[Senate Hearing 113-264]
[From the U.S. Government Publishing Office]





                                                        S. Hrg. 113-264

                    HEALTH INFORMATION TECHNOLOGY: 
                A BUILDING BLOCK TO QUALITY HEALTH CARE

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

                                HEARING

                               before the

                          COMMITTEE ON FINANCE
                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 17, 2013

                               __________

       [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]                              
                                     

            Printed for the use of the Committee on Finance
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                          COMMITTEE ON FINANCE

                     MAX BAUCUS, Montana, Chairman

JOHN D. ROCKEFELLER IV, West         ORRIN G. HATCH, Utah
Virginia                             CHUCK GRASSLEY, Iowa
RON WYDEN, Oregon                    MIKE CRAPO, Idaho
CHARLES E. SCHUMER, New York         PAT ROBERTS, Kansas
DEBBIE STABENOW, Michigan            MICHAEL B. ENZI, Wyoming
MARIA CANTWELL, Washington           JOHN CORNYN, Texas
BILL NELSON, Florida                 JOHN THUNE, South Dakota
ROBERT MENENDEZ, New Jersey          RICHARD BURR, North Carolina
THOMAS R. CARPER, Delaware           JOHNNY ISAKSON, Georgia
BENJAMIN L. CARDIN, Maryland         ROB PORTMAN, Ohio
SHERROD BROWN, Ohio                  PATRICK J. TOOMEY, Pennsylvania
MICHAEL F. BENNET, Colorado
ROBERT P. CASEY, Jr., Pennsylvania

                      Amber Cottle, Staff Director

               Chris Campbell, Republican Staff Director

                                  (ii)




















                            C O N T E N T S

                               __________

                           OPENING STATEMENTS

                                                                   Page
Baucus, Hon. Max, a U.S. Senator from Montana, chairman, 
  Committee on Finance...........................................     1
Hatch, Hon. Orrin G., a U.S. Senator from Utah...................     5

                               WITNESSES

Mostashari, Farzad, M.D., ScM, National Coordinator for Health 
  Information Technology, Department of Health and Human 
  Services, Washington, DC.......................................     3
Conway, Patrick, M.D., MSc, Chief Medical Officer and Director, 
  Center for Clinical Standards and Quality, and Acting Director, 
  Center for Medicare and Medicaid Innovation, Centers for 
  Medicare and Medicaid Services, Washington, DC.................     6

               ALPHABETICAL LISTING AND APPENDIX MATERIAL

Baucus, Hon. Max:
    Opening statement............................................     1
    Prepared statement...........................................    31
Conway, Patrick, M.D., MSc:
    Testimony....................................................     6
    Prepared statement...........................................    33
Hatch, Hon. Orrin G.:
    Opening statement............................................     5
    Prepared statement...........................................    43
Mostashari, Farzad, M.D., ScM:
    Testimony....................................................     3
    Prepared statement...........................................    45
Thune, Hon. John:
    ``Reboot: Re-examining the Strategies Needed to Successfully 
      Adopt Health IT,'' by Senators Thune, Alexander, Roberts, 
      Burr, Coburn, and Enzi, dated April 16, 2013...............    78

                             Communications

athenahealth, Inc................................................   109
Health Record Banking Alliance...................................   114

                                 (iii)

 
 HEALTH INFORMATION TECHNOLOGY: A BUILDING BLOCK TO QUALITY HEALTH CARE

                              ----------                              


                        WEDNESDAY, JULY 17, 2013

                                       U.S. Senate,
                                      Committee on Finance,
                                                    Washington, DC.
    The hearing was convened, pursuant to notice, at 10:20 
a.m., in room SD-215, Dirksen Senate Office Building, Hon. Max 
Baucus (chairman of the committee) presiding.
    Present: Senators Wyden, Stabenow, Casey, Hatch, Grassley, 
Roberts, and Thune.
    Also present: Democratic Staff: Mac Campbell, General 
Counsel; David Schwartz, Chief Health Counsel; Karen Fisher, 
Professional Staff Member; and Peter Sokolove, Robert Wood 
Johnson Fellow. Republican Staff: Kristin Welsh, Health Policy 
Advisor.

   OPENING STATEMENT OF HON. MAX BAUCUS, A U.S. SENATOR FROM 
            MONTANA, CHAIRMAN, COMMITTEE ON FINANCE

    The Chairman. The hearing will come to order.
    First, I apologize to the witnesses for the delay. We had a 
vote scheduled at 10. Senators are voting, and they will be 
coming back in the next, roughly, 10 minutes or so.
    Senator Hatch, though, did tell me he had an interim 
conflict. He will be here a little bit later, but he had 
something else that came up that he has to take care of.
    Ralph Waldo Emerson once wrote, ``Progress is the activity 
of today and the assurance of tomorrow.'' This committee has 
held several hearings on overhauling the health care system to 
emphasize value over volume. Today we will discuss a vital tool 
to assure that this mission is completed: health information 
technology.
    Over the past decade, when you went to the doctor, he or 
she likely kept track of your important health information by 
handwriting notes onto a paper chart. Then that chart, several 
inches thick, was filed away, often in a storage room, where no 
other doctor saw it or had access to it.
    If you needed to see a cardiologist or surgeon, that 
specialty doctor could not see your paper record. Maybe your 
primary care doctor faxed over your information, but more 
likely the specialist would just ask you the same questions and 
create their own paper record and duplicate the same tests as 
your primary doctor.
    If you went to the hospital, the situation was about the 
same. Diagnostic and lab tests were all recorded on paper, and 
your primary care physician might have no idea what happened 
during your hospital stay. What resulted from this system? 
Duplicate, costly tests, fragmented care, and often dangerous 
medical errors. We needed a better system. Other industries 
were using information technology to reduce their costs and to 
improve their service. Health care needed to catch up.
    In 2009, Congress passed the Health Information Technology 
for Economic and Clinical Health Act, known as HITECH. Under 
this law, Medicare and Medicaid gives providers financial 
incentives to adopt health information technology and 
meaningful use.
    ``Meaningful use'' means prescribing medication 
electronically to eliminate errors from scribbled, handwritten 
notes. It means ordering a different medication when the IT 
system informs the doctor that the patient has a drug allergy. 
It means sharing information electronically among providers so 
they can coordinate the patient's care. The result is better 
care at reduced costs.
    In 2009, we allocated $33 billion to help hospitals and 
physicians move to electronic systems. To date, Medicare and 
Medicaid have given out $15 billion. As of this past May, 
nearly 80 percent of hospitals and half of physicians have 
received incentive payments because they have invested in 
health information technology.
    One of our witnesses, Dr. Farzad Mostashari, will tell us 
that 
3 years ago nearly 93 percent of prescriptions were 
handwritten. Today, that number has dropped to less than half. 
There are clear signs of progress, but we need to learn more 
and do better. Is the 2009 law working as intended? Is the 
money being spent efficiently? How much longer until there is 
seamless, coordinated care for patients?
    We also need to understand why there are disparities 
between rural and urban doctors. Only a third of rural 
hospitals have a health information technology system compared 
to half of all urban hospitals. What can be done to reduce this 
disparity? I might say that I hear it in spades from my 
hospitals and critical access facilities in Montana.
    Ultimately, technology must become part of the culture of 
health care delivery. New payment models such as Accountable 
Care Organizations, medical homes, and bundled payments will 
drive providers to use information technology.
    Providers are being held financially responsible for 
providing high-quality, low-cost care. To succeed, physicians 
must engage in coordinated care, disease prevention, and 
chronic care management. Health information technology is 
indispensable to accomplish this. Key to this transformation is 
interoperability. Computers must be able to talk to each other 
so that patients and the providers can access information 
wherever and whenever they need it.
    We need to know where we are in achieving interoperability, 
how far have we come, what barriers are preventing us from 
moving faster, and how do we overcome these barriers?
    Today we will hear from the administration about all of 
these issues. So let us assess the challenges and 
opportunities, and, more importantly, let us learn how we can 
best leverage technology to achieve better quality and better 
value for patients. The stakes are too high to let this 
opportunity elude us.
    [The prepared statement of Chairman Baucus appears in the 
appendix.]
    The Chairman. Senator Hatch is on his way, and, when he 
arrives, he will want to make a statement.
    I am pleased to welcome our witnesses. First is Farzad 
Mostashari, National Coordinator for Health Information 
Technology at the Department of Health and Human Services; 
next, Patrick Conway, who is the Chief Medical Officer and 
Director of the Center for Clinical Standards and Quality, and 
Acting Director of the Center for Medicare and Medicaid 
Innovation at the Centers for Medicare and Medicaid Services.
    I will just remind you that your statements will 
automatically be included in the record, and I urge you to 
summarize in about 5 minutes. You can take a little longer if 
you want, just whatever works.
    Dr. Mostashari?

