[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]
NOT WHAT THE DOCTOR ORDERED: BARRIERS TO HEALTH IT FOR SMALL MEDICAL
PRACTICES
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH CARE AND TECHNOLOGY
of the
COMMITTEE ON SMALL BUSINESS
UNITED STATES
HOUSE OF REPRESENTATIVES
ONE HUNDRED TWELFTH CONGRESS
FIRST SESSION
__________
HEARING HELD
JUNE 2, 2011
__________
[GRAPHIC] [TIFF OMITTED] TONGRESS.#13
Small Business Committee Document Number 112-019
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HOUSE COMMITTEE ON SMALL BUSINESS
SAM GRAVES, Missouri, Chairman
ROSCOE BARTLETT, Maryland
STEVE CHABOT, Ohio
STEVE KING, Iowa
MIKE COFFMAN, Colorado
MICK MULVANEY, South Carolina
SCOTT TIPTON, Colorado
JEFF LANDRY, Louisiana
JAIME HERRERA BEUTLER, Washington
ALLEN WEST, Florida
RENEE ELLMERS, North Carolina
JOE WALSH, Illinois
LOU BARLETTA, Pennsylvania
RICHARD HANNA, New York
NYDIA VELAZQUEZ, New York, Ranking Member
KURT SCHRADER, Oregon
MARK CRITZ, Pennsylvania
JASON ALTMIRE, Pennsylvania
YVETTE CLARKE, New York
JUDY CHU, California
DAVID CICILLINE, Rhode Island
CEDRIC RICHMOND, Louisiana
GARY PETERS, Michigan
BILL OWENS, New York
BILL KEATING, Massachusetts
Lori Salley, Staff Director
Paul Sass, Deputy Staff Director
Barry Pineles, Chief Counsel
Michael Day, Minority Staff Director
C O N T E N T S
Opening Statements:
Page
Ellmers, Hon. Renee.......................................... 1
Richmond, Hon. Cedric........................................ 2
Herrera Beutler, Hon. Jaime.................................. 3
WITNESSES
Farzad Mostashari, M.D., Sc.M., National Coordinator for Health
Information Technology, U.S. Department of Health and Human
Services, Washington, DC....................................... 5
Ms. Karen Trudel, Acting Director, Office of E-Health Standards
and Services, Centers for Medicare and Medicaid Services,
Baltimore, MD.................................................. 7
Sasha Kramer, M.D., Olympia, WA.................................. 18
Denise Elliott, D.P.M., Marrero, LA.............................. 20
Mr. Andrew Slavitt, Chief Executive Officer, OptumInsight, Eden
Prairie, MN.................................................... 23
David L. Baumer, Ph.D., Professor of Law and Technology, North
Carolina State University, Raleigh, NC......................... 25
APPENDIX
Prepared Statements:
Farzad Mostashari, M.D., Sc.M., National Coordinator for
Health Information Technology, U.S. Department of Health
and Human Services, Washington, DC......................... 32
Ms. Karen Trudel, Acting Director, Office of E-Health
Standards and Services, Centers for Medicare and Medicaid
Services, Baltimore, MD.................................... 50
Sasha Kramer, M.D., Olympia, WA.............................. 64
Denise Elliott, D.P.M., Marrero, LA.......................... 69
Mr. Andrew Slavitt, Chief Executive Officer, OptumInsight,
Eden Prairie, MN........................................... 76
David L. Baumer, Ph.D., Professor of Law and Technology,
North Carolina State University, Raleigh, NC............... 85
Questions for the Record:
Ellmers, Hon. Renee for Ms. Karen Trudel..................... 92
Ellmers, Hon. Renee for Dr. Farzad Mostashari................ 105
Statements for the Record:
The Computer Technology Industry Association................. 118
The National Partnership for Women & Families................ 123
Additional Materials for the Record:
``E-Prescribing Penalty Could Hit Up to 109,000 Clinicians''
By: Robert Lowes, Medscape Medical News.................... 126
HEARING: NOT WHAT THE DOCTOR ORDERED: BARRIERS TO HEALTH IT FOR SMALL
MEDICAL PRACTICES
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THURSDAY, JUNE 2, 2011
House of Representatives
Committee on Small Business,
Subcommittee on Healthcare and Technology
Washington, DC.
The Subcommittee met, pursuant to call, at 10 a.m., in room
2360, Rayburn House Office Building. Hon. Renee Ellmers
(chairwoman of the Subcommittee) presiding.
Present: Representatives Ellmers, Herrera Beutler, Tipton,
Hanna, Richmond, Altmire.
Chairwoman Ellmers. We will go ahead and get started. Thank
you, Mr. Richmond, our ranking member. And we have today with
us Congresswoman Herrera Beutler from Washington, who is on our
Subcommittee.
This is the Subcommittee on Health and Technology of the
House Committee on Small Business. And the title of our
Subcommittee hearing is Not What the Doctor Ordered: Barriers
to Health IT for Small Medical Practices.
Good morning to everyone. I call the hearing to order.
This is a very important issue for our health care
providers and health care across our country.
Health information technology is the computerized
management of health information. It has the potential to
improve health care delivery, decrease medical errors, increase
clinical and administrative efficiency, and reduce paperwork.
Studies have shown that adoption of health IT is becoming more
common, but the transition is a slow one. In 2010, the Centers
of Disease Control and Prevention found that only 25 percent of
office-based physicians had fully functional electronic health
records or EHR. And 10 percent had a basic EHR system. Studies
have shown that there is a digital divide on health IT between
large and small medical practices. A study of eastern North
Carolina confirmed the existence of the digital divide and
found that the smaller medical practices is, the less likely to
be using the EHR.
As a registered nurse and the wife of a surgeon who has
health IT, I understand that a modern efficiency and well-
equipped office is critical to the practice of medicine. Health
IT offers promise to all medical professionals; however,
financial, legal, and technology barriers prevent many,
particularly small practices, from moving forward on EHRs. This
issue is critical because almost 60 percent of office-based
physicians work in practice with fewer than 10 doctors. In
fact, the small practice is said to be the best indicator of
the success of EHRs because it is likely to be the last to
widely adopt the technology.
Since 2009, many physicians have received Medicare
incentive payments for e-prescribing part D medications.
Beginning this year, doctors are eligible for Medicare and
Medicaid incentives under a separate program if they
demonstrate meaningful use of electronic health records. I am
particularly concerned that physicians may not be aware that
they must report e-prescribing activity this year to avoid e-
prescribing penalties that will begin next year. There are
other challenges, too. As more personal information is
available electronically, patients must feel confident that
their medical information is secure and their privacy is
protected. And physicians need to be assured that the
information that they transfer is not changed or misused.
We look forward to hearing from today's witnesses about how
these barriers can be addressed. I now yield to our Ranking
Member Richmond for his opening statement. [The information
follows:]
Mr. Richmond. Thank you, Madam Chairwoman. And I want to
thank our panelists and our guests that are here today to
discuss this very important issue, specially as we try across
this country very diligently to improve our health outcomes and
to make sure that we provide the best medical care that we can
do--that we can possibly do. And that means effectively using
our information technology to do that.
So today's hearing will offer an opportunity to examine
ways that we can improve the implementation of health
information technology. Health IT has the potential to advance
health care quality while reducing costs, but right now many
small health care providers simply cannot afford it. We have
seen the benefits recent technology can bring to our daily
lives in a variety of ways. It is now time for our health care
system to catch up with the benefits of health IT that are
numerous and wide-reaching for all sizes of medical practices.
Those fortunate enough to have access to this technology
already know how it decreases health care costs, improves
patient safety, and reduces the practice of defensive medicine.
These system-wide benefits ultimately to an increased access to
affordable health care.
Since Hurricanes Katrina and Rita, when physicians struggle
to provide adequate care because they lacked access to
patients' health IT, it has been a key concern for my state,
which is Louisiana, and our health care industry. I am proud to
say Louisiana has been focused on creating a health information
exchange since 2007 and was among the first states to offer
incentive patients to Medicaid providers this year. We have
made upgrading our health IT infrastructure a priority and I am
honored to have Dr. Elliott, a solo practitioner from my
district here today to share her experiences.
From a business perspective, fully functional electronic
health records have the potential to improve a practice's net
profit by over $80,000 during a five-year period. In addition,
effective health IT can increase the doctor's time with the
patients and improve administrative efficiency by reducing
paperwork. Such benefits make a clear case as to why health IT
is needed to assist small practitioners who strive to provide
the best care to their patients. However, right now there are
inadequate incentives for health care providers to adopt many
of these technologies. With 80 percent of the nation's patient
care delivered by small practices, it is important to
understand why most of them do not use health IT. Small
practices face a number of unique challenges, including
financial barriers and complex regulations. Besides upfront
costs exceeding $40,000 to implement the technology, small
practices face additional design costs, practice disruption,
and a lack of certified products. As a result, a significant
gap exists in health IT adoption between large and small
practices.
I will just--I will insert the whole statement for the
record but I just want to say and comment our Chairwoman
Ellmers and add to the audience that I think that this is where
Congress works best, when we acknowledge that we know what we
know and we know what we do not know. And those things that we
do not know we look to the people who do it on a daily basis
and the people who have the on-the-ground expertise. So we look
forward to hearing the testimony today because it will be your
testimony, your suggestions, and your input that guides the way
that we work towards solving this issue in a bipartisan way
because the issue is too important not to get it done. It saves
lives, reduces costs, and all of those things that I know we
are all committed to doing on both sides of the aisle across
every walk of life.
So thank you to the Chairwoman and thank you to the
panelists. [The information follows:]
Chairwoman Ellmers. Thank you, Mr. Richmond for your
comments. And I cannot agree more on what you stated.
I now would like to ask Ms. Herrera Beutler for her opening
comments.
Ms. Herrera Beutler. I will keep it brief. I want to share
a story. I had a young nurse, a young woman in my district in
Clark County come and visit with me a month or two ago. And she
was there to talk about electronic medical records, personal
health records, or e-records for hospitals or small practices
or solo practices. And her story was compelling.
