, it took place 
in the record-breaking snowstorm in February, and we funded 
those programs in the order in which they were picked by the 
external reviewers, just as an NIH grant would be awarded. The 
criteria took into account of course the quality of the 
application. It did take into account diversity. Seven of the 
15 are rural communities. And it took into account the 
commitment of the communities, the quality of the health IT 
infrastructure, the governance arrangements and the 
believability, the credibility of their goals which were very 
precisely laid out in the applications.
    Mrs. Christensen. Did you identify or have to respond to 
any unique challenges in the implementation process or through 
the comment process from poor, rural or communities of color?
    Dr. Blumenthal. We certain tried to. There is a beacon 
community in the Mississippi delta. There is one in the 
Piedmont area of North Carolina. There is one in Tulsa, 
Oklahoma. So they really go from Hawaii to upper New York and I 
think are quite representative of the country as a whole.
    Mrs. Christensen. And I guess to both of you, and you may 
have answered this already but I didn't see it in reading your 
testimony specifically. How have the providers been 
incorporated into the setting of the standards, not just in the 
comment period but as you were developing the standards? Were 
doctors, hospitals, other providers included?
    Dr. Blumenthal. We have two advisory committees that you 
all provided us under the statute, the policy committee and 
standards committee. They meet in public. Their work groups 
meet in public. We have had over 180 public meetings of those 
groups. We have had testimony from a wide range of advisors.
    Mrs. Christensen. One other question. I am sorry. I am 
hearing your answer. But there is room, because many older 
doctors are used to dictating. Is there room in EHR for 
including the dictation transcription process in the 
implementation since that might provide an easier transition? I 
needed to get that question and I have to leave, so I am sorry 
for cutting you off but I hear where you were going with your 
answer.
    Dr. Blumenthal. Well, progress notes are not part of the 
requirement for meaningful use in stage 1, so yes, there would 
be an opportunity to dictate into the record in stage 1.
    Mrs. Christensen. Thank you, Mr. Chairman.
    Mr. Pallone. Thank you.
    Next is the gentleman from Ohio, Mr. Space.
    Mr. Space. Thank you, Mr. Chairman.
    Mr. Trenkle, like many of my colleagues, the hospitals, as 
I mentioned in my opening, in my Congressional district are 
going to be impacted, at least some of them, by your decision 
on multiple-campus hospitals, and in fact, Genesis, which is 
one of the largest hospitals in my district in Zanesville, 
Ohio, the largest city in my district, stands to lose about $2 
million in incentive payments based on your rule and, as you 
might understand, they are little frustrated by that rule. 
Won't decisions like this ultimately make it more difficult for 
hospitals like Genesis Hospital to adopt the very technology 
that this law is designed to promote?
    Mr. Trenkle. As I mentioned in my written and in my oral 
testimony that we base this on existing policy and the provider 
number is based on how the hospitals choose to organize 
themselves for payments under other Medicare programs, so what 
we did here without clear statute intent was to be consistent 
with the payment policies that we have adopted for other 
programs, many of which, as I said, were due to hospitals 
themselves wanting to be organized in this manner to be paid in 
a certain way.
    Mr. Space. So absent clear statutory intent, at this point 
you don't envision reconsideration of that rule?
    Mr. Trenkle. That is correct, although we are happy to be 
working with committee staff and others to look at potential 
ways to work with us. We recognize that there has been a lot of 
public comment as well as comment from yourself, your staff and 
other staffs here that express concerns about them. We have 
heard, of course, from many hospital groups as well.
    Mr. Space. I appreciate your working with us on it because 
it is a real problem for us and for our health care providers 
which already are at so many disadvantages, given the rural 
nature of our district, and the class of patients, the 
Medicare, Medicaid, self-pay percentages are so high. In fact, 
we have got one hospital now that is desperately attempting to 
avoid bankruptcy and if these hospitals can't survive, it will 
have a direct and profound impact on the folks that live in 
places like Ohio's 18th district, and broadband and health IT 
represents an opportunity to bridge many of the divides that 
exist between rural America and urban and suburban area. So I 
am grateful that you have expressed a willingness to work with 
us.
    Dr. Blumenthal, I understand last week you testified before 
Ways and Means and you mentioned that Secretary Sebelius had 
convened a working group on rural providers. Can you talk a 
little more about how this working group will help hospitals 
like the ones that I represent meet the health IT standards?
    Dr. Blumenthal. Secretary Sebelius, as you know well, 
Congressman, was the governor of a rural State so she has been 
very interested in the issues that pertain to HIT access in 
rural areas. She is convening the secretaries of commerce, 
Agriculture, the Veterans Administration and the chairman of 
the Federal Communication Commission actually next week for a 
first meeting to discuss ways in which we can work together 
using the resources of these different departments to bring to 
rural communities the resources they need to be meaningful 
users of health information technology. I don't want to presume 
what is going to come of that meeting, it hasn't been held yet, 
but there are broadband resources available at Commerce and 
USDA. There are tele-health resources. The VA does a lot of 
outreach in its communities. The FCC spends $400 million a year 
on broadband and communications so we are trying to make sure 
that between the Department of Health and Human Services and 
these other agencies that we are dedicating all the resources 
we can to making up for the differences, the special burdens 
that rural communities have.
    Mr. Space. Thank you, Dr. Blumenthal and Mr. Trenkle.
    I yield back my time, my one second.
    Mr. Pallone. I thank the gentleman and recognize the 
gentleman from Connecticut, Mr. Murphy.
    Mr. Murphy of Connecticut. Thank you very much, Mr. 
Chairman. Thank you both for your all your work and for being 
here today.
    I wanted to build on a question that Chairman Waxman 
raised, and let me first pose it to you, Dr. Blumenthal. I 
think one of the most exciting pieces of the health care reform 
bill is the path forward we have set on the change in delivery 
system and the change in which we pay for medicine to really 
move from a system in which we today value volume to a day in 
which we can place the appropriate value on outcomes and 
quality. I am obviously very happy to hear your emphasis on the 
connection between health care IT and the day in which that can 
happen. I think your response to him was in regard to 
accountable care organizations, which I think will be 
transformative.
    I wanted to ask you about some other potential payment 
changes and new models of delivery. One of the pilot programs 
that I and others worked very hard on was looking at new ways 
to bundle payments in particular with respect to post-acute 
care, and in that setting, you are dealing with complex 
patients that are coming in and out of hospital and physician 
settings, often having some of their most expensive care in, 
for instance, skilled nursing facilities. I know we can't cover 
everybody with the payments in this law but I wanted to get 
your thoughts on how we continue to broaden out the number of 
providers that are eligible for these payments, or in the 
absence of doing that, how we find a way to get comprehensive 
health care information technology to places like skilled 
nursing centers so that we can really implement these payment 
delivery system changes that we know have the potential to do 
some great things.
    Dr. Blumenthal. Well, in my role as a provider, as a 
practitioner, a primary-care practitioner, I am extremely 
sympathetic to the need to bring long-term care, home care, 
rehab in coordination and get the information from those sites 
into the acute care part of the system. As you pointed out, the 
law as currently structured does not make incentives available 
to those provider settings, and that is a limitation. It 
doesn't prevent, though, those institutions from finding 
electronic heard record technology themselves, especially if 
bundled payment arrangements were to make available some 
savings that they could get access to and if having that 
technology enabled those savings as I am certain it would.
    So I don't think we should forget that the rest of the 
health care world continues to march along and that this 
technology is really inevitable. It is the way to collect and 
use information and it will take over other sectors as well.
    Mr. Murphy of Connecticut. I don't know exactly what the 
number is but the statistic always given about the very small 
number of patients who comprise a very large number of costs, 
these are patients that are obviously in and out of hospital 
settings and so whether it is through bundled payments or 
another way, I do think we have to find a way to get some help, 
especially skilled nursing.
    Maybe I will ask the question, a little different version 
to you, Mr. Trenkle. As HHS is looking at and CMS is looking at 
how to implement these new payment methodologies or these new 
pilot programs for delivery system change, are you looking at 
implementing them on a time schedule that is consistent with 
the rollout of health care information technology and 
specifically on this change, post-acute-care bundle payments, 
are you worried that there will be a lag in development of good 
IT systems in skilled nursing facilities that might present a 
barrier to that particular pilot program?
    Mr. Trenkle. I don't have all the implementation dates here 
but I will tell you, we are working closely with other parts of 
the agency to ensure that we are coordinating with the rollout 
of the health care reform implementation and the HITECH 
provisions.
    Mr. Murphy of Connecticut. One last question, back to you, 
Dr. Blumenthal. Talking about certification, the temporary 
system that we have set up today, obviously one of the things 
you hear a lot about is providers and hospitals who have been 
early adopters and who fear that they are going to be forced to 
make some expensive and onerous changes going forward. Do we 
expect that the certification process will be only for new 
technology or do you think we will have existing technology 
that might be out there today, it might have been out there for 
a period of time certified as well?
    Dr. Blumenthal. The requirements for certification are new 
because the meaningful-use requirements are new, and we know 
that frequently technology that is in place, though it may be 
beneficial, doesn't meet the standards or the certification 
requirements that meaningful use has created. So we can't 
assume that technology in place right now is capable of 
supporting meaningful and therefore we can't assume that it is 
certified. So yes, if you have technology right now that hasn't 
been certified under the new certification process, you will 
have to get it certified. It may be quite easy to do that. It 
may be that you have technology that is very capable. But we 
can't assume that, and we don't want to create the impression 
for providers that something they are using now will be capable 
of meaningful when it is not.
    Mr. Murphy of Connecticut. Nothing preventing an existing 
system from being stamped as certified as long as it meets that 
requirement?
    Dr. Blumenthal. Absolutely not.
    Mr. Murphy of Connecticut. Thank you. Again, thank you for 
all your work. This is incredibly important. I appreciate your 
being here.
    Mr. Pallone. Thank you, Mr. Murphy. I am going to recognize 
myself since I wasn't here earlier.
    I assume, and I missed the beginning, that there was some 
discussion about meaningful but it is the most or one of the 