STATEMENT OF FARZAD MOSTASHARI, M.D., ScM, NATIONAL COORDINATOR 
  FOR HEALTH INFORMATION TECHNOLOGY, DEPARTMENT OF HEALTH AND 
                 HUMAN SERVICES, WASHINGTON, DC

    Dr. Mostashari. Thank you, Chairman Baucus, Ranking Member 
Hatch, distinguished committee members. Thank you for the 
opportunity to appear today on behalf of the Department of 
Health and Human Services. My name is Dr. Farzad Mostashari. I 
am the National Coordinator of Health Information Technology.
    Building on decades' worth of bipartisan legislative work, 
in 2009 the Congress and President Obama enacted the Health 
Information Technology for Economic and Clinical Health Act as 
part of the American Recovery and Reinvestment Act of 2009.
    I am pleased to be here today to discuss the policies and 
programs we have implemented to meet the goals of the HITECH 
legislation and the progress made by America's health care 
providers in expanding health information technology use. 
Working in close collaboration with our CMS colleagues and our 
Federal advisory committees, we have defined what it means to 
make meaningful use of electronic health records and the key 
certification criteria and standards for those software 
systems.
    America's providers and software developers have stepped 
forward. Throughout the country, 62 regional extension centers 
have signed up more than 147,000 providers in over 30,000 
different practices. This means that over 40 percent of the 
Nation's primary care providers have committed to meaningfully 
using EHRs by partnering with their local extension center.
    The financial incentives and the hands-on assistance have 
contributed to a greater than two-fold increase in the EHR 
adoption among eligible professionals and a five-fold increase 
among hospitals.
    As described in recent publications, there has also been 
strong progress in the routine use of specific functions that 
are strongly aligned with other policy drivers, including those 
championed by this committee, to help our health care system to 
become safer and more efficient and achieve higher quality.
    For example, computerized provider order entry for 
medication orders, which is a meaningful use requirement, has 
been shown to cut out nearly half of all medication errors. 
Since HITECH was enacted, the percentage of physicians with 
CPOE has increased from 45 to 80 percent. For non-Federal acute 
care hospitals, the percent with CPOE more than doubled between 
2008 and 2012, rising from 27 percent to 72 percent.
    Our aging population and the rise in chronic diseases place 
a premium on population health management, which requires data 
systems that can routinely measure the quality of care 
delivered, provide recommendations for guideline-based care, 
and reach out to patients. As one provider remarked, ``You 
can't provide accountable care if you can't count.''
    Improved care coordination among providers is another one 
of the goals of the HITECH legislation. Patient information 
must be available when and where it is needed.
    However, much work remains to be done to achieve the full 
promise of meaningful use. While increasing rapidly, adoption 
still lags behind in small practices and critical access 
hospitals. The usability of many of the legacy software 
products is suboptimal and the cause of frustration for many 
clinicians on the front lines.
    While the digitization of health care is well under way, 
the complementary and necessary optimization and redesign of 
practice work flows is still in its infancy. Perhaps most 
importantly, there is much work yet to be done to achieve 
higher levels of interoperability between health care providers 
who use EHR products from different developers.
    As several Senators on this committee have pointed out, it 
is a daunting task to enable secure and private health 
information exchange among hundreds of thousands of providers 
using disparate systems already in place, while accommodating 
changes in technology.
    Nevertheless, I believe that through the exercise of 
multiple policy levers and substantial public/private 
collaboration, we are on the path toward better care 
coordination through health IT.
    Through leadership and support from the States, operational 
health information exchange organizations are increasing in 
number and in size, now covering over 120,000 health care 
providers. We have worked with industry and experts to achieve 
hard-fought consensus on technical standards for key health 
care transactions. The health care IT marketplace is currently 
in the process of undergoing more rigorous testing, validation, 
and certification to meet these interoperability standards.
    Stage 2 meaningful use requirements significantly raise the 
bar for actual information exchange when care transitions, and 
patients, all too often caught in the middle between doctors 
who do not speak to each other, can finally get their own data 
in structured electronic format to share with whomever they 
please.
    But perhaps most significant has been the work of this 
committee and CMS in shifting incentives towards rewarding 
value and discouraging uncoordinated and wasteful care. 
Readmission penalties, value-based purchasing, shared savings 
programs, and bundled payments are all contributing to a sea 
change in the incentives of health care providers and 
encouraging greater information sharing.
    There is much work yet to be done before we realize the 
full value of health information technology, but, in 
partnership with the Congress and the community of health care 
providers, software developers, patient advocates, and 
researchers, we are well on our way to establishing the 
foundation for better health and better care at lower cost.
    Thank you.
    The Chairman. Thank you, Doctor, very much.
    [The prepared statement of Dr. Mostashari appears in the 
appendix.]
    The Chairman. We are honored to have Senator Hatch join us. 
Senator Hatch, would you like to make a statement? We would 
certainly like to hear it.