Her father, who was a constituent of mine, would bike every
day up and down a certain--perfect physical health. He was
between 55 and 60, I believe. Tremendous. And he had had--I do
not know if it was a palpitation. He had a problem. They took
him to the ER. And she was a nurse. She went with her mom and
she said we think there is something here. She said I think
there is a specific issue here. And they ran the tests and they
waited and the tests came back negative. They said you are
fine. So they sent him home. And I think within--I think it was
two weeks. It was a shorter period of time. He had it happen
again and he died. And, you know, she was devastated. The
family was devastated. And she said about--a short period of
time after that she received a call from the hospital that said
we are so sorry. We lost the paper record. And it actually was
not negative. And went on to explain it was a problem with the
paper. It was a problem with losing the paper.
And it is so hard to sit there and have someone--you hear
about it. You hear this is partially why we need to upgrade and
we need to get there. And here is someone who works in the
medical profession and she was looking at me saying do
everything you can to speed the implementation of electronic
medical records for many reasons.
We talked about Katrina. I have Lewis County in my
district. We have--Kent has severe flooding, which wipes out
homes. Floods eight feet plus of the bottom and up to second
story homes. And when that happens, these are older
communities, their medical records could be--I do not know.
Their immunizations could be stuffed somewhere in a file. And
what happens? We lose patient records. And it is imperative.
I served here on the Hill as a health policy aid before
elected office, before going home and then coming back here.
And this was a bubbling issue, you know, in the last decade.
This has been something Washington State has worked towards, a
state partnership along with the federal efforts in a very
bipartisan way because we recognize we have to get there.
The challenges are costs and implementation. I have a
doctor from southwest Washington who is going to share a little
bit about her experience, but the reality is we are trying to
find out what we do not know, to Mr. Richmond's point, and
figure out how we can speed this along. Because paper is--as
someone who represents a timber industry, I like using paper in
a lot of areas. Let me put that on the board. But when it comes
to this issue we need to make sure that we are entering the
21st century.
So with that I yield back. I look forward to our testimony.
Chairwoman Ellmers. Thank you. And I will just start off by
a little housekeeping. As far as the light system, you will
have five minutes to deliver your testimony. I will be lenient
if you go over because I value so much your input. And the
light will start out as green. When you have one minute
remaining the light will turn yellow. Finally, it will turn
red. And then that basically ends your five-minute period of
time. And I ask you to try to stay to that, but again, we will
be lenient today for the purposes of this Subcommittee.
STATEMENTS OF FARZAD MOSTASHARI, M.D., NATIONAL COORDINATOR FOR
HEALTH INFORMATION TECHNOLOGY, U.S. DEPARTMENT OF HEALTH AND
HUMAN SERVICES; KAREN TRUDEL, ACTING DIRECTOR, OFFICE OF E-
HEALTH STANDARDS AND SERVICES, CENTERS FOR MEDICARE AND
MEDICAID SERVICES; SASHA KRAMER, M.D.; DENISE ELLIOTT, M.D.;
ANDREW SLAVITT, CEO, OPTUMINSIGHT; DAVID L. BAUMER, PH.D.,
PROFESSOR OF LAW AND TECHNOLOGY, NORTH CAROLINA STATE
UNIVERSITY
Chairwoman Ellmers. With that, I would like to introduce
our first panelist, Dr. Farzad Mostashari. He is the national
coordinator of health information technology with the U.S.
Department of Health and Human Services. Dr. Mostashari became
the national coordinator in July 2009. Previously, he served in
the New York Department of Health and as Assistant Commissioner
for the Primary Care Information Project, where he facilitated
the adoption of health information technology by providers in
underserved communities. Dr. Mostashari did his graduate
training at the Harvard School of Public Health and Yale
Medical School, and his internal medicine residency at
Massachusetts General Hospital.
Thank you so much for being here today, and again, you have
five minutes.
STATEMENT OF FARZAD MOSTASHARI
Mr. Mostashari. Good morning, Chairwoman Ellmers, Ranking
Member Richmond, distinguished members of the Subcommittee. I
am Dr. Farzad Mostashari, the national coordinator for health
information technology at the Department of Health and Human
Services. Thank you for giving me the opportunity to appear
before you today to talk about what the Office of the National
Coordinator is doing to support the deployment and meaningful
use of electronic health records, especially among smaller
physician practices.
I know from personal experience, both the importance and
the challenges of using better information to improve
individual and population health, especially in a small
practice setting. As the former head of the Primary Care
Information Project in New York City, we reached out to
practices that served Medicaid patients and signed agreements
with providers in small practices and community health centers
and hospital outpatient departments to establish electronic
health records systems.
Over half of small practices in the city's three most
underserved communities eventually signed up with the program.
In a little over a year, more than 1,000 providers started
live-use of EHR systems with a 99 percent implementation
success rate. It was hard.
The Office of the National Coordinator's Core mission is to
improve patient care, improve health outcomes, and make the
health care system more efficient through the effective use of
health IT. Much of ONC's work is aligned in support of a
Medicare and Medicaid meaningful use EHR incentive programs.
These programs, which my colleague from CMS will talk about in
more detail, provide financial incentives to eligible providers
and hospitals that adopt and use electronic health records in a
meaningful way to improve health and health care outcomes. This
unprecedented public investment does not treat technology as an
end to itself. Rather, it will result in concrete progress
towards our policy objectives--measurable improvements in
health and reduction in costs.
I would be happy to talk about all the ways that ONC is
supporting this transformation in health care, but in the
interest of time today I will highlight some of our major
initiatives.
ONC is at the center of efforts to establish standards for
EHR systems and let providers and the public know which EHR
systems are meeting these standards. We currently have six
authorized private sector certification bodies which have
certified more than 700 separate EHR products. This is
indicative of the development of innovative EHR products that
are less expensive and easier to implement for small practices
than ever before. Of note, 60 percent of the vendors of these
systems are small businesses with fewer than 50 employees.
Our Regional Extension Center program, inspired by the
Agricultural Extension Center program, supports a network of 62
state and local organizations that offer training, information,
project management, and technical assistance to providers in
order to ease and accelerate the adoption and meaningful use of
EHR technology. Particularly by primary care providers, small
practices, critical access hospitals and other underserved or
underresourced providers. The Regional Extension Center program
has enrolled more than 70,000 providers, 94 percent of whom are
primary care providers and about half are in individual or
consortia of small practices.
ONC's Health Information Exchange program is helping build
the infrastructure for sending and receiving electronic health
information securely across the nation's health care system
with a focus of simple but secure technologies that can be used
by all providers to improve coordination of care, whether they
care for patients in small practices, urban clinics, or rural
hospitals.
These efforts have sparked a remarkable growth in the
health IT industry as a whole, which has led to a strong demand
for skilled works. To address this emerging shortage, ONC has
supported 82 community colleges in establishing health IT
certificate programs where training can be completed in six
months or less. So far, over 2,400 students have graduated from
the community college programs. Another 4,700 are currently
enrolled, and we are on our way towards our target of
graduating 10,000 students every year. Many of these graduates
will end up helping small practices who often lack the
resources for dedicated IT staff to successfully implement EHR
systems.
Finally, I want to point out that ONC, along with our
partners at CMS, the Office of Civil Rights, and other federal
agencies have taken a number of important steps towards making
sure electronic health records remain private and secure. ONC
has embedded privacy and security into all of our programs and
policies. For example, the standards and certification criteria
I spoke about require that EHRs have the capability of
encrypting electronic health information, tracking who accesses
each record, and limiting user access. Meaningful use requires
that providers conduct a security risk assessment and mitigate
any risks identified. Our Regional Extension Centers are
providing technical assistance on protecting privacy and
security and our new health IT training programs ensure that
the future generation of technical workers are well grounded in
privacy and security.
Health information technology is indeed a critical
foundation that supports efforts to modernize and transform our
health care system. Now is the time to get down to the hard
work of implementing and using health IT in a way that leads to
better health care that is high quality, safe, coordinated,
efficient, effective, and patient-centered. And I am proud of
ONC's role in achieving that goal.
Thank you for giving me the opportunity to appear before
you today. I look forward to answering any questions you might
have.
[The statement of Mr. Mostashari follows:]
Chairwoman Ellmers. Thank you, Dr. Mostashari.
I would now like to introduce our second panelist today,
Karen Trudel. Ms. Trudel is acting director of the Office of E-
Health Standards and Services for the Centers of Medicare and
Medicaid Services in Baltimore, Maryland. The Office of E-
Health Standards and Services coordinates implementation of the
comprehensive e-health strategy for CMS. Ms. Trudel also has
responsibility for enforcement of Health Insurance Portability
and Accountability Act standards and oversees the areas of
personal health records and electronic prescribing.
Welcome to you. And you have five minutes for your
testimony.
STATEMENT OF KAREN TRUDEL
Ms. Trudel. Thank you, Chairwoman Ellmers, Ranking Member
Richmond, and members of the Subcommittee. Thank you for the
invitation to discuss CMS's implementation of the Electronic
Health Record (EHR) Incentives program created by the Recovery
Act and specifically the impact of this implementation on small
and solo providers.
The widespread adoption of certified EHR technology used in
a meaningful way is one piece of a broader health information
technology infrastructure needed to modernize our nation's
health care system. As we have worked to implement the EHR
incentive program, we have sought to strike a balance between
setting program requirements high enough to move providers
expeditiously towards this goal but not so high that providers
choose not to participate in this voluntary initiative.
The Medicare and Medicaid incentive programs provide
incentive payments for eligible professionals and hospitals
that demonstrate meaningful use of EHR technology. The Medicaid
incentive program also provides incentive payments to providers
in their first year of participation if they adopt, implement,
and upgrade EHR technology. Eligible professionals can receive
up to $44,000 over five years from the Medicare program, or up
to $63,750 or six years through the Medicaid program. The
hospital incentive payments for Medicare and Medicaid are
calculated with a formula that begins with a base amount of $2
million with an added amount based on the number of discharges.
Providers must register to participate in the programs and
attest that they have either adopted, implemented or upgraded
certified EHR technology or that they have meaningfully used
that technology during a 90-day reporting period. We recognize
that for some providers, particularly small and solo practices,
moving to adoption and meaningful use of EHRs is a huge shift
from current practice. For that reason, CMS has taken an
escalator approach to meaningful use envisioning three separate
stages that demand increasingly vigorous requirements.