most controversial aspects of this round of rulemaking, and 
demonstrating meaningful use is the key to attaining 
eligibility for incentives for Medicare and Medicaid so there 
is a lot of interest from provider communities about how those 
rules are structured. So I wanted to ask each of you, first, 
Mr. Trenkle, you have been criticized for setting the bar too 
high for providers to demonstrate meaningful use. Others have 
said the agency isn't demanding enough from providers. I 
actually haven't heard that one. Please, if you would explain 
to the committee how you define the balance between high 
standards and reasonable expectations and how the final rule 
reflects that balance.---
    Mr. Trenkle. Yes, I would be happy to do that. I think it 
is important to point out that the final regulation reflects a 
17-month process. The Recovery Act was passed in February of 
2009. The final rule came out in July of 2010. And during that 
time we convened several committees that as Dr. Blumenthal 
mentioned received input from a number of stakeholders. We had 
a public comment period of 60 days. We came out with a notice 
of proposed rulemaking. We heard back from the community that a 
lot of the objectives were too high so we adjusted in response 
to the comments. So I think a combination of all these efforts 
have led us to what we believe is a balance between a strategic 
framework for promoting future adoption and meaningful use and 
recognizing the realities of the infrastructure and the 
adoption rates today.
    Mr. Pallone. I mean, I guess the concern that I hear is 
that a lot of providers simply won't meet the bar and then our 
efforts are in vain, but at this point you don't feel that is 
the case?
    Mr. Trenkle. Well, I think we heard loudly from the 
community that the bar was too high so we have added 
flexibility in terms of the objectives. They have a core and 
they have a menu set. We lowered some of the thresholds. We 
eliminated the administrative transactions and we did a number 
of other changes to the meaningful-use requirements that 
reflected a need to lower but also maintain a framework that 
will propel us towards future stages.
    Mr. Pallone. All right. Let me ask I guess essentially the 
same question of Dr. Blumenthal. from your experience, do you 
believe that providers will be able to meet the meaningful-use 
criteria laid out in the final rule?
    Dr. Blumenthal. I believe they will. I believe there are 
tens and even hundreds of thousands of physicians who are 
already effectively using electronic health records and are 
close to meeting meaningful-use criteria. By the way, that is 
true of many small hospitals as well, critical-access 
hospitals. I have met with them and seen them with my own eyes. 
So I think it is quite possible to do this, and the question 
will be whether the physicians and hospitals feel that it is 
possible and will devote themselves and make the effort. We 
have to make sure that the taxpayer was rewarded with getting 
real value from these records for the tens of billions that 
were in the legislation, but at the same time we have to make 
sure that it was achievable, and that is a balance that we have 
been trying to find constantly over this 17-month period. We 
will closely at what the experience is, try to learn from that 
experience and see whether we have set the bar at the right 
level. So we have done our due diligence. We have made our best 
analyses and we are moving forward from there.
    Mr. Pallone. I heard some of the members say that they were 
concerned about the penalty if someone doesn't move forward at 
a certain point with the HIT, but there is also an exemption. 
Do you want to address that, Mr. Trenkle, in case we run into a 
situation where they are facing the penalty but----
    Mr. Trenkle. Yes, I should have mentioned that earlier, 
that there is a legislative exemption in case of hardship on a 
case-by-case basis, and we will need to define the criteria for 
that hardship in future rulemaking.
    Mr. Pallone. But that is not something you are doing in 
this first round, in other words?
    Mr. Trenkle. No, because the adjustments aren't scheduled 
to come in until 2015 so we will be addressing that in future 
rulemaking.
    Mr. Pallone. All right. I know I have got a couple minutes 
here. I just wanted to ask, you know, I always get the 
questions, Dr. Blumenthal, about the small practices. The 
majority of physician practices continue to be small practices 
of one or a few physicians and of course, you know, given the 
economics today, a lot of them are struggling, and it is an 
investment obviously to move towards health IT and they say it 
is going to decrease productivity when it is initially 
implemented, a lot of things of that nature. What would you say 
about that? I mean, the HITECH Act provides $2 billion to your 
office but there is also the regional extension centers and 
beacon community programs. Is this going to be some way to help 
these single practitioners, or how do you envision that?
    Dr. Blumenthal. Well, the small practice if the target of 
the Regional Extension Center program. That is where we are 
focusing our effort because we realize that those are the 
practitioners who are going to have the hardest time and are 
going to be the least attractive and have the fewest resources 
to attract a commercial vendor, a commercial consulting company 
or a so-called integrator to help them. So we are intending to 
enroll 100,000 small practices through the Regional Extension 
Center program in programs to assist them becoming meaningful 
users, and I think that is going to be a big opportunity for 
small practices, and over time I think we will learn how to do 
that better and better and we will continue to provide that. 
That is over the first couple of years. Later on I think we 
will be able to do more as time goes on. So they are very much 
aware of this group and the practice is changing and younger 
physicians are much more adept at adopting these technologies 
than physicians my age, and so I think over time this problem 
is going to largely take care of itself.
    Mr. Pallone. All right. Thank you.
    The gentleman from Texas, have you been recognized? I 
wasn't here earlier. The gentleman is recognized.
    Mr. Gonzalez. Thank you very much, Mr. Chairman. I 
apologize. I have been absent for much of the hearing, but I do 
thank the witnesses.
    I have a couple of questions. One is going to be more 
parochial. I will start with the more general one, and that is 
going to be--and first of all, the sources of the questions 
come from the medical community, hospitals and such in my area 
because my staff is very sensitive to getting their input, and 
they say why don't you ask these particular questions, and they 
are much better questions than I would come up with on my own, 
so I want to make sure that I get some of the, I guess the 
verbiage here, the quality improvement organizations and the 
proposed rules, and back home they are saying because of 
preexisting relationships with these quality improvement 
organizations with the regional extension centers, what do you 
see prospectively as those particular right now it may be prime 
or subcontractors with individuals in San Antonio--I am from 
San Antonio--as we go forward? Will you have some of these same 
individuals, organizations playing a role? It seems like it 
would be a good idea just because of preexisting relationships 
and of course the expertise that they would bring to the table.
    Dr. Blumenthal. Our regional extension centers, which is 
what you are referring to, I think, here were chosen on a 
competitive basis. We had many more applications through the 
regional extension centers than we were able to fund. I think 
about a third, if I am not mistaken, of our regional extension 
centers are quality improvement organizations so that that 
coincidence, that overlap already exists. Where are there are 
not quality improvement organizations, we are instructing the 
regional extension centers to work with quality improvement 
organizations and with all the other pertinent organizations in 
their community.
    Mr. Gonzalez. The other question, and I don't know how 
unique it is to San Antonio but obviously we have a very large 
military presence. At the present time we have two major 
military hospitals. One actually just closed recently, Wilford 
Hall, but BAMC is being plussed up, Wilford Hall will have a 
state-of-the-art ambulatory center, and we have a major VA 
hospital. The issue that comes up is of course can they still--
will they be able to communicate, the interoperability issue 
that comes up, the different guidelines and requirements that 
maybe a military hospital or a VA may be subjected to as 
opposed to the other hospitals in San Antonio because there is 
quite a bit of overlap, believe it or not, as far as patient 
care. Your thoughts on that?
    Dr. Blumenthal. We work very closely with the VA and DOD to 
help them achieve seamless interoperability between their local 
facilities. As a matter of fact, we prioritize some beacon 
communities where there were VA and DOD facilities that were 
trying to communicate because we wanted to support that 
activity. So one of the ways we are doing that is by developing 
software and standards that will work specifically to 
facilitate their interoperability so very much on our radar 
screen, Congressman, and we hope we can continue to help them 
and make this a reality because I know it is also of great 
concern to the President that our current servicemen and our 
veterans get integrated care that benefits from all the 
information that is available about them.
    Mr. Gonzalez. Well, thank you very much, and I yield back, 
Mr. Chairman.
    Mr. Pallone. Thank you. I want to thank both of you for 
your testimony and answering our questions. As I mentioned 
before, obviously some members have said they are going to 
follow up with written questions as well, but this is an issue 
that is hugely important to our hospitals and our providers, so 
thanks a lot really for----
    Mr. Shimkus. Mr. Chairman, will you yield?
    Mr. Pallone. Sure.
    Mr. Shimkus. And I would hope that our first panel would 
follow the hearing record. On the second panel, we have seven 
folks on there. They are from small hospitals. They are from 
family practitioners. A lot of these questions that we have 
addressed come from them. I know you probably won't stay, but I 
would encourage you to get the hearing record and see some of 
the issues that have been raised in the second panel.
    Dr. Blumenthal. Absolutely.
    Mr. Pallone. I agree with Mr. Shimkus. Thank you very much.
    Dr. Blumenthal. Thank you.
    Mr. Trenkle. Thank you.
    Mr. Pallone. And I will ask the second panel to come 
forward. Now, we are expecting votes on the floor fairly 
quickly so I doubt we will get through all seven people that 
are on the panel but we are going to try to start and get as 
far as we can because there are seven of you, I believe.
    Well, first of all, let me welcome everyone. I know we have 
a large panel here. I am going to introduce each of you. 
Beginning on my left is Frank Vozos, Dr. Vozos, who is 
Executive Director of Monmouth Medical Center speaking on 
behalf of the New Jersey Hospital Association. Thank you for 
being here, Frank. Monmouth Medical Center is in my hometown of 
Long Branch, and I was actually born there. Next is Mr. Gregory 
Starnes, who is CEO of Fayette County Hospital. That is Fayette 
County, Georgia?
    Mr. Starnes. Illinois.
    Mr. Pallone. Fayette County, Illinois. OK. Sorry. And then 
we have Ms. Christine Bechtel, who is Vice President of the 
National Partnership for Women and Families; Dr. Roland Goertz, 
who is President-elect of the American Academy of Family 
Physicians and CEO and Executive Director of the Heart of Texas 
Community Health Center; Dr. Matthew Winkleman, who is a 
physician with the Primary Care Group in Harrisburg, Illinois; 
Dr. Glen E. Tullman, who is Chief Executive Office of 
Allscripts; and Dr. Peggy C. Evans, who is Director of the 
Washington and Idaho Regional Extension Center with Qualis 
Health.
    We ask each of you to limit your testimony to 5 minutes. 
You can certainly add additional testimony if you like and then 
you will get more written questions from us later, and I will 
start with Dr. Vozos.