           OPENING STATEMENT OF HON. ORRIN G. HATCH, 
                    A U.S. SENATOR FROM UTAH

    Senator Hatch. Well, thank you, Chairman Baucus. I am sorry 
I was a little late, but I had to go to a press conference. I 
hate press conferences, but I had to do this one.
    But I appreciate you holding this hearing about health 
information technology, or health IT. This is really an 
important subject and topic, and the chairman has rightly 
stated that it can help improve the quality of health care in 
this country. I appreciate the witnesses who are here today.
    I have witnessed firsthand the power of using IT to 
transform the delivery of health care. In Utah, Intermountain 
Healthcare System has long been one of the leaders in the 
field. This transformation did not happen overnight.
    Dr. Homer Warner, a University of Utah cardiologist, helped 
establish the field of health IT in the 1950s. Now, his work 
and teaching, coupled with that of his colleague, Reed Gardner, 
inspired generations of clinicians to enter the field of 
informatics long before it became popular.
    The promise of health IT is that it can facilitate 
evidence-based clinical care to decrease the number of errors, 
which are far too frequent in our complex, fragmented health 
care system, and allow each clinical visit to a health care 
provider to increase our knowledge base about effective care.
    In preparing for this series of hearings on health 
information technology, we have heard from many providers, both 
large and small, as well as the vendor community. Most have 
said that they believe that the meaningful use program has 
spurred the investment in technology. Many were already in the 
process of establishing and purchasing health information 
technologies, and the meaningful use funds that they received 
simply helped offset the costs.
    For others, it was the threat of financial penalty that 
spurred this type of investment. Regardless, I think health IT 
can be a very valuable tool, and its use should be encouraged. 
However, it is my hope that we are not judging the success of 
this program simply on the number of dollars going out the 
door, but rather by the positive impact on patient care and 
decreases overall in health care costs.
    I also hope that as both CMS and ONC* establish 
requirements for the program, they consider all of the other 
burdens that providers face. As we have seen time and time 
again, not all providers are created equal. The size, 
sophistication, and availability of resources vary greatly.
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    * The Office of the National Coordinator for Health Information 
Technology.
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    I am very proud of the work that Intermountain Healthcare 
has done in this area, and their use of health information 
technology should be an example to all. But we have to 
acknowledge that they are really the exception, not the rule. 
As CMS and ONC develop future stages of meaningful use, we need 
to take into account all that we ask of our providers.
    Let me be clear: I do not want to see progress stalled on 
implementing the use of technologies, but, if we ignore 
problems along the way and simply expect everyone to catch up, 
we will end up in worse shape.
    The Federal Government cannot afford to spend money on 
programs that do not yield results. At the same time, providers 
cannot afford to invest in systems that do not work or have to 
be overhauled a year later as requirements change. It would 
seem to me that we have an opportunity to push the ``pause'' 
button and make sure that the program is working before we 
continue down a potentially unsustainable path.
    I think many members would agree that we should hold 
providers and vendors to high standards, and perhaps the 
meaningful use program in its various stages has set the bar 
too low. In the end, I would rather ask more of our providers 
and vendors, and provide them with a reasonable time line to 
achieve those goals.
    This hearing, along with the one scheduled for next week, 
is being held to allow us to hear from the administration's 
leaders in health information technology and from the community 
of vendors and providers using health IT and clinical care. It 
is an opportunity to take a mid-course pulse of the ongoing 
meaningful use incentive payments to providers, and to assess 
the kinds of improvements in health care that these funds 
intended.
    Mr. Chairman, I am grateful that you are holding this 
hearing, and I look forward to hearing from our two witnesses.
    The Chairman. Thank you, Senator.
    [The prepared statement of Senator Hatch appears in the 
appendix.]
    The Chairman. Let us hear from our other witness. Dr. 
Conway, you are next.

 STATEMENT OF PATRICK CONWAY, M.D., MSc, CHIEF MEDICAL OFFICER 
 AND DIRECTOR, CENTER FOR CLINICAL STANDARDS AND QUALITY, AND 
 ACTING DIRECTOR, CENTER FOR MEDICARE AND MEDICAID INNOVATION, 
   CENTERS FOR MEDICARE AND MEDICAID SERVICES, WASHINGTON, DC