We are currently in the first stage, which focuses on using
EHRs to collect clinical data, electronic prescribing, initial
steps toward patient engagement, and, as Dr. Mostashari
mentioned, ensuring privacy and security of patient
information. We originally proposed 25 meaningful use criteria
for eligible professionals and 24 for hospitals. The provider
community commented that meeting all those criteria would be
difficult and they requested flexibility. We responded by
separating the criteria into a core set that all providers must
meet. And those are 15 for eligible professionals and 14 for
hospitals. And a menu set with providers being able to select
five of the remaining 10 criteria to implement.
Less than a year after publishing the final rule, CMS is
already providing incentive payments to providers. Since
January 1, 2011, more than 42,600 eligible professionals and
hospitals have registered for either the Medicare or the
Medicaid EHR incentive program via a web-based application. The
same application is used for Medicare providers to attest to
their meaningful use of the EHRs. States are developing their
own out-of-station mechanisms and data is exchanged bi-
directionally with CMS and the States. Providers were first
able to begin to attest to meaningful use beginning April 18th
of this year, and 485 providers did so successfully in the
first month of the program. The first Medicare payments
totaling $75.9 million went out to meaningful users on May
19th.
CMS is encouraged that States across the country have
already shown strong enthusiasm for the EHR incentive program.
States began launching their programs in January. Fifteen
states have launched to date and two more are set to come
online next week. Further, the majority of states have
indicated to us they will launch by the end of calendar year
2011. And as of May 4th, over $83 million in Medicaid incentive
payments have been made.
CMS strives to increase awareness and participation in the
incentive programs by offering a variety of information and
tools that providers can use to learn about and successfully
participate in the programs. We use a variety of mechanisms to
engage providers, including social media, national provider
calls, and webinars. We have developed a special website
containing guides that explain the meaningful use requirements,
user guides for the web-based system, and many other products.
Our strategy focuses on making free, high quality information
available through mechanisms that are accessible to busy
providers.
The administration has made the adoption of meaningful use
of EHR technology a high priority. Our stage one rule lays the
groundwork for establishing a robust national health
infrastructure that supports the adoption of EHRs and PHRs and
will help providers practice safer and more productive
medicine. We look forward to working with Congress, our many
stakeholder partners, and our colleagues at ONC to ensure that
the implementation of the EHR incentive program fosters an
expanded use of health information technology, broadens the
information exchange infrastructure, and promotes the adoption
of electronic health records as intended by Congress.
I am happy to answer any questions you might have. Thank
you.
[The statement of Ms. Trudel follows:]
Chairwoman Ellmers. Thank you so much. I am going to ask a
few questions and then I will yield to Mr. Richmond, our
ranking member. And we will go from there.
My first question is for you, Ms. Trudel. The meaningful
use, you touched on it in your opening statement. Can you once
again reiterate what it is and how it is that physicians and
hospitals are adhering to it? Because that is obviously the
proof that they have to provide.
Ms. Trudel. Right. Exactly. I will walk through some of the
core requirements for meaningful use, and I think that will
give you a good idea of where we are trying to go with that. A
number of the core requirements focus around capturing data in
the electronic health record so that it can be used over and
over for clinical reasons. Some of those include capturing a
list of current and active problems, medication lists, vital
signs, allergies, smoking status, demographics. So those are
the things that we are capturing in the EHR. Then there are
some things that are action-oriented, like computerized
provider order entry and electronic prescribing. And of course,
the privacy and security requirements.
Chairwoman Ellmers. What would happen if a physician did
not actually--what would happen if they were not able to
provide that information to you?
Ms. Trudel. For this first year, and again this is a
voluntary program, the provider can register for the program
and then has the entire year through to February of 2012, to
report that they have meaningfully used for a 90-day period of
their choosing. So they can decide what that period is. They
track these requirements, make sure that they have met them,
and at that point they would sign on and say I am a meaningful
user. If they do not do that in the first year, they can choose
to wait until the next year to start out and it does not have
any effect on the total payment that they could receive.
Chairwoman Ellmers. So there are no penalties assessed for
the first year?
Ms. Trudel. Absolutely. The penalties do not take effect
until 2015.
Chairwoman Ellmers. 2015. And that would not reflect
retroactively at all?
Ms. Trudel. No.
Chairwoman Ellmers. Okay. I do want to clarify one thing
and I hope you can do this for me. You mentioned the incentives
in Medicare and Medicaid but you cannot get incentives for
both. You basically have to--correct me if I am wrong, but the
physician would have to choose which one he would--he or she
would like.
Ms. Trudel. Right. The eligible professionals must select
one or the other. Hospitals, on the other hand, including
critical access hospitals, can participate in both programs.
Chairwoman Ellmers. Okay. So hospitals can participate in
both but physicians cannot. Thank you.
Dr. Mostashari, I have a question about funding that was
provided with the American Recovery and Reinvestment Act for
HIT. Our records show that $2 billion was provided for this.
How has that been utilized? And has all of it been utilized? Or
is there other monies out there? How are we going to apply
that?
Mr. Mostashari. Thank you. Yes. ARRA provided for $2
billion for the national coordinator to help establish the
infrastructure that would permit providers to achieve
meaningful use of electronic health records as well as
increasing the privacy and security of such systems. We have
obligated $1.97 billion of the $2 billion. The largest single
chunk goes towards the Regional Extension Center program. Some
$720 million to establish those assistance--technical
assistance and project management facilities for small
practices and critical access hospitals and so forth. There is
approximately $560 or so million that went to state and state-
designated entities for information exchange purposes. We have
$265 million that went to beacon communities. These are 17
communities, kind of our crown jewels. And I promise the fact
that on this panel--have beacon communities in your states is
completely accidental. And these are really the crown jewels
that are showing how information technology can work.
Chairwoman Ellmers. Oh, so when you say beacon, is that,
your field test?
Mr. Mostashari. These are communities that were ahead of
the curve, whether it is in Piedmont, North Carolina; whether
it is Crescent City; the inland Northwest beacon community or
Grand Junction, Colorado which are putting it all together.
They have higher rates of electronic health record adoption
than other parts of the country. They also have governance
mechanisms and leadership to use those--the technologies, the
redesign of physician practices, the performance monitoring and
feedback, and really bringing all the tools to bear to show how
health information technology and its meaningful use can show
demonstrable and near-term impact on cost and quality of health
care.
Chairwoman Ellmers. Thank you so much. I yield now to Mr.
Richmond, our ranking member.
Mr. Richmond. Thank you. I will direct this question
actually to both witnesses. And I can only think back to my
life, and especially my childhood when we talk about motivating
me to do one or two things. It was either the carrot or the
stick. And in thinking of that I guess my question would be for
many physicians. Medicare and Medicaid reimbursements are
already low. The penalties that could further diminish these
payment rates for practices that do not transition to
electronic health records. And what I am afraid of is,
especially in Louisiana, where we see more physicians denying
to see Medicaid and Medicare patients. And as HHS and CMS
examine how these penalties may ultimately affect access to
health care.
Ms. Trudel. I would start by pointing out that there are no
penalties in the Medicaid program at all. The payment
adjustments are related to the Medicare program solely.
However, you make a good point and I think that the balance in
the legislation was that there was a carrot and stick approach
but I would venture to say that when you add the incentive
programs together with what ONC has done to help to assist
providers, especially small and solo providers, to move toward
electronic health records, the carrot is a lot larger than the
stick.
Mr. Mostashari. And I would add that our goal is to have as
few providers, eligible professionals and hospitals that would
incur the payment adjustments as possible. We want to help
everybody succeed in this program. We really want and are doing
everything we can to make it so that we not only have an
ambitious program but one that is achievable and that we
provide the supports and whatever else is needed to help every
provider succeed on this track. And I think you do need both
the incentives and the penalties to get to this transformation,
but you also need the supports around it to help people
succeed.
Chairwoman Ellmers. Mr. Richmond, will you yield? I have a
question about the penalties versus the incentives. Is there a
time limit on the incentives? I know the penalties start in
2015 but do the incentives continue on or does that stop at
2015?
Ms. Trudel. For Medicare purposes, the incentives extend
for a five-year period. And they start with a maximum of
$18,000 per year per provider and are scaled down to $2,000 per
year per provider. For Medicaid, the incentive period goes on
for six years and it is frontloaded with a first year incentive
of $21,250.
Chairwoman Ellmers. And the penalties? Starting in 2015,
does that extend on?
Ms. Trudel. Right. No penalties for the Medicaid side, as I
said. And for Medicare, they phase in, again, with a one
percent penalty in 2015, moving to a two percent in 2016, and
then between three and five extending indefinitely after that.
Chairwoman Ellmers. So there are penalties indefinitely?
Ms. Trudel. Exactly.
Chairwoman Ellmers. Okay, thank you. And I thank Mr.
Richmond.
Mr. Richmond. And this question would be for Dr.
Mostashari. The question is based on the idea, and I want to
commend you all for a very open and competitive certification
process and market.
The concern is whether the deal in accreditation has
burdened small providers. And if it is true, especially for
those in need of practice compatible EHRs, did you all consider
the potential impact of the delays when developing the
certification program?
Mr. Mostashari. It was quite a concern. A little bit of
background on this. Prior to the passage of HITECH there was
only a single accreditation body. There was the Certification
Commission for Health Information Technology. And the
legislation--the HITECH legislation asked us to take another
look at that. And the reason was because there were some who
were concerned about having only a single point and not having
options or choice and a competitive marketplace around that
process.
So we were required to take a look at that, and our federal
advisory committees recommended to us that we, in fact, change
that. And we opened it up and have more competition in the
accreditation process. There was a risk, however, that you
point out in this switchover that there would be a time where
we would not have sufficient products certified or the pipeline
for getting a product certified could hinder the ability of
providers to meet meaningful use. And so we created a temporary
program that could go into place quickly and a permanent
program. The temporary program, indeed, went into effect very
quickly and I think we have not heard much in the way of
concerns about the certification program. And that is a good
thing because it is working. We have now six accredited testing
and certification bodies instead of where we had one. The cost
of certification has come down. The speed of certification has
gone up. We hear from vendors that the quality of service they
are receiving has increased, and we now have more certified
products than ever before. So in this case, it was a concern
but I think with the right policies and with the right
implementation we have managed to address that well.
