[House Hearing, 112 Congress]
[From the U.S. Government Publishing Office]



 
              IS ``MEANINGFUL USE'' DELIVERING MEANINGFUL
                   RESULTS?: AN EXAMINATION OF HEALTH
         INFORMATION TECHNOLOGY STANDARDS AND INTEROPERABILITY

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

                                HEARING

                               BEFORE THE

               SUBCOMMITTEE ON TECHNOLOGY AND INNOVATION

              COMMITTEE ON SCIENCE, SPACE, AND TECHNOLOGY
                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED TWELFTH CONGRESS

                             SECOND SESSION

                               __________

                      WEDNESDAY, NOVEMBER 14, 2012

                               __________

                           Serial No. 112-105

                               __________

 Printed for the use of the Committee on Science, Space, and Technology


       Available via the World Wide Web: http://science.house.gov



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              COMMITTEE ON SCIENCE, SPACE, AND TECHNOLOGY

                    HON. RALPH M. HALL, Texas, Chair
F. JAMES SENSENBRENNER, JR.,         EDDIE BERNICE JOHNSON, Texas
    Wisconsin                        JERRY F. COSTELLO, Illinois
LAMAR S. SMITH, Texas                LYNN C. WOOLSEY, California
DANA ROHRABACHER, California         ZOE LOFGREN, California
ROSCOE G. BARTLETT, Maryland         BRAD MILLER, North Carolina
FRANK D. LUCAS, Oklahoma             DANIEL LIPINSKI, Illinois
JUDY BIGGERT, Illinois               DONNA F. EDWARDS, Maryland
W. TODD AKIN, Missouri               BEN R. LUJAN, New Mexico
RANDY NEUGEBAUER, Texas              PAUL D. TONKO, New York
MICHAEL T. McCAUL, Texas             JERRY McNERNEY, California
PAUL C. BROUN, Georgia               TERRI A. SEWELL, Alabama
SANDY ADAMS, Florida                 FREDERICA S. WILSON, Florida
BENJAMIN QUAYLE, Arizona             HANSEN CLARKE, Michigan
CHARLES J. ``CHUCK'' FLEISCHMANN,    SUZANNE BONAMICI, Oregon
    Tennessee
E. SCOTT RIGELL, Virginia
STEVEN M. PALAZZO, Mississippi
MO BROOKS, Alabama
ANDY HARRIS, Maryland
RANDY HULTGREN, Illinois
CHIP CRAVAACK, Minnesota
LARRY BUCSHON, Indiana
DAN BENISHEK, Michigan
VACANCY
                                 ------                                

               Subcommittee on Technology and Innovation

                  HON. BENJAMIN QUAYLE, Arizona, Chair
LAMAR S. SMITH, Texas                DONNA F. EDWARDS, Maryland
JUDY BIGGERT, Illinois               FREDERICA S. WILSON, Florida
RANDY NEUGEBAUER, Texas              DANIEL LIPINSKI, Illinois
MICHAEL T. McCAUL, Texas             BEN R. LUJAN, New Mexico
CHARLES J. ``CHUCK'' FLEISCHMANN,    SUZANNE BONAMICI, Oregon
    Tennessee                        VACANCY
E. SCOTT RIGELL, Virginia            VACANCY
RANDY HULTGREN, Illinois             VACANCY
CHIP CRAVAACK, Minnesota             EDDIE BERNICE JOHNSON, Texas
RALPH M. HALL, Texas


                            C O N T E N T S

                      Wednesday, November 14, 2012

                                                                   Page
Witness List.....................................................     2

Hearing Charter..................................................     3

                           Opening Statements

Statement by Representative Benjamin Quayle, Chairman, 
  Subcommittee on Technology and Innovation, Committee on 
  Science, Space, and Technology, U.S. House of Representatives..     9
    Written Statement............................................    10

Statement by Representative Hansen Clarke, Acting Ranking 
  Minority Member, Subcommittee on Technology and Innovation, 
  Committee on Science, Space, and Technology, U.S. House of 
  Representatives................................................    12
    Written Statement............................................    12

                               Witnesses:

Dr. Farzad Mostashari, National Coordinator for Health 
  Information Technology, The Office of the National Coordinator 
  for Health Information Technology
    Oral Statement...............................................    14
    Written Statement............................................    17

Dr. Charles H. Romine, Director, Information Technology 
  Laboratory, National Institute of Standards and Technology
    Oral Statement...............................................    30
    Written Statement............................................    32

Mr. Marc Probst, Chief Information Officer and Vice President, 
  Information Systems,
    Oral Statement...............................................    41
    Written Statement............................................    43

Ms. Rebecca Little, Senior Vice President, Medicity
    Oral Statement...............................................    53
    Written Statement............................................    55

Dr. Willa Fields, DNSc, RN, FHIMSS, Professor, School of Nursing, 
  San Diego State University
    Oral Statement...............................................    59
    Written Statement............................................    61

             Appendix I: Answers to Post-Hearing Questions

Dr. Farzad Mostashari, National Coordinator for Health 
  Information Technology, The Office of the National Coordinator 
  for Health Information Technology..............................   114

Dr. Charles H. Romine, Director, Information Technology 
  Laboratory, National Institute of Standards and Technology.....   119

Mr. Marc Probst, Chief Information Officer and Vice President, 
  Information Systems, Intermountain Healthcare..................   122

Ms. Rebecca Little, Senior Vice President, Medicity..............   125

Dr. Willa Fields, DNSc, RN, FHIMSS, Professor, School of Nursing, 
  San Diego State University.....................................   128


         IS ``MEANINGFUL USE'' DELIVERING MEANINGFUL RESULTS?:
                  AN EXAMINATION OF HEALTH INFORMATION
               TECHNOLOGY STANDARDS AND INTEROPERABILITY

                              ----------                              


                      WEDNESDAY, NOVEMBER 14, 2012

                  House of Representatives,
         Subcommittee on Technology and Innovation,
               Committee on Science, Space, and Technology,
                                                   Washington, D.C.

    The Subcommittee met, pursuant to call, at 10 a.m., in Room 
2318, Rayburn House Office Building, Hon. Benjamin Quayle 
[Chairman of the Subcommittee] presiding.

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    Chairman Quayle. The Subcommittee on Technology and 
Innovation will come to order. Good morning. Welcome to today's 
hearing entitled ``Is `Meaningful Use' Delivering Meaningful 
Results?: An Examination of Health Information Technology 
Standards and Interoperability.''
    In front of you are packets containing the written 
testimony, biographies, and truth-in-testimony disclosures for 
today's witnesses.
    I now recognize myself for five minutes for an opening 
statement.
    Throughout this Congress our Subcommittee has been focused 
on advancing U.S. innovation in a constrained budget 
environment. We held hearings on cloud computing, start-up 
companies, standards development, spectrum R&D, manufacturing, 
and innovation policies. Today's discussion is a continuation 
of this conversation.
    This is also the fourth hearing the Committee on Science, 
Space, and Technology has held on health information technology 
standards since the 109th Congress.
    Effective utilization of information technology in the 
medical field has the potential to fundamentally change health 
care in our country. Application of health IT could lower 
healthcare costs by reducing duplicative and unnecessary tests 
and procedures. It could also lead to more effective care by 
helping to reduce medical errors and could help to improve 
public health outcomes by aiding in clinical decision making.
    Given the strain of rising healthcare costs on our budget 
and the diverse array of healthcare providers, information 
technology will be a critical component of our future 
healthcare system. However, while information technology has 
become pervasive in our everyday lives, the healthcare industry 
has historically been slow to effectively deploy IT.
    In 2004, President Bush signed an Executive Order 
establishing the Office of the National Coordinator for Health 
Information Technology, or the ONC, within the Department of 
Health and Human Services to develop, maintain, and direct a 
strategic plan to guide the nationwide implementation of health 
IT in the public and private healthcare sectors.
    The National Institute of Standards and Technology has 
worked with industry and other stakeholders to advance 
healthcare information technology infrastructure since the 
early 1990s.
    In 2009, the HITECH Act was passed as part of the American 
Recovery and Reinvestment Act to promote the adoption of health 
IT products, services, and infrastructure through a series of 
discretionary and mandatory funding programs. This legislation 
included $2 billion in discretionary funds for the ONC to 
invest in health IT architecture and to provide grants and 
training programs to encourage health IT adoption.
    Furthermore, the legislation provided financial incentives 
in the form of mandatory payments through the Medicare and 
Medicaid programs to encourage physicians and hospitals to 
adopt and use certified electronic health records, or EHRs. To 
date, incentive payments under these programs have totaled over 
$7.7 billion. It is estimated that CMS will pay out 
approximately $20 billion in incentive payments to providers 
under this program.
    This is a significant Federal expenditure. Given our 
current budget situation, it is vital that these taxpayer 
dollars are spent effectively in ways that lead to reduced 
costs and better health care down the road. Nearly four years 
after the HITECH Act, taxpayers should know what we have to 
show for it.
    While adoption of health IT products and services has 
increased since the passage of the HITECH Act, I have serious 
concerns about our progress towards greater interoperability of 
health IT systems. Without interoperability many of the 
potential benefits of health IT could go unrealized.
    Interoperability depends on the development and utilization 
of strong technical standards. I am interested in hearing from 
our witnesses about progress being made towards the development 
of these standards and what policy makers can do to advance 
interoperability.
    Further, I am concerned that the meaningful use 
requirements do not effectively take into account the 
complexity and diversity of the healthcare marketplace. It is 
crucially important that health IT is used to improve care 
without burdening certain providers with requirements that 
divert valuable time and resources.
    Clearly there are key questions that must be answered to 
ensure that taxpayer dollars are spent wisely and to ensure 
that IT in the healthcare industry is used to reduce costs and 
improve care.
    We thank all of our witnesses for being here today, and we 
look forward to your testimony.
    [The prepared statement of Chairman Quayle follows:]