 STATEMENTS OF FRANK J. VOZOS, M.D., FACS, EXECUTIVE DIRECTOR, 
   MONMOUTH MEDICAL CENTER, ON BEHALF OF NEW JERSEY HOSPITAL 
ASSOCIATION; GREGORY D. STARNES, CEO, FAYETTE COUNTY HOSPITAL; 
  CHRISTINE BECHTEL, VICE PRESIDENT, NATIONAL PARTNERSHIP FOR 
 WOMEN AND FAMILIES; ROLAND A. GOERTZ, M.D., M.B.A., PRESIDENT-
ELECT, AMERICAN ACADEMY OF FAMILY PHYSICIANS, CEO AND EXECUTIVE 
   DIRECTOR, HEART OF TEXAS COMMUNITY HEALTH CENTER; MATTHEW 
  WINKLEMAN, M.D., PHYSICIAN, PRIMARY CARE GROUP, HARRISBURG, 
ILLINOIS; GLEN E. TULLMAN, CHIEF EXECUTIVE OFFICER, ALLSCRIPTS; 
  AND PEGGY C. EVANS, PH.D., CPHIT, DIRECTOR, WASHINGTON AND 
         IDAHO REGIONAL EXTENSION CENTER, QUALIS HEALTH

                  STATEMENT OF FRANK J. VOZOS

    Dr. Vozos. Good afternoon, Mr. Chairman, Ranking Member 
Shimkus and distinguished members of the committee. Thank you 
for inviting me to testify today. I am Dr. Frank Vozos, 
Executive Director of Monmouth Medical Center located in Long 
Branch, New Jersey. Monmouth Medical Center is a member of the 
San Barnabas Health Care System, the largest not-for-profit 
integrated health care delivery system in New Jersey and one of 
the largest in the Nation. I am also here on behalf of New 
Jersey Hospital Association.
    I am pleased to appear before you today to highlight how 
the HITECH Act will support the transformation of Monmouth 
Medical Center by helping us successfully fulfill our goals 
related to the acquisition and implementation of health 
information technology and to applaud the federal government 
for establishing a program that will provide incentive payments 
through Medicaid and Medicare to doctors and hospitals who 
demonstrate meaningful use of the certified EHR system.
    By way of background, Monmouth is a 527-bed community 
teaching hospital that provides a full spectrum of services 
from neonatology to geriatrics with more than 800 medical and 
dental staff members. The medical center admits more than 
22,000 adult and pediatric patients and cares for over 120,000 
outpatients annually. We are one of the largest and oldest 
teaching hospitals in New Jersey and we are the largest 
academic affiliate of Drexel University College of Medicine and 
that is a relationship that we have had for over 4 years. We 
are further distinguished among the landscape of health care 
providers in New Jersey by our relationship with the Long 
Branch federally qualified health center, which opened in April 
2004 and grew directly out of Monmouth Medical Center's 
longtime motto of providing primary care to the community 
through charity care clinics.
    It is important to note that Monmouth is the leading health 
care provider in the city of Long Branch, a multi-ethnic 
enclave of residents who are disproportionately poor, young, 
uninsured and members of minority groups. More than 35 percent 
of the city's population lives at or below 200 percent of the 
federal poverty level. There are four census tracks with the 
city that have been federally designated as low-income, 
medically underserved populations, and although there are 40 
primary care health care providers located in the area, most do 
not accept Medicaid or offer charity care. So as a result, the 
medically indigent population of Long Branch and its 
surrounding communities use the low-income clinics or our 
emergency room at Monmouth as their only source of health care.
    While Monmouth was moving fairly well down a path of HIT 
adoption before the passage of the HITECH Act, the new law 
certainly strengthens our ability to effectively transition to 
more comprehensive adoption. I think we have pursued this goal 
enthusiastically, embarking on a facility-wide effort to 
upgrade our health information technology capabilities on 
multiple fronts.
    As an example, in our emergency department we have invested 
significant resources to install many sophisticated information 
technology components including directing the interface between 
the emergency room clinical information system and hospital 
charts using the EDIMS computer framework. All records and 
tests are available of the care of the patient and it links to 
our medical center health information record. Repeating testing 
unnecessarily has declined and patient safety combined with 
more timely care has been the core outcome of this initiative.
    Monmouth Medical Center's clinical information system suite 
of products, which is current the Cerner Millennium, is 
currently CCHIT certified. These products adhere to 
requirements dealing with functionality, security and 
interoperability. On a regional level, we are one of the 
leaders in developing protocols and an infrastructure to share 
clinical data with four medical centers through Monmouth and 
Ocean County, and that is regardless of our competitive 
marketplace.
    One aspect of the new system we are very focused on is 
computerized physician order entry. We are dedicating 
significant time and effort to changing behavior of physicians 
to enter orders into the computer instead of handwriting them. 
In a teaching hospital, it becomes important to leverage that 
technology infrastructure such as CPOE as a teaching modality 
as well as a recordkeeping modality as the large resident staff 
interacts most frequently with the patients and completes 
written orders.
    Moving outward from our emergency department, the extent of 
EMR use is varied throughout the rest of the hospital. In the 
emergency department, EMR includes medication orders, lab 
results, radiology readings, history and physicals, nurse and 
physician notes as well as discharge instructions. On the 
floors, the EMR has lab results, radiology readings and other 
test results and other parts of the record are still 
handwritten, although with easy access. So it is part of our 
global IT initiative that all areas of the medical center will 
be EMR active by 2011.
    Further meaningful-use requirements with a compliance goal 
of 2011 at Monmouth include provisions for a physician to take 
advantage of EHR in their own private practice. Private 
physician offices and their style of practice are being taken 
into account as vendors are linked with these clinical partners 
to create the EMR interface with Monmouth. By 2011, there will 
be active physician connectivity with the hospital. Part of 
this deliberate strategy includes the costs associated with 
linking physicians and the medical center through EMR. What can 
be subsidized and what is funded by the medical center or 
physicians are important factors as we work through this 
connectivity goal. The ability to eliminate potential errors 
and medical errors including handwriting and timeliness of 
order gives clear quality markers for both private physician 
practice and care provided at Monmouth Medical Center.
    In addition, we were recently selected and are currently 
actively engaged as one of only two hospitals in New Jersey to 
begin a CMS-funded 21-month pilot project to test and model 
transitioning Medicaid patients who present to the emergency 
department with non-emergent care needs to the appropriate 
primary care setting through collaboration with our federally 
qualified health center. This data-driven pilot has further 
integrated electronic referral systems and electronic health 
records through infrastructure enhancements and a 
recommendation to the State and federal agencies administering 
and coordinating the pilot in New Jersey and in 19 other 
States. Currently, the FQHC clinicians can electronically 
access the hospital record for a previous hospital history and 
test results for their patient. By 2011, the new CPOE 
functionality will be fully interoperable between the emergency 
department and the Long Branch federally qualified health 
center, allowing for truly comprehensive EMR for our patients 
as well as CPOE for our physicians and other clinicians both in 
the medical center and private offices.
    Mr. Pallone. Frank, I am going to have to ask you to 
summarize the rest.
    Dr. Vozos. OK. I am done. I just want to let you know that 
for the patients in this pilot study, we have seen a 70 percent 
conversion rate from people that have been using the emergency 
room as their medical home now to the federally qualified 
health center as their primary care.
    So again, thank you for inviting me. I appreciate this 
opportunity to appear before you today and I will answer any 
questions.
    [The prepared statement of Dr. Vozos follows:]
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    Mr. Pallone. Thanks so much, really.
    Now, that was the bell. I think we can get at least two 
more in, maybe three, before we go vote.
    Mr. Starnes.

                STATEMENT OF GREGORY E. STARNES

    Mr. Starnes. Chairman Pallone, Ranking Member Shimkus and 
other distinguished members of the committee, thank you for 
this opportunity. My name is Greg Starnes and I am the Chief 
Executive Officer of Fayette County Hospital and Long Term Care 
in Vandalia, Illinois. I have been in health care 
administration my entire career, and I consider it an honor to 
be here today to talk with you about the HITECH Act.
    First, please know that my colleagues and I support the 
HITECH initiatives. Fayette County Hospital and Long Term I is 
a critical-access hospital with 25 beds and 85 long-term care 
beds. The facility serves a county of 21,000 people and resides 
in the county seat of Vandalia with a population of 7,000. The 
average household income is below the State average. The 
percentage of elderly in the population is higher than the 
State average. The unemployment rate is 10.8 percent. The 
number of Medicaid eligible has increased in the last year and 
the numbers of individuals who find themselves with no ability 
to pay for health care services have also risen. They represent 
the reality in today's rural health care environment and many 
parts of Illinois.
    The challenges I have faced during the last 18 months have 
been the most difficult of my career. In early 2009, my 
hospital began to feel the effects of the changing economy. 
July of each year has typically been the month during which I 
have been able to provide merit pay increases for my dedicated 
employees. In May of 2009, I informed my employees they would 
not be receiving any wage increases in July. The hospital 
finances did not improve in the ensuing months as a local 
employer with 140 employees relocated to another State. In 
early October 2009, I conducted numerous meetings with all 
employees to inform them that I was reducing the work hours by 
5 hours per 2-week pay period, which represented a 5 percent 
decrease in their wages. My managers and I accepted a 10 
percent reduction in our salaries. I reduced vacation accruals 
and temporarily halted the employees' 401(k) match and I 
eliminated several positions. We saved a great deal of month in 
the fourth quarter of 2009 yet we finished the year in the red 
with a net income of a negative $74,000. On January 1, I 
increased the managers' salaries 5 percent. Since that time 
there have been no hour or wage increases for anyone. The 
number of full-time-equivalent employees in September of 2009 
was 225. The total now is 195. I represent only one example of 
many hospitals that have faced those same challenges, hospitals 
that are within the top three employers in the communities we 
serve.
    We are not just about health care in our communities, we 
are also about jobs. We are about jobs for nurses, nurse aids, 
physicians, lab and X-ray technicians, housekeepers, cooks, 
maintenance workers, therapists and so on, and of course, 
information technologists. In some of these jobs categories, 
there are shortages of qualified personnel. In all of these 
categories, these workers need the proper tools to do their 
jobs to the best of their abilities. CT scanners, MRI units, 
operating room equipment, ambulances, et cetera are hugely 
expensive. Software, hardware and training are extremely cost. 
To achieve the expectations of our patients along with those of 
the governing authorities requires a great deal of money. 
Awareness of this among our Congressmen and Congresswomen is 
vital as we endeavor to improve health care in America.
    There are 51 critical-access hospitals and another 15 rural 
hospitals in Illinois out of 200 plus total hospitals. All are 
taking steps toward meaningful-use criteria. At least 10 of the 
critical-access hospitals have less than 20 days cash on hand 
because of the impact of increased Medicaid and self-pay 
patients. A reasonable estimate would suggest that roughly half 
of the hospital have inpatient health information systems and 
two-thirds of them have lab and radiology systems. However, 
only 20 percent have physicians using computerized physician 
order entry. The new meaningful-use rule with allow other 
practitioners to enter orders into the system and that will 
help but it will also place additional burdens on the hospital 
staff.
    Thank you for your support of the changes in the final 
meaningful-use objectives. Some of them indeed lessen the 
burdens for critical-access hospitals to achieve those 
objectives. The loosening of the CPOE requirements as well as 
inclusion of critical-access hospitals for Medicaid incentives 
represent a very positive change from the original proposed 
guidelines. That said, the challenges our hospitals still face 
should not be underestimated. The capital necessary to 
procedure the software and hardware is still less accessible in 
today's economy than it was 12 to 18 months ago. In my case, 
the estimated cost for software and hardware necessary to 
achieve meaningful use will likely be close to $750,000. There 
will also be substantial costs associated with establishing 
interfaces to enable hospitals and providers systems to 
connect. An additional $50,000 to $100,000 will be necessary 
for training and process changes. So these numbers are large 
for my hospital and for many others.
    At this time my hospital needs a new CT scanner for a 
minimum of $350,000 because the one we currently have is 8 
years old and increasingly unreliable. We also need to buy a 
digital mammography unit for approximately $350,000 so that 
women in the community can take advantage of up-to-date 
technology and so that unit can work with an electronic health 
records system. There are numerous other needs that are very 
expensive, and we all face challenges like that already, and I 
know that we face the acquisition implementation of EHR as 
well. I believe there may be rural hospitals that will not meet 
the imposed timeline under HITECH.
    Additionally, qualified health IT professionals are in high 
demand and the supply is currently a problem. So increased need 
for them in order for hospitals to achieve the IT requirements 
for EHR systems may present real-time and cost concerns. It is 
indeed fortunate that there are efforts underway to boost the 
health IT workforce through funding for community colleges. 
However, the boost might not materialize in time for hospitals 
to realize the currently structured incentives for meaningful 
use. Failure on the part of some hospitals to arrive at 
meaningful-use capabilities could jeopardize patient safety.
    It is my understanding that assistance to overcome these 
challenges will be available through the RECs, and I applaud 
that effort. However, I am concerned as we have seen through 
other federal offices and programs there will not be a 
sufficient focus on the challenges----
    Mr. Pallone. Mr. Starnes, I am going to have to ask you to 
summarize the rest, too.
    Mr. Starnes. All right. Thank you.
    My colleagues and I truly want to offer patients the 
benefits of a fully functional electronic health record system. 
We understand the advantages it can have in reducing overall 
costs, duplication and errors while also improving 
accountability and patient safety. However, I also want this 
committee to understand that rural providers and patients face 
unique challenges. A recent survey exemplifies that only about 
30 percent of the critical-access hospitals nationwide would 
quality for stage 1 incentives.
    Thank you for this opportunity to offer my testimony. I 
look forward to working with you to ensure that all hospitals, 
providers, urban and rural, realize the benefits of electronic 
health record systems. Thank you.
    [The prepared statement of Mr. Starnes follows:]
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    Mr. Pallone. Thank you.
    We still have another 6\1/2\ minutes, so I am going to ask 
Ms. Bechtel to go and then we will break.