Mr. Richmond. Good. And then my last question directed at
both of you or both of you feel free to answer or not answer.
But the last question is just in today's age with so many
concerns with security and privacy--I also sit on Homeland
Security so I am very aware of the fact that everyday there are
thousands of people that wake up trying to hack into either the
.gov world or the .com world. And we have to be concerned about
that.
And what I am asking about now are complaints that
especially for small practitioners that there is little
guidance on how to safeguard to ensure HIPAA compliance. And
what can we do, what can you all do to help those small
practitioners overcome that fear? And after that I will yield
back, Chairman.
Mr. Mostashari. Absolutely. And maybe after my colleague
from CMS can speak about that.
Safeguarding privacy and security is a shared
responsibility. And the practices, not just in terms of their
professional responsibilities, not only in terms of patient
expectations, but also under the law have a responsibility to
safeguard the patient information that has been entrusted to
them. And the Office of Civil Rights has the ability to
investigate any complaints and can levy substantial fines as
they have done against some hospitals and health plans
recently.
But we need to, as you say, support providers, particularly
the smaller practices in being able to do this. We are working
with the extension center program to provide that technical
assistance, to provide that checklist, that easy to understand,
easy to use checklist. Some templates and best practices are on
how to do the appropriate way, whether it is physical security,
administrative security, clinical security settings,
configurations and so forth in the small practice setting. And
that information is available not only to providers who work
with the extension centers, but to any provider.
We are also working to make it easier on the technology
side through our research and development programs. We have a
consortium of academic medical centers who are at researchers'
institutions who are working to develop the next generation of
technologies to make it the easy thing to do, the secure thing
to do. And to make it almost a default and to bake into the
products the ability to encrypt automatically, for example, and
to safeguard patient privacy.
But as you point out, it is a--we can just remain ever
vigilant. This is a daily war where the folks of the other side
are constantly looking for new opportunities, new
vulnerabilities, and new technologies. And we have to, on our
side, be ever vigilant as well.
Chairwoman Ellmers. Well, thank you, Mr. Richmond. And I
now yield to Ms. Herrera Beutler, for her questions.
Ms. Herrera Beutler. I will make it brief. Thank you, Madam
Chair.
A couple of things you mentioned, Ms. Trudel, that kind of
sparked my interest, with regard to penalties, did I understand
you right when you were saying that for hospitals versus, you
know, group practices there were different--I know they went
into effect on different implementation dates and I know
Medicaid is withheld from the penalty side. Did I hear you say
that hospitals are exempt? At the very beginning, what did----
Ms. Trudel. No, hospitals and eligible professionals are
both subject to the same penalty at the same time.
Ms. Herrera Beutler. Okay. Okay. And in terms of small
group or solo practitioners, I mean, a hospital system is going
to have a lot more wherewithal to implement any HER, period--a
small group practitioner or a solo provider in a rural area,
who is not a critical access hospital. Right? I know we have
brought that up--is going to have a hard time making this
investment, particularly if they are the only family physician
or OB in a region. And I have met some of those doctors. Are
you taking extra precaution and care and assistance? Because I
heard you talk about a lot of--the goal is to assist--with some
of those in recognizing--especially if we are talking about a
family doc--it is an aging population. Right? Not very many
people are going back into this practice and that is a whole
other issue. But some of them I have met have said do you know
what? I can run my practice. I have figured this out. I have
enough problems with med-mal and everything else. Do not bring
this my way. How are you overcoming that in a non, you know,
penalty way?
Ms. Trudel. First, I would like to talk a little bit about
the outreach that we have been doing which is very much geared
toward reaching exactly those kinds of providers.
As an example, our 10 regional offices over the past nine
months have conducted over 400 events, more than half of which
were targeted specifically to, or included, significant
quantities of small and rural physicians to try to explain to
them what the program is, what the advantages are of it, how to
take advantage of it, and what some of the other tools and
resources, including the Regional Extension Centers, are
available to them so at least they have the ability to fully
and completely assess the opportunity and make a decision as to
whether or not they want to take advantage of it.
Ms. Herrera Beutler. What kind of feedback, and this is a
question I will ask of the next panel as well because they are
the docs doing this, what kind of feedback have you had from
them? What kind of uptake--positive or negative?
Ms. Trudel. We are actually getting good uptake. We have
been doing some trending over the period of the last year and
we are getting a sense that many, a large percentage, I would
say over 70 percent of the physician practices that we are
talking to, actually have exhibited some interest and are
thinking about it.
Ms. Herrera Beutler. So when they have problems, right,
with a company that was certified by one of the six, you know,
certification agencies, what is their recourse?
Mr. Mostashari. Let me talk about the supports that we are
offering. Dr. Brull was one of the first providers to get their
payments for meaningful use last week, and she spoke about
working with the Regional Extension Center in Kansas where she
is a family practitioner in a small practice. And she talked
about how when she first saw the--started adopting the systems
and saw the list of requirements, that she was daunted by that.
But that the Extension Center helped give her an understanding
of what is really behind the meaningful use, practical steps on
how to achieve it, help with project management. And she gave
one example about saying there were quality measures around
colonoscopies. And she thought she was doing a pretty good job
with colonoscopies that can be lifesaving if they identify
cancers early on and they can be removed. And she said when she
actually had the information to look within her data she was
only doing it about 40 percent of the time. And she was really
upset. But then the technology helped her make a list of all
the patients, reach out to them, have reminders in the system.
Those are all part of meaningful use. And she reported that she
was not satisfied yet but things were better; she was at 84
percent now. And she said I would never go back to being on
paper.
So I think what we have in our favor is that providers,
even though the road is hard, providers like Chairwoman Ellmers
husband, who has gone through the hard work, would never go
back to using paper-based systems. And it is rewarding because
it is in line with what they want to do as physicians and
nurses.
Ms. Herrera Beutler. And really quickly, if they have not
just a bump in filling out the paperwork or jumping through the
hoop or meeting the quality measure, if they have a real
substantive problem----
Mr. Mostashari. Yes.
Ms. Herrera Beutler [continuing]. Or IT provider, I mean,
do they have recourse?
Mr. Mostashari. Yes. The Regional Extension Centers--let me
give the example. Georgia and Massachusetts Regional Extension
Centers are working with banks to help their providers get
loans for the hardware and software. Very practical, addressing
a real need that they have. The Extension Center in L.A. are
doing project management, helping them do every phrase of
project management of going from implementation to meaningful
use and are working directly with the vendors to identify
problems and mitigate them when they have it. Ohio REC has
developed a comprehensive needs assessment that goes through
and helps the practices identify what are some of the weak
points and gaps and barriers and working with the provideri to
address any issues before they go live, rather than trying to
fix things afterwards.
So those are all examples of practical ways that the
extension centers all across America are working with the
70,000 providers to help them address any problems they might
have and move forward productively.
Chairwoman Ellmers. Thank you. And I now yield to Mr.
Altmire for his questions.
Mr. Altmire. Dr. Mostashari, I represent an area in western
Pennsylvania that has some rural areas, it has some very highly
developed health care systems, as well as smaller providers
like you are talking about today. But what I hear all the time
is that the certification process is still very cumbersome, the
additional certifying entities that were there. And for folks
who have failed certification, if a provider fails
certification, does HHS encourage the certifying bodies to
share why the certification failed, to recommend improvements
that could be made the next time?
Mr. Mostashari. the certification process, the way it works
is that a vendor of a system, a company that manufacturers the
software, would go to the accredited testing and certifying
body and they would seek certification of their product. So
that process we have heard relatively few complaints about.
There is, as I mentioned, more competition in that area that
has reduced the costs. It has increased the timeliness and the
level of service that the vendors are achieving. And as a
result, we now have more products certified by a whole range of
vendors than ever before. So providers have--now, the health
care providers who purchased these systems, they do not
themselves need to go to get certified for the product. They
can purchase the system that has already been certified.
There are, particularly for the larger health systems who
have self-developed their own systems, we have created an
opportunity for them in the regulation to get self-certified,
to say I do not want to buy a product that is commercial, off-
the-shelf; I want to be self-certified. And for that purpose we
do have a program that would allow them to be self-certified.
We have not heard much in the way of--I mean, the standards
that they have to meet are the same as the standards that a
vendor would have to meet and it is a rigorous process. They
have to show that the products have the same security as a
commercially-developed product, the same level of
interoperability as a commercially-developed product, and that
can be a challenge. But many of the organizations who have
developed their own products are very capable and we have not
heard too much in the way of concerns about that.
Mr. Altmire. And that is where I was going to go actually.
How do you distinguish--how does HHS distinguish between a
large, very advanced on the health IT side, provider that has
already spent in some cases hundreds of millions of dollars to
upgrade their IT to become compliant, to go through the
certification process, and then contrast that with the money
that is available, the incentives, the meaningful use
regulations, to a much smaller provider, maybe out in a rural
area that does not have anywhere near the resources, but we all
want to go in the same direction. You do not want to end up
with a VA DOD circumstance where they are incompatible, they
cannot communicate with each other, you want to all make sure,
especially in a region but eventually for the country, we have
an interoperable IT system. So how do you navigate those two
very different situations?
Mr. Mostashari. That is exactly right. And I think that is
why the certification is so important because it says that no
matter what system you are using, whether it is self-developed,
whether it is the biggest vendor in the country or the small
vendor in the country, they all have to meet certain
requirements around interoperability. But they all have to have
the codes that map to a same set of codes that if I get a piece
of information from one vendor to another vendor, it can be
understood across the systems, that they can produce the same
sort of messages when they are reporting to public health, for
example. On the quality measures, producing those. So the
certification process really is our most important tool in
ensuring the interoperability between vendor systems, large or
small.
Mr. Altmire. so you do have an end in mind. You are not
just allowing everyone in sort of a free-for-all manner to come
up with their own systems and get certified, but you are saying
we are not going to tell you how to do it. We are not going to
tell you what direction to go and what is best for you, but in
the end we want to have a system where everyday can communicate
with each other.