         Prepared Statement of Subcommitte Chairman Dan Quayle

    Good morning, I'd like to welcome everyone to today's hearing, 
which is being held to examine the development of health information 
technology interoperable standards, and the implementation of the 
Health Information Technology for Economic and Clinical Health Act, 
more commonly known as the HITECH Act.
    Throughout this Congress, our Subcommittee has been focused on 
advancing U.S. innovation in a constrained budget environment. We held 
hearings on cloud computing, startup companies, standards development, 
spectrum R&D, manufacturing, and innovation policies. Today's 
discussion is a continuation of this conversation.
    This is also the fourth hearing the Committee on Science, Space, 
and Technology has held on health information technology standards 
since the 109th Congress.
    Effective utilization of information technology in the medical 
field has the potential to fundamentally change healthcare in our 
country. Application of health IT could lower health care costs by 
reducing duplicative and unnecessary tests and procedures. It could 
also lead to more effective care by helping to reduce medical errors 
and could help to improve public health outcomes by aiding in clinical 
decision making.
    Given the strain of rising health care costs on our budget and the 
diverse array of healthcare providers, information technology will be a 
critical component of our future healthcare system. However, while 
information technology has become pervasive in our everyday lives, the 
healthcare industry has historically been slow to effectively deploy 
IT.
    In 2004, President Bush signed an executive order establishing the 
Office of the National Coordinator for Health Information Technology 
or, the ONC, within the Department of Health and Human Services to 
develop, maintain, and direct a strategic plan to guide the nationwide 
implementation of health IT in the public and private health care 
sectors.
    The National Institute of Standards and Technology has worked with 
industry and other stakeholders to advance healthcare information 
technology infrastructure since the early 1990s.
    In 2009, the HITECH Act was passed, as part of the American 
Recovery and Reinvestment Act, to promote the adoption of health IT 
products, services, and infrastructure through a series of 
discretionary and mandatory funding programs.
    This legislation included $2 billion in discretionary funds for the 
ONC to invest in health IT architecture, and to provide grants and 
training programs to encourage health IT adoption.
    Furthermore, the legislation provided financial incentives in the 
form of mandatory payments through the Medicare and Medicaid programs 
to encourage physicians and hospitals to adopt and use certified 
electronic health records, or EHRs.
    To date, incentive payments under these programs have totaled over 
$7.7 billion. It is estimated that CMS will pay out approximately $20 
billion in incentive payments to providers under this program.
    This is a significant Federal expenditure. Given our current budget 
situation, it is vital that these taxpayer dollars are spent 
effectively in ways that lead to reduced costs and better health care 
down the road. Nearly four years after the HITECH Act, taxpayers should 
know what we have to show for it.
    While adoption of health IT products and services has increased 
since the passage of the HITECH Act, I have serious concerns about our 
progress towards greater interoperability of health IT systems. Without 
interoperability, many of the potential benefits of health IT could go 
unrealized.
    Interoperability depends on the development and utilization of 
strong, technical standards. I am interested in hearing from our 
witnesses about progress being made towards the development of these 
standards, and what policy makers can do to advance interoperability.
    Further, I am concerned that the meaningful use requirements do not 
effectively take into account the complexity and diversity of the 
healthcare marketplace. It is crucially important that health IT is 
used to improve care without burdening certain providers with 
requirements that divert valuable time and resources.
    Clearly, there are key questions that must be answered to ensure 
that taxpayer dollars are spent wisely, and to ensure that IT in the 
healthcare industry is used to reduce costs and improve care.
    We thank our witnesses for being here today and we look forward to 
your testimony.
    Chairman Quayle. I now recognize the gentleman from 
Michigan Mr. Clarke for his opening statement.
    Mr. Clarke. Thank you, Mr. Chair.
    First of all, I would like to say, as someone who will not 
be returning to Congress, it has been an honor to serve with 
you. I also appreciate your diligence on examining this 
important need that we have, which is to make sure that we have 
electronic health records shared in a way that all physicians 
and healthcare providers will be able to exchange this 
information.
    The Chair laid out the benefits of health IT in terms of 
the money that could be saved by eliminating duplicative 
testing, and also how health IT could help improve the quality 
of health care, especially with diabetics. There have been 
studies that have shown that when electronic health records are 
used, diabetic patients are able to manage their disease more 
effectively.
    Now, the Chair mentioned his concern about the value of the 
incentives payments, and I acknowledge that, you know, our goal 
is to spend approximately $20 billion, I believe, by 2015 on 
these incentive payments. I think they are absolutely critical, 
because if you look at the fact that most Americans get their 
primary care from offices that have five or fewer physicians, 
these small offices, they don't have the money or the resources 
to be able to set up a health IT system, especially when those 
physicians may not be sure if that system is going to really 
work in an interoperable way or if it could become obsolete in 
a short period of time. So I believe it is critical for us to 
move forward on the full implementation of this platform.
    I look forward to speaking to the National Coordinator 
about his work with NIST since the HITECH Act directs a 
partnership--or I should say that this rule that we are now 
reviewing establishes a partnership which could help further 
develop a health IT platform that could result in the 
interoperability of electronic health records.
    My one closing statement is this, is that even though this 
area is complex, because the healthcare industry is complex and 
health IT itself is complex, being able to have these records 
in an electronic form that could be shared can make a 
difference. Two months ago my first cousin, the closest blood 
relative I have here in this country, who is younger than me, 
passed away. She suffered organ failure, and I believe that a 
combination of prescription drugs may have been a contributing 
factor to that. It is likely that with these electronic health 
records we would be able to identify that type of prescription 
drug interaction before it happens.
    So with that, I yield back the balance of my time.
    Chairman Quayle. Thank you, Mr. Clarke.
    [The prepared statement of Mr. Clarke follows:]

 Prepared Statement of Subcommittee Acting Ranking Member Hansen Clarke

    Thank you, Mr. Chairman for calling this hearing on health 
information technology. Before I begin my opening statement, I'd like 
to take a moment to recognize Chairman Quayle for his leadership on the 
Subcommittee. It has been a pleasure working with you to address a wide 
range of issues. I thank you for your service to the Subcommittee and 
Congress and wish you the best in your future endeavors.
    Today's hearing is fitting as just a few months ago the 
requirements for the second stage in the ``meaningful use'' of 
electronic health record technologies were announced by the Department 
of Health and Human Services. This morning's hearing provides us with 
the perfect opportunity to examine the progress we've made to date and 
to discuss what needs to happen in the future to increase the use of 
information technology in the healthcare industry.
    Over the past 20 years, we have experienced a dramatic change in 
the way we share information. Nearly every sector across our economy, 
from financial services to entertainment to manufacturing, has embraced 
information technology and used it to increase productivity and 
quality. Yet the healthcare industry has lagged far behind with many 
physicians and healthcare providers keeping track of our medical 
information the same way they were 50 years ago.
    The use of electronic health records--or EHRs--has real-world 
implications for the cost and quality of health care. Right now, a 
physician may order a duplicative test because previous test results 
from another hospital or doctor are not readily at hand, or they may 
miss a harmful drug interaction because a patient's full medication 
list is not available and the patient is not in a condition to provide 
that information.
    Increasing the adoption and use of health IT could help prevent 
some of the medical errors that injure at least 1.5 million Americans 
each year and lead to an estimated 98,000 deaths annually. For example, 
a study of a medical center in Arizona found that the use of EHRs 
reduced prescription errors by 88 percent and in a Florida health 
system the use of electronic reminders decreased the number of patient 
charts that were missing allergy information from 36 percent to 11 
percent.
    Studies have also shown that the use of EHRs has helped diabetic 
patients manage their disease more effectively--lowering their blood 
pressure, cholesterol, and glucose levels. In addition to improving the 
quality of care and health outcomes, estimates have shown that a fully 
interoperable health IT system could save the United States billions of 
dollars in health care costs each year.
    Given the complexity of our healthcare system, the task charged to 
the Office of the National Coordinator by the HITECH Act to promote the 
development of a national health IT infrastructure that allows for the 
electronic use and exchange of information is a difficult one. However, 
in the two years since the Subcommittee last examined this topic, the 
National Coordinator, by all accounts, has done an admirable job 
meeting tight deadlines and navigating the needs of various 
stakeholders. NIST has also played an important role by lending to HHS 
its extensive expertise in standards, testing, and certification.
    Still, there are a number of factors that have contributed to the 
slow adoption of health IT such as the availability of a qualified 
workforce or privacy and security concerns. I believe a key barrier to 
adoption has been the lack of technical standards to support 
interoperability. In order for the full potential of health IT to be 
realized, adoption and implementation of EHRs must increase and true 
interoperability -meaning the seamless exchange of health information 
across vendors and providers must be achieved. Most Americans get their 
primary health care at offices with five or fewer doctors. These small 
offices are hesitant to take on the considerable expense of a health IT 
system that may not work with the system of a neighboring healthcare 
provider or may become prematurely obsolete.
    However, I am encouraged by the criteria and standards included in 
the final rule for Meaningful Use Stage 2 released in August and hope 
to gain some insight from today's witnesses about the implementation of 
Stage 2. As I understand it, Stage 2 focuses on the challenge of 
interoperability in a number of ways. First, it defines a common 
dataset, including vital signs, medications, and discharge instructions 
that must be a part of a patient's summary of care record. Next, it 
details the standards and specifications necessary for the exchange of 
typical, but important medical information like laboratory results, 
immunizations, and electronic prescriptions. And maybe most 
importantly, Stage 2 creates a partnership between the Office of the 
National Coordinator and NIST in the development of a rigorous 
interoperability testing platform. Such a platform will ensure that 
once a physician or healthcare provider has adopted a certified EHR 
technology they will be able to send, receive, and use this critical 
health information.
    However, as I am sure we will discuss today, we still have a ways 
to go in promoting interoperability, coordinating the numerous health 
IT projects that are underway, and implementing best practices to 
address privacy and security concerns.
    The widespread use of health IT is imperative for lowering costs 
and improving patient care, and I look forward to hearing from our 
witnesses about how we can successfully meet the challenges ahead.
    Thank you, again, Mr. Chairman, for calling this important hearing 
and I yield back the balance of my time.
    Chairman Quayle. I now recognize the gentleman from Texas, 
Mr. Smith, for his opening statement.
    Mr. Smith. Thank you, Mr. Chairman. I do not have an 
opening statement, but I did not want it to go unnoticed that 
this might be your last hearing that you chair, and I just 
wanted to say that all of us who have been associated with you, 
whether it be on committees, and in this case you and I serve 
on two committees together, that all those who have known you 
and worked with you appreciate your service to the 
Subcommittee, the full Committee, the Congress, and our 
country, and I thank you for that.
    Chairman Quayle. Thank you very much. Those are probably 
the most important words of this whole hearing today. I thank 
the gentleman for those kind remarks.
    And I want to thank Mr. Clarke for his opening statement.
    If there are Members who wish to submit additional opening 
statements, your statements will be added to the record at this 
point.
    Chairman Quayle. At this time I would like to introduce our 
witnesses, and we will proceed to hear from each of them in 
order. Our first witness is Dr. Farzad Mostashari, National 
Coordinator for Health Information Technology at the United 
States Department of Health and Human Services.
    Next we will hear from Dr. Charles H. Romine, Director of 
the Information Technology Laboratory at the National Institute 
of Standards and Technology.
    Our third witness is Mr. Marc Probst, Chief Information 
Officer and Vice President of Information Systems at 
Intermountain Healthcare.
    Our fourth witness is Ms. Rebecca Little, Senior Vice 
President of Medicity.
    Our final witness is Dr. Willa Fields, Professor of Nursing 
at San Diego State University and Chair of the Board of 
Directors of the Healthcare Information and Management Systems 
Society. Thank you all for being here today.
    As our witnesses should know, spoken testimony is limited 
to five minutes each. After all witnesses have spoken, members 
of the Committee will have five minutes each to ask questions.
    I now recognize our first witness Dr. Mostashari for five 
minutes.

              STATEMENT OF DR. FARZAD MOSTASHARI,

          NATIONAL COORDINATOR FOR HEALTH INFORMATION

       TECHNOLOGY, THE OFFICE OF THE NATIONAL COORDINATOR

               FOR HEALTH INFORMATION TECHNOLOGY

    Dr. Mostashari. Chairman Quayle, Ranking Member Clarke, 
distinguished Subcommittee Members, thank you for the 
opportunity to appear today on behalf of the Department of 
Health and Human Services. I am Dr. Farzad Mostashari. I am the 
National Coordinator for Health IT.
    I am delighted to be here today to tell you about the 
remarkable progress in health IT the country has made in the 
relatively short time since HITECH's passage. Under HITECH, 
eligible professionals and hospitals can qualify for incentive 
payments from the Centers for Medicare and Medicaid Services 
when they adopt and meaningfully use certified EHR technology 
as defined by ONC certification criteria and interoperability 
standards.
    HITECH also funded a number of other supporting activities, 
such as 17 beacon communities, community college and 
university-based workforce programs, and 62 regional extension 
centers that provide hands-on technical assistance to providers 
and hospitals transitioning away from paper.
    HITECH is working. Between 2008 and 2011, the percentage of 
office-based physicians adopting the EHR system has doubled, 
and hospital adoption leaped almost threefold. As of September 
2012, more than 300,000, or more than half of the Nation's 
eligible professionals, as well as over 75 percent of eligible 
hospitals have registered to participate in the incentive 
programs. More than 154,000 eligible professionals and 3,000 
hospitals have earned their first incentive payment.
    Achieving meaningful use is meant to be hard, but 
achievable. We need to strike a balance between the urgency of 
modernizing our healthcare system and the pace of change that 
can be absorbed by providers and IT vendors. Each stage of 
meaningful use is designed to build increased functionality and 
interoperability to improve patient care, enhance care 
coordination in population health, increase patient and family 
engagement, and protect patient privacy and security.
    Recognizing that health IT is a complex and quickly 
evolving field, HITECH established two Federal Advisory 
Committees. The HIT Policy Committee Members are appointed by 
the Comptroller General, the Secretary of Health and Human 
Services, the Majority and Minority Leaders of the Senate, and 
the Speaker and Minority Leader of the House of 
Representatives. The HIT Standards Committee includes 
providers, consumers, health plans, vendors, researchers, and 
other stakeholders.
    As HHS develops the rules for the incentive program, we 
fully engage experts in the field, listening to both our 
private- and public-sector stakeholders and actively soliciting 
input through many mechanisms, including through the thousands 
of comments received and reviewed in response to our Notices of 
Proposed Rulemaking. One of the key messages we have heard time 
and time again is that successful health IT implementation 
relies on a predictable roadmap and adequate time.
    In 2009, when we were drafting the initial set of 
meaningful use criteria and required standards, our plans 
necessarily responded to the reality we faced. Different vendor 
products used different proprietary or local codes. There were 
strong disagreements about how laboratory results or patient 
summaries should be packaged. There was simply no consensus on 
how the Internet could be used to securely send patient 
information. So we took initial steps that put us on the road 
to interoperability and focused Stage 1 on functionalities that 
support the consistent electronic capture of data and its 
effective use within practices.
    Over the past two years, we worked with industry to 
accelerate the painstaking work of building consensus on these 
technical standards that were required. We provided an open, 
trusted place where the diverse health IT community can come 
together to work, developing and harmonizing the standards and 
specifications they need to support interoperability.
    Nearly 1,000 people, representing over 300 diverse 
organizations, have participated in 1 of more than 10 priority 
initiatives. As a result the Stage 2 rules, set to take effect 
for hospitals in October 2013 and for eligible professionals in 
January 2014, make substantial progress on standards-based care 
coordination and health information exchange. For the first 
time there is defined a common dataset to be sent securely 
during transitions of care, upon hospital discharge, and to be 
shared with the patients themselves. It is worth emphasizing 
that patients will have the ability to securely access this 
same information, download it or share it electronically with 
other providers and caregivers as the need arises.
    Our good colleagues at NIST continue to play a key role in 
supporting the design, implementation, and maturation of the 
ONC HIT Certification Program, including the accreditation of 
testing laboratories and the test procedures and testing tools 
and infrastructure used by them. ONC is working with NIST to 
develop an interoperability testing platform for Stage 2 that 
will rigorously test that the EHR technology can indeed send, 
receive, and incorporate standardized data across vendor 
boundaries. Any EHR technology that meets the demanding testing 
requirements should be able to send and receive standardized 
information with other certified EHRs.
    In conclusion, our progress on the road to interoperability 
has been steadfast. Working in an open and transparent process, 
HHS has developed the meaningful use roadmap in stages to serve 
as milestones toward the future. Stage 1 focused on gathering 
structured data and basic EHR functionalities, including 
privacy and security protections. With Stage 2, HHS is working 
to improve care coordination and increase standards-based 
health information exchange between providers and with 
patients.
    We anticipate that future rules will continue to advance 
health IT capability and interoperability as the foundation for 
better health and better care at lower cost. We look forward to 
continuing to work with you to accomplish these goals, and I 
would be happy to answer any questions you may have regarding 
my testimony.
    Chairman Quayle. Thank you very much.
    [The prepared statement of Dr. Mostashari follows:]