                 STATEMENT OF CHRISTINE BECHTEL

    Ms. Bechtel. Good afternoon, Mr. Chairman, Congressman 
Shimkus, Congressman Gonzalez. Thank you for having me here 
with you today. I am Christine Bechtel and I am the Vice 
President of the National Partnership for Women and Families. 
We are a nonprofit consumer advocacy organization here in D.C., 
and I was also appointed as a consumer representative to the 
Federal Health IT Policy Committee.
    So I am honored to be with you today to discuss the ways in 
which meaningful use of information technology will benefit 
patients and their families. That said, our discussion today 
shouldn't actually be about technology. It should be about the 
ways in which changes in health care payment and delivery can 
create the kind of truly patient-centered system that we all 
envision and that every consumer deserves. That means designing 
systems around what patients say they want and need to improve 
their own health outcomes, and what patients want is simple and 
straightforward. They want their doctors to talk to each other. 
They want information about their conditions. They want 
providers to know them well enough to make treatment 
recommendations that actually make sense for them and they want 
their care team to have the information and support that they 
need to do the best job they can. Technology plays a critical 
role in delivering this kind of patient-centered care. It 
cannot be done right, done well or done consistently without 
interconnected health IT, and the regulations issued by the 
Administration on meaningful-use lay the groundwork for doing 
just that.
    I would like to highlight some of the ways that the 
meaningful-use program will result in tangible improvements for 
patients and families by sharing with you the story of Susan 
Crowson, who is a family caregiver from Maryland. Susan looks 
after her father, Pop, who has Alzheimer's disease, heart 
arrhythmia, prostate problems, low blood platelets and is 
susceptible to other infections. He sees a primary care 
physician, a cardiologist, a urologist, a hematologist and a 
neurologist. Each monitors and treats a separate problem and 
yet they don't talk to each other. So Susan had to build a 
spreadsheet to keep track of it all. She leaves copies with 
each doctor and asks that Pop's records be sent to his primary 
care physician and his other specialists, but it is rarely 
done. When she takes her dad for lab tests, she is the one who 
makes sure that each doctor gets the results or it just doesn't 
happen. Pop takes there prescription drugs, two over-the-
counter drugs and vitamins as well as occasional antibiotic. 
These drugs are prescribed by different doctors. When his 
doctors prescribe a drug, they actually tell Susan to make sure 
that she checks with Pop's other doctors about potential drug 
interactions.
    Susan's situation is common. Millions of patients struggle 
to gather and update hundreds of pages of medical records if 
they can get them at all, toting them from doctor to doctor, 
knowing that no provider is likely to have their full medical 
history and test results.
    Mr. Chairman, I am confident that we can help Susan and 
other patients and families get better care by leveraging the 
requirements that are now part of the meaningful-use program. 
The new regulations are strong, sensible and patient-centered. 
If the members of Pop's team were meaningful users of EHR 
today, they would maintain up-to-date problem lists of his 
conditions and medications. They would check those lists for 
drug-drug interactions and allergies. They would provide Susan 
with education resources, summaries of care after every office 
visit, reminders about follow-up care and more, and his care 
team would also start to develop the ability to communicate 
with each other electronically.
    Stage 1 of meaningful use also builds the foundation for 
overall improvements in the quality, safety and efficiency of 
care. For example, it requires the collection of race, 
ethnicity, preferred language and gender data so that we can 
identify and target health disparities. It asks physician 
meaningful users regardless of specialty to focus on 
hypertension, smoking and obesity so that we can better address 
the public health challenges are driving the increase in 
chronic conditions and causing costs to skyrocket, and it 
advances an important set of criteria for protecting the 
privacy and security of health information.
    But our work on meaningful use is not done. Stage 2 should 
enable the robust, secure exchange of clinical information 
across all the providers in settings involved in the patient's 
care in compliance with federal and State privacy laws. 
Patients and families should have timely, ongoing access to 
their health information in a way that is portable so that they 
can assemble it in a secure place and quality measures should 
assess outcomes, functional status and patient and caregiver 
experiences.
    Put simply, future criteria should be driven by the goal of 
high-patient patient-centered care. It is what Susan deserves 
and what all patients deserve. After all, health care 
transformation is not about money and it is not about 
technology, it is about people and it is about leadership, and 
we thank you for yours.
    [The prepared statement of Ms. Bechtel follows:]
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    Mr. Pallone. Thank you.
    We have three votes which normally takes about half an 
hour, so we are going to recess and then we will come back and 
hear from the rest of you and then take questions, so the 
subcommittee now stands in recess.
    [Recess.]
    Mr. Pallone. The Subcommittee on Health will reconvene, and 
we left off with Ms. Bechtel, so Dr. Goertz, you are next.

                 STATEMENT OF ROLAND A. GOERTZ

    Dr. Goertz. Thank you, Chairman Pallone and Ranking Member 
Shimkus and other members. As you said, I am Dr. Roland Goertz, 
President-elect of the American Academy of Family Physicians 
and I really am excited about the opportunity to give you our 
testimony. As a user of EHR for nearly 14 years, the CEO of a 
federally qualified health center that has won the HIMS award 
for EHR use, and a representative of 94,700 members of the 
AAFP, many in small- and medium-sized practices, I believe my 
perspective and the AAFP's will be useful, particularly as to 
how to implement HIT in small practices, how to serve diverse 
populations with its use and how the HITECH subsidies will help 
them.
    Nearly one in four of all office visits is made to family 
physicians. We provide more care to America's underserved and 
rural populations than any other medical specialty. Our 
commitment to improving patient care and clinical outcomes has 
long made us supporters of HIT. We believe that the recent 
meaningful-use regulations will support what the AAFP already 
has been doing for many years. Our focus has been to ensure 
that the meaningful-use rules are achievable by physicians in 
small- and medium-sized practices and also improve patient 
care. Our members want to accomplish what Congress intends. 
Fifty-nine percent of our members currently have electronic 
health records but their use of it varies greatly. We need to 
help the rest purchase IT, encourage those who have it to 
become more comprehensive users of it and have all begin to use 
it more effectively. We ask that your committee ensure that the 
first rounds of reporting and incentives from CMS be both 
consistent and reliable.
    Let me talk briefly about my FQHC's experience with HIT. 
The mission of FQHCs is to provide health care to those under 
200 percent of poverty, which includes Medicaid patients and 
those who are dual eligible. Our center serves almost 50,000 
people in the Waco-McClellan County area of Texas. That is 
about 18 percent of the total population of the county. Our 
center has 13 sites, two of which are in rural communities. I 
am absolutely convinced that our use of EHR has led to improved 
patient care and efficiencies.
    Fourteen years ago, a number of our physicians were 
uncomfortable with computers. Indeed, some even got cold, 
clammy, sweaty hands when they came close to a keyboard. We 
also are in a rural area, which is more challenging for 
physicians using EHRs. Today, not one of our providers would 
return to paper records.
    Let me make two general observations about adoption of HIT. 
One, physicians coming out of residency today expect to use HIT 
and do so almost automatically. The issue of adoption is a 
generational one and will resolve over time. However, we are in 
the middle of a significant health care transition and must 
assist all physicians by supporting the regional extension 
programs, beacon communities, medical-home pilots and 
dissemination of best practices.
    Two, small, solo, rural practices in particular are short 
of time and dollars. They are busy focusing on patient care and 
operating on small margins. Assisting them is critical to 
making HIT work in the United States. As an example, if your 
office has a major computer problem, you have an outside 
support team to analyze and fix the problem. I think of the 
regional extension centers as a comprehensive support team for 
small practices. These centers will provide not only technical 
assistance but general information when these small practices 
need help. Therefore, we ask you to closely monitor the 
implementation and resources of the regional extension program 
because they are essential to success of these practices. We 
strongly support the HITECH Act incentives. These investments 
are staged and crucial to improve quality and cost-
effectiveness of patient care. FQHCs also will need similar 
support.
    Let me conclude by restating three points. Number one, HIT 
is critical to improving quality and effectiveness of patient 
care; number two, physicians in small rural practices must 
receive effective technical support during implementation and 
use of HIT; and number three, the HITECH grants are crucial as 
physicians make these transformative changes to their practice.
    I thank you again, and I am personally excited about the 
potential for improving patient care that the tools of HIT 
offer us.
    [The prepared statement of Dr. Goertz follows:]
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    Ms. Schakowsky. [Presiding] Thank you, Goertz.
    Dr. Winkleman.