Mr. Mostashari. That is exactly right. We have to balance
between allowing innovation to flourish, not overspecifying to
say that, you know, the box has to be this big and this wide
and this is how it has to look. Allowing innovation to flourish
but saying there are some bottom-line outcomes that we are
going to hold you to. Can you produce a message, an electronic
message for interoperability that is specified exactly thus?
Can you meet these functional requirements and ensure that we
do have, not just a collection of systems that are deployed but
actually systems that can work together to create the bigger
public benefit.
Mr. Altmire. Thank you, Madam Chair.
Chairwoman Ellmers. Thank you. I now yield to Mr. Tipton
for his questions.
Mr. Tipton. Thank you, Chairwoman Ellmers and Ranking
Member Richmond, for convening this. Obviously, a very
important issue for all of our areas. And Dr. Mostashari, I
appreciate you bringing up Grand Junction on the western slope
of Colorado, and we are seeing that extension actually in terms
of the quality health care network going down through Montrose
with the idea of extending it throughout the entire western
slope of Colorado.
I do have a couple of questions here in terms of just
having an idea of really where we are at right now. What is the
timeframe that it takes--weeks, months--to be able to get to
the certification? For either of you. For doctor. Do you have
any kind of averages?
Mr. Mostashari. So for a provider to adopt an electronic
health record system, it depends upon--very much on the product
they select and the assistance they have around project
management. So there are some vendors who very effectively can
get a provider from start to finish in a matter of weeks. There
are others, particularly for larger, much longer lead time
planning, implementation, and so forth, design and custom
configuration that is needed to take place. Every provider
makes a decision for themselves in terms of what is in their
best interest. And our hope with the extension centers is to
give them the best advice we can or the extension centers can
about what it right for that provider, that group, that
hospital, in terms of the system that they implement.
It is a challenging process. I want to make no bones about
the transformation of workflows and processes and the
difficulties that many practices, particularly smaller
practices, will face as they make this difficult transition.
But it is a rewarding process and ultimately will be not only
leading to improved patient care and coordinated care but
actually will help those practices succeed financially over the
long run.
Mr. Tipton. And if I missed this I apologize. But how many
people--how many practices, if you have got an average, have
signed up? And out of those, how many are solo practitioners?
Ms. Trudel. I do not have any information about how many
are solo practitioners. So far, since January we have had
42,600 health care providers register for either the Medicare
or the Medicaid program. Almost all of those were physicians.
And, at this point, we have had our first payment run. Let me
just kind of tack onto the back of the how long it takes
question. Once a provider has gotten to the point where they
believe they can meet the meaningful use requirements, they
then have a 90-day reporting period during which they must meet
all of those requirements. As soon as they have done that, they
can go online to a web system and attest to that meaningful use
and in a month or so they will have their incentive payment.
Mr. Tipton. This may be a question maybe for the next
panel. But if you would like to maybe contribute into one of
the big complaints that I hear consistently from a lot of our
physicians gets down to the coding issue which Dr. Mostashari,
you were talking about just a moment ago. When we are talking
about, like, Medicaid, is there kind of a streamlining process
between requirements at the state and federal level? Because
that has been a real cost-driver. I know, I believe in the
state of Colorado we have a different from than the federal
government has, you know, which is additional costs that the
doctors actually have to be able to assume.
Ms. Trudel. This has very much been foremost in our
thoughts through the entire development and standing up of this
program because there are both Medicare and Medicaid
incentives. And in the case of hospitals, they can qualify for
both. So, we have worked very closely with the states to make
sure that the requirements for both, the meaningful use
requirements, are essentially identical. The web-based system
that we use for registration is the same for Medicare and
Medicaid. The states will handle their own attestation and
payments but we communicate with the state on an online basis
so that we are comparing information and making sure that we
have the right providers in the right programs.
Mr. Tipton. And Madam Chairwoman, this may take just a
second more if you would allow the answer on it, but one of the
other concerns that we have from the patient side is certainly
the privacy issues. Are you comfortable that, you know, we are
making the strides and then are going to have, I think, Dr.
Mostashari had taken to it being ever vigilant in terms of
making sure that we are going to be able to have the patient
privacy which I think has been an obstacle for some physicians
as well?
Mr. Mostashari. I think that we are making strides,
important strides in that direction, everything from the laws
and regulations that were passed through the HITECH Act that
increased protections for patient privacy. They gave patients
the right to see who has looked at their information and who
their information has been divulged to, which I think is going
to serve an important role in providing that assurance to
patients. It provides for higher penalties, civil penalties for
violations, consistent violations of HIPAA. It extends the
range of HIPAA to business associates, that they must follow
the same security requirements as the covered entities. There
are, as we mentioned, protections that we put in place under
the certification program, as well as through meaningful use
that security be assessed and any gaps mitigated. We are
working very hard to establish a governance mechanism for
health information exchange entities. These are all pieces of
this and I think we will see more and more of an impact on
making sure that there is more of a sense of public
understanding and public comfort, that their information is if
anything, more secure in electronic format than in a paper-
based world where you do not know where your record is
oftentimes. Records can be lost as Ms. Beutler recounted where
you do not know who has looked at your record, where there is
no way of limiting access to certain parts of the record. For
example, the front office who maybe do not need to know all
your diagnoses. So there are important protections, but we need
to be ever vigilant and we need to do everything we can to
ensure that we maintain the public trust.
Mr. Tipton. Thank you, sir. And I yield back.
Chairwoman Ellmers. Thank you. And I would like to thank
our first panel for being here today and giving us your very
important insight on the adoption of health IT for small
medical practices. We will continue to watch all of this, and I
want to work with you on helping to reduce the barriers that
small medical practices encounter.
And I would like to suggest, in regard to our second panel,
if you both have staff here, if one of your staff members could
remain and if you would identify those individuals to us. And
again, thank you.
We will now call the second panel to the table.
Okay. I think we can go ahead and get started. And with
that, I would like to say to our panel thank you very much for
coming and sharing your comments and concerns with us on health
IT. And I would like to yield to Ms. Herrera Beutler to
introduce Dr. Sasha Kramer.
Ms. Herrera Beutler. Thank you, Madam Chair.
It is my pleasure to introduce Dr. Kramer. Dr. Kramer is a
resident of southwest Washington. She serves Olympia, which is
the northern part of my district on I-5, if anybody wants to
know where that is. We are in between Seattle and Portland, but
we are neither Seattle or Portland. Serves in Olympia and the
surrounding areas in the field of dermatology. After completing
a residency at Geisinger Medical Center in Danville,
Pennsylvania, Dr. Kramer moved to Olympia in 2005 where she now
lives with her husband and two sons. In May of 2009, she opened
her own practice and has been an asset to our community ever
since.
Dr. Kramer, thank you very much for coming today and we
look forward to your testimony as we move forward.
STATEMENT OF SASHA KRAMER, M.D.
Ms. Kramer. Good morning, Madam Chairwoman and
distinguished members of the Committee, especially
Congresswoman Herrera Beutler who represents my hometown of
Olympia. As she said, Washington State.
My name is Sasha Kramer. I am a board-certified
dermatologist and I appreciate the opportunity to talk to you
today about health information technology and the challenges
that are facing physicians surrounding the selection, purchase,
and implementation of electronic health records and their
practices.
So as Ms. Beutler mentioned, two years ago I opened my own
practice in Olympia, where I currently employ two full-time and
one part-time employee, and I see an average of 125 patients
per week with 40 to 45 percent of my revenue coming from
Medicare and Medicaid. Over two years ago I invested in an EHR
system at a total cost of about $41,000. I did receive a
$20,000 grant funded through the Washington Health Information
Collaborative for Health Information Technology and paid for
the remaining $21,000 out of my business cash reserves.
As a solo practitioner, I was solely responsible for the
research, selection, and implementation process of the EHR
vendor and system. Initially, during system implementation my
patient volume was dramatically reduced in order to accommodate
the learning of the system by myself and the staff. It did take
me about four weeks to return back to my normal patient
schedule. However, two years later I am faced with the
situation where I have to completely reinvest in a new system.
Approximately one and a half years after I implemented my
original system, my software vendor was acquired by another
company that will not support my current network platform. Now
I have no choice but to purchase a new system that will cost
approximately $30,000 with $6,000 in annual charges. And aside
from the financial investment, I once again have to take time
away from my patients to implement and train my entire practice
on this new system.
Having said this, I fully support the use of health
information technology. My practice and patients benefit from
HIT in a number of ways, including improved patient safety,
increased practice efficiency, and simplified claims
processing. While I see these as benefits in my practice, there
are significant barriers to full-scale adoption and
implementation of HIT, including cost, regulatory barriers, and
financial penalties and system integration.
According to the American Medical Association, the average
cost of an EHR system is estimated to be $30,000 per physician,
with an average maintenance cost of between $3,000 and $15,000
per year. This is a significant barrier for a specialty like
dermatology where over 40 percent of the practitioners are in
private practice or solo practitioners and half of those are in
rural areas. Physicians seeking investment capital are having
issues finding a lender willing to provide them with an
unsecured loan. Others may attempt to finance their HIT system
purchase with the vendor, but small practices like mine have
little or no leverage in negotiating the terms and rates
because of a limited market share.
My practice is a great example of the unpredictable
marketplace as I will have invested over $53,000, which would
have been $73,000 if it were not for the grant, in two
different systems over just a three-year time period.
In addition, there are regulatory burdens with financial
penalties that could hurt the full-scale adoption of HIT.
Dermatologists and other providers are struggling with the CMS
meaningful use timeline. For early adopters who have a contract
with a service provider to meet 2011 and 2012 requirements
under phase one, there will be a very short window between the
release of phase two requirements and the deadline for meeting
them in 2013. Furthermore, physicians are facing financial
penalties on their annual Medicare billables of seven percent
by 2017 if they are not in compliance with the meaningful use
criteria, the physician quality reporting system, and e-
prescribing. This seven percent could be a practice's entire
profit margin and could make the difference between a practice
staying open and a practice closing. Simply understanding and
implementing all of these different programs is extremely
difficult and often overwhelming, especially to a small
practice.