    Dr. Conway. Thank you, Chairman Baucus, Ranking Member 
Hatch, and members of the Finance Committee, for the 
opportunity to speak with you today about CMS's role in the 
adoption of health information technology.
    When I started practicing medicine, I distinctly remember 
trying to read hand-scrawled notes, struggling to find an X-ray 
in the basement of the hospital, faxing or mailing discharge 
summaries, and going to the lab to track down lab results for 
patients. It was not an efficient or effective system; worse, 
missed information can lead to patient harm.
    Now I practice as an attending physician on weekends, 
including this past weekend, in a hospital with an electronic 
health record, or EHR, networked with other hospitals across 
the region. With the click of a button, I can pull up any lab 
result, X-ray, or CAT scan.
    I can even show, as I did this past weekend, a radiologic 
image to a worried family on the computer screen and explain 
the treatment of care. Medication orders are checked for 
errors, and clinical guidelines are encompassed in the 
computerized order sets.
    When I was at Cincinnati Children's Hospital, I led efforts 
using EHRs to measure quality across our system. We used EHRs 
as an essential tool to transform care. For example, I led 
quality improvement work that used the EHR as a key driver to 
rapidly adopt new evidence-based practices, as was just noted, 
across our large system in a matter of weeks, leading to better 
patient outcomes. Health IT alone does not make care better, 
but it is an essential ingredient to care improvement.
    It is important to note that health IT has traditionally 
had bipartisan support, as was just noted, and I personally 
worked for former HHS Secretary Leavitt on health IT 
initiatives.
    CMS is incentivizing and enabling the use of health IT to 
improve care for beneficiaries. The Medicare and the Medicaid 
EHR incentive programs provide incentive payments to eligible 
professionals, hospitals, and critical access hospitals as they 
adopt, implement, upgrade, and demonstrate meaningful use of 
certified EHR technology.
    The process for becoming a meaningful user of EHRs is 
staged, with increasing requirements for participation. Stage 1 
focuses on basic use and data capture. Stage 2 focuses on more 
advanced EHR functions, including interoperability, patient 
engagement, clinical decision support, and quality measurement. 
In Stage 3, we expect to focus on increasing interoperability 
in health information exchange and to focus on improved patient 
outcomes.
    The incentive programs are achieving their intended result 
of encouraging and increasing EHR adoption. More than half of 
all eligible professionals in the U.S. and approximately 80 
percent of all eligible hospitals and critical access hospitals 
have adopted EHRs.
    But incentives alone cannot sustain the transition to EHRs. 
The long-term sustainability of investments in health IT will 
come as a result of the movement away from fragmented fee-for-
service care and toward value-based, coordinated accountable 
care models.
    CMS programs like Accountable Care Organizations and 
hospital value-based purchasing, and proposed rules like the 
recent one for complex care management, incentivize well-
coordinated care and build a business case for providers to 
sustain their EHR systems over time.
    The incentive programs are also helping to improve the 
quality of care for patients. By requiring reporting on quality 
measures, we establish quality benchmarks. We can provide 
feedback to providers, and we can focus quality improvement 
efforts on measures that matter most to patients. The incentive 
programs are also facilitating safer, more efficient care 
delivery.
    One great example, as was noted, is e-prescribing, which 
gives providers the ability to better manage patient 
prescriptions and reduce adverse drug events. The EHR incentive 
programs require the use of this technology.
    In the first 2 years of the program, health care providers 
who met meaningful use standards reported sending 190 million 
electronic prescriptions. The incentive programs are also 
improving the care experience for patients.
    I helped take care of my father, who was a Medicare 
beneficiary with chronic illness, for many years before he 
passed away. We built his own personal health record from 
scratch, entering data from many paper records. No beneficiary 
or family will ever have to do this again, and can access their 
information electronically.
    Meaningful use Stage 1 requires providers to give patients 
electronic copies of their diagnostic test results, problem 
list, and medication list, and the Blue Button initiative 
allows patients and families to download and use their health 
information.
    By incentivizing the adoption of EHR, CMS is making a 
commitment to the health care delivery system of the future, a 
system that values high-quality, well-coordinated care for CMS 
beneficiaries. Health IT is a foundational building block for 
delivery system transformation and achieving better health 
outcomes for all Americans. I want to thank you for the 
opportunity to speak with you today, and I am happy to answer 
any questions that you have. Thank you.
    The Chairman. Thank you, both of you, very much.
    [The prepared statement of Dr. Conway appears in the 
appendix.]
    The Chairman. First, I would like to remind everyone that 
we will have another hearing on this subject. Next week we will 
hear from providers and vendors to get a little bit different 
perspective here.
    I would like to ask two questions. One is about the various 
stages. Would you modify them at all? How are they working out? 
For example, it is my understanding that in Stage 1 there are 
eligible professionals who must meet about 15 core objectives 
and 5 of 10 menu objectives. Eligible hospitals and CAHs must 
meet 14 core objectives and 5 to 10 menu objectives. In Stage 
2, there are 17 core objectives, and 3 of 6 menu objectives 
must be met, and eligible hospitals, CAHs, must meet 16 core 
objectives and 3 of 6 menu objectives. Stage 3 requirements 
will be determined a little bit later.
    Does that all make sense to you, those core objectives and 
those menus? How would you modify them, if at all, or do we 
need to worry about that?
    Dr. Conway. I will start, and Dr. Mostashari may build on. 
I think the concept behind the core objectives was to require 
the core objective aspects of electronic health records and 
functionality that we thought were critical to coordinate care. 
With the menu objectives, the principle was to allow 
flexibility with selection of the menu objectives.
    We also removed some core objectives and added some 
additional core objectives to raise the bar from Stage 1 to 
Stage 2. With Stage 3, we are evaluating that approach versus 
other approaches, based on stakeholder feedback. With that, I 
will turn it over to my colleague, Dr. Mostashari.
    Dr. Mostashari. As Dr. Conway said, the structure that was 
recommended to us by the Health IT Policy Committee has this 
feature for flexibility. As noted, all providers are not the 
same, and they do not all do the same things. Some of those 
menu objectives may not be applicable to all.
    So, by providing the flexibility, we can say, if you report 
to a professional registry, that can count; but not everybody 
does. If you access imaging results a lot in part of your day, 
that can count; but not everybody does that. So it provides 
flexibility. It also provides the ability for us to introduce 
and signal functionality that is on its way, but it may be too 
soon to require everybody to be able to step up to it.
    The Chairman. Well, there are $15 billion in payments. Are 
the dollars just paid, or is it paid under conditions, such as 
the providers meeting certain conditions?
    Dr. Conway. I can start, if that is all right, and Dr. 
Mostashari can build on. So, they do have to meet requirements 
to receive payments, and you mentioned the core and menu 
objectives which are a significant portion of that requirement 
and the functional measures, if you will, for electronic health 
records. They also have to attest to electronic clinical 
quality measurement. In 2014, with Stage 2, they will be 
electronically submitting, either as individuals or batch 
reporting for groups, on those functional measures and the 
electronic clinical quality measure.
    The Chairman. Are you on track? The administration delayed 
a floor mandate for various reasons, probably because they were 
not quite ready. How are we doing here? Are we on track? Have 
there been any delays?
    Dr. Mostashari. We are finishing Stage 1, and we have had, 
I think, good results in terms of participation and achievement 
of the standards for Stage 1. We are working, in 2013, on 
implementation of Stage 2, which is going to be a big step 
forward, particularly around patient engagement and 
interoperability. We are going to continually monitor where we 
are, how we are doing, how things are going, and react and 
adapt as needed.
    The Chairman. This committee wants to help, so let us know. 
Just do not blind-side us with a telephone call one day that 
says, uh-oh, we are not doing this. Rather, let us know if 
there are some problems that we can help with, because clearly 
I do not know a Senator who does not believe in better health 
IT as a critical component.
    About rural providers.
    Dr. Mostashari. Yes?
    The Chairman. How are we going to help rural providers? It 