                 STATEMENT OF MATTHEW WINKLEMAN

    Dr. Winkleman. Chairman Pallone, Ranking Member Shimkus and 
Congressman Gonzalez, let me begin by thanking you for the 
opportunity to provide testimony today. My name is Matt 
Winkleman. I am a family physician practicing in Harrisburg, 
Illinois. Our community is in rural southern Illinois and has a 
population of about 10,000. I practice full time and I am one 
of the owners of Primary Care Group in Harrisburg where we 
serve patients not only from Harrisburg but from several 
surrounding communities and rural counties. Our practice is a 
rural health clinic that includes eight primary care doctors, 
five mid-level providers and a general surgeon. In total, the 
clinic employs around 50 people. I am honored to share with you 
today our experience with an electronic health record and a 
little bit about it impacts our practice and the care we 
provide to our patients.
    One of the obstacles many physicians cite in the decision 
to employ an electronic record is the initial upfront cost. Not 
only is the software, hardware and necessary infrastructure 
costly but the process of seeing patients at least in the 
initial weeks of transitioning requires changes in work flow 
that will likely decrease efficiency and the number of patients 
seen. As you are all aware, under our current reimbursement 
system, fewer patients means less added to the bottom line, and 
as a result, many physicians calculate they cannot afford the 
initial financial investment. This is especially true for 
physicians like myself who practice in rural areas where the 
average payer mix includes minimum commercial insurance and 
where profit margins may already be thin.
    Thankfully, the HITECH bill is going to help physicians 
address many of the challenges and begin reaping the benefits 
of electronic health records. The approach taken within the 
legislation to reward utilization and not just purchase was 
smart. The regional extension centers will be immensely useful 
to small practices without the know-how to feel comfortable 
moving to an EHR on their own and the funds going to develop 
broadband networks and other infrastructure will be crucial in 
eventually allowing us to exchange clinical information.
    The benefits of EHR use, as I said, are significant. At a 
time of great uncertainty within the general health care 
industry, at least one thing seems clear to me: technology will 
have a role in helping us provide the kind of high-quality, 
safe, efficient care our patients deserve. On nearly a daily 
basis, my EHR helps me avoid prescribing a medication to a 
patient because they have an allergy to it, allows me to print 
out materials for patients to help them understand their 
diagnosis and reminds me to order a mammogram on a 55-year-old 
patient who came in only for a sore throat.
    It is not uncommon for me to see patients struggling to 
manage six to eight medications, caring for three to four 
chronic diseases. Medicine is complex, and the reality is that 
even the most astute of clinicians can benefit from the safety 
checks provided by an electronic health record. Furthermore, 
while the individual patient benefits from the improved safety 
that stems from use of an EHR, my practice has begun to see the 
benefits to the population as a whole. With the use of our EHR, 
we were recently able to generate a report of all the diabetic 
patients from the practice's census who had not received 
appropriate follow-up and proactively schedule an office visit 
to get them back in, giving them a much greater chance of 
avoiding the costly complications that can result from 
diabetes. Additionally, after the recently controversy 
surrounding the diabetes drug Avandia, we were able to generate 
a list of all of our patients receiving this medication within 
a matter of only minutes. These types of things would have been 
nearly impossible with a paper system.
    It is also important to keep in mind, however, that all of 
these things I am describing would have been just as impossible 
if the information in our EHR such as lab data and medication 
history were not included as discrete structured elements in a 
database. Had they been scanned copies of paper reports, the 
information may as well have been in a paper chart. There must 
be standards in place which foster the use of technology in 
such a way that it truly benefits patients and provides the 
most value to the physicians when they are making care 
decisions. For this reason, while I am not generally an 
advocate of large-scale government involvement and government 
management of health care, I do think this is an area where 
focused guidance steering the medical community is absolutely 
needed.
    In summary, as a rural family physician practicing with an 
electronic health record, I have seen the benefit they can 
provide by helping improve safety, increase compliance with 
recommended preventative care and proactively manage chronic 
diseases. My practice is located in a county ranked by a recent 
Robert Wood Johnson Foundation study as 98th out of 101 in 
Illinois with regard to the health of its population and many 
of the neighboring counties were also near the bottom of that 
list. I am optimized that the meaningful-use incentives and the 
work of the regional extension centers can help providers in 
rural areas like Harrisburg to begin not only to take advantage 
of health information technology but recognize it as another 
instrumental tool in the pocket of their white coats. I am 
excited about what the future holds and look forward to the 
next steps in the process as we move even further forward in 
connecting providers to allow the exchange of health 
information.
    Thank you for the opportunity to provide testimony today.
    [The prepared statement of Dr. Winkleman follows:]
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    Mr. Pallone. Thank you, Dr. Winkleman.
    Dr. Tullman.

                  STATEMENT OF GLEN E. TULLMAN

    Mr. Tullman. Actually I am not a doctor.
    Mr. Pallone. Mr. Tullman, CEO Tullman.
    Mr. Tullman. Chairman Pallone, Ranking Member Shimkus and 
other distinguished members of the committee, thank for the 
opportunity to testify today. My name is Glen Tullman and I 
serve as the Chief Executive Officer of Allscripts. Allscripts 
is the largest provider of electronic health records, 
electronic prescribing, practice management software and other 
software that helps physicians manage their patients. More than 
160,000 physicians, which is one-third of all practicing 
physicians outside the four walls of the hospital, use 
Allscripts software along with 800 hospitals and over 10,000 
other health care providers in post-acute care facilities and 
home care agencies to manage their patients. Allscripts 
solutions automate daily activities and connect their clinical 
and business operations.
    It is now 17 months since the passage of the American 
Recovery and Reinvestment Act and it is clear that health care 
information technology as an industry is forever changed. It is 
my belief that we are at the beginning of the single fastest 
transformation of a major industry in the history of our 
country. Congress and the Administration in a sign of true 
leadership have provided an investment in technology that will 
lead to the delivery of better care for all Americans, improve 
patient safety and deliver significant savings due to 
efficiency.
    I speak to hundreds of health care professionals every 
month across the entire spectrum of care and it is clear from 
them that the meaningful-use incentives in the stimulus package 
are an essential component of the sea change that health care 
is undergoing and that will benefit all of us today. However, 
understanding how the stimulus and meaningful use applies to 
our clients and how to implement an electronic health record 
can be challenging. This is especially true because our clients 
span the entire continuum of care from single physician primary 
care practices and rural geographies to federally qualified 
health centers to the largest and most prestigious academic 
medical centers in the country.
    Allscripts have committed extensive resources over the past 
17 months to educating all of these groups, not just our 
clients, about meaningful-use incentives. We have hosted 
hundreds of free educational sessions across the country and 
webcasted many more, and in 2 weeks since the release of the 
final rules on July 13th, we have already provided educational 
content to thousands of webcast attendees. We expect our 
educational efforts to continue as we work closely with 
regional extension centers in the coming months and years.
    The HITECH incentives had a measurable stimulative effort 
on our business in three ways. First, inquiries about our 
electronic health records have been at record levels since the 
initial passage of ARRA. Second, we have increased our annual 
R&D expenditures a full 25 percent from $72 million to $90 
million, which will help drive innovation into the industry. 
And third, we have hired more than 560 people since the passing 
of ARRA with plans to hire several hundred more in the next 
year. These are high-paying technology-centered jobs, just the 
kind of jobs that the American workforce needs.
    Even more importantly, our clients are also hiring directly 
as they work to ensure success in their health care IT adoption 
efforts. For example, Denver-based Catholic Health Care 
Initiatives, in part spurred by the meaningful-use incentive 
program, has announced that they will be hiring 200 health IT 
professionals over the next year, and we have many other 
clients with similar plans. So if you had any questions, the 
health care incentive stimulus plan is working in our industry.
    Now, the final rule is out and hospitals and health care 
organizations among our client base are very pleased. The 
uncertainty about meaningful use has been removed and many of 
the changes that the provider community requested during the 
comment period were in fact incorporated. This process was a 
positive example of a productive public-private partnership. 
Many physicians particularly appreciated the flexibility 
related to what constitutes meaningful.
    You have created real incentive and real momentum with 
meaningful and with health care reform efforts. Now I would 
encourage you to take three steps to build on that success. 
First, push vendors like Allscripts and providers to achieve 
even higher standards related to more-robust connectivity. All 
systems should be able to connect and accept data from outside 
systems as if it were their own by using common standards as 
the banking industry does today. Second, it is time to mandate 
electronic prescribing. This is a patient safety issue and one 
we believe we can address. And finally, let us continue to 
focus on performance metrics and use payment and delivery 
system reforms to reward physicians who demonstrate positive 
outcomes for their patients.
    In summary, the final rule on meaningful use will result 
not only in a higher number of providers participating in the 
incentive program but more importantly higher quality and safer 
care for patients. We expect most providers not only to meet 
but to exceed the requirements of meaningful use, which we call 
meaningful value, by doing more than the minimum. We have key 
clients across the country who are doing just that. For 
example, the University of South Florida and Wellspan in 
Pennsylvania are both using electronic health records to 
deliver better diabetes care and better inform patients. Sharp 
Healthcare in San Diego is approaching 90 percent electronic 
orders. Heritage Valley Health System in Pittsburgh is writing 
100 percent of their prescriptions electronically and there are 
a host of others who are leading the way. We also see leaders 
like North Shore Long Island Jewish, Hartford Hospital and the 
University of Massachusetts, who are leading the way by 
connecting their communities for better care with the goal of 
one patient record.
    Your actions have served to both encourage and accelerate 
all of these activities and to spur other organizations to take 
similar actions. As the technology becomes part of the regular 
work flow and electronic health records provide critical 
information, we will see that meaningful use is essentially a 
jumping-off point, ultimately resulting in the connected system 
of health that we are all working towards.
    Thank you for all of your efforts and the opportunity to 
testify today, and I would be happy along with the panel to 
answer your questions. Thank you.
    [The prepared statement of Mr. Tullman follows:]
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    Mr. Pallone. Thank you, Mr. Tullman.
    Dr. Evans.