In improving HIT adoption across dermatology, I urge the
Committee to address three issues. Number one, provide
sufficient financial and other resources so solo physicians are
able to select and implement HIT system. Number two, consider
delaying the penalties associated with HIT adoption until such
a time as a functional integrational system is in place. Short
of that, consider grandfathering in some physicians and
exempting them from financial penalties so that they are not
pushed into early retirement which could further exacerbate the
physician shortage in this country. And number three, if
penalties are not delayed, provide a safe harbor for those
early adopters of HIT to protect them from financial penalties
related to the meaningful user requirement. They should not be
punished for the failure of their EHR vendor to implement new
criteria.
In closing, I will absolutely continue to incorporate HIT
because I see its benefits to my practice and patients, and I
look forward to working with you. And thank you for the
opportunity to testify before the Committee today.
[The statement of Ms. Kramer follows:]
Chairwoman Ellmers. Thank you, Dr. Kramer. And now I will
yield to Ranking Member Richmond, who is going to introduce his
witness.
Mr. Richmond. Thank you, Madam Chairwoman.
It is now my pleasure and honor to introduce Dr. Denise
Elliott, who is from Marrero, Louisiana, who practices in
Marrero, Louisiana. She is a graduate of Loyola University and
Barrett University of Podiatric Medicine. Dr. Elliott has
served as an insurance advisor for the APMA and is board-
certified by the American College of Podiatric Surgery. She has
over a decade of experience as a medical specialist running her
own practice. So with that I will welcome you, Dr. Elliott, and
say that we look forward to hearing your testimony.
STATEMENT OF DENISE ELLIOTT
Ms. Elliott. Chairwoman Ellmers, Ranking Member Richmond,
and members of the Subcommittee.
I welcome the opportunity to testify before you today on
behalf of myself and the American Podiatric Medical
Association. I commend the Subcommittee for its focus on the
vital issue of how the implementation of health information
technology and electronic health records under the Medicare
program will impact small medical practices.
I am Dr. Denise Lea Elliott and a member of the American
Podiatric Medical Association and Doctor of Podiatry.
Currently, I am a solo practitioner and the owner of the Foot
and Ankle Center in Marrero, Louisiana. I know there are
members of the Subcommittee who are quite familiar and
supportive of the podiatric profession, but for those who may
not know, today's podiatrists are physicians and surgeons
licensed in the state in which they practice podiatric
medicine. We are qualified by education and training to
diagnose and treat conditions affecting the foot, ankle, and
related structures, and provide the majority of foot care
services to the Medicare population.
Podiatrists receive medical education and training
comparable to medical doctors, including four years of
undergraduate education, four years of graduate education at
one of eight accredited podiatric medical colleges, and two or
three years of hospital residency training. Most podiatrists
are board certified in podiatric orthopedics and medicine or in
surgery. I have been board certified in surgery since 2007.
More than 65 percent of the podiatrists in this country
practice in one- or two-person groups, usually employing a very
small support staff and enjoying modest annual revenues. Truly
the definition of a small business. We face the same challenges
confronted by all small businesses that must compete in
marketplaces that do not always provide a level playing field.
Podiatry practices and other small businesses can and do
compete successfully against large businesses when the terms of
that competition are fair. But success becomes difficult when
the same demands are made upon large and small businesses with
no consideration of the unique pressures placed on the small
business.
Congress is to be commended for recognizing the potential
value of health information technology to improve patient care
and produce efficiencies that reduce costs. Chronic diseases,
such as diabetes, heart disease, and kidney failure have
devastating effects on patients. Many of these ailments have
significant effects on the lower extremities and the feet in
particular. In efficiencies abound in the treatment of such
disease that could be alleviated through communication and
record sharing between family physicians, cardiologists,
nephrologists, vascular surgeons, podiatrists and others.
Giving doctors the ability to access information on the
patients they care for in real-time has the potential to
significantly improve the treatment and the lives of patients.
At the same time, such communication and coordination
should save the cost of duplicate tests, reduce emergency care,
and hospitalization admissions, and decrease the practice of
defensive medicine. The APMA fully supports this initiative
that will help podiatrists provide better care for the patients
they serve. However, Congress' requirement that eligible
providers implement electronic health care records for Medicare
over the next five years places an undue financial burden on
the majority of podiatrists that are small business owners. And
while we are well aware of the incentive program to encourage
practitioners such as myself to adopt an EMR program, it in no
way begins to take into account the great expense that a solo
practitioner will incur. I do not have access to the economies
of scale that work in favor of larger practices, nor do I have
the opportunity to participate in a hospital cost-sharing
program.
I have not yet implemented an electronic health record
system in my office although I have explored and continue to
explore the possibilities. In addition to the cost, I fear the
effect it may have on my practice. Typical EMR implementation
takes anywhere from six to eight months, and I anticipate that
I will not be able to treat the same patient load during that
period. To what extent will care be disrupted during the
procurement and installation process? How long will it take to
convert all my patient records? Will I be able to adapt to an
EMR system? Will my staff? How long will it take? And while I
certainly understand that an EMR system would benefit patients,
will it ultimately benefit my practice? The worst thing that
could happen for me and for my patients would be to lose my
practice because of the cost of implementing an EMR system that
is supposed to help them.
It has been daunting to try to figure out where to start
with the almost 300 certified programs listed on the ONC health
information technology product list. I am affiliated with West
Jefferson Medical Center, a large hospital in Marrero,
Louisiana, so I decided to initially look at a product that is
utilized by this hospital. It seemed logical to me to put a
system in my office that would work seamlessly with my hospital
system and could potentially simplify my efforts in
establishing electronic health records in my practice. But I
was astounded at the cost. More than $14,000 in start-up costs
just for the actual electronic health record software lease.
The cost for additional hardware, computers, and servers that I
would have to purchase could run an additional $15,000 to
$20,000. What do I do about my film x-ray equipment? I have not
yet tallied the cost to purchase a digital x-ray system that
would be compatible with an EMR. All of this I might add, at a
time when Medicare is decreasing my reimbursements for
radiology services and for physicians.
I am also evaluating other EMR options, but am consistently
learning that the software purchased, installation, and
training costs run approximately $25,000 to $30,000 per system,
plus additional per doctor monthly fees of up to $600. In
Washington, D.C., this may not seem like a big deal, but it
certainly is in Marrero, Louisiana. The current Medicare
incentive program offers $18,000 this year or next year if I
implement an EMR program and demonstrate meaningful use for 90
consecutive days, but it appears payments in subsequent years
will be significantly delayed. At first, $44,000 over five
years sounded like a great deal of money but I have learned
that it will not begin to cover all the costs incurred over
those five years to become fully compliant with what is hoped
to be a fully certifiable, reliable, and interoperable system.
EMR vendors are currently not certified beyond stage one of
this three-stage meaningful use implementation plan. In fact,
vendors have only temporary certification of their software
programs. What happens if the vendor and product I choose is
not certified for all three stages? If continuing certification
is costly----
Chairwoman Ellmers. Dr. Elliott----
Ms. Elliott. Yes, ma'am.
Chairwoman Ellmers [continuing]. I am going to interrupt
you there but I am going to ask the rest of your opening
statement will be submitted for the record. And just in the
constraints of time. And I apologize for that because you are
obviously presenting some very vital information. So thank you.
Ms. Elliott. Thank you.
[The statement of Ms. Elliott follows:]
Chairwoman Ellmers. I will now introduce our next witness,
Andrew Slavitt. Mr. Slavitt is the chief executive officer of
the OptimumInsight, one of the largest health information
technology and consulting companies.
He has held executive positions with several other health
care companies. He also worked at McKinsey and Company and
Goldman Sachs. Welcome. And you have five minutes and we will
be lenient with you as well.
STATEMENT OF ANDREW SLAVITT
Mr. Slavitt. Thank you, Madam Chair, Ranking Member
Richmond, members of the Subcommittee, for the opportunity to
testify today on the barriers faced by small group physicians
and single physician professionals in adopting and implementing
health information technology.
My name is Andy Slavitt. I am the CEO of OptumInsight, and
we are one of the world's largest health information technology
companies with about 14,000 people worldwide. And we have
worked with thousands of physicians to help them implement
health information technology and help them overcome their
greatest concerns--cost, uncertainty, and complexity. We have
learned a lot about what works. Health doctors make the complex
simple and you will see improvements in productivity and
adoption. Resist the urge to support efforts even tied to
financial incentives that do otherwise by adding complexity. It
is not just technology adoption that is at stake; what is at
stake is actually the very future of the solo practitioner in
this country where costs, complexity, and uncertainty are
driving consolidation into hospitals.
So to be adopted, technology must meet the needs of
supporting the physician and the patient in something
beneficial to them. And it can. Consider how the example of how
technology could help reduce unnecessary hospital admissions. A
doctor may see 40 or so patients in a day. Data suggests that
only a small handful of these patients will drive the majority
of costs and potential hospitalizations if not treated. Without
technology, every patient looks alike until the doctor walks
into the exam room. As the doctor gives our orders for a
prescription, lab tests, a dietary restriction, those that go
unfollowed are more likely to end up with a patient needlessly
hospitalized. Without technology to help, doctors do not know
who is complying and who is not until the patient shows up in
the hospital even then, data suggests that doctors only become
aware of this about half the time, and without the technology
to trigger a follow-up visit, the chances of a longer stay or
readmission to up.
All of these changes require less information technology
than is used by an airline reservation clerk. In communities
where this sort of technology adoption is occurring, like Grand
Junction, Colorado, there is evidence that unnecessary
hospitalizations, which cost us $30 billion annually, may be
dramatically reduced. So I would urge us to focus on these
basic things which simplify a physician's life and add more
productive time to their day before we focus on more abstract
requirements.
So what is it about technology that is creating these
barriers? Physicians will point to several issues that have
been brought up on this panel already--costs, legal
uncertainty, and privacy regulations. But perhaps the greatest
barrier is simpler than those. Productivity-enhancing
capabilities that I describe are not today driving the purchase
and design of this technology. Ironically, in a world where
cloud computing, mobile technology, and social networking are
creating low-cost access to a variety of capabilities for
individuals and small businesses, the typical physician may
tell you that the technology in their office or hospital has
often become a contributor to regulatory burdens they face.