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    Chairman Quayle. I now recognize Dr. Romine to present his 
testimony.

              STATEMENT OF DR. CHARLES H. ROMINE,

          DIRECTOR, INFORMATION TECHNOLOGY LABORATORY,

         NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

    Dr. Romine. Chairman Quayle and Members of the 
Subcommittee, I am Chuck Romine, Director of the Information 
Technology Laboratory at the Department of Commerce's National 
Institute of Standards and Technology. Thank you for the 
opportunity to appear before you today to discuss our roles in 
advancing the Administration's commitment to enabling 
electronic health records and developing a nationwide health 
information network that is reliable, usable, interoperable, 
and secure.
    NIST has been hard at work fulfilling the mandate of making 
our Nation's healthcare system safer, more accessible, and more 
affordable through the use of information technology. This 
objective remains a priority for the Department of Commerce and 
the Acting Secretary. Reaching our common goal of interoperable 
EHRs will improve health care for all Americans.
    Through direction in HITECH, NIST and ONC are collaborating 
with industry, healthcare informatics-related standards 
organizations, consortia, and government agencies to develop 
consensus-based, complete and unambiguous standards, and to 
build tools and prototypes to advance the adoption of IT in 
health care. For future stages of meaningful use, NIST is 
providing technical leadership in evolving standards for 
interoperable EHRs as well as medical devices, genomics, 
imaging, and text retrieval and analysis.
    The Medicare and Medicaid EHR incentive programs are 
successfully increasing the rate of adoption of health IT, thus 
enabling the achievement of health and efficiency goals. The 
program is designed in a staged approach, with each stage 
providing more rigor in what is expected in a certified product 
and in meaningful use. Stage 1 standards and criteria, for 
example, set a baseline for electronic data capture and 
information sharing and were specifically selected to be 
achievable by the Nation's providers. Stage 2 takes the next 
step by reducing the optionality found in Stage 1 and includes 
new standards, including those for electronic health 
information exchange between providers.
    To support these changes, the 2014 edition EHR 
certification criteria included new or updated requirements for 
security, usability or safety-enhanced design, and 
interoperability.
    Each stage of meaningful use advances interoperability. 
NIST has developed a conformance test tool that will be used 
for the certification and testing program for the 2014 
standards and certification criteria that will also be an 
initial tool in a test bed that simulates exchange between a 
test EHR technology and a standards-compliant EHR technology. 
This will eventually allow for all levels of interoperability 
to be assessed in the electronic exchange of transition-of-care 
and referral summaries. This capability will also provide a 
platform for testing more comprehensive forms of 
interoperability between EHR technologies.
    The HITECH Act calls for ONC, in consultation with NIST, to 
recognize a program for the voluntary certification of health 
IT as being in compliance with certification criteria for EHR 
technology that can support meaningful use requirements. Under 
this program testing organizations authorized by ONC, use the 
NIST test methods and tools to evaluate EHR systems so 
healthcare providers have confidence in the systems they 
purchase. NIST's National Voluntary Laboratory Accreditation 
Program has been acknowledged by ONC in regulation, as the 
accreditation body for private-sector labs that perform the 
testing.
    Some lessons learned about why these programs are 
succeeding and have received positive feedback from all sectors 
of the healthcare enterprise, including clinicians, consumers, 
developers, standards develop organizations and others: 
following a staged approach, allowing vendors and providers 
adequate time to transition to more advanced health IT; 
engaging the community throughout the process; relying on a 
consensus-based standards-development process that actively 
engages industry; soliciting and incorporating broad public 
comment; engaging the Federal Advisory Committees; and 
transparency in the process. We will continue to be guided by 
these lessons learned and are prepared to meet the challenges 
as each stage becomes more rigorous in its requirements.
    In addition to its collaborations on standards, testing, 
security, usability, interoperability, and certification for 
meaningful use, NIST's cutting-edge research, advanced 
measurement science, and participation in standards development 
are building the infrastructure for a future that offers even 
more promise for emerging healthcare breakthroughs in the 
United States.
    NIST initiatives are examining the best ways for humans to 
interact with next-generation health IT. They are significantly 
improving medical device interoperability and making health 
care safer in the process. NIST researchers are exploring 
innovative techniques by which critical patient diagnostic and 
treatment information can be collected and transmitted 
continuously in a safe and secure manner, which addresses 
patient privacy concerns.
    NIST is pleased to contribute to making our exciting vision 
of health IT a reality. Thank you for the opportunity to 
testify today on NIST's activities in health IT, and I would be 
happy to answer any questions you may have.
    Chairman Quayle. Thank you very much.
    [The prepared statement of Dr. Romine follows:]

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    Chairman Quayle. I now recognize Mr. Probst for five 
minutes.

                 STATEMENT OF MR. MARC PROBST,

         CHIEF INFORMATION OFFICER AND VICE PRESIDENT,

         INFORMATION SYSTEMS, INTERMOUNTAIN HEALTHCARE

    Mr. Probst. Chairman Quayle, distinguished Committee 
Members, thank you for inviting me to testify today. My name is 
Marc Probst. I am the Chief Information Officer at 
Intermountain Healthcare, a nonprofit, integrated health system 
in Salt Lake City, Utah. I am also an appointed member of the 
Health Information Technology Policy Committee.
    Nationally, Intermountain is known for providing high-
quality care at sustainable costs. One way we achieve this is 
by identifying best clinical practices and applying them 
consistently. Research reviewed by Dr. John Wennberg of 
Dartmouth showed that Intermountain is the best model in the 
country of how you can actually change health care for the 
better. Dartmouth estimated that if health care were delivered 
nationally in the way it is provided at Intermountain, the 
Nation could reduce healthcare spending for acute and chronic 
illnesses by more than 40 percent.
    Absolutely essential to Intermountain's ability to deliver 
high-value, coordinated patient care is the effective use of 
information technology.
    As requested by the Subcommittee, I will address the 
question, has progress been made as a result of the HITECH Act 
towards greater health information technology interoperability? 
My answer is yes. Progress has been made, but it is only a 
beginning. We must commit ourselves as a Nation to set a clear 
roadmap and support an exchange infrastructure and the adoption 
of standards that will make it easier to share health 
information so clinicians and patients have the information in 
the form and at the time they need it to make appropriate 
healthcare decisions.
    The Australian railroad provides a useful example of the 
importance of standards. In Australia, railroads developed 
independently, one by one. While trains and tracks did get 
built, the railroad system was constructed with many different 
gauges of rail, preventing railroad cars on one set of tracks 
from running on others. After many years of subpar train 
service, expensive workarounds, and increasing costs, Australia 
defined a standard gauge system. The process of standardizing 
the gauges was expensive and disruptive, but efficiencies 
continue to be realized today for those decisions.
    There are parallels between the Australian railroad 
experience and America's HIT experience. On the HIT Policy 
Committee, work began almost immediately, and requirements were 
created with the goal to increase the meaningful use of EHRs 
across the country. The vast majority of these meaningful use 
requirements deal with functions that any EHR should be able to 
perform and requirements for what functions or data should be 
shared between EHRs.
    The existing HIT systems, be they vendor-developed or self-
developed, also were built one by one and applied differing 
standards. Although very effective for each institution, 
heroics are required to share even basic data between them. 
Applying standards is really hard. This is why we now 
essentially have our own Australian railroad, and fixing it 
will require leadership and investment.
    Numerous market-driven and private efforts have recognized 
the value of standards, and significant funds and efforts have 
been applied toward defining standards. Clearly there are 
examples of open markets which have achieved a set of standards 
that have yielded tremendous benefits to the citizens of our 
country, such as the financial industry and ATMs. However, 
health care is more complex than financial transactions. The 
vast quantity of data and the requirements for painstaking 
accuracy set health care apart. Further contributing to the 
complexity surrounding health data is both the overlay of 
regulations and the absolute need for privacy of health data. I 
simply do not believe that the current voluntary approaches to 
standard definition work.
    In my opinion, what is needed is a mandate to: one, define 
the set of information system-related standards which will be 
applied to health care; two, ensure accountability to 
appropriately develop and document these standards; three, set 
a time frame in which to define and document the standards 
measured in months, not years; and, four, establish a realistic 
time frame in which the HIT community must adopt a federally 
supported set of standards, say 10 to 15 years.
    I realize this is a long time, but like the Australian 
railroad analogy, there is much infrastructure to be aligned, 
and we cannot stop providing health care or HIT services during 
the transition. In this way, we will achieve a nationwide 
health information technology infrastructure as called for in 
ARRA.
    In conclusion, I believe that with true leadership and a 
commitment for long-range planning and support for transitions, 
appropriate standards and exchange infrastructure can be 
defined and implemented. If this is done, innovation in HIT 
will skyrocket, health-related data will be more secure, costs 
for technology and access to knowledge will be significantly 
reduced, and quality care across the country will be improved. 
If this is done, all ships can rise.
    I look forward to working with you to achieving these goals 
and would be pleased to answer any questions you may have.
    Chairman Quayle. Thank you very much.
    [The prepared statement of Mr. Probst follows:]

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    Chairman Quayle. I now recognize Ms. Little for her 
testimony.