is harder for the smaller hospitals in a rural setting.
    Dr. Mostashari. It is. It is much more difficult. There are 
providers who live in areas where EHR vendors will not come out 
to demonstrate the system for them.
    The Chairman. Right.
    Dr. Mostashari. Workforce is a major limitation for them to 
be able to do it themselves. Critical access hospitals have, on 
average, 0.8 FTEs working on IT. The same person is often in 
charge of maintenance as well as IT.
    The Chairman. Right.
    Dr. Mostashari. So they face unique challenges. One of the 
approaches that we have taken is to target rural providers, 
rural health clinics, critical access hospitals, for extra 
assistance through the Regional Extension Center program. The 
majority of rural primary care providers are working with an 
extension program modeled after the agricultural extension 
program that rural providers are familiar with. I think that 
has contributed to rural eligible professionals not falling 
behind in terms of the adoption rate.
    The Chairman. Do you think it has contributed enough?
    Dr. Mostashari. We can always do more. The one area where 
we are working is on better collaboration between all the 
different Federal programs that touch rural providers. In Iowa, 
we recently did a pilot where we worked with the USDA to 
encourage them to look at the rural health care providers for 
the grant programs, the loan programs, that are available 
through the FCC Rural Utility Service. There are many programs 
that target rural providers, rural settings, and we need to 
bring all of our forces to bear in a coordinated way.
    The Chairman. Thank you very much.
    Senator Hatch?
    Senator Hatch. Mr. Chairman, I am going to yield to Senator 
Grassley, who has a conflict and needs to leave.
    The Chairman. I do not know if we can do that. [Laughter.]
    Senator Grassley?
    Senator Grassley. Thank you, Senator Hatch, Mr. Chairman.
    I have just one question for both of you, but I want to 
lead up to that question, so please listen. The purpose of our 
investment in health information technology is to make it 
possible to quickly capture, store, and share data.
    It was our belief when we first started legislating in this 
area that quicker and more accurate data-sharing would lead to 
better care coordination and improve outcomes for patients, as 
well as savings to the Medicare program.
    I recently introduced a bill with Senator Wyden that would 
advance the idea of data-sharing. The Medicare Data Act would 
require the Secretary of HHS to create a searchable database of 
all Medicare claims and payments made to providers. Last 
Congress, we saw increasing support for our bill and a 
broadening belief that more data transparency in the Medicare 
program is a good thing.
    I applaud recent efforts taken by CMS to release Medicare 
hospital data for a limited set of procedures. Despite its 
limited fashion, I take the action to mean CMS recognizes the 
value of transparency in this area. The Grassley-Wyden bill 
goes even further by making public all Medicare claims and 
payments made by all participating Medicare providers.
    Taxpayers deserve to know where their hard-earned dollars 
are going. More transparency also means more provider 
accountability to communities they serve and other 
professionals they work with.
    So here is my question. You have described how health 
information technology will improve communication between 
providers and promote care coordination. Could a searchable 
claims database be used to complement these efforts by making 
providers more accountable to their peers and the public?
    Dr. Conway. So, I will start, and then Dr. Mostashari can 
build on. First, we would welcome the chance to work with you 
and provide technical assistance on this legislation. As you 
noted, CMS is committed to transparency, committed to 
transparency both on performance and quality information, as 
well as cost data. We are committed to utilizing data to drive 
improved quality and decrease costs.
    We have a number of mechanisms now where we are sharing 
data, both, as you noted, public use files for the public, and 
also our various compare sites which are run out of my center 
in CMS, both with data on the compare sites, downloadable data. 
We would welcome the opportunity to expand the ability to 
utilize CMS data to drive improvements and to work with the 
Congress on that.
    Senator Grassley. Dr. Mostashari, I would like to hear from 
you.
    Dr. Mostashari. We believe in the power of data for better 
decision-making and open data to the extent possible, given 
privacy concerns and operational realities. We have been, I 
think, strong supporters of making available data sets as part 
of meaningful use, making part of our certification products 
available, and working with the developer community to make 
good use of that open data.
    Senator Grassley. Thank you, Mr. Chairman. Thank you, 
folks.
    The Chairman. Thank you, Senator.
    Senator Wyden?
    Senator Wyden. Thank you very much. I want to thank Senator 
Grassley for the chance to work with him on that important 
bill, and I look forward to working with our colleagues on it.
    Dr. Mostashari, let me start with you because, as you know, 
we are asking a lot of the Centers for Medicare and Medicaid 
Services in the days ahead, and we are obviously talking about 
medical records today. Just talking with Senator Stabenow, 
sometimes you feel, in discussing these issues, that it does 
not resemble English, that, if you parachuted in, you would be 
trying to figure out what in the world we are talking about.
    So let me start with a question for you, Dr. Mostashari. 
How would you assess the quality of the computers today at the 
Centers for Medicare and Medicaid Services?
    Dr. Mostashari. I do not think that I have enough 
experience with computer systems at the Centers for Medicare 
and Medicaid Services to be able to answer that question. I do 
not know if Dr. Conway would----
    Senator Wyden. Well, I wanted to ask you, because it is 
kind of a lead-up, and maybe we will get into some other areas 
that would shed some light on it. Now, you mentioned that you 
are ``encouraging institutions that have health data to make it 
easier for patients to gain easy electronic access to their 
data and to use that information in ways that improve their 
health and health care.''
    Dr. Mostashari. Yes.
    Senator Wyden. Do you believe that CMS is one of those 
institutions?
    Dr. Mostashari. In fact, I believe that CMS is a key 
institution for doing so. My mom, whom I have health care proxy 
for, downloaded 3 years of every claim submitted on her behalf 
and paid on her behalf from Medicare, and that information on 
her smartphone and on my smartphone has actually been really 
revolutionary in terms of us being able to manage her care 
better. So I think CMS----
    Senator Wyden. That would be a statement that the CMS 
computers are not exactly in the Dark Ages. Would that be fair 
to say?
    Dr. Mostashari. They have done a great job allowing the CMS 
Medicare Blue Button to be available to all 37 million Medicare 
beneficiaries.
    Senator Wyden. All right. So we have made some headway on 
the patient side, and I think that is clearly a plus. We also 
are hearing continually from providers that they are waiting 
for their data, that they are having problems getting it. We 
touched on this a little bit at our hearing last week. This is 
a hugely important point, as you know, because right at the 
heart of the bill is the concept of shared savings.
    What we want to be able to say to providers all over the 
country is--and there is great bipartisan interest in this--
that when you do well, when you are able to give good-quality 
care at more affordable prices, you will in fact get to share 
in the savings. It is locking in a set of incentives that has 
not traditionally been available in fee-for-service.
    It is pretty hard to tap the potential of shared savings if 
the providers keep reporting to us and our various staffs that 
they cannot get their data. So what is your take on that, 
Doctor, and what do you think we can do to make sure that the 
providers can also get their data in a timely kind of fashion?
    You have told me something that I think is plenty useful 
this morning. You said your mom essentially got a lot of useful 
data in a fashion that was helpful to her, but I am still 
getting complaints and concerns from providers. So what is your 
take about how we turn that around?
    Dr. Mostashari. Well, I will allow Dr. Conway to answer, 
but providers are now getting more data from Medicare than they 
ever have before, through the shared savings programs, the new 
CMMI programs, and also through, I think, the important measure 
in section 10322 for qualified entities to receive Medicare 
data for the purpose of benchmarking and providing assistance 
to providers.
    So I think the Affordable Care Act provided important 
enablers of better data-sharing, and it is much improved 
compared to where it has been. I am sure that there are ways to 
improve, but it is better than it ever has been, I believe.
    Dr. Conway. And just briefly, to build on that, through our 
various payment models, we do have monthly data feeds now. For 
example, in the Medicare shared savings program, Pioneer ACOs, 
and a number of payment models, that is much better in terms of 
frequency than previously, as you may have heard.