                  STATEMENT OF PEGGY C. EVANS

    Ms. Evans. Thank you. Good afternoon, Mr. Chairman and 
members of the subcommittee, thank you for inviting me here 
today. I am Peggy Evans, Director of WIREC, the Washington and 
Idaho Regional Extension Center for Health Information 
Technology. I represent Qualis Health, a private not-for-profit 
health care consulting firm and a Medicare quality improvement 
organization for the States of Washington and Idaho. I am 
honored to be here today to tell you about how WIREC will 
provide vendor-neutral EHR adoption services to help health 
care providers attain meaningful.
    Providers often start their EHR adoption believing that 
once the technology has been installed, they are at the end of 
their EHR implementation journey. In fact, once implementation 
has occurred, the journey has just begun. Technology is a great 
tool when it works well, but no matter how well it works, it is 
just a tool. Training people to utilize their technology is an 
essential component of successful EHR adoption.
    Our initial experience working with providers strongly 
indicates that there is a need for EHR technical assistance 
service through the REC program. For example, there is a 
community health center in the readiness planning stage of EHR 
adoption. They received a bid from a commercial, that is a non-
REC, consultant for services at $225 an hour for a total bill 
of $45 million. The cost of a commercial consultant was 
prohibitively expensive for a community health center and they 
enrolled in WIREC, thus saving $45,000 for support of patient 
care and other administrative needs.
    Another story is that at our first site with another small 
clinic, we learned that the practice had not considered 
designating a project manager for their EHR implementation with 
only six weeks until their go-live date. While EHR vendors help 
providers with a bulk of their implementation and technology 
needs, providers often need to understand that there are tasks 
on their end that should be completed in order to help them 
help themselves, which is where WIREC steps in.
    WIREC's program strategy is threefold. First, we provide 
on-the-ground health IT coaches that deliver one-on-one 
customized technical assistance to providers. Second, we 
establish and maintain network IT communities of practice to 
share learning. For example, we have implemented an EHR 
regional group purchase committee with an independent 
consultant who is facilitating the process and committee 
members supporting the work. Third, we plan to support peer-to-
peer networking activities that will allow participating 
providers to learn from one another, a very powerful method of 
communication. Our WIREC staff delivers a suite of services to 
providers across the three stages of the EHR adoption 
continuum: selection, go live and optimization. For providers 
in all stages, we disseminate information about the CMS 
incentive payments, help providers understand the meaningful-
use criteria within a framework for reaching that level of EHR 
use and provide assistance in workflow evaluation and redesign.
    The importance of workflow redesign cannot be stressed 
enough. Many providers are under the assumption that they will 
transition from paper to EHRs but continue to use the same 
workflow processes that supported their paper-based records, 
but if they do that, they are unlikely to succeed with their 
EHR adoption. Health IT professionals and researchers have 
shown time and time again that workflow redesign is critical 
for successful EHR implementation and that it is not business 
as usual.
    Recognizing that providers in our region may have already 
adopted a multitude of EHR systems as a starting point toward 
meaningful use, WIREC offers vendor-neutral services and will 
work with providers regardless of their choice in EHR systems. 
Among the first several hundred providers who have enrolled 
with WIREC, they are currently 14 different EHR products 
already in use which hopefully you can see displayed on the 
screen. There you go. I won't take the time to read them all 
but you can see that there is a wide variety of EHRs that we 
currently support.
    Because one of WIREC's major objectives is to assist 
providers in meaningfully using their EHR systems, our 
consultants help identify the gaps between where the provider 
is now and where he or she needs to be in order to reach 
meaningful use. We then lay out a customized path for how to 
achieve meaningful use. We have received feedback from many 
providers that the meaningful-use criteria just seem like a 
long list of unorganized requirements. WIREC staff provides a 
framework for organizing the criteria in a way that is more 
readily digestible by providers and their staff and then 
suggest doable chunks that providers can tackle without being 
overwhelmed. To date, we have successfully enrolled practices 
that represent about 500 primary care providers as indicated on 
the map. Among our initial enrollees, there is a distribution 
of practice locations across the two-State region that includes 
both urban and rural sites.
    The REC program focuses on smaller provider offices, 
community health centers, rural health clinics and other 
ambulatory practices affiliated with the critical-access 
hospitals and rural hospitals and providers that primarily 
treat the underserved and uninsured. As you can see on the 
display graph, a vast majority of our enrolled providers are 
from smaller practices. Of the larger practices that we are 
serving, mostly all are community health centers or rural 
health clinics.
    The WIREC consulting team has now begun providing 
educational programs and direct assistance in the field to our 
participating practices. Initial survey results suggest that 
providers find REC services to be valuable. As you see on the 
display screen, among our practice sites thus far, 100 percent 
of the providers have reported satisfaction with WIREC 
services. The number of practices surveyed thus far is small 
but the results are encouraging.
    Additionally, our educational webinar series for providers 
has been well received with evaluation responses showing 
consistent ratings around 90 percent of respondents agreeing 
that each of the sessions has been a value as indicated again 
on the display.
    In conclusion, Qualis Health's startup experiences show 
that providers across our region, both urban and rural, are 
enrolling into the WIREC program and initial feedback from 
providers shows that they are finding value in working with the 
REC program as a supplement to the support that they may 
receive from their EHR technology vendor. Implementing an EHR 
system and moving toward meaningful use is a transformation far 
beyond the technical aspects of implemented a computer system. 
WIREC looks forward to helping providers embark on that 
transformation through our vendor-neutral support.
    Thank you again for the opportunity to share our 
experiences.
    [The prepared statement of Ms. Evans follows:]
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    Mr. Pallone. Thank you, Dr. Evans.
    We are going to take questions now, and if we don't have 
votes, we will do two rounds. I just don't know when the votes 
are coming to come. I will start with myself for 5 minutes.
    I want to start with Dr. Vozos. One of the most important 
functions of health IT is to connect a patient's doctor and 
hospitals together across a patient's illness, and EHR could 
follow a patient from an outpatient clinic to the hospital, 
back home again, facilitating communications and care along the 
way, and of course, I am following up on my visit to Monmouth 
Medical Center where we discussed this. You describe how 
Monmouth is integrating its health records across settings 
including with your affiliated federally qualified health 
clinics. Just tell us more about how that project is 
progressing, and I of course witnessed part of it when I was 
there a few weeks ago.
    Dr. Vozos. Our health system, as you know, was developed 
really back in 2004, April 2004, and the reason we put it 
together was that though we had a lot of clinics, you know, we 
saw that the long-term evolution of those clinics was going to 
be a continuing loss of money and plus we had declining of 
services to the community in our area there. So converting that 
to a federally qualified health center and also with the 
reimbursement that was available to a federally qualified 
health center, you know, really kind of saved it, not only 
saved it, actually grew it to where it is probably one of the 
premier health providers in the area. In fact, it provides 
pretty good competition to private practitioners.
    Mr. Pallone. I used an example about one day when I visited 
and there was a guy sitting there in a business suit, which I 
thought was unusual, but may not anymore.
    Dr. Vozos. Well, what is a little bit unique about this 
particular FQHC is that it was necessary that we incorporate 
our teaching programs into the FQHC because the clinics, as 
everybody knows, are a major source of teaching for residency 
programs so we did incorporate them in, so our faculty actually 
are doctors in the clinic and the residents are also there. So 
it is a little bit unique, maybe not quite as efficient as Dr. 
Winkleman's FQHC or, I mean, Dr. Goertz's FQHC, but it is an 
excellent source of care. So it has grown tremendously.
    Mr. Pallone. How does the HIT fit in with----
    Dr. Vozos. What we did was initially we connected them. It 
is a one-way connection right now from the FQHC into our 
hospital, meaning that they can access all the record of the 
patients that are in our hospital that they see in the clinic, 
and as you could imagine, most of the patients in that clinic 
when they do need to come to the hospital, they use Monmouth 
Medical Center or the Monmouth emergency room. So the 
physicians of the FQHC have direct access through the Internet 
into our----
    Mr. Pallone. But wasn't there also something where if you 
went to the emergency room and they thought that you could use 
the services of the community health center, that they set up 
an appointment or something for you, right?
    Dr. Vozos. Well, that is our other pilot program where, you 
know, under a grant we----
    Mr. Pallone. This is the demonstration program?
    Dr. Vozos. Right.
    Mr. Pallone. That was my second question.
    Dr. Vozos. Yes, and that program, what the pilot was to 
take all the patients who really were using our emergency room 
as their medical home, so to speak, identified those that 
really needed to have a primary care provider and arranged for 
them to be followed up in our federally qualified center. We 
thought initially we could easily make that happen once but we 
were kind of curious as to what the true conversion was going 
to be where they were not going to use the FQHC as their 
private, you know, physician office. There has been a 70 
percent conversion. It has been really a tremendous success, 
and what it has done is, it has decompressed the emergency 
room, improved the throughput for the emergency room and really 
unclogged our emergency room and created a whole--a much better 
atmosphere even in our emergency room.
    Mr. Pallone. But it also made it possible for the people 
that have regular care so they didn't----
    Dr. Vozos. Well, they now have----
    Mr. Pallone [continuing]. End up just using the emergency 
room.
    Dr. Vozos [continuing]. A regular physician in the FQHC.
    Mr. Pallone. Now, is there also a Medicare demonstration 
program that looked at whether gain sharing between hospitals 
and physicians can reduce cost?
    Dr. Vozos. Right.
    Mr. Pallone. And then there was an electronic health 
records component of that too?
    Dr. Vozos. Yes, there is. We are part of a Medicare 
demonstration project, which is 12 hospitals in New Jersey, 
where we put together a set of criteria with the coordination 
of the New Jersey Hospital Association, a set of criteria to 
measure quality care, and if in the performance of these 
measures there was a savings of money, you know, the federal 
government has kind of relaxed itself a little bit and allowed 
us to share in those cost savings. So we have recently gone 
through the first phase of that where there was not only the 
signing up of physicians but we completed the first 6 months of 
measuring data, and what we are looking at right now is length 
of stay, complications, mortality rates and readmission rates, 
and there was--we actually issued the first set of checks and 
now we are going through the second phase of additional 
enrollment because initially not everybody wanted to enroll. 
They either didn't trust the project, they didn't want to have 
their name in some file that the federal government could be 
steering. There is all kind of reasons why doctors wouldn't 
sign up. But after the first phase of this, not we have had 
about three times the number of physicians signing up. So we 
are going to be well over 200,000 physicians signed up for 
this, and it has actually produced savings.
    Mr. Pallone. All right. Thanks.
    Mr. Shimkus.
    Mr. Shimkus. Thank you, Mr. Chairman. I have been writing 
and scratching notes all over the place, so this may get really 
disjointed, which would be very similar to most of my questions 