Whether meaningful use standards are right or wrong is not
the real issue. What is important is that today the end-users,
doctors and patients, are further away from the actual product
design because new product development is focused on satisfying
those regulatory hurdles of a payer, CMS, rather than on simple
innovations that improve productivity.
The HITECH Act created important momentum. Approximately a
third of office-based physicians are currently planning to
achieve meaningful use of EHRs and apply for incentive payments
this year. We need to consider that for the rest of the
physician practices, the smaller ones, the temporary financial
incentives will not be enough to compensate for productivity
losses and private sector innovation is at work to demonstrate
the power of technology where meaningful use is just the
starting point.
Our company, OptumInsight offers technology, for example,
with no upfront costs or maintenance required, no purchase of
servers, automating the coding process for billing and
collecting from health plans, and most importantly, it is
instantly updatable based on the needs of the user right from
the cloud. The way the world is going, we believe technology
should be free. Services should cost money; technology is
becoming more and more a part of the fabric of our lives.
Our written testimony offers five common sense
recommendations for Congress. Allowing the requirements and
regulations placed on physicians in the multitude of programs
Congress oversees. Second, continue Federal investments in
HIEs, which should be as essential to CMS as MMIS systems which
pay Medicaid claims and administer benefits. Third, reduce
uncertainty over the legal environment. Fourth, provide SBA
loans, guarantees for small and solo practices and other
clinicians not eligible for Medicaid meaningful use incentives.
We understand this to be budget-neutral. Continue support for
the Regional Extension Centers you heard about on the first
panel, which are providing to be a strong tool to provide
expertise to small practices which lack resources.
In conclusion, I applaud the Subcommittee for focusing
attention on this issue. Physicians who practice in small
practices, who were once the cornerstone of health care in most
communities, are already an endangered species. In the 10 years
prior to 2007, the percentage of visits to physicians who are
solo practitioners decreased 21 percent. The trend has only
grown more severe since. Simplifying the environment for these
practices and private sector innovation should be the goal,
while supporting and improving upon the efforts that got
underway with the HITECH Act.
Thank you for the opportunity to testify.
[The statement of Mr. Slavitt follows:]
Chairwoman Ellmers. Thank you, Mr. Slavitt, for your
testimony, your opening statement.
I am going to introduce Dr. Baumer now, our last witness.
Dr. Baumer is a professor of law and technology at North
Carolina State University, which I was just there about a week
ago, in Raleigh, North Carolina. Dr. Baumer has written
extensively on the security and privacy of electronic medical
records as well as legal liability in the information age. He
received his B.A. from Ohio University, his J.D. from
University of Miami, and his Ph.D. from the University of
Virginia. Welcome, Dr. Baumer. And you have five minutes for
your testimony. And I will be equally as lenient with you.
STATEMENT OF DAVID L. BAUMER
Mr. Baumer. Thank you very much. It is a pleasure to be
here. Actually, it is a pleasure and an honor to address the
House Subcommittee on Health Care and Technology with
Congresswoman Renee Ellmers and Congressman Richmond.
I am the head of the Business Management Department at
NCSU. I have a Ph.D. in economics and a law degree. I have been
a member of the bar for 31 years. And within the field of law
and technology, I have examined security and privacy issues. My
work has been published in economic, engineering, accounting
and law reviews. But enough bragging.
I delivered this speech to my wife and she said tell them
what you are going to talk about and then get to it. So let me
just say that I believe the written statement that I provide
outside fills in a lot of the gaps relative to this PowerPoint
presentation.
However, my recommendations to get right to the point are
that small health care firms should be provided with safe
harbors in the form of EHR software that insulates them from
suit by the Federal Trade Commission, by private class actions,
and by State attorney generals. Secondly, currently there is no
private right of action under HIPAA, nor should there be.
Third, small health care providers should not have to be IT
specialists aware of the latest techniques in combating
identity thieves. And fourth, a step in the right direction and
I am gratified to hear this discussion, is certified software
under ARRA, which creates, I would hope, a due diligence
defense if somehow a cyber break-in occurs.
So finally, I would like to point out that removing legal
uncertainty as we have see will not result in widespread
adoption of EHR unless other obstacles are dealt with,
including start-up costs and interoperability. However, going
back to some of the work that I have done, we have--I have
worked with people at Carnegie Mellon, Virginia Tech, Georgia
Tech, examining FTC interventions on behalf of citizens'
privacy and security. And the FTC has done a very good job.
They are dealing with some very clever people. But what we have
found and what we have discussed in the FTC's interventions is
that the FTC standards for commercially reasonable security
evolves from case to case. And that is because the IT
technology continues to evolve.
So encryption. People talk about encryption. Forty-point
encryption is no longer state-of-the-art. It is now up to 130
and it could be higher. So these interventions by the FTC
create uncertainty in my opinion, even among large firms, but
certainly small firms are overwhelmed.
In 2004, I wrote an article, co-wrote internet privacy law
comparison between the United States and the European Union. It
was apparent to me that E.U. protection of PII (personally
identifying information) is much more extensive and effective
than in the U.S. More recently, I co-authored an article,
Privacy and Security in the Implementation of Health
Information Technology: U.S. and E.U. Compared. Now, we start
with the assumption that there will be significant efficiency
gains, but there could be some diminution in the privacy of
medical records. Let me just provide you with some overall
statistics.
In some E.U. countries, 90 percent plus of their medical
records are electronic. In the United States it is fewer than
50 percent. And it is also true that in economic parlance there
are significant and positive network externalities associated
with making all medical records electronic so that there is,
excuse me, an economic justification for subsidizing startup
costs.
All right. I know I was supposed to confine my remarks to
legal, but these things are interspersed. Let me just jump
ahead and point out, for example, that HIPAA has over 15
exceptions in which medical information can be transmitted to
third parties without patient consent. In the E.U., there are
only three exceptions, which I would be glad to go into.
Let me cite a couple quotes and then finish up. There was a
recent article in November 2010 in the New England Journal of
Medicine in which it was stated the question is whether EHRs
will help providers defend against such claims, medical
malpractice and medical liability, or leave them more
vulnerable. The answer seems to be it will do both. I am sure
that is reassuring to providers.
Compliance with FTC and security protection standards
necessitates firms to be cognizant of recent FTC actions which
requires firms to possess substantial expertise in IT. And yet,
in my opinion, security breaches are inevitable. An article
written by my colleague, Professor Fay Cobb-Payton at NCSU----
[The statement of Mr. Baumer follows:]
Chairwoman Ellmers. I am sorry, Dr. Baumer, I am going to
stop you there but your testimony will be submitted for the
record. And I do appreciate that insight regarding all of the
security issues that we face.
And I would just further that by saying that you have
highlighted an area that I think shows just some of the hurdles
and barriers that we are up against, which is that technology
keeps building upon itself so quickly and yet we are putting
this on our physicians who are small business owners. And how
can our physicians be able to incur that cost and stay up-to-
date with the mandates of meaningful use as those evolve, the
dollar signs. And I can speak to this on a personal level. In
our practice, having had IT for probably going on about five
years now, now in order for us to be compatible with meaningful
use we are going to have to encounter about another $20,000.
And that is for the meaningful use as it is applied now and not
considering the possibilities of changes in the future.
So thank you, Dr. Baumer. I do have a couple of questions
and then I will be yielding to our ranking member.
To Dr. Elliott, I know you have stated that you have not
put into place your IT yet because of all of the costs that you
know you are going to have to incur. One, being a podiatrist,
what is the percentage of Medicare patients that you see? Or
no, in relation to, I mean, if you could say how many patients
you see a week and of that, if you have an idea of the
percentage.
Ms. Elliott. I see an average of 30 to 40 patients a day,
four days a week. So 120 to 150 patients. And about 15 percent
is Medicare. The majority of those Medicare patients are
hospital-based patients, the patients with the end-stage renal
disease, diabetics----
Chairwoman Ellmers. Right.
Ms. Elliott [continuing]. Being called for wounds or
amputations----
Chairwoman Ellmers. Sure.
Ms. Elliott. [continuing]. Things along that line. The more
severe type of foot conditions.
Chairwoman Ellmers. So I guess the question is, and of
course this is completely your opinion, is it cost effective
for you to incur the cost for health IT in relation to the
possibility of future penalties that you may incur? Because as
you have seen as of 2015, the penalities will increase and will
be sustained. Can your practice take on that penalty if you do
not implement the IT?
Ms. Elliott. My practice can because it is a small
percentage of my practice. So that one percent then becomes two
percent and three percent but it is only 15 percent of my
practice. So if I was going to do a cost analysis and I had to
outlay all of this money, for me it might be a better financial
decision not to implement it.
Chairwoman Ellmers. Not to implement it at all.
Ms. Elliott. Correct. And my big fear is what my colleague
here went through where you do spend all this money and in the
future things change and you have to start over again. I
already have 11,000 patients. I have to convert all those
records from paper to electronic. Now I have to go with a
different company and I have to convert again. Those are all
costs that are involved once you convert from one system to
another system because it is not ready for the second phase or
it has gotten booted out or bought out by a bigger company. So.
Chairwoman Ellmers. There again, the implementation and the
changes in the technology world are really affecting us
directly because, how can we comply with these issues? And that
is one of our concerns. And I thank you for that.
I will now yield to Ranking Member Richmond.
Mr. Richmond. Dr. Elliott, I know that you did not get a
chance to finish your testimony but I believe in the portion of
your testimony that you did not get to talk about you talked
about your concerns about meaningful use criteria. So I will
ask you, consistent with what you said, that we have heard from
providers who are concerned that they will not meet the
ambitious definition of meaningful use goals required for stage
one demonstration. And do you believe widespread adoption can
be accomplished within CMS's aggressive timeline? And are there
unique challenges to specialists in this area?
Ms. Elliott. I think that most of the subsystems out there
are designed for your primary are physicians. So as far as the
specialists, I think it is a little more challenging. I think
you have to go with a smaller company that is going to cater to
my specialty, which will not necessarily integrate as well with
the larger hospitals. Then there is interface fees. If you want
to try to connect with a smaller company to a larger company.