    To build on the previous point on technical assistance, I 
think we would welcome the opportunity to provide technical 
assistance for what level of resources we would be able to 
achieve, what level of data feed, to what percentage of 
providers in America. So we would welcome the opportunity to 
work with you on this critical issue.
    Senator Wyden. My time is up. I am going to ask you to get 
back to me on the record, Dr. Conway, about a statement in your 
testimony. You make a point with respect to the vendors sharing 
information, because we obviously have to hold the vendors 
accountable. You state, ``We recognize that some providers and 
electronic health record vendors may not have a business 
imperative to share health information across providers and 
settings of care.''
    Now, that is a pretty troubling statement, because 
taxpayers have spent billions of dollars to make this work, and 
the vendors have seen enormous growth since 2009. I think we 
need to know more, and specifically I would like to hear, in 
writing, how you are holding these vendors accountable, because 
that money is out the door. As Chairman Baucus talked about, it 
is huge sums. So can you get back to us, say, within a week on 
that, Dr. Conway?
    Dr. Conway. We can commit to working with the Office of the 
National Coordinator to get back to you, and we will try to 
meet that time frame.
    Senator Wyden. Great.
    Thank you, Mr. Chairman.
    The Chairman. And send that to the committee.
    Senator Wyden. Yes. That is what I meant.
    The Chairman. Senator Hatch?
    Senator Hatch. Well, thank you, Mr. Chairman.
    Dr. Mostashari, I do not think I can get mad at somebody 
who would wear a bow tie like that, I just have to tell you. 
[Laughter.] It is a beauty. I am kind of envious, to be honest 
with you.
    Now, Dr. Mostashari, do you believe that a pause in 
meaningful use payments to hospitals and eligible providers 
would allow us to evaluate progress and readjust, if necessary, 
to get the return on investment that we have searched for with 
the electronic health record incentive program? Should a pause 
also coincide with a delay in penalties for the non-adopters?
    Dr. Mostashari. No, sir. I believe that a pause in the 
program would stall the progress that has been hard-fought. 
Given the movement that we have accomplished through Stage 1, 
we need to give Stage 2 a chance to move ahead and to meet the 
urgency of the moment in providing support for coordinated 
care, for the transformation in health care, and I believe that 
a pause would take momentum away from progress.
    Senator Hatch. All right.
    Dr. Conway, in your testimony you recognized the changes 
that providers experience in trying to comply with multiple, 
and each slightly different, quality measure reporting 
outcomes. Now, my constituents would agree. When can we expect 
all of these measures to be ``harmonized'' and, more 
importantly, reportable as an automated function from within 
the EHR itself?
    Dr. Conway. Thank you for the question, Senator Hatch. So 
we have made significant progress in the last 2 years on this 
issue in my tenure as Chief Medical Officer. Specifically, we 
just proposed, in the physician fee schedule rule, the ability, 
for 2014, for groups of clinicians to report once and receive 
credit for all applicable programs, so the meaningful use 
program, PQRS--the Physician Quality Reporting System--
physician value-based modifier, and, if they are an ACO, the 
ACO program. This is a very different place than we were a year 
or 2 years ago, so we are accepting comments on that rule, but 
we look to finalize it to meet your vision of reporting once on 
an aligned set of measures.
    For hospitals, likewise, they now can, with this proposal--
which we have comments coming back on, and look to finalize by 
August 1st--report once and receive credit for all hospital 
programs: inpatient quality reporting, hospital value-based 
purchasing, and the meaningful use program.
    So it is a critical point. I used to manage reporting on 
quality measures for my health system in Cincinnati, and we 
have now met that goal of an aligned set of measures to allow 
people to report once and receive credit for all programs.
    Senator Hatch. Well, thank you.
    Dr. Mostashari, I have heard from providers that 
significant obstacles to interoperability still exist. Do you 
share this perspective? If so, what are these obstacles, and 
how can we resolve them?
    Dr. Mostashari. The obstacles include technical standards, 
non-proprietary open standards, for sharing information that 
there is consensus around.
    Another obstacle is the business case for information 
sharing on the part of providers, which this committee has done 
really important work towards resolving.
    Third, trust. Many health care providers feel that they are 
entrusted with the patient's information, and they are much 
more comfortable sharing as part of their normal delivery 
patterns of care than with remote individuals whom they are not 
on a first-name basis with. We are making progress on all three 
of those.
    We heard testimony from Marc Probst, CIO of Intermountain 
Healthcare, at the House hearing last fall, that more could be 
done--and we are pushing on the standards--but that there has 
been clear progress toward the interoperability standards. 
Stage 2 of meaningful use and the 2014 certification criteria 
that the vendors are testing now, are taking a big step ahead. 
If you would like, I can describe a little bit what is on the 
pathway here.
    Senator Hatch. All right.
    Dr. Mostashari. The standards that we are working on are in 
three domains. The first is around language, so terminologies, 
vocabularies, so that one person's medication list can be 
compared to and added to another person's medication list. We 
have never had a single standard for comparing medication 
lists. We do now as part of the 2014 certification criteria.
    There are single vocabularies for immunizations, there is a 
single vocabulary for clinical diagnoses, there is a single 
vocabulary for procedures. So these are important to make sure 
that we reduce the cost and, frankly, safety problems when two 
different institutions try to compare local codes and local 
words and local maps. Laboratory results is another.
    The second area we have made progress on is, for the first 
time in our Nation's history, we have consensus--hard-fought 
consensus--on a single standard for packaging patient 
information in an electronic format, so we move beyond PDFs and 
text files to actual structured data, where you know where the 
data elements are and you can reduce the cost of those 
interfaces between different systems. That is the consolidated 
Clinical Document Architecture which is part of the 2014 
certification criteria.
    Finally, we have, for the first time, agreement on what 
protocols to use when sending health information over the 
Internet in a way that can be secure and encrypted. So the 
combination of those building blocks are in the 2014 
certification criteria, and, when they take effect, I believe 
we will see a measurable improvement in the ability of 
organizations to talk to each other.
    Senator Hatch. Thank you, sir.
    Mr. Chairman, thank you.
    The Chairman. Thank you, Senator.
    Senator Thune, you are next.
    Senator Thune. Thank you, Mr. Chairman. I want to thank you 
and Senator Hatch for holding this hearing. This is a hearing 
that I had written to you and requested a year ago, and I 
appreciate the fact that we are having a couple of hearings on 
what I think is a very important topic.
    Earlier this spring, I worked with a number of my 
colleagues, including some on this committee, on a white paper 
that explored issues I hope we address today. I would like, if 
it is all right with you, Mr. Chairman, to submit it. It is 
called ``Reboot: Re-examining the Strategies Needed to 
Successfully Adopt Health IT.'' I would submit it for the 
record.
    The Chairman. Without objection.
    [The white paper appears in the appendix on page 78.]
    Senator Thune. I want to start by thanking Dr. Mostashari 
for the efforts that he has made in responding to questions 
posed to the administration as part of that ``Reboot'' report. 
We received a response last week, and I appreciate the 
substance of that response.
    I want to ask a question. I am really concerned about the 
argument that we need to make sure that there is a sufficient 
business case for continued progress on interoperability and 
exchange of data between unaffiliated providers. At some point 
the ability for the Federal Government to provide sufficient 
carrot and stick incentives is limited by the resource 
constraints and an appropriate level of financial penalties.
    So I am curious to know what you are doing to encourage the 
use of real market forces, not just government incentives and 
penalties, to create the business case for continued progress. 
I also wish to know what role the anti-kickback statute plays 
in constraining the types of market incentives that could be 
used to help make that business case.
    Dr. Mostashari. Absolutely. And to clarify, we believe that 
it is important for government to be part of, along with the 
States, along with commercial payers and purchasers, changing 
the context in terms of how the market operates.
    We are not suggesting that we need more incentives akin to 
the health IT incentive program--paying people per transaction 