that I ask. But it has been very educational. I am a very 
outspoken critic of the stimulus bill but obviously we can se 
some future benefits down the line in this provision.
    My first question is, all of the examples of health care 
information technology that is being used now, how many have 
been deployed based upon stimulus dollars? I mean, there are a 
lot of examples of health information technology that have been 
talked about. Mr. Tullman, you sell it. Dr. Winkleman, you are 
using it. Dr. Vozos, you are using it. How much of that 
deployment was based upon taxpayer dollars?
    Dr. Vozos. I would say at Monmouth the upgrade to the 
Cerner Millennium----
    Mr. Shimkus. Let us talk about stimulus dollars.
    Dr. Vozos. Right. I mean, we need to do that in order to be 
able to qualify at any point for the stimulus dollars.
    Mr. Shimkus. So your upgrade was, but your original 
deployment was not?
    Dr. Vozos. No, original deployment was Cerner.
    Mr. Shimkus. And Dr. Winkleman, I know that none of yours 
was done based upon--your practice made the decision on their 
own and incurred the capital expense and assumed the risk.
    Dr. Winkleman. Yes. I mean, our practice made the decision 
to move forward with this several years ago before there was 
discussion of money available.
    Mr. Shimkus. OK. I just want to put that--I mean, it is an 
important thing to be placed on the record. Again, no one is 
argue that is not beneficial and that we shouldn't be all in 
but I also want to point out that a lot of the examples being 
used are people who have done it without government help and 
government intervention.
    I want to go to the--again, Mr. Tullman, we understand how 
this really does benefit your business plan and your ability to 
hire a lot of folks because there is a new market being 
generated by this government push, which we hope will provide 
savings and better recordkeeping and hopefully lower medical 
liability costs based upon all those benefits. But Mr. Starnes 
from my district, in your opening statement you made some 
compelling arguments about the crisis in rural America of 
operating a small rural hospital. Can you incur these costs and 
provide the continued service?
    Mr. Starnes. Well, the economic downturn did play a very 
devastating role for us, so we have had to make lots of changes 
in order to rebound from that. What we find and what I was 
commenting about was we do have several capital needs, you 
know, diagnostic equipment----
    Mr. Shimkus. And you would put those above HIT?
    Mr. Starnes. If I have a person come into the emergency 
room and need a CAT scan, I need a reliable CAT scan machine in 
order to provide that service, so I have got to put that just 
ahead of EHR at this point.
    Mr. Shimkus. Right, and that does segue into kind of Dr. 
Evans' point because I think your testimony mentioned about how 
you can be in essence a low-cost consultant for small rural 
hospitals and practitioners but you are paid on the government 
dole, you are not a private consultant that is for profit, 
paying taxes, paying for the office space, paying properly 
taxes and other issues because you are part of this government 
payout that we are doing, but I am not going to argue with the 
help but there is probably some computer consultants who now, 
you are the lowest bidder on providing, you know, consulting 
services and so they are probably going to Mr. Tullman trying 
to find a job over in his sector.
    Let me--my time is short. For the two hospitals here, the 
CMS actuary stated that about 15 percent of Part A providers 
would become unprofitable within 10 years based upon the new 
health care law because of lower payments, and the new health 
care law cuts $500 billion from Medicare. Dr. Vozos, are you 
going to be one of those 15 percent?
    Dr. Vozos. If that it all that occurs, yes.
    Mr. Shimkus. You would be?
    Dr. Vozos. Of course I would be.
    Mr. Shimkus. You are a major----
    Dr. Vozos. I am a major teaching hospital but I am going to 
rely on those 32 million or the 1.3 million people in New 
Jersey who now have insurance to cover that reduction in 
Medicare reimbursement. I have to rely on that.
    Mr. Shimkus. Well, we can talk about that later on. And Mr. 
Starnes, kind of the same question. I am shocked. I thought you 
would be saying I can survive it because we are big.
    Now Mr. Starnes.
    Mr. Starnes. Under the critical-access hospital 
designation, then hopefully we will be fine, but it is not 
going to be easy for sure. We will have to be lean from----
    Mr. Shimkus. You are already lean. You already can't 
provide needed capital equipment to your hospital.
    Mr. Starnes. Right. Yes.
    Mr. Shimkus. Mr. Chairman, my time is expired and I will 
yield back.
    Mr. Pallone. Mr. Gonzalez.
    Mr. Gonzalez. Thank you very much, Mr. Chairman.
    My first question, and it may have been covered in the 
absence with the other witnesses and it would have been 
appropriate for them, but it is a situation that in San Antonio 
the hospitals have made me aware of, and I want to make sure 
that I frame the question, that is that the Medicare incentives 
to grantees would be based on a CMS provider number if you have 
multiple campuses, so if there is anyone on the panel can 
explain the consequences of having one Medicare number but 
having more than one campus as far as the incentives and how 
that would be paid. I don't know if Doctor, is it Vozos?
    Dr. Vozos. Yes. I mean, it doesn't affect us because we 
have our own Medicare provider number but I can explain to you 
how it works. You know, there are hospital systems, let us say, 
five hospitals within one system all operating under one 
provider number so therefore they are going to get the stimulus 
once, not for each of the five hospitals. So theoretically some 
of the smaller or more rural hospitals in that system on a 
standalone basis would never be able to probably go through all 
this.
    Mr. Gonzalez. Anyone else have an opinion on the problems 
that that may present?
    Mr. Starnes. We just have the one campus and so it really 
doesn't apply for us, but I can imagine that it is going to be 
devastating for hospitals with several campuses because each 
facility is going to have its own separate staff to be trained 
and all of those costs that they will incur.
    Mr. Gonzalez. I understand a rural setting is totally 
different from what I have described, and Mister--let us see. 
Where is--well, it is Dr. Winkleman. I apologize. Mr. Shimkus 
has touched on the cost and how we would go about assisting. We 
know about the stimulus money but of course that is finite and 
such, but prospectively, as a physician, how is someone's 
practice going to afford the technology and the training? We 
introduced a bill a couple of years ago and it was a bipartisan 
bill. It was never passed, but we had everything in there. But 
I want your opinion, anyone on this panel that could give me an 
opinion as to the best way to assist the physicians to make 
that transition. We could have grants, a combination of grants. 
We could have low-interest loans, guaranteed, or tax credits or 
tax incentives. Is there any way that we should rank those or 
just have them all available? Anybody?
    Dr. Winkleman. Well, I think that having money and grants 
available to help physicians use electronic records is a 
positive thing but ultimately I think even better than that is 
that physicians begin to get paid for doing a good job and that 
as we start to--that our practice gets transformed by things 
like electronic health records, that industry will be motivated 
to make a product that works well, they will be motivated to 
make a product that produces better care, I am going to be 
motivated to use that product to provide better care, not just 
intuitively for my patients but because I am rewarded for it. 
So I think creating an environment where we are encouraged to 
use things like this to improve the quality helps make that 
transition make financial sense to a doctor because when you 
look at it on paper, sometimes it is a tough sell. There is a 
lot of upfront capital cost. There is initial reductions in 
productivity. On the long term, there are gains. I think a lot 
of practices become more efficient. They certainly do a better 
job of billing and coding to get paid for what they actually 
do. So I think one of the ways to do it is to make them make 
financial sense, and part of that would involve creating a 
situation where our reimbursement is tied to us doing a good 
job, not just seeing a volume of patients.
    Mr. Gonzalez. I think that is built in as far as the 
incentives and how we proceed with that and do it right. Of 
course, any time you have some positive reinforcement or reward 
or whatever you want to call it that encourages that behavior, 
there is another way of doing that, and that is obviously you 
are penalized for not adopting, for not being more efficient in 
the use of the technology, so there is all sorts of different 
angles. Of course, we would like to do it in a positive mode, 
and I appreciate your testimony today and I yield back, Mr. 
Chairman.
    Mr. Pallone. Thank you. I am going to have a second round 
for anyone who would like to participate, and I will start with 
myself.
    I am going to go back to Dr. Vozos, but I guess any of you 
could answer it. When I was--I mean, we asked many of you to 
come here today because we knew that you were being innovative 
with HIT, you know, before we passed the Recovery Act and we 
put in this legislation that we have been discussing. I mean, 
the idea at least in my mind was to hear from those who have 
sort of been the precursors and did this before there was any 
money from the federal government through the Recovery Act. But 
I would like to know, because I know when I went to Monmouth 
Medical Center that even though we discussed all the things 
that we are doing, you also discussed with me what you could do 
if you were able to tap the funds under this legislation. So 
maybe you should talk to me a little bit about where you would 
go from here, assuming you participated in this program.
    Dr. Vozos. I mean, we are on the road and we are making a 
lot of moves but we are far from there, and it is going to be a 
tough journey and an expensive one, so really funding for us it 
going to be a big issue going forward. You know, for Monmouth 
Medical Center the full-blown HIT system is going to be about 
$19 million over some period of time, and when I listened to 
Mr. Starnes talk, I said I want to go find out where you are 
buying that one, that $750,000 one. So it is a $19 million 
project for our system. It is just shy of $100 million. So as 
you can imagine, there needs to be all type of incentives to be 
able to spend that kind of money. Now, there is the return on 
investment so I would say right now, you know, we are moving 
forward on a regular basis. We still have to install more 
modules into our system to be able to get to the level where we 
are fully operable to even qualify for the stimulus money and 
that is what we are doing right now. So it will change the 
practice at the hospital for sure. I mean, it will change even 
how testing is done and what the residents are learning and the 
efficiency of the hospital but we have a road to go, but there 
is a bit team working on it and continues to work on it. And 
our big thing is linking the physicians and private practices 
and private offices and having a two-way exchange of 
information. We want to be able for them to populate the record 
in the hospital from what they're doing in the office but at 
the same time what is happening with their patients in the 
office should be able to go the opposite direction back into 
their office records too, so that is why we view as very 
important to have very compatible EMRs in the physician office 
and at the hospital with the appropriate interfaces set up, and 
we are putting a lot of effort into doing that.
    Mr. Pallone. Maybe I will go to Mr. Tullman because Dr. 
Vozos gives me the analysis from the hospital, but what about 
you in terms of your systems? I think I said in my opening 
statement that currently less than 20 percent of hospitals and 
10 percent of physicians are using electronic health records, 
and CMS is saying that they are going to go to 95 to 100 
percent of hospitals and 70 percent of physicians. How are you 
going to get there? Are you prepared, and what are the 
pitfalls?
    Mr. Tullman. I think it is a good question. What we have 
seen, and you recognized that this panel includes a number of 
innovators who have taken those steps, and I commend Dr. 
Winkleman and the other physicians and members of the panel for 
taking those first steps, but in technology adoption generally 
you get the first 20 percent are early adopters. The next 70 
percent are where the real dollars and the benefits are and 
they take longer, and so the incentive program that you have 
put into place will help us get the next 70 percent and drive 
that throughout the rest of the market. From our perspective, 
we believe we are ready. We are investing heavily in making 
sure that the systems are easier to use, more easily deployed, 
and again produce the kind of measurable results that we need 
in health care, and I think the RECs, the regional extension 