    STATEMENT OF MS. REBECCA LITTLE, SENIOR VICE PRESIDENT, 
                            MEDICITY

    Ms. Little. Good morning, Chairman Quayle and Members of 
the Subcommittee. Thank you for inviting me to participate in 
today's discussion. My name is Rebecca Little, and I am here on 
behalf of Medicity, a health information exchange, commonly 
referred to as an HIE technology company, headquartered in Salt 
Lake City, Utah. Medicity is a wholly owned subsidiary of 
Aetna.
    The software Medicity provides facilitates health 
information exchange. What that means is we supply the 
plumbing--the intelligent plumbing rather--that allows 
electronic medical records, electronic health records, lab 
services, pharmacies, hospitals, doctors' offices, and other 
providers to connect to one another.
    To continue with the metaphor, it doesn't matter what 
electronic medical record or fixture a provider uses, whether a 
provider is using health information technology for the first 
time or has been using it for years. We can accommodate their 
needs at any state of readiness or sophistication. The Medicity 
HIE plumbing can connect any type of fixture to another so that 
health information and patient data can be safely and securely 
transmitted.
    This matters to you as policy makers because Medicare and 
Medicaid costs are unnecessarily greater when the lack of 
information leads to bad outcomes or repetitive testing and 
procedures. The results can translate directly into lower 
healthcare costs. Improved use of diabetes medicine can cut 
risk of hospitalization by half. Diabetics who take their 
medicine less than 80 percent of the time were 2-1/2 times more 
likely to be hospitalized for a diabetes or cardiovascular-
related condition in the next year. In total, poor adherence 
results in 33 to 69 percent of medication-related 
hospitalizations at a cost of roughly $100 billion per year. 
These are costs that are absorbed by taxpayers in Medicare and 
Medicaid and cannot be addressed effectively without robust 
patient information. This is why interoperability across 
providers is so important.
    Our plumbing is truly interoperable, allowing for the safe 
exchange of patient information across public and private HIEs, 
across multiple provider systems, between small and large 
physician practices, and across and within hospital systems.
    True HIE interoperability, the seamless flow of patient 
data in a secure framework, is the necessary ingredient to 
transforming patient care and creating a more effective, 
efficient, and ultimately less costly healthcare system, 
because once the electronic connections are established across 
providers and networks, and the patient data begins to flow, 
other health information technologies can be put to work to 
turn that data into useful information for physicians and 
patients, saving lives, reducing medical errors, and 
substantially lowering costs.
    These successes are happening today. A recent Health 
Affairs article demonstrated the success of a Medicare 
Advantage pilot in Maine where the provider collaboration 
relied on shared patient data in conjunction with patient 
coordination. The result of using patient data to improve 
patient outcomes and lower costs could not be clearer.
    The result of the study of the population had a 50 percent 
fewer hospital days, 45 percent fewer admissions, and the 
corresponding costs were 16-1/2 to 33 percent lower than costs 
for patients not included in this pilot, but these types of 
successes could not be achieved without robust standards for 
interoperability and data sharing.
    Even though health information exchange is a requirement 
for demonstrating meaningful use under the HITECH Act, health 
information exchange is really about preparing providers and 
healthcare organizations for the future of health care as 
delivery models and reimbursement constructs continuously 
evolve. This exchange of health information across providers, 
hospital networks, between different HIEs holds the power to 
improve care and improve efficiency by fostering care 
collaboration and lowering administrative costs. We are already 
seeing encouraging outcomes of how patient data can be turned 
into actionable information for physicians to use--to improve 
clinical outcomes for patients.
    The rest of my written testimony provides examples around 
how Medicity and Aetna are meeting providers at their stage of 
readiness to employ cost-effective technology solutions that 
will drive towards efficient, low-cost, high-quality patient 
care.
    Thank you again for the opportunity to testify in front of 
you.
    Chairman Quayle. Thank you very much.
    [The prepared statement of Ms. Little follows:]

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    Chairman Quayle. I now recognize Dr. Fields to present her 
testimony.

                 STATEMENT OF DR. WILLA FIELDS,

                  DNSC, RN, FHIMSS, PROFESSOR,

         SCHOOL OF NURSING, SAN DIEGO STATE UNIVERSITY

    Dr. Fields. Chairman Quayle, Members of the Subcommittee, 
thank you for the opportunity--whoops, excuse me. I knew that.
    Chairman Quayle, Members of the Subcommittee, thank you for 
the opportunity to testify before you today. I am Willa Fields, 
a professor in the School of Nursing at San Diego State 
University in San Diego, California. Additionally, I was 
honored to be selected as the Chair of the Board of Directors 
of HIMSS, the Healthcare Information and Management Systems 
Society, as of July 1st this year.
    I am honored to have the opportunity to provide you the 
perspective of HIMSS as well as my own on the status of health 
information technology adoption, some of the challenges we 
still face as a Nation, and recommendations on selected issues 
requiring Congressional attention in the coming years.
    HIMSS is a cause-based, not-for-profit association 
exclusively focused on providing global leadership for the 
optimal use of health information technology for the betterment 
of health care. Founded 52 years ago, HIMSS is headquartered in 
Chicago, with additional offices in the United States, Europe, 
and Asia. We represent 50,000 individual members, of which more 
than 2/3 work in provider, government, and not-for-profit 
organizations. We also have 570 corporate members and more than 
225 not-for-profit organizations that share our mission.
    As you recognize, health IT is an essential foundational 
element of any meaningful transformation of the Nation's 
healthcare delivery system. Robust nationwide adoption of 
health IT, including electronic health records, health 
information exchange capabilities, and mobile health devices, 
all of these are essential to achieving safe, effective care 
delivery, payment reforms, and engaging patients in their care. 
Health IT also enables timely, accurate, and appropriate 
collection and dissemination of patient information in a 
private and secure manner.
    While there is still much work to be done, adoption of 
interoperable health IT systems continues to expand thanks to 
the incentives provided by the HITECH Act. We are only two 
years into the program, and there has been a great shift toward 
electronic health records throughout the Nation.
    HIMSS Analytics has performed a cross-reference of 
hospitals achieving Stage 1 meaningful use against their scores 
on the Electronic Medical Records Adoption Model, or EMRAM, 
which is a HIMSS analytic tool to track U.S. civilian hospitals 
on their progress toward a mature, paperless, electronic 
environment. The results demonstrate that hospitals are rapidly 
evolving to higher stages on the EMRAM scale. Such results are 
clear indicators that government incentives are achieving their 
mission at accelerating the widespread implementation and 
meaningful use of certified electronic health records in the 
United States. More importantly, the top-ranked EMRAM Stage six 
and seven hospitals reflect the rapidly escalating move of 
United States hospitals toward interoperability, which will 
lead to information exchange. The EMRAM system and its findings 
are explained further in my written statement.
    The evidence, including data from the Centers for Medicare 
and Medicaid Services, the Centers for Disease Control and 
Prevention, and HIMSS Analytics suggests that as a result of 
the HITECH Act and the substantial investment the public and 
private sectors have made, a groundswell has been achieved in 
the adoption of health IT and specifically electronic health 
records.
    We believe the time is very near when informed patients 
will use adoption and meaningful use of health IT as a key 
factor in selecting a caregiver and a care setting because of 
the opportunities these systems provide for access to 
information. Without the HITECH-authorized meaningful use of 
Electronic Health Record Incentive Program, the Nation would 
not be realizing adoption and implementation of these systems, 
which includes the rapidly expanding ability to exchange 
information privately and securely across systems and regions.
    HIMSS strongly encourages the continued bipartisan support 
of Congress for the earliest nationwide adoption and 
implementation of electronic health records and the Meaningful 
Use Program.
    In conclusion, in order to improve the quality of health 
care for all Americans, while also controlling costs, HIMSS 
recommends seven strategies for Congress: One, continue your 
strong bipartisan support for the adoption and meaningful use 
of electronic health records; two, continue to support and 
sustain the Meaningful Use Electronic Health Records Incentive 
Program; third, direct the Administration to initiate 
collaboration with the private sector on an appropriate study 
of patient data matching and the adoption of a nationwide 
patient data-matching strategy; fourth, support harmonization 
of Federal and State privacy laws and regulations to encourage 
the exchange of health information across systems, payers, and 
vendors; continue to support programs and services to educate 
providers and provider organizations on how health IT can and 
should be used to engage patients in their health care; 
continue to support and sponsor pilot programs addressing the 
collection, analysis, and management of clinical data and 
quality for reporting purposes; and, seven, preclude any 
additional delay in the nationwide implementation of ICD-10, 
the International Classification of Diseases that is set to be 
implemented October 1, 2014.
    Let me reiterate, electronic health record adoption and 
implementation has passed the tipping point in America. The 
evidence, including HIMSS' own analysis, indicates continued 
process--I am sorry, continued progress on the implementation 
of health-information technologies. My written statement citing 
evidence of these upward trends in health IT adoption and 
discussing the rationale for these recommendations in more 
depth--in more depth has been provided for the record.
    Clearly the Nation would not have made the significant 
progress toward electronic health record adoption and health 
information exchange that it has without the Meaningful Use 
Program authorized by the HITECH Act. Perhaps in many years 
health care might have caught up with other industries in the 
adoption in information technology, but in the meantime quality 
of care and access to care have continued--would have continued 
to suffer, and the Nation would have continued to pay much more 
for health care than necessary.
    There is more work to be done, especially in 
interoperability, health information exchange, privacy, and 
security. HIMSS recommends that in order to improve the quality 
of your constituents' health care while also reducing its 
costs, Congress should continue its strong bipartisan support 
for health information technology. I and my 50,000 professional 
colleagues stand ready to work with Congress and the 
Administration.
    Thank you for the opportunity to speak with you today, and 
I would be happy to answer your questions.
    Chairman Quayle. Thank you very much.
    [The prepared statement of Dr. Fields follows:]