to create a business case for information exchange. It is more 
creating the context.
    The readmission adjustments have had a market effect on 
hospitals' interests in coordinating care once they discharge 
their patients. They just have. We see that every day. The 
vendors now are much more interested in having interoperability 
because their customers are saying to them, the market is 
working.
    Their customers are saying to them, when I discharge a 
patient to a nursing home, I want that nursing home to be able 
to get this information electronically. I want the primary care 
provider to get the discharge summary. If someone shows up in 
another emergency room, I want to hear about it, because I do 
not want them readmitted. That is what we mean by creating the 
business case for information exchange. It is really the 
business case for care coordination, which is what this 
committee is taking such important steps on.
    In terms of the Stark law and the anti-kickback statute, we 
worked with CMS and the Department of Justice on a Notice of 
Proposed Rulemaking on that, and I will let Dr. Conway speak to 
that. But it was clearly one of the policy issues that we could 
use as a lever to make sure that if information systems and 
software are donated, that we also get the expectation out of 
them that they will not be used to lock in patient data to a 
given institution.
    Dr. Conway. So, as Dr. Mostashari said, we have proposed a 
regulatory change that we think addresses some of those issues. 
Obviously, there are additional statutory changes you or other 
Senators are interested in. We would work with you on that. 
Just to amplify what Farzad said about the incentive structure, 
I have worked in delivery systems that migrated their contract 
models away from fee-for-service to accountable care models, 
and it does shift your incentives in a private market setting 
to incentivize sharing of information and coordination of care.
    So, whether it is a readmissions program or new payment 
models, our goal is to incentivize those models that enable 
providers in the private market to achieve better health 
outcomes at lower cost.
    Senator Thune. I want to come back to something that 
Chairman Baucus talked about earlier. I am concerned about the 
digital divide that may only get larger as rural hospitals are 
expected to take a leap into the more rigorous requirements of 
Stage 2. They have already expressed grave concerns about Stage 
2.
    I am of the view that ONC and CMS ought to develop a way 
for rural hospitals to have more time to achieve Stage 2, while 
allowing the more advanced health care systems and providers to 
move on to Stage 3 if they are ready. So the question would be, 
will you commit to giving rural providers more time to achieve 
Stage 2?
    Dr. Mostashari. We meet with the rural providers, and we 
hear from them. Marty Fattig, whom you will hear from next 
week, is on our advisory group, and we have been, I think, 
quite open to dialogue with the rural community in terms of how 
we can help them achieve success and not necessarily accept 
that they are going to be further behind.
    I think the Regional Extension Centers have helped now. We 
set a goal of getting a thousand critical access hospitals to 
meaningful use by the end of 2014. We are going to revise that 
goal to get a thousand critical access hospitals to meaningful 
use by the end of this year.
    We think that we are making good progress with those 
hospitals through the technical assistance and through the 
coordination that is possible, so we are open to dialogue. But 
I would much rather see the rural hospitals be able to keep up 
rather than acknowledge that they are going to fall behind.
    Senator Thune. My time has expired, Mr. Chairman.
    The Chairman. All right. Thank you, Senator, very much.
    Senator Casey?
    Senator Casey. Mr. Chairman, thank you very much.
    Dr. Mostashari and Dr. Conway, thank you for your testimony 
and your public service. When medical doctors and people with 
your education and experience are dedicating their time to 
helping all of us with regard to health care in the Federal 
Government, implementing the Affordable Care Act and all the 
work that you do, that is of great significance, so we are 
appreciative of your work.
    I wanted to try to explore maybe two issues, but the 
principal focus that I will have in my questions will be with 
regard to children and pediatrics. Dr. Conway, you have spent a 
lot of years laboring in the vineyards of children's hospitals 
and working with kids, I know both in Cincinnati and in 
Philadelphia. How many years, one versus the other?
    Dr. Conway. Approximately 2\1/2\ years in Philadelphia and 
5 total in Cincinnati.
    Senator Casey. We want you to increase that Pennsylvania 
number. [Laughter.]
    Dr. Conway. I am sorry; I will work on that.
    Senator Casey. I wanted to ask you in particular, when you 
focus on where we hope we are in Stage 3, when you are 
measuring quality more than you are in the earlier stages, tell 
us a little bit about how you measure quality, but in 
particular how you measure it as it relates to children.
    Because, as you know, as you have, I am sure, said and the 
advocates tell us all the time, children are not small adults, 
so how you measure for adults will differ from children. But 
tell us about that, how you are beginning to implement it and 
how you hope it works in Stage 3.
    Dr. Conway. Thank you for the question, Senator Casey. 
There are a couple of ways we are trying to address that issue, 
and it is a critical issue, as you mentioned. One, especially 
for Stage 2, we actually ensured that we had sufficient 
measures covering pediatric care so that, if you are a 
pediatric provider, you can report on measures relevant to your 
practice.
    Two, we had had the concept of an adult-recommended core 
set of quality measures previously. We actually also did a 
recommended set of pediatric core measures to report on. Also, 
working with our colleagues at the Agency for Healthcare 
Research and Quality and Medicaid, we have worked on 
initiatives related to standardized electronic health records, 
working with vendors to make sure that there are electronic 
health records that meet the pediatric population needs.
    In addition, through the CHIPRA funding, the Children's 
Health Insurance Program reauthorization, as you know, there 
was funding for pediatric measurement development. We are 
working with our colleagues on developing measures that I think 
will be the next generation of pediatric measures, everything 
from safety measures to care coordination to dental health, a 
wide spectrum of pediatric measures that will really put us in 
a much better place to make sure we are ensuring that we are 
measuring quality robustly for pediatric patients.
    Senator Casey. Dr. Mostashari, would you like to add 
anything on this in terms of your work?
    Dr. Mostashari. I would just agree with Patrick that there 
has been a lot of work to move measurement from many of the 
process measures, of which we have lots, to more outcome-based 
measures, measures that are more parsimonious, more broad-
based, and more designed from the ground up to be used with 
electronic health records, instead of re-tooling measures that 
are meant for chart reviews, for which the data elements can 
often not be found or only found with difficulty with an 
electronic health record.
    There was a recent article published last week out of 
Kaiser that found that they reduced the cost of chart review 
for quality measures by half. They cut it in half based on 
being able to extract information from the electronic health 
record. But it is still not good enough.
    There are still too many quality measures that are re-
tooled, that require elements that just do not make sense 
within the electronic health record context, and we are working 
in close collaboration with CMS to build new measures from the 
ground up that actually matter and that work.
    Senator Casey. And also, with regard to children, the 
development of databases, both regional and national--can you 
tell us about that?
    Dr. Conway. I will start, and Dr. Mostashari may add on. I 
think we are working with our Medicaid office, for example, on 
the CHIPRA quality measures, working with States on quality 
reporting. In terms of database development, we are actually 
working across the Federal Government, from the National 
Institutes of Health to the Administrative Resource Center to 
others, on what would be the infrastructure to collect data to 
inform care for children.
    I currently care for mainly children in the hospital with 
multiple chronic conditions who are hospitalized, and that is a 
population where we often do not have the data and the evidence 
necessary to guide their care as best we can. Prior to coming 
to the Federal Government, I was part of an effort that 
actually linked children's hospitals on an electronic platform, 
both for improving care quality and also research to inform 
that next stage of care delivery.
    Dr. Mostashari. One thing I will add is that the pediatric 
community has actually been great at working together in 
collaboratives, whether it is around cancer or cystic fibrosis, 
and is a real model. If you look at the improvements in the 
death rates from childhood cancers and the number of children 
who end up in clinical trials, it is really a model for what we 
hope to be able to do for adults.
    It is one of the goals, I think: not having a single 