centers, the other programs that have been designed are going 
to help us move that along. There are tremendous employment 
opportunities. There is tremendous work to do, and that is not 
just from the vendors, that is from actually the medical 
centers across the country.
    You know, the one thing I would say in terms of a 
recommendation that we were asked about before is, I think 
there is an opportunity to open the program even further to 
rural providers who in some cases are excluded because they are 
not off the same revenue schedules and to certain other 
programs like Medicare Advantage where some of our leading 
clients like Sharp Healthcare in California in fact have 
problems in terms of getting their physicians covered to use 
that, and they cover a significant amount, but overall, we 
think we are ready and we think the country is ready for better 
health care.
    Mr. Pallone. All right. Thank you, Mr. Tullman.
    Mr. Shimkus.
    Mr. Shimkus. Thank you, Mr. Chairman.
    Mr. Starnes, do you know, what is your closest REC? do you 
know it?
    Mr. Starnes. It is Northern Illinois University.
    Mr. Shimkus. And that is located where? DeKalb?
    Mr. Starnes. Yes.
    Mr. Shimkus. And how far is DeKalb from Vandalia?
    Mr. Starnes. I couldn't tell you. Somebody else?
    Mr. Shimkus. Four and a half, five hours.
    Mr. Starnes. OK.
    Mr. Shimkus. I know Idaho-Washington is a big area too, so, 
I mean, it is just a point I wanted to raise.
    If we follow up on the chairman's point, Mr. Tullman, about 
trying to get those numbers of 75 percent to 90 percent, that 
is really a rush for obviously a population that you and the 
other 12, 15 providers--Dr. Evans, you had that list up, I 
don't know how many there were, 12, 15 providers who provide 
the same type of services as Mr. Tullman. Are we concerned that 
they will go to the bigger institutions prior to the smaller 
ones?
    Mr. Tullman. We really--I will take the first shot at that. 
We believe and what we are seeing is accelerated adoption 
across the board, so we know that at least until the stimulus 
package, the larger organizations were in fact advantages 
because they had CIOs, they had a capital budget and the like. 
What the stimulus program does it open it up so smaller 
physician groups and offices and independent physicians can do 
that. That is number one. Number two, a lot of the larger 
organizations, for example, I mentioned North Shore Long Island 
Jewish, what they have done is, they not only bought licenses 
for their 1,200 employed physicians but they have actually 
extended that offer to 7,000 affiliated physicians in the 
community to help connect them up and bring those benefits. The 
last point is that many of the vendors have come out with 
innovative programs like a financing program with no payments 
for 6 months to help bridge the gap until smaller providers 
actually get the stimulus funding. So I think you are seeing a 
lot of innovation.
    Mr. Shimkus. And I appreciate that. My time is short and I 
don't mean to be disrespectful but I think that is going to be 
an interesting case study to follow to make sure that happens. 
There are just in the broadband world, the other committee I 
serve on is Telecommunications. There are still communities on 
dial-up. There are still communities not--and one of our 
attacks on the stimulus bill is they are overbuilding broadband 
areas and not deploying to what we call unserved areas. Well, 
Dr. Evans, you probably know that. Probably in Idaho and the 
eastern part of Washington State, there are unserved areas. So 
the stimulus on the other end has to get broadband out so 
everyone can take advantage of this.
    I got a chance to visit with Dr. Winkleman earlier today, 
and he brought up this issue that even though he is--and I have 
to do this before I do that. I am sorry. Two letters, I ask for 
unanimous consent, and one is a compelling argument of a 
community of 15,000--Mr. Starnes would know-- Washington County 
Hospital, Nancy Newby, president and CEO, a population of 
15,000. They are on HIT already and did the risk, did the same 
thing. So there are folks who realize the importance of this 
and did it previous to the government intervening.
    In the HITECH Act, incentives are based on charges under 
the Medicare fee schedule or a provider can qualify for more 
than 30 percent of their volume is from Medicaid patients. As a 
rural health clinic, will you meet either of these criteria?
    Dr. Winkleman. We will have a very hard time achieving the 
standard under the--well, let me back up. We will be very close 
under the Medicaid, the arm of being 30 percent. Our problem 
under the Medicare arm is that since our reimbursement comes 
via the rural health clinic system and not directly from 
Medicare. Our charges to the Medicare fee schedule are very 
limited. The only thing we bill to Medicare fee schedule under 
fee-for-service are some ancillary things. So we really don't 
have a Medicare option despite the fact that we see a good 
percentage of Medicare patients. You know, we really are 
limited to the Medicaid option. And so for some of my 
partners--it would be different for me, I do family medicine 
where a see a good portion of children and a lot of them are 
Medicaid, but some of my partners that do primarily internal 
medicine, primary care and see mostly adults, a lot of those 
patients are Medicare and then they could be sort of left out 
in the cold. Seeing a large number of Medicare patients, having 
adopted EHR, using them meaningfully, and yet we don't really 
have the Medicare charges per se technically that qualifies 
under the incentive.
    Mr. Shimkus. Thank you, Mr. Chairman. My time is expired 
but I want to note Dr. Evans was nodding yes, I think and I 
guess she would agree with pretty much of that analysis.
    Ms. Evans. Yes, and actually we have heard the same concern 
from many of the rural health clinic providers that we have 
been talking to that they are shut out because they may not--
they basically bill via a bundled mechanism rather than the 
provider fee schedule so that leaves them out of Medicare, and 
then they don't see the 30 percent patient panel required for 
Medicaid or 20 percent of their pediatricians. So they are 
really very much interested in how CMS is going to address the 
fact that there may be no incentive payments coming to them.
    Mr. Shimkus. Well, hopefully CMS is paying rapt attention 
to this hearing and that is part of the record.
    We haven't talked about HIPAA implications. We haven't 
talked about the whole privacy debate. That is really critical 
when data is flowing, and I am not smart enough to go into, Mr. 
Chairman, so I yield back.
    Mr. Pallone. Thank you. Mr. Shimkus has asked unanimous 
consent to enter these two documents into the record. Without 
objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Mr. Pallone. Mr. Gonzalez.
    Mr. Gonzalez. Thank you, Mr. Chairman.
    This question will go to Dr. Evans. Has it been your 
experience--now, my understanding is, you are vendor neutral. 
That means when you go on site, the hardware has been 
purchased, the software. The system is in place, you just--I am 
going to read something to you. I am almost embarrassed, Mr. 
Chairman, and I am hoping Mr. Shimkus is not listening as to my 
sources of information.
    Mr. Shimkus. I usually don't.
    Mr. Gonzalez. That is an understatement. But anyway, this 
is Hilda Gorito of Kaiser Permanente: ``If you give a 
lumberjack who has been using an ax his whole life a chainsaw 
and he starts hacking at a tree with it, it is not going to 
help him at all. It is what you do with the technology that 
makes the difference.'' So you go there, and so now the 
physician who used to be a lumberjack now has the chainsaw, and 
you are going to teach him basically how to use that 
effectively about the technology. When you go on site, are you 
discovering that many times--I don't know how to put this--they 
have overpurchased? One size doesn't fit all, and my experience 
has been with my friends who are physicians and a couple of 
friends who actually sell the systems that a lot of physicians 
really are not--because you are coming after the fact, that 
prior to the purchase of what is a very expensive investment 
that it is not done many times with the knowledge. And Mr. 
Tullman, I want you to chime in as soon as Ms. Evans finishes. 
Where does a physician or a small practice get the direction 
and the advice to purchase only that which they really need and 
to make an investment and not realize the return that they 
could?
    Ms. Evans. Well, my experience in doing some of the 
consulting out in the field is that many times providers 
purchase something and then underutilize the system for a 
variety of reasons. I can't really speak to whether they have 
overpurchased, but what I have seen is that there are many 
functions and features that are available to them, particularly 
for reaching meaningful use, that they haven't even necessarily 
looked at or they don't know exist. And so we go into the 
practice to educate them about some of the availability of the 
features and functionality as well as determine the workflow by 
which they might be able to use the system is a more effective 
manner.
    Mr. Gonzalez. Your thoughts, Mr. Tullman?
    Mr. Tullman. Yes, I think I would concur, and we think the 
largest problem, most significant problem is underutilization, 
and that would be true in most pieces of software that people 
buy. They tend to use them not at the maximum but the minimum, 
so we think the RECs are a good idea. We also are seeing more 
and more physicians get counseling from a variety of ratings 
services so as a vendor we are evaluated by a number of 
different organizations and of course CCHIT, there are minimum 
requirements, so there used to be about 300 different 
electronic health record providers. Last year under CCHIT to 
meet the minimum standards, that 300, only 70 qualified as 
meeting the minimum requirements. Those requirements are now 
even greater and will continue to get greater, and we think 
that is a good thing. We think that it improves the value of 
the products.
    But your point I think is very important, and that is, and 
we believe it is one reason this legislation made sense and 
that was you weren't simply buying physicians electronic health 
records, you were saying we will help pay for them if you use 
them, and that is really the critical aspect of meaningful use, 
which we are very supportive of.
    Mr. Gonzalez. Last question. I have a minute. Ms. Bechtel, 
you represent the consumer and such, and I am one of those that 
just believe that a patient goes in there believing that the 
doctor is up to date on the latest literature, continuing 
education, has the best equipment and so on. Do you believe 
that HIT should be part of that equation, that each patient 
should expect that that particular physician have that 
electronic medical records and the efficiency, effectiveness 
and cost savings that it should bring?
    Ms. Evans. I do, and I think it is interesting because 
there are a number of consumers who see technology in every 
other sector in this country and assume that their physicians 
have it as well, but then they experience the acute challenge 
of trying to communicate with the care team, trying to 
coordinate their own health care, understanding that doctors 
just aren't talking to each other fully and in the way they 
could be without interoperable health IT and so we have done 
actually a fair amount of research with consumers directly to 
understand what do they think about information technology and 
the reasons that it appeals to them are exactly those but they 
get that it will begin to reduce the burden that they face, 
particularly around care coordination. So we would be delighted 
to start to see consumers asking their physicians are you a 
meaningful user of information technology, do you have an 
electronic health record. I know that when I chose my own 
doctor recently, it took me several months to find out that has 
an electronic health record, and I did, but to the point of 
this hearing, the practice actually doesn't use it in a 
meaningful way whatsoever. They really just actually automated 
paper. So I think the conversation has to start with, do you 
have an electronic health record, but it can't end there. It 
has to be, how are you giving me access to my health 
information, how are you sending me reminders, how are you 
summarizing my care for me and other benefits of technology.
    Mr. Gonzalez. Well, I thank all of you for your testimony. 
I yield back, Mr. Chairman.
    Mr. Pallone. Thank you. That concludes our questions, so we 
want to thank all of you for spending all of your time here 
today, and obviously this is very helpful and it is probably 
just the beginning of what we are going to have to look at in 
dealing with HIT.
    The way the rules work, you will get some written questions 
from members. We try to have them to you within 10 days, and 
then of course we ask you to respond as quickly as you can, and 
if you want to submit testimony, you can. But thank you very 
much. I really appreciate it.
    Without objection, this meeting of the subcommittee is 
adjourned.
    [Whereupon, at 5:30 p.m., the Subcommittee was adjourned.]
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