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    Chairman Quayle. And I want to thank all the witnesses for 
their testimonies.
    Reminding Members that Committee rules limit questioning to 
five minutes, the Chair will at this point open the round of 
questioning, and I recognize myself for five minutes.
    Dr. Mostashari, I want to start with you. One of the 
things--I had a lot of inquiries and comments from constituents 
leading up to this hearing about the meaningful use 
requirements and how they might not be applicable to their 
practice. They were more specialists in different fields, and 
Stage 2 provided a temporary hardship exemption. But we need to 
ensure that the criteria is going to be applicable for these 
types of physicians, and so my question is, is it appropriate 
to have the same core and menu requirements for different types 
of physicians? Are there steps that the Administration is 
taking to ensure that the requirements take into consideration 
the unique nature of different medical fields and practices? 
Because what I have been hearing is that the various meaningful 
use requirements in different specialties do not match up, make 
it more difficult for them to actually fulfill these 
requirements, and then if they are going to be punished for not 
actually doing this, it is going to have a detrimental effect 
on their own practices.
    Dr. Mostashari. That is an issue that we have been working 
on with stakeholders in the Policy Committee for the past two 
years. The Stage 1 rules did set in place a kind of common 
infrastructure and common core set. So the assumption was that 
if we are going to be able to exchange information, there 
should be a common set of information around medical diagnoses, 
or smoking status, or blood pressure. And we heard a lot, and 
since the implementation of Stage 1, that that may not be 
relevant; this is a national program, and it may not be 
relevant for all practices.
    So the challenge is how do we get to a place where there 
is, for the things that really--at the planning level, the 
things that really we want interoperability on, we get that 
sort of interoperability across all practices, and yet allow 
for the differences in practice and what is relevant to 
different specialists.
    In Stage 2 we made a number of accommodations to that 
reality. So we, for example, provided guidance and in the rule 
said if it is really not--if collecting blood pressure is not 
relevant to your practice, you are a pathologist, then you can 
have an exclusion from that requirement.
    And we also heard from Stage 1 that many of the quality 
measures were--the ones that were available at the time were 
not relevant to all specialists. So for Stage 2 we said, okay, 
you don't have to report on the quality measure for smoking if 
that is really not relevant to your practice, although it is 
hard to imagine; you know, there is not that many practices for 
whom smoking status is not relevant, but----
    Chairman Quayle. So will all these kind of kinks be ironed 
out prior to the temporary reprieve where people will start 
getting penalized for not actually complying with this when in 
certain specialties smoking would not be extraordinarily 
useful? So will that all get ironed out? That is one of the big 
things that I am trying--those will get ironed out before the 
penalties will be put into place?
    Dr. Mostashari. So all of the flexibilities that I 
mentioned, there are many more, are part of Stage 2, which is 
going to be in effect before the penalties.
    Chairman Quayle. Okay. Okay, great. Thank you very much.
    And Mr. Probst, I want to get to your testimony, because in 
your testimony you stated that, you know, voluntary 
consistent--consensus-built standards don't work within the 
healthcare industry. And in previous hearings, you know, we 
have had NIST here a lot, and that was one of the main things 
with NIST--is it is very consensus driven with the 
stakeholders, and it has worked very well.
    Why do you not think in the healthcare industry that that 
is the best way to go and instead come up with a set of 
standards from basically kind of more of a top-down approach 
rather than the voluntary consensus? I just want to get your 
take on that.
    Mr. Probst. Well, I think the very fact that we are having 
this conversation suggests that it hasn't worked. They have 
been doing it for a long time. And that is not to slam HL7 or 
DICOM or any of the groups that have been working towards 
standards. There are varying incentives in those groups. The 
people that formed those groups have different rationales for 
why they want standards or what standards they might like.
    But, again, I think the fact that we haven't come to some 
basic standards, like the gauge of rail that they did in 
Australia, we are dealing with all the discussions around 
health information exchange, what kind of contraptions can we 
put together to move data from one system to another that loses 
fidelity and costs time. So I just think history is a good 
educator for the future, and I don't see how we are going to 
get to standards without some direction on some basic core 
standards.
    Chairman Quayle. If we are going to have that direction, 
how, in your estimation, do we set those standards so that we 
can still have the flexibility for technological innovation 
going forward, since that seems to be--from past testimony on 
the consensus building, that seems to be where we have had some 
really good innovation? But in the way that you are kind of 
seeing this in the outlook, how do we leave that flexibility in 
place so that the innovation can continue to progress?
    Mr. Probst. I think what we don't want is standards that 
suggest everything that we have to do. But we do need 
standards, and I listed several of them in my written 
testimony, basic core foundational IT standards toput in place. 
If those are put in place, then innovation happens. Then you 
have Internet kind of innovation that can occur ubiquitously 
across large groups of people. So that is the gist of my 
testimony.
    Chairman Quayle. So you basically--you put the trunk, and 
then the tree--you know, the limbs of that trunk can go up, and 
that is where the innovation would be able to take place, 
something--I mean, to use a----
    Mr. Probst. Exactly, if you get the foundation in place.
    Chairman Quayle. The foundation. Okay, great. Thank you 
very much.
    I now recognize the gentleman from New Mexico Mr. Lujan for 
five minutes.
    Mr. Lujan. Thank you. I yield to Mr. Clarke.
    Mr. Clarke. Thank you, Mr. Lujan, for yielding me time.
    In order to implement these health information technologies 
and to operate them on a day-to-day basis, you need an adequate 
workforce. I represent the City of Detroit, the metro Detroit 
area. We have very high unemployment, but also we have got some 
great hospital systems. The potential for job growth in that 
region and also nationally, because of the complexity of our 
healthcare delivery system and the growing number of people who 
need health care--we are going to need a lot of people in this 
workforce area. An interoperable health IT system will create 
jobs.
    The HITECH Act directed your Office, the Office of National 
Coordinator, to establish education programs, which I think is 
great. Now, one thing that causes me concern, though, is this 
eHealth Initiative survey that indicates that nearly a quarter 
of the health information exchanges are not hiring students 
from ONC-funded workforce development programs.
    You know, Dr. Mostashari, or anyone who would like to 
comment on that, I mean, is this survey accurate? Is there some 
fundamental basis for concern about the adequacy of the 
training programs that your office is funding? And if that is 
the case, what can we do to correct that? My assumption is that 
this is a whole new industry that can be created that could 
transform our entire workforce nationally and even 
internationally. How can we get people prepared to operate 
these health IT systems?
    Dr. Mostashari. Your concern is very well put. There is 
going to be a lot of jobs in--and there are a lot of job 
openings, huge increases in job openings, for skilled health IT 
workforce, even as we have many students and others who would 
wish to fill those jobs. So to meet that we have established a 
curriculum that is openly available, we have created a 
competency exam working with AHIMA, we have funded university-
based training slots as well as 81 community colleges that have 
graduated over 15,000 students to meet the expected need of 
50,000--a shortage of 50,000 jobs in health care IT.
    As you say, one of the things we have learned is if you 
don't have experience in health care, it is hard to get into 
health care IT and get a job. So one of the things we are 
working with, for example, in Ohio at the community college 
there is working with a hospital association to have 
internships and placements and apprenticeships. Those are, I 
think, some of the answer to meeting--making these two sides 
connect up with each other.
    Mr. Clarke. Thank you, Doctor.
    Anybody like to comment on this?
    Dr. Fields. I actually would----
    Mr. Clarke. Dr. Fields?
    Dr. Fields. Thank you.
    I would like to expand on the program through ONC. I 
personally use some of the slides that have been posted to 
teach my students, graduate students in informatics in nursing. 
So what that says-- you don't capture that in your numbers of 
the benefits. So I am using the materials that ONC has funded 
through work done by others. I then have up-to-date information 
that I can incorporate into my classes, which makes the 
graduate students in nursing more capable of taking these 
complex HIE jobs. And then when they move into the health care 
IT positions, it opens up less experienced types of positions, 
which the survey that you quoted in the information, Dr. 
Mostashari, that you talked about, this information, these data 
don't get captured.
    Mr. Clarke. Thank you, Dr. Fields.
    And I yield the balance of my time to the gentleman from 
New Mexico, Mr. Lujan.
    Mr. Lujan. Thank you very much, Mr. Clarke.
    A lot of conversation as to what we need to get done here 
with the implementation of this, and I think in the end what we 
can all certainly agree on is that we all want to make sure 
that we have more consistent treatment, better outcomes, cost-
saving measures as well.
    And with the limited time that I have left, one thing I 
just want to point out is as we implement medical records, and 
we hopefully will find a way to do this as effectively and 
efficiently as possible, the importance of partnerships between 
the Federal Government, local governments, and private entities 
to be able to implement this, the importance of standards.
    And I just want to highlight one project that has come out 
of New Mexico. It is Project ECHOTM, which is the Extension for 
Community Health Care Outcomes, led by Dr. Sanjeev Arora out of 
the University of New Mexico Hospital, who are now partnering 
with the VA as well, a program dependent on the implementation 
of distance medicine, and we are seeing huge, huge benefits and 
positive outcomes there. So I look forward to talking about 
that a little bit more throughout this hearing and getting your 
perspective on that.
    Thank you, Mr. Chairman, and with that I yield back.
    Chairman Quayle. Thank you very much.
    I now recognize the gentleman from Illinois, Mr. Hultgren, 
for five minutes.
    Mr. Hultgren. Thank you, Mr. Chairman. Thank you all very 
much.
    A question for all of you. Interoperability--I can't speak 
this morning--is critical to realizing the many potential 
benefits for health information technology. So far the Federal 
Government, I know, has spent approximately $2 billion in 
appropriated funds for HIT infrastructure and $7 billion in 
mandatory incentive payments for HIT adoption. Wondered if each 
of you could give thoughts, given this investment, have we made 
appropriate progress on interoperability, and why have we or 
why have we not made the progress that you all think we should?
    Dr. Mostashari. I believe that we have made substantial 
progress on both the adoption and the meaningful use of 
electronic health records, which includes the interoperability. 
And this is a long road. As Marc pointed out, these are 
complex. It is much more complex than saying 4 feet, 8-1/2 
inches should be the width of the railway gauge, which the U.S. 
Congress did in 1853.
    These are quite complex, but I think we have a roadmap, and 
we have, through meaningful use, a phased approach to being 
able to bring the whole country, bring the floor up and create 
that infrastructure in stage after stage after stage to help 
increase that journey towards interoperability.
    Dr. Romine. I would certainly like to agree with my good 
friend and colleague Dr. Mostashari about this. I think we have 
made substantial progress. NIST has a long history of working 
on both conformity assessment and also interoperability, and I 
think the steps that we are taking, and particularly the 
emphasis on this phased approach that allows us to sort of 
bring the community along in an aggressive but achievable 
manner, is absolutely essential to doing this.
    Mr. Probst. Yes, I believe meaningful use has made good 
progress forward toward the exchange of information and the 
ability to use it, you know, between organizations. Although it 
was 4 feet, 8 inches for the rail gauges, and that is pretty 
simple, this is incredibly complex, and therefore 
interoperability is way more complex than the rail system, and 
it needs to be taken care of.
    So I agree with what we are doing around meaningful use 
because we have an infrastructure we need to leverage and we 
are providing better care, I believe, because of the efforts 
that are happening. But I still would stand on the fact we need 
to divine a--define--maybe divine, but define a core set of 
standards that would allow for true interoperability, because 
the way we are saying interoperability right now, what is 
really happening is information exchange. Interoperability, to 
me, is far deeper, with a far greater capability to save lives 
and money.
    Ms. Little. We would also agree that substantial progress 
has been made, and we certainly agree that meaningful use Stage 
1 began the proliferation of adoption of electronic health 
records, and without robust standards for interoperability, the 
spread of electronic health records will be stifled or limited.
    We encourage HHS to adopt standards that would support the 
clinical needs of coordinated care, such as requirements for 
accountable care organizations, medical homes, and hospital 
readmission programs.
    Lastly, I would observe that occasionally Federal programs 
and program rules are not aligned. Providers must comply with 
different standards for different programs, which make them 
less attractive. We are pleased to see HHS proposing alignment 
of rules across meaningful use, accountable care organizations, 
physician quality reporting, and medical homes.
    Dr. Fields. And, yes, I am going to agree also, but with 
that I am going to tell you some data that I personally 
collected on a research study at a hospital in San Diego.
    So I look at interoperability not only across 
organizations, but within organizations, and this particular 
hospital had been digital for decades. The emergency department 
had one system, critical care had one system, women services 
had another, pharmacy was on another, and on and on and on. And 
so this is--yes, it was the railroad gauge absolutely. So each 
group of practitioners had the best system for them, but they 
couldn't share easily information across systems.
    We implemented an integrated--I wouldn't call it 
interoperable because it doesn't go across organizations except 
within our healthcare system. And in this research study when I 
surveyed the nurses on the use of the system before we went 
live with the integrated one and then one year after 
implementation with the one system or with the sharing of the 
information, that they clearly were using the new system much 
more. They were accessing it for information, for patient data, 
for patient engagement.
    I then interviewed the nurses one year after to find out 
what did the transition go like, how was the system, what were 
the changes they found, and without a doubt the nurses 
resoundingly said that they were able to provide better care 