centralized database of patient information, but rather having 
networks of organizations and institutions that can collaborate 
together. We are working on the standards for that to be able 
to share that information, and working with the Patient 
Centered Outcomes Research Institute to create that data 
infrastructure for distributed research as opposed to combining 
information in one database.
    Senator Casey. Thank you very much.
    The Chairman. Thank you, Senator.
    Senator Enzi, you are next.
    Senator Enzi. Thank you, Mr. Chairman. Thank you for having 
this hearing. I am also pleased that next week we are going to 
have one with the private technology industry so that we can 
learn more about their involvement, as well as Federal 
impediments. I think that will be very helpful.
    Dr. Mostashari, I have heard concerns from the Wyoming 
Health Information Exchange that the requirements for data 
exchange in Stage 2 of the meaningful use program represent a 
step backwards for the program. In particular, representatives 
from the health information exchange have informed me that the 
secure data exchange requirements are limited to e-mails and 
text messages, when their system has a much more advanced 
capability already.
    Can you tell me how ONC is coordinating with States like 
Wyoming to ensure that the meaningful use program is not 
hindering State progress in deploying HIT? What is being done 
to ensure that these innovative approaches are not hamstrung by 
current Federal rules?
    Dr. Mostashari. Absolutely. We are working very closely 
with all of our grantees on the State health information 
exchange grants. We have health IT coordinators in every State 
funded through the program and designed by the Governors to 
coordinate with their local needs, their local resources.
    The different models in different States are different. 
What happens in Texas and the approach taken there is different 
from the approach taken in Maryland. We do work with them to 
make sure that the plans that they have are in alignment with 
the national standards and have a path to sustainability.
    Senator Enzi. Are you currently just doing the e-mails and 
the text messages? What about the other advanced capability? 
That is the main part of the question.
    Dr. Mostashari. Sure. No, sir. The requirements, both for 
meaningful use, the certification of electronic health records, 
and for the health information exchanges, are not limited. They 
are a floor, not a ceiling. We are supporting the States in 
development of more complex, more comprehensive query systems, 
even as we are also supporting the more directed messaging, 
which, to clarify, is not text or PDF, it is actually exchange 
of structured, codified electronic information through direct 
messaging.
    Let me give you an example of a rural provider in Wyoming 
who has an independent practice in a small town.
    Senator Enzi. That would be Dr. Gee. I talk to him all the 
time, so you do not need to answer any questions in regard to 
that. He is my authority.
    Dr. Conway, a recent news article noted that more than 
10,000 providers who participated in 2011 did not do so in 
2012. Does this trouble you, as these providers are subject to 
penalties if they do not meet the Medicare meaningful use 
requirements year-on-year? What will you do to simplify the 
program, and were these providers more rural or urban 
providers, or located in a particular type of practice or area 
of the country? Who is it who dropped out?
    Dr. Conway. So it is important to note that it was a 
relatively small percentage who dropped out of the program. 
However, it is an important question to look into the reason 
for it, so we have started.
    Senator Enzi. Ten thousand is a small number?
    Dr. Conway. What I mean by that is, if you think of the 
300,000 participating providers, 10,000 is a significant number 
that we did look into. I just mean, as a percentage basis, it 
is a small percentage. We did, though, investigate this and 
look into the reasons. It was a mix of factors: people who were 
retiring, often people who were switching practices to a new or 
a different practice setting.
    For some, there was education outreach. They did not 
realize you needed to come back in every year, so now we are 
doing some reeducation and outreach, working with physicians 
and especially societies to make sure people understand it is 
an annual update program. So there were a host of other 
reasons--they wanted to switch vendors, for example. So there 
were a host of reasons. In terms of the program burden, we 
always look to find the right balance of moving the program 
forward but minimizing burden and eliminating unnecessary 
burden on providers.
    Senator Enzi. Thank you. Because we have to work with these 
people one-on-one, even though it is 10,000.
    Dr. Conway. Yes, sir.
    Senator Enzi. And it is a small percentage, but each one of 
them has a major concern.
    I have another question, I think along those lines. CMS 
stated it is increasingly incorporating the electronic quality 
measurements into payment systems. How are you going to assure 
providers that their performance is being fairly and accurately 
represented in the data submitted to CMS as part of that 
meaningful use program? What is your time line and plan for 
improving the integration of the quality measurement, 
especially the outcomes-based measurement, into the electronic 
health records?
    Dr. Conway. Thank you for that question. We are aligning 
measurement programs. As I mentioned briefly, we have proposed, 
for this year's physician fee schedule rule, to enable 
providers to report once and receive credit for all applicable 
reporting programs: the EHR incentive program, PQRS, physician 
value-based modifier, and, if they are an ACO, the ACO program.
    In terms of the validity and the reliability of the 
measures, we also work with the Office of the National 
Coordinator on certification criteria to attempt to ensure that 
electronic health records are capturing and reporting the data 
reliably.
    Also, for Stage 2 we are enabling data intermediaries, 
enabling a private market for data intermediaries, to serve 
both for frequent feedback to clinicians and for standardized 
reporting to CMS, and, similar to what we have done in the 
hospital program, our goal is to provide feedback to providers 
and to ensure that we have valid and reliable electronic 
clinical quality measures.
    Senator Enzi. I have to talk to my doctors to see if they 
can understand what you just said, because I had a little 
difficulty with it. I will have more specific questions on all 
those acronyms that you mentioned. My time has expired; I 
apologize.
    The Chairman. No problem, Senator.
    Senator Stabenow?
    Senator Stabenow. Thank you very much, Mr. Chairman. This 
is a very important hearing. Let me just start by saying we 
have given you a massive task. When I think about where we 
started a few years ago with a number of us working on this for 
a long time and talking about going from a paper-based system 
to a digital, electronically based system, it is just amazing. 
So I know there is a lot of work to do.
    I have a lot of concerns about specifics, but I just want 
to say in the beginning that we should at first recognize the 
fact that 50 percent of eligible providers, 80 percent of 
eligible hospitals, have gotten incentives to move to 
electronic health records, and, overall, adoption has more than 
doubled for physicians and quadrupled for hospitals.
    So we have done a lot of important work, I think, together 
on the committee, as a Congress, working with all of you. The 
fact that participating provider practices have increased from 
45 percent to 80 percent from 2008 to 2012, in terms of 
electronic health records, is very significant. We need to get 
it done, and we need to get it done right. As the chairman 
said, I do not know anyone who does not think this is 
absolutely necessary to do.
    Given that, let me associate myself with Senator Hatch, who 
asked about health IT and quality measures, and just reiterate 
that. Dr. Mostashari, we are in a situation where I know that 
you are focused on streamlining measures, and we have all kinds 
of examples. I have hospitals in some cases reporting the same 
information twice in two different formats. We have to address 
that if this is going to be successful.
    Let me talk about vendors and interoperability. I know that 
Senator Wyden and our chairman have expressed interest and 
asked you to respond for the record, but I would like to ask 
you to just talk about it for a moment, because I am hearing a 
lot of frustrations from hospitals and physicians.
    They are purchasing systems that are unable to communicate 
with other systems. There is not enough information exchange 
infrastructure. The costs of products are overwhelming. In some 
cases, they are being sold products that are not interoperable 
and told, if they want them to be interoperable, it is going to 
cost them more money.
    So what are we going to do about this? I mean, we see 
situations where some vendors form contracts that block the 
exchange of information. Certainly the vendors are very 
important, but this seems like it is a real problem, so I am 
wondering, Dr. Mostashari, if you would speak to that.
    Dr. Mostashari. Yes. Absolutely. There needs to be action 
on multiple fronts. We need to exert the regulatory levers 
judiciously, to not take too heavy of a hand, but