So I think it will be a challenge. I would love to see more
efforts being placed on the specialist as far as the software
vendors. I think it is possible from a timeline to put this in
practice, to answer that question.
Mr. Richmond. The other one, and this question would be for
Dr. Elliott and Dr. Kramer. A lot of times, I guess, there are
not clear instances of where reality and theory just do not
meet. And when we talk about the incentive program, and I am
curious especially for both of you as small practitioners
where, Dr. Elliott, I think you said that you estimate spending
$25,00 to $30,000 to implement, you may be reimbursed $18,000.
And that is after a 90-day period of demonstrating use. Then
four to eight week after that. Is that just a reasonable
timeline or reasonable expectation to expect a small
practitioner to be able to front that money and float all of
the necessary bills and recoup it at the end? And at the end of
that question, do you all have the access to capital to, if you
do not have the money within your budget, are there lenders out
there willing to lend you that money to get you through that
hurdle?
Ms. Elliott. Do you want to go? I know the software
companies I have looked at, some of them have invested in
different loaning programs. So the individual vendors have
partnered with banks or loaning institutions. But now you are
taking on a loan. You are taking on a business loan. It would
not be a desirable thing for me as a small business owner. So,
of course, it would put a kink in your cash flow if you had to
outlay all this money and then wait for the timeframe for it to
come back to you. So.
Ms. Kramer. I think it is difficult for many practices.
Most of the companies do give you a 12-month lease period where
you divide the payments over a year. And so that makes it more
manageable. But it is still a large amount of money at the
beginning, which you basically just, as a small business owner,
you are the last person to get paid. So you pay yourself last,
you save money, and I mean, I would much rather do that than
take out a business loan.
Mr. Richmond. And my last question, what was the decrease
in the number of patients you could visit while you went
through your installation and your 90-day?
Ms. Kramer. It is very significant because it is not just
me who has to learn how to use it but it is the front desk
staff who has to register the patient, get the information in
the system. The nurses have to enter the medications and
allergies. So the first week I saw one patient an hour. And I
normally see between four, six, seven patients an hour. So that
is a huge--not only do you have to front the cash for the
system but it is a big dip in your cash flow for the month or
months. Usually it takes approximately six to nine months for a
practice to get up and running fully with the system. So it
took me about four to six weeks but the average, I believe, is
six to nine months.
Mr. Richmond. Wow.
Ms. Kramer. Yeah.
Mr. Richmond. According to my quick math over here, I mean,
that is almost a reduction from anywhere of 75 percent to 85
percent of the number of patients you can see, which reduces
your income 75 to 85 percent during this time period.
Ms. Kramer. It is huge.
Mr. Richmond. Thank you.
Ms. Kramer. And I am looking at having to do it all over
again and that is really concerning. And I also mentioned that,
you know, a lot of practices, especially in my field, there is
a huge wait period to see specialists. I am booked five to six
months out and so that just puts me even another month behind.
Mr. Richmond. Thank you so much.
Ms. Kramer. Thank you.
Mr. Richmond. All of you.
Chairwoman Ellmers. Thank you. And I now yield to Ms.
Herrera Beutler for her questions.
Ms. Herrera Beutler. Thank you. And Mr. Richmond kind of
asked what I was thinking. How long is the recoup time? You
know, exactly what you said. I was thinking you have to front
the money upfront. You have to put the cash down and then you
are not having the same revenue that you had in months
previous.
Ms. Kramer. Correct. Yeah.
Ms. Herrera Beutler. So nine months? How long does it take
you to break even? Did you break even up to this point and now
you are having to look at another IT provider?
Ms. Kramer. Yeah. It probably takes, I would say, to
increase productivity--I mean, in my mind there is no doubt
that over the long term it will increase productivity. I mean,
I have fewer staff and if I had paper charts I do not have
someone that has to be pulling charts, etcetera. But I think it
would probably take several years to turn a profit. I would
think three, four, five, six years.
Ms. Herrera Beutler. So it is a long-term investment.
Ms. Kramer. Yes, it is.
Ms. Herrera Beutler. I was disappointed not to have our
previous panel here. I did not know they were going to leave or
I would have asked them to stay because I think it is
incredibly important for them to hear. And I was trying to get
at it a little bit what happens to the small and solo guys who
run into a problem like this. There is no real hold harmless, I
think, in a contract for you.
Ms. Kramer. Nothing----
Ms. Herrera Beutler. Is there anything that even as you are
negotiating with vendors, is that something that you can
require? Or do you need--or are they just going to kind of
laugh at that?
Ms. Kramer. Yeah, I asked and I asked, you know, the new
vendors that I was interviewing and they said, yes, you know,
our company is stable. But what does that really mean?
Ms. Herrera Beutler. Thank you for that.
I wanted to also ask Dr. Baumer, I had a physician in my
office a few weeks ago and they were talking to me. You kind of
came at the security portion from the cyber attack side of it
and you mentioned med-mal, but in terms of discoverability, I
have had physicians say, look, once I put all this on line it
is discoverable in a med-mal case. What is the case with paper
records? And is that something you are hearing? Is it the same?
Mr. Baumer. I do not think that there is a difference
between paper records in terms of discoverability and
electronic records.
Ms. Herrera Beutler. You know what? Part of what he was
saying was so you have this great new metrics, right, you put
the information in and they can--then the computer can generate
are you looking at this? Are you looking at this? Are you
looking at this? Well, a physician may be looking at certain
criteria. It is probably not one of these one percent chance it
is one of these other things, but if the computer brings it up
there is a one percent chance and you did not go after it, is
it expanding your liability exposure?
Mr. Baumer. Well, I think that is a very good question. I
mean, if the computer puts out four or five scenarios, do you
have a due diligence obligation to investigate each of these?
And, you know, that problem, however, has been dealt with for
some time. There is kind of recommended treatment and then
physicians reject that and use their own judgment. So I am not
sure that because we have electronic records that that is going
to be a new source of liability. But as that New England
Journal points out, we do not know. And there has not been, you
know, hopefully in the long run, but people cannot hold their
breath in the long run, that we will have a reduction in
liability. I think that most of these providers are very
concerned about lawsuits from people they do not even know
about issues that they are not trained about, namely IT issues,
which Mr. Slavitt might be able to talk about.
Ms. Herrera Beutler. Did you have a thought?
Mr. Slavitt. Yeah. I think there is a slight difference,
Congressman, and that difference is that in a paper record it
may say that a patient is taking certain medication. Now, an
electronic system may say because this patient is taking this
medication do not give them this treatment or there is going to
be a bad interaction. And so I think the fear is that that
creates a level of liability. Invisibility in the liability
that did not exist before. So what we obviously need to do is
encourage the development of--encourage people to learn and
improve and not penalize people for improving. And to self-
report and so forth. That type of environment, I think, you
know, will balance the needs and interests of the patient with
the, I think, very real concerns of a physician to make sure
that they do not get penalized for effectively trying to
advance the care they are delivering.
Ms. Herrera Beutler. Absolutely. Thank you. I yield back.
Chairwoman Ellmers. Thank you. And I now yield to Mr.
Hanna. Mr. Hanna, you are fine? With that I will----
Mr. Slavitt, I did have a couple of questions along the
same lines of what we were just discussing. With the incredible
rate of innovation in technology and the changes and all of the
concerns that you have brought up, and you did an excellent job
of outlining some of the areas that we need to address, with
that I just want you to elaborate a little bit more on the cost
and the time that it does take for our physician offices to
implement this. You know, many times the software company, the
vendor will say, within three months you will be up and running
and you are going to turn a profit. Realistically, and I know
Dr. Kramer you had outlined, you know, six to nine months. And
each office is certainly going to be different based on the
number of employees that will be working with it, and the time
that the physician can afford to devote to it. In your opinion,
are those costs and time estimates underestimated? Because that
was certainly our experience.
Mr. Slavitt. Sure. It is a great question and I think Dr.
Kramer's story is really probably one of the most important
cautionary tales for what can be avoided. And, you know, I
think that to the extent that we think physicians and a large
integrated delivery system and in Geisinger where you have come
from, you have got to think of it very differently than small
business, solo practitioners, who are very much--they are very
much consumer professionals all at the same time. And they need
to be treated differently. And so, you know, if you think about
what companies like Intuit charge for practice software for a
small business, for a small physician office where they have
75,000 physicians, it is very small. The training time is easy.
It is a very intuitive set of applications.
Likewise, you know, I do not think there is a great future
in charging individuals $75,000 to install technology in their
offices and maintain it. We all know that is not the direction
things are going. If you are not happy with Google, you switch
to Microsoft. And if you are not happy with Microsoft, just
switch to Google. That is the environment that needs to be
stimulated out of ONC here. And I think there is good news and
I think the kind of questions that I think need to be asked
when talking to vendors are how updatable? Can it be delivered
through the cloud? Can you provide guarantees that I can reach
meaningful use? Can you give me a money back guarantee on the
loan if I do not reach meaningful uses? And the competition--
the good news is that some of the competition that has been
spurred are actually driving in that direction. It clearly has
not gotten out to you, Dr. Kramer, but that is what needs to
happen.
Ms. Ellmers. Thank you so much. And at that I will say
thank you to our panel. This will conclude our hearing today.
This Subcommittee will continue to closely follow and take
into account all of your comments and concerns, and I certainly
do appreciate your time. We will be sending a letter to CMS on
the e-prescribing incentive program proposed rule during the
comment period that is now currently in effect.
I ask unanimous consent that members have five legislative
days to submit statements and supporting materials for the
record.
I have an article here that was just posted in Medscape
Medical News and I will just briefly touch on it. Centers for
Medicare and Medicaid Services, CMS, is proposing more
exceptions to an electronic prescribing requirement that could
penalize as many as 109,000 physicians, nurse practitioners,
and other prescribers who do not adopt the technology. The
title of the article is E-Prescribing Penalty Could Hit up to
109,000 Clinicians.
With that, this meeting is adjourned. [Whereupon, at 11:57
a.m., the Subcommittee hearing was adjourned.]
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