because they had all of the information in front of them. They 
had the emergency department information in front of them. With 
the click of a button, they would be able to look up past 
hospitalizations.
    So we have improved care in this one organization where 
they can look at the physician office patient episode, they can 
look at previous hospitalizations, they can look at the 
information from throughout that hospitalization, yet if that 
same patient goes to another hospital within our community, 
that information is not available.
    But I will also compliment ONC because San Diego is 
fortunate enough to be one of the beacon communities, and so 
money has been invested so that in San Diego we can have that 
same type of sharing of information not only within Sharp 
Healthcare, but we can have it throughout San Diego.
    Mr. Hultgren. Thanks. I see my time has expired. I yield 
back. Thank you.
    Chairman Quayle. Thank you very much.
    I now recognize the Ranking Member, the gentlelady from 
Maryland, Ms. Edwards, for five minutes.
    Ms. Edwards. Thank you, Mr. Chairman, and I want to thank 
my colleague Mr. Clarke for sitting in for me today, I really 
appreciate that. And Mr. Chairman, thank you as well for your 
service. We have had some great hearings in this Subcommittee, 
and I really do appreciate your leadership.
    To our witnesses today just a couple of questions. Dr. 
Mostashari, in your testimony you indicate that any rulemaking 
includes some compromises between the aspirational goals we 
want to achieve and the reality of where the market is, really 
important questions for us today. And I wonder if you could 
elaborate on that and additionally what the impact on small or 
rural practices is if the expectations of meaningful use are 
set too high.
    Even in my own State of Maryland, we are a small state, 5.5 
million people, a lot of people live in our metropolitan areas, 
but a lot of folks don't. And so even in a small State you 
could have a two-tier system if we are not really careful about 
this.
    Dr. Mostashari. Thank you, Ranking Member Edwards, for the 
question. It is absolutely true that one of the fundamental 
challenges we face in setting the meaningful use policy is this 
is an escalator that we want people to get on and continue to 
advance through the different stages. How fast up that 
escalator can we push? What is the rise and the run so that 
people don't fall off the escalator? Because we could set the 
standards very, very high, and, you know, only a few 
institutions, signal institutions, across the country would be 
able to qualify for those standards, and we would not have 
succeeded in improving health and health care for all 
Americans. So it becomes really important for us to not set 
them so low that we are not changing the intrinsic capabilities 
and interoperability of the systems, but not set them so high 
that only a few can participate as well.
    The issue around the rural providers and small practices 
are particularly important because historically those have been 
the kinds of providers who haven't had the resources to 
implement health IT effectively, and they have consequently the 
lowest rates of adoption of EHRs. So when we took our Regional 
Extension Center Program funded through HITECH, we said focus 
on the small practices, focus on the primary care providers, 
focus on the critical access hospitals, the rural health 
clinics, the community health centers. And I think it is in 
part due to these efforts that we have seen, for example, rural 
adoption of electronic health records now among office space 
providers is 38 percent higher than the national average of 34 
percent. So it can be done, but we have to make sure that we 
set the rules appropriately and we provide them with the 
services they need to be able to get there.
    Ms. Edwards. I want to ask you a question that is somewhat 
related, and it is regarding the issue of upcoding. The New 
York Times recently profiled and wrote about some instances in 
which hospitals, particularly those Medicare providers, in 
using these IT systems actually were billing at much higher 
rates. And I have a question just about the design, whether it 
is--and maybe NIST can comment on this, too--we can have some 
way of testing these, the designs of IT systems, so that we get 
a more intelligent design that might factor in the potential 
for abuse or the potential for upcoding when it doesn't result 
in a better patient outcome or a better quality of care so that 
we can actually guard against increases in costs in a system 
rather than seeing more efficiency in the system because of the 
implementation of the technology.
    Dr. Mostashari. I would note that the article you mentioned 
examined trends in billing leading up to 2010, which actually 
predates the implementation of the EHR incentive program, which 
is moving electronic health records industry away from just 
being documentation and billing machines and towards things 
that, as Ms. Little commented, help us do the new payment 
models of the future with accountable care, and bundled 
payments, and shared savings and so forth.
    That said, I want to assure you that HHS is taking the 
appropriate steps to investigate and correct any possible 
improper billing associated with EHRs. The Centers for Medicare 
and Medicaid Services is conducting a comprehensive review of 
potential improper billing through the use of electronic health 
records. We also plan to convene a summit of stakeholders to 
develop those potential policy and EHR design responses, as 
well as conduct a pilot of hospital audits using EHR technology 
functionality that supports fraud enforcement and investigation 
so that EHRs are used as tools to combat fraud, not encourage 
it.
    Ms. Edwards. And is it possible, though, that in testing 
for standards that NIST actually might come up with a design 
that looked more intelligently at these systems so that, you 
know, if there were system prompts or the software was coded in 
such a way that it would automatically kick out things that, 
you know, looking at an entire record, might actually indicate 
that there was that upcoding going on, as opposed to coding 
correctly for a given medical condition or circumstance.
    Dr. Romine. So from this perspective--thank you for the 
question.
    Our role has really been in trying to ensure that we 
provide the best technical advice to get the best technical 
standards from the community with regard to interoperability, 
security, privacy, and so on. But that also includes usability. 
And one of the things that may be related to this issue is 
ensuring that the usability of these systems are testable in a 
way that might prevent I would call inadvertent, mistaken 
coding, or things of that nature where the usability of the 
system can help avoid those kinds of issues.
    With regard to the policy issue of trying to prevent 
intentional fraud, I think that would really kind of be beyond 
our scope. I'm not sure how we would contribute to that.
    Ms. Edwards. Thank you, Mr. Chairman.
    Chairman Quayle. Thank you very much.
    I now recognize the gentlelady from Oregon, Ms. Bonamici, 
for five minutes.
    Ms. Bonamici. Thank you very much, Mr. Chairman. And thank 
you for calling this hearing today.
    Thank you for all of our panelists for sharing your 
thoughts and ideas about this important issue. Many people in 
my home State of Oregon are talking about the importance of 
increasing access while reducing costs. So this is certainly an 
important topic.
    I represent a district that includes an area that's known 
as the Silicon Forest; it's like the Silicon Valley, only with 
trees.
    And we have a lot of technology companies, Intel, doing a 
lot of great work in developing our health IT infrastructure. 
The Oregon hospital systems have been early adopters of using 
common IT systems, and they have been working through informal 
collaboration.
    I recently hosted a roundtable discussion that brought 
together many of the stakeholders. We had the Oregon Office of 
Health Information Technology, the Medical School, Oregon 
Health Sciences University, the Oregon Healthcare Work Force 
Institute, community colleges, software developers, the Oregon 
Center for Aging and Technology, and many others, to talk about 
where we were going, the development so far, and some of the 
challenges.
    One of the interesting issues that came up, and I believe 
you touched on, Dr. Mostashari, was the importance of having 
some medical knowledge in the actual software and systems 
development phase. The medical workflow is really important in 
the initial design of the software and the developments. So 
that's an issue that we feel really needs to get addressed.
    And also there was a discussion about involving providers 
at every level from, you know, hospitals to home care and in 
many cases to completely fulfill the use of the medical 
records. You have patients and caregivers who are involved, and 
they need to be comfortable with the technology as well.
    So could Dr. Romine, and perhaps Dr. Mostashari, I know 
there has been some discussion about how you go about engaging 
healthcare professionals in the actual development of the 
technology. But would you also comment, please, about the work 
that you've done in engaging healthcare professionals in the 
implementation as well?
    Dr. Romine. The way that NIST works most effectively in 
working with the community to develop standards, particularly 
in a space where historically we don't have a lot of expertise 
in medicine. We do a lot of life science research, but that's 
quite different from clinical practice, for example.
    And so we have to engage the communities. Most effectively, 
we do that with the standards development organizations that do 
have the various technical background that we need. So 
standards development organizations such as--we've worked with 
ASTM and HL7 and other organizations that are involved in this 
arena specifically to look at the ways that we can help develop 
the standards necessary in this space to be the most effective. 
And that does include looking at the workflow associated with 
this.
    We also could not actually contribute to this without the 
very strong partnership with ONC, where a lot of that expertise 
resides. And so I'm very pleased that the partnership that we 
have with ONC is as strong as it is.
    Dr. Mostashari. The issue you raise is of critical 
importance. The software, and there are--and it is wonderful. 
There are hundreds of new vendors, hundreds of new products. 
And 60 percent of those vendors have 50 or fewer employees. 
They are small companies. And it's critical that as we have 
technological innovation, those technologies are more usable 
and work for the frontline clinical staff, the nurses and 
doctors. And the usability issue here is something absolutely 
critical.
    We've been doing a lot of work with our stakeholders, 
including our Chief Medical Officer, with many of the providers 
groups within the usability space.
    I do, though, having been in the space for some time now, I 
might be interested in hearing Willa's perspective on this as 
well. The products are a lot more usable today. If you look at 
products that came out four or five years ago, it's really 
night and day in terms of how usable they are, you know, iPad 
applications, and a whole host of new innovations around 
usability are now coming to the forum. As it should be, 
competition between vendors for the most useful product I think 
is going to be yielding us tremendous results in the future.
    Ms. Bonamici. Thank you. Dr. Fields, did you want----
    Dr. Fields. Yes. The usability is an issue. They are more 
usable than they used to be, and hopefully they aren't as 
usable as they will be, that we aren't where we need to be. 
That said, we need to continue with the implementation. And one 
of the barriers in the United States, if you look at the 
literature, clearly a major barrier to implementing these 
systems is cost. And thanks to our Federal government, the cost 
barrier is being lessened because of the incentive program.
    So with that we'll have the--what Dr. Mostashari talked 
about, all the new vendors. We're having the increased 
competition in the innovation. And the users, the nurses I talk 
to, the physicians I talk to, they want systems that are easy 
to be used.
    And we as a public are very computer savvy. I looked up 
some data--80 percent of the households have computers. And of 
that 80 percent, 70 percent of adults--so that's not kids--it's 
70 percent of the adults, are using the Internet, and 80 
percent of that 70 percent are getting health information. So 
that means that the majority of your constituents in getting 
their health care, the number one thing is looking for 
healthcare information. They know how to use the systems. They 
are going to be demanding that our clinicians know how. And the 
usability is getting better, but it's not written in slate.
    Ms. Bonamici. Thank you. My time has expired. Thank you.
    Chairman Quayle. Thank you very much. Now recognize the 
gentleman from Maryland, Mr. Harris.
    Mr. Harris. Thank you very much, Mr. Chairman.
    And I have a couple of specific questions, and then a more 
general, I guess.
    Dr. Mostashari, it's good to see you again.
    As you know, last time we met, we'd talked about the 
difficulties that some different specialties have, which I 
think you appreciated, with regard to meaningful use.
    Now, as an anesthesiologist, you know I know that hospital-
based physicians a lot of times lack face-to-face interactions 
and other things. And I--so that I think Stage 2 granted the 
hardship exemptions to at least three categories--radiologists, 
pathologists, anesthesiologists. But in the absence of 
meaningful--of developing meaningful use criteria for those 
specialties, is it the intention of the Administration to 
continue a hardship exemption until those are worked out, you 
know, some kind of meaningful use parameters are worked out? I 
mean, to my understanding, this is kind of a one-time, one-year 
hardship exemption. That doesn't provide consistency long term.
    Dr. Mostashari. Yes. As you know, the--particular issue for 
those three categories, anesthesiologists, pathologists, and 
radiologists, was not only that they practiced, in some cases, 
where they have less patient interaction, it's also that the 
systems that they use are oftentimes provided by the hospital 
where they practice rather than purchased by the providers 
themselves within their private practice.
    So the exemptions, we asked about whether there should be 
more blanket exemptions for those categories, and in Stage 2, 
we find that it can be up to five years.
    Mr. Harris. Okay.
    Dr. Mostashari. So I think that given the current 
legislation, I think that is the means that are available to 
us.
    Mr. Harris. Thank you very much.
    Dr. Romine, is that how I pronounce it? Okay.
    I have a very specific question. It has to do with one of 
these things that I think NIST is involved with, which is the 
prescription, the drug-to-drug interactions and drug allergy 
checks. And this is very specific to anesthesiology.
    And when I was in the operating room last week, on one 
patient, I had a list of 10 drugs, if you count two inhalation 
agents. Only one of those was one where another provider was 
involved, which is the prophylactic antibiotic, which a nurse 
had requested from the pharmacy, which an electronic system in 
use could have picked up a drug-to-drug interaction or an 
allergy. But of the other nine drugs I administered, all of 
them are documented really after the administration. That's 
just the way the workflow occurs. So software in a health 
information technology system really wouldn't pick up drug-to-
drug interactions or drug allergy interactions in that setting.
    Do you think that--and anesthesiologists are kind of unique 
in the number of times we--the number of drugs we use and the 
fact that we are doing it on a momentary basis. So there's no--
it's hard to prospectively identify and write an order, check 
it in the computer, things like that.
    Should they be exempt from the requirement until such time 
that we can figure out how to work that into an electronic 
system?
    Dr. Romine. Congressman, I'm a mathematician, but I'll try 
to address that.
    I would say--I don't know the system that you used in to 
obtain the nine drugs that you did apply.
    Mr. Harris. No, they sit in a cart in the room.
    Dr. Romine. I see. Okay.
    Mr. Harris. We have access. They sit in a cart. That's the 
problem. And that's the way anesthesiologists practice in most 
settings. You have access to a variety of drugs. You make a 
decision sometimes on a momentary basis which drug you have to 
administer without time to prospectively enter it into a 
system.
    Dr. Romine. From this perspective, we're happy to work on 
developing the standards. But the expertise with regard to 
where certain interactions might take place, or working with 
ONC, for example, on drug-to-drug interaction, allergies, and 
so on, all of the guidance with respect to the kinds of issues 
that you're just talking about would not come from NIST. We 
don't have that expertise.
    Mr. Harris. All right. We have to work with Dr. 
Mostashari's office, I guess, with that.
    One final thing is, I guess the question of 
interoperability, and Ms. Little kind of suggested, I guess 
Medicity is kind of a translator system. No matter what 
language a given group speaks, you're the translator between 
these.
    And I guess interoperability can occur two ways, it can be 
by declaring that everybody speaks the same language, or that 
everybody has access to a translator that works.
    Which is the system that we're going to go to? Because a 
lot of institutions, as Mr. Probst indicated, a lot of 
institutions invested heavily in a proprietary scheme. And it 
would seem that the easiest way to get a broad--if it's 
technologically feasible--broad acceptance at this point is 
just to allow translators to exist. Is that the scheme?
    Dr. Mostashari. I think the answer is yes. We need both.
    Mr. Harris. But both is not specific. I mean--and, again, 
if you're going to tell a provider, why don't you go--you know, 
you got to go ahead and invest in a system now. But we might 
down the road change the rules and say that you actually have 
to have a system has these qualifications and too bad if yours 
didn't, as opposed to saying, okay, you have now invested in 
this now we're going to actually spend our energies on making 
sure translators exist that accurately translate.
    Dr. Mostashari. Let me be more specific. I think it is 
important to, as much as possible, make sure that two different 
certified EHR systems can talk to each other without the need 
for requiring that a translator be present, particularly since 
the availability of such, you know, health information exchange 
organizations throughout the country are still limited. It's 
growing, but it's still limited. So I think it's important for 
us to have, as much as possible, the precoordination and have 
those national standards at the electronic health record in 
place so that the systems can talk to each other.
    It also greatly, I think, reduces the work of the 
translators if the people speaking the languages at least speak 
them consistently instead of having to translate. And much of 
the cost on the information exchange side is doing all those 
variations on all the different languages that people are 
speaking.
    So I think the reality is that there are translators in 
place today. And we've made--I think we've encouraged the 
development of information exchange at the state level and 
others. And it's a reflection in reality. But we can't give up 
on the idea that we're going to get to the point where the EHRs 
can speak to each other without the need for translators.
    Ms. Little. I would agree with Dr. Mostashari. I think the 
need for the middle-ware, the translator or the plumbing, as 
you called it, is particularly important now as standards are 
relatively nascent.
    We see--and Dr. Romine and Dr. Mostashari may have a 
different statistic than I--but dozens if not hundreds of 
permutations of the continuity of care document today.
    And so, for us, it's an important part of making sure that 
the right information gets to the right person at the right 
time within their workflow. I do also agree that over time 
systems will be better able to communicate with each other.
    Dr. Fields mentioned that the systems we have today are 
better but hopefully not as good as the ones we'll have in the 
future.
    The other, I think, important component part that the 
translator provides for, as to the point you made, sir, whereby 
changes evolve and standards evolve, the middle-ware, the 
translator oftentimes can buffer and provide a little bit of 
runway as systems become more operable and then adopt those new 
standards. So I agreed with Dr. Mostashari, I think we need 
both.
    Mr. Harris. Thank you very much, Mr. Chairman.
    Chairman Quayle. Thank you very much. Now recognize the 
gentleman from Michigan, Mr. Clarke, for five minutes.
    Mr. Clarke. Thank you, Mr. Chair.
    And I wanted to thank the Ranking Member from Maryland, Ms. 
Edwards, for giving me this opportunity. Back two years ago 
when I served as Ranking Member of the Michigan Senate 
Committee on Health Policy, I actually convened an informal 
hearing on the health information exchanges to see how we could 
get those set up. So this is an issue that's important to me. 
And thank you again.
    With that, I yield my time to the gentleman from New 
Mexico, Mr. Lujan.
    Mr. Lujan. Thank you very much, Mr. Clarke.
    And, Mr. Chairman, I also, as our Ranking Member, Ms. 
Edwards, want to commend you for your work on this 
Subcommittee, Committee as a whole, and your time in the House. 
It's been great to get to know you. Appreciate your leadership, 
and I know that it won't be too long before we see you again, 
sir. So it's always an honor, Mr. Quayle. Really appreciate 
that, sir.
    Dr. Mostashari, all of us as Representatives represent 
about the same population, plus or minus a few hundred or maybe 
a few thousand people. The difference between our districts is 
some of us represent a few square blocks, others represent 
47,000 square miles, like my district in New Mexico. The 
longest drive I have is about 8-1/2 hours drive time. Out here, 
we can go through about six, seven States in that amount of 
time.
    The reason I bring this up is when we talk about the stages 
of the implementation versus urban, metro, and rural areas, 
what sensitivity is paid attention when we start talking about 
the smallest of clinics, smallest of communities, that need 
more assistance or time as we talk about the implementation of 
the stages and the requirements associated inherently therein 
and the capital necessary to be able to do that?
    Dr. Mostashari. You're absolutely right that we need 
different approaches in different parts of the country.
    This is why the regional extension center program is based 
out of local institutions that understand the local needs and 
the local resources.
    So a program like the one I ran in Brooklyn and the Bronx 
in New York City is going to be structured differently than the 
program in New Mexico. Both are successful, but they take 
different approaches to the issue. And I think it's been that 
sensitivity to what the local needs are that has made the 
success that we've enjoyed in making sure that a digital divide 
does not develop. Because as one rural provider said to me, 
``My patients now come to me knowing that the best technology 
that they could get anywhere in the world is in their doctor's 
office here in my rural practice.''
    He also said it's very important on the telehealth side, 
that you mentioned earlier, ``that if my patient drives 300 
miles to go to a specialist that I referred them to that when 
they get there they have the information that they need instead 
of having the patient turn around or be told, `sorry, we're 
going to have to repeat all those tests,' or, `sorry, we didn't 
get the paperwork on you.'' So we have to pay particular 
attention to the rural areas and we are doing that.
    Mr. Lujan. I appreciate that.
    If anyone else would like to weigh in and in addition to 
the impact as we talked about the standards on telemedicine as 
well.
    Mr. Probst. Yes. And I think I come from a geography in 
Utah very similar to yours.
    And I can assure you that our smallest hospital, which 
probably consists of about eight beds, very small, serving a 
rural population, has the exact same level of sophistication as 
our Salt Lake City based hospitals. That comes down to using 
standard technologies and the ability to train across the 
organization and move those things out.
    If we had to do something independent in each of those 
rural areas, the costs would be prohibitive and the value to 
the organization would be very slim. So I guess I'm stuck on 
the standards route. But, again, by applying good, solid 
standards with good technology, if I get in an accident in 
Panguitch, Utah, which hopefully none of you know where it is, 
they have exactly the same information and can provide me just 
the exact level of care.
    Mr. Lujan. Appreciate that, Mr. Probst.
    Dr. Romine. I appreciate that. I also agree that standards 
actually can help to drive the adoption more readily in all 
sectors, including rural sectors, because of products that are 
affiliated with those standards or that conform to those 
standards are well understood.
    I will also say some of the testing infrastructure that 
NIST is developing in partnership with ONC is publicly 
available. In fact, all of our testing infrastructure is 
publicly available, our test tool kits are publicly available. 
We try to make them as friendly as possible for providers to be 
able to use.
    And so we pay close attention to that.
    Mr. Lujan. I appreciate that.
    And as my time expires, Mr. Chairman, just again, as we 
look to programs across the United States, again to highlight 
what's happening in New Mexico with Project ECHOTM, the 
extension for community healthcare outcomes, now providing 
opportunities with our veterans as well, where via telehealth 
they are able to reach out across rural parts of the country 
now. And through the communication they actually have a series 
of physicians that can enter into any of these diagnoses and 
they can work together collectively. They can also come out and 
talk about the best-case scenarios or mistakes that were made. 
So they are learning together, they are keeping their 
certifications up together. But they are also making sure that 
they are delivering the best possible care, especially when it 
comes to the shortage that we have of family care specialists 
in some areas, that even in the most remote parts of the 
country they are able to get that.
    So thank you very much, Mr. Chairman.
    Chairman Quayle. Thank you, Mr. Lujan.
    Now recognize the gentleman from Texas, Mr. Neugebauer. 
Five minutes.
    Mr. Neugebauer. Thank you, Mr. Chairman. Mr. Mostashari, 
Mr. Romine--Dr. Romine.
    Authenticating the patients is an important part of the 
critical health IT part and setting up security parameters to 
protect that. And how--what are we doing in the IT world to be 
able to make sure we got the right patients being matched up 
with the records?
    Also, what are we doing to allow patients to look at and to 
use those records and to, you know, verify them that those 
records are correct? And can you kind of share a little bit 
about what's going on in the next phase?
    Dr. Mostashari. Absolutely. When we talk about being 
patient centered, we have to take that very seriously. And one 
of our most important principles is not just having the patient 
be at the center of the care, but the patient literally being 
able to access their own information and to participate in 
their care as partners. Someone said if we want to get better 
care at lower cost, we've got to use every resource we have. 
And the patient is the most underutilized resource in 
healthcare.
    So we've actually been big advocates for and pushing on the 
standards side as well as on the policy side for patients to be 
able to exercise their legal right to get access to their own 
health records online and to be able to view it, to be able to 
download it, to be able to store it securely.
    That all requires, as you point out, that there be means of 
authenticating the patient. And many of the organizations who 
have implemented this at a large scale are able to--whether 
it's the Veterans Administration, which has had a million 
downloads among veterans of the blue button of their health 
record, whether it's other organizations, healthcare 
institutions that have found that by engaging with their 
patients online, they help have patients keep their 
appointments, take their medications, and be more active in 
their healthcare. It's a high priority for us.
    Dr. Romine. I'd like to make mention of three quick things. 
One is we're working in the area of patient identification 
matching and our researchers have developed a tool that 
supports the testing of patient identifier cross-reference and 
patient demographic query, test cases for both HL7 versions 2 
and 3.
    The second thing is NIST is the home to the program office 
for the National Strategy for Trusted Identities in Cyberspace, 
which is a major program for identity management, broadly 
speaking, but I think will have serious implications with 
regard to helping in this context.
    And, third, we have a National Cyber Security Center of 
Excellence that we have just stood up. And our first use case 
is going to be on health IT and patient records, particularly 
focused on small providers' ability to transfer secure and 
private records.
    So all of those things I think will contribute.
    Mr. Neugebauer. I think someone--did you?
    Dr. Fields. Yes. I wanted to comment on your question 
patient matching. The lack of patient matching is a major 
health safety issue. You can imagine if we merge records that 
shouldn't be merged.
    Congress actually prohibited the use of appropriated 
funds--I'm going to quote here--``to promulgate or adopt any 
final standard for unique health identifier for an 
individual.''
    You may remember that part of HIPAA, back in 1996 or '98, 
there was the request for a unique patient identifier. And it's 
been prohibited by Congress to actually evaluate that.
    And one of the tasks that HIMSS had when we were on the 
Hill in the fall was not that we dictate what type of 
identifier we have, but that Congress have a consistent, 
nationwide patient data matching strategy that we start to look 
into, that Congress actually authorized the ability for us to 
look into a patient data matching strategy. Because without 
that, we are at risk for patient safety.
    Mr. Neugebauer. Yes.
    Mr. Probst. Might I second Dr. Fields.
    We spend about $5 million a year trying to do patient 
identification accurately for our patients. You talk about 
waste in the system, that's a significant amount of waste and 
it seems to be something--it's one of the seven standards I 
wrote in my written testimony--that we need to tackle because 
it's incredibly frustrating and unsafe.
    Dr. Fields. And it takes time and delays care. What happens 
from a practical point in a hospital, when the computer 
doesn't--when the computer is programmed to say these two 
patients, these two records may not be the same patient, but 
maybe they are, then that data goes into a holding zone where a 
human being then looks at it to determine what happens to it. 
So while it's in that holding zone, that data is nowhere near 
available for clinicians to be able to give care.
    So each organization has come up with their own strategy, 
because we as providers recognize the importance that the data 
that goes into the computer has to be for the patient that we 
think it is. So we have these complex algorithms and complex 
human processes that eat up time and actually interferes with 
the ability to give care.
    So I really plead with you to promote this investigation 
for a national strategy for patient identification. We have it 
for the clinicians, we have it for the insurers. We do not have 
it for the patients. And that's where the risk is.
    Mr. Neugebauer. I would make a suggestion that--you say 
Congress hasn't given that permission. I'm pretty sure that the 
patients would be better off if Congress didn't make that 
decision.
    But if the industry would come forward with, you know, a 
recommendation where you've actually had some experience, 
what's working, what's not working, but, you know, for Congress 
to set those standards----
    Dr. Fields. Oh.
    Mr. Neugebauer. --I think we would rather hear from you 
than--I'm pretty sure I've got some really smart colleagues, 
but I feel a lot of them don't really know a lot about this 
particular issue.
    Dr. Fields. Thank you. Let me correct myself. I don't mean 
for Congress to in any way set the standard. What I am asking 
for Congress is to take away what had previously been stated 
and that we come up with a strategy that Congress allow the 
investigation, that Health and Human Services, ONC, the 
appropriate government agency, bring together the private 
sector, the government sector in to study the situation and 
come up with a strategy. Because from my understanding that 
Congress prohibits the use of appropriated funds to be able to 
look into this.
    Ms. Little. I think I would just like to add and agree with 
Dr. Fields. What I think we would really like to see is an 
opportunity to collaborate on a strategy and see a strategy 
come forward.
    As a technology supplier who provides software that 
connects things together, we also provide software that 
provides patient matching. And once you get outside of an 
individual healthcare organization, even a large delivery 
network like Intermountain Healthcare, and you complicate that 
with a regional implementation or a statewide health exchange 
implementation, those complexities and algorithms become even 
more important and the accuracy of them become more important. 
So we would also value and look forward to participating in the 
opportunity to see a strategy.
    Chairman Quayle. Thank you very much.
    Now recognize the gentleman from California, Mr. 
Rohrabacher, for five minutes.
    Mr. Rohrabacher. Thank you very much, Chairman Quayle, and 
to our witnesses as well.
    I'm the first one to admit that I have limited knowledge 
into the area that we are talking about. So I guess I have to 
ask some fundamental questions.
    We seem to be talking about interoperability and privacy is 
some of the issues, but as the discussion has gone on, it seems 
that we are talking about more than electronic health records. 
It seems to me that we're morphing into a discussion at some 
point into setting up a system of medical cooperation that will 
ensure that any hospital has the best technology available to 
it. That's different than medical records.
    So far, I take it the original goal was to have a national 
system where we could easily exchange information. That seemed 
to be a goal that people could actually accomplish within a 
certain budget.
    I mean, I know people have apps right now. My wife actually 
invented an app over the Internet. And it's relatively--a lot 
of people are utilizing the Internet in a relatively 
inexpensive way. But we've already spent $2 billion on this 
information sharing, which does mirror some of the things that 
I think I've seen on the Internet.
    But are we now morphing this into something that's far 
beyond just medical records that's going to cost more money 
that we may not ever have?
    Dr. Mostashari. The payments authorized under the CMS 
Medicare and Medicaid Health IT Incentive Program are 
specifically for the meaningful use of certified electronic 
health records.
    Mr. Rohrabacher. Just for the records----
    Dr. Mostashari. Certified----
    Mr. Rohrabacher. I'm not saying that we can't do a lot of 
other things in the healthcare arena that are--that will be to 
the benefit of our people. But I do know that when people try 
to do everything, they generally don't get anything done.
    And so we're just focused on the records. This program is 
still focused on just setting up a system so that if someone 
goes into a hospital his medical records can immediately be 
available?
    Dr. Mostashari. The Medicare and Medicaid incentive 
payments are specifically for the meaningful use of electronic 
health records that are certified to meet interoperability and 
functional standards.
    Mr. Rohrabacher. How much has been spent for that already? 
You said it was $2 billion?
    Dr. Mostashari. There's $2 billion in appropriated funds 
for the grant programs and to establish the infrastructure like 
the regional extension centers is the examples I gave. And then 
there are mandatory payments, as Chairman Quayle described in 
the beginning, for eligible professionals and hospitals, and 
approximately 7--a little bit over $7 billion has been spent to 
date out of an estimated $20 billion.
    Mr. Rohrabacher. That's to come up--that money was spent to 
come up with a basic set of standards or to set up a system?
    Dr. Mostashari. Those payments are for individual eligible 
professionals and eligible hospitals who earn those mandatory 
payments if they adopt a certified a health record and they use 
them in these certain ways, check for drug, drug allergies, 
collect information needed, and exchange it.
    Mr. Rohrabacher. So what we have spent the $2 billion on is 
to encourage people to participate in a system that is a 
standard system for the country. Is that right?
    Dr. Mostashari. The incentive payments, which is the--the 
44,000--up to $44,000 over five years for eligible 
professionals and the 2 million-plus for hospitals is payments 
to them for whatever system they choose, but the systems have 
to meet the national standards.
    Mr. Rohrabacher. And so but the point is to establish the 
national standard?
    Dr. Mostashari. The goal is to get widespread adoption and 
meaningful use of the electronic health records, which include 
the standards.
    Mr. Rohrabacher. Let me just suggest that $20 billion to 
set up a standard is a big price category.
    Dr. Fields. May I jump here?
    Mr. Rohrabacher. Chairman Quayle will----
    Dr. Fields. May I speak?
    Chairman Quayle. Go right ahead.
    Dr. Fields. Further, the point I want to make is that the 
goal is to have tools to help clinicians provide care. The 
ultimate outcome is improved patient care and health outcomes, 
a healthy American population.
    Mr. Rohrabacher. Okay, that's different than what he just 
said.
    Dr. Fields. No, it's the same.
    Mr. Rohrabacher. No, I'm afraid it's not. That's your 
opinion on that. He just said it was medical electronic 
records, not what you just said.
    Dr. Fields. And what I am saying is the medical electronic 
record is imperative for us in the United States to be able to 
give high quality care, which ultimately will be healthy 
people. Without these tools so we can go through research study 
after research study that those organizations that have 
standards based electronic health records, and they are using 
it in a meaningful way, like Intermountain Healthcare, and many 
other organizations, because of the data that is available to 
them to give care to individual patients and then to their 
population, it's because of that information that we're able to 
have healthier populations, which I believe is something that 
everyone in this room wants.
    Mr. Rohrabacher. No one has any argument with the fact that 
we need to have the ultimate amount of information available to 
anyone who's a health provider for the person that comes in for 
treatment. There's no doubt about that.
    It seems to me, however, Mr. Chairman, that billions of 
dollars were to set a standard that would permit that type of 
availability. As I say, I see people setting up businesses 
every day on the Internet that provide information on a global 
scale to various businesses and various enterprises. And it 
just doesn't seem to take that much money. And at a time when 
we're trying to bring down the level of deficit spending so we 
can actually provide the medicine, provide the x-ray, that it 
seems like to me the $20 billion expenditure is an awfully high 
price tag for something that the private sector seems to be 
doing and offering at a much lower rate.
    Thank you very much.
    Chairman Quayle. Thank you.
    Now recognize the gentleman from Michigan, Mr. Benishek, 
for five minutes.
    Mr. Benishek. Thank you, Mr. Chairman.
    I have a question. I'm a physician as well. And I've been 
familiar with several different electronic medical records. And 
some of them work better than others. I mean, I worked at the 
VA system, and that's a pretty good system as far as they go, 
as far as I'm concerned.
    My biggest concern really is this mandating the 
implementation of electronic medical record that doesn't work 
as well as the VA system. Because many of the systems I've seen 
in the private sector are expensive, they are costly to 
maintain, and they don't do what we want them to do, which is 
provide, you know, sort of a universal access to information.
    You know, I know in my practice we have electronic medical 
records but we're still sending or trying to get a fax of an x-
ray report because it's not available on this electronic 
medical record that I have.
    And there's a lot of people in private practice that simply 
can't afford to spend, you know, 65,000 or $150,000 dollars on 
a electronic medical record system for their practice, plus a 
$5,000 a month maintenance fee for a system that doesn't 
produce.
    So I have a real problem with, you know, mandating 
implementation of a system that doesn't do, you know, what 
result that we want.
    And I think that, frankly, this implementation or 
interoperability, you know, when you can't get a lab test 
because it was done in another hospital that your system does 
not talk with, it wasn't worth that $150,000 for me to tell my 
girl to have to get, you know, get this test. You know.
    So explain to me why are we implementing it before it's 
universally interoperable.
    Dr. Mostashari. So I think you're raising the issue of 
upfront costs and not just the costs for purchasing the system, 
but also implementing it and changing the work flows and the 
challenges that are there.
    And you mentioned, you know, for a practice with a few 
physicians, it can cost tens of thousands of dollars. That has 
been what has held back the adoption of the electronic health 
records in the U.S.
    And Congressman Rohrabacher's question about what are we 
paying for, what we're paying for is providers like yourself to 
be able to be receiving the payment over a period of several 
years if they choose to adopt and meaningfully use the 
technology.
    Mr. Benishek. Payment doesn't cover those costs. Okay. I've 
talked to, since I've been here in Congress, I've been talking 
to many small hospital administrators. And they say, we got 
this one-time payment to implement this electronic medical 
record, but, you know, it's not going to cover what it's going 
to cost us. So I don't know what we're going to have to cut in 
order to comply with this rule. But, you know, our budget is 
not getting bigger, you know, with reimbursement. It's getting 
smaller. And this is a one-time payment we got but now we have 
an ongoing cost associated with it that we're not being paid 
for.
    It's really frustrating to me to hear, you know, a small, 
critical-access hospital telling me this.
    Dr. Mostashari. Sure.
    Mr. Benishek. Because, you know, they don't have any extra 
places to find money.
    Dr. Mostashari. There are--one of the approaches that 
Congress took in HITECH was not to have the Federal government 
procure the software, but to really leave it to the market-
based approach to let the hospitals and providers be the ones 
to choose what system works best for them. And there are a 
greatly expanded range now of software products each with their 
own usability and the cost structures, lease models, web-based 
models and so forth that providers can now choose from.
    And what we're seeing in practice is that the amount of the 
incentive payments has been sufficient to produce this great 
acceleration in the adoption of electronic health records.
    Mr. Benishek. Well, the people have implemented them 
because they are sort of terrified of the Federal government, 
you know, cutting their reimbursement. The people I've talked 
to said they had to do it because the rule came in. But they 
are finding that their costs exceed, you know, what they're 
getting reimbursed. So to me, that's a problematic issue.
    And I didn't hear any answers in any of your testimony to 
this part of the problem. Because I have seen it in real life 
myself and, you know, I visit lots of hospitals. What I just 
mentioned to you, you guys didn't talk about at all in any of 
your testimony.
    So it's a great concern to me.
    I mean, it all sounds great. I mean, I want great medical 
records. And, you know, it's great to have the medical record 
in your hand. But if the hospital goes broke, that access to 
care is not there either.
    I think my time is up. Thanks.
    Chairman Quayle. Doctor, you want to answer that?
    Dr. Mostashari. The program is designed and legislation 
passed by Congress in HITECH does not have a mandate, that it's 
a voluntary program. And if providers sign up for the program, 
as 75 percent of the hospitals have already done and more than 
half of providers have done, then they can earn the incentive 
payments. And if they don't, it basically says that the 
Government feels that Medicare is not getting 99 cents on the 
dollar value for the care that we are buying from the 
providers.
    So it is the way that the legislation was set up. And I 
believe that it is an important step towards getting a national 
infrastructure that can help public health, that can help 
research, and that can help patient care.
    Chairman Quayle. I want to be real quick.
    But it is true that if you don't participate, you get cut 
in your Medicare and Medicaid reimbursements. Is that correct?
    Dr. Mostashari. Yes.
    Chairman Quayle. I do want to thank all of the witnesses 
for their valuable testimony, and the Members for their 
questions.
    Members of the Subcommittee may have additional questions 
for the witnesses, and we will ask you respond to those in 
writing. Record will remain open for two weeks for additional 
comments and statements from members.
    Before we gavel this closed, this is more than likely going 
to be the last Subcommittee hearing of this Congress. And I 
just want to thank all of the Members of this Subcommittee for 
their valuable input. I really want to thank the Ranking 
Member. She has been a great partner to work with. And this 
Subcommittee has been very bipartisan. We want to focus on the 
technological and innovation in this country.
    And I also do want to thank all of the staff both on the 
majority and the minority side for making sure that this whole 
Subcommittee runs so smoothly.
    And, Ms. Edwards, would you like to say anything?
    Ms. Edwards. Mr. Chairman, I want to echo that. And I just 
want to say to you that I know a lot gets said about how 
Congress works or it doesn't. And I just want to say to you 
that it has actually been a real joy to be on this Committee 
with you as Chairman because we've had some incredibly 
thoughtful discussions with great witnesses and exploring areas 
that you don't often get to do in the Congress and looking for 
the future. And this panel today was more evidence of that.
    So I really do appreciate your leadership, appreciate your 
service in the United States House of Representatives 
representing your Congressional district in Arizona. And I wish 
you incredibly good luck, good fortune into the future. Thank 
you.
    Chairman Quayle. Thank you very much. And I echo those 
sentiments to you as well. This has been a great two years on 
this Subcommittee.
    And I want to thank you, the witnesses, again. This was a 
great hearing today. And you are excused. Thank you all for 
coming. Hearing is now adjourned.
    [Whereupon, at 11:45 a.m., the Subcommittee was adjourned.]

                               Appendix I

                              ----------                              


                   Answers to Post-Hearing Questions

Responses by Dr. Farzad Mostashari

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Responses by Dr. Charles H. Romine

[GRAPHIC] [TIFF OMITTED] T7035.081

[GRAPHIC] [TIFF OMITTED] T7035.082

[GRAPHIC] [TIFF OMITTED] T7035.083

Responses by Mr. Marc Probst

[GRAPHIC] [TIFF OMITTED] T7035.084

[GRAPHIC] [TIFF OMITTED] T7035.085

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Responses by Ms. Rebecca Little

[GRAPHIC] [TIFF OMITTED] T7035.087

[GRAPHIC] [TIFF OMITTED] T7035.088

[GRAPHIC] [TIFF OMITTED] T7035.089

Responses by Dr. Willa Fields, DNSc, RN, FHIMSS

[GRAPHIC] [TIFF OMITTED] T7035.090

[GRAPHIC] [TIFF OMITTED] T7035.091

[GRAPHIC] [TIFF OMITTED] T7035.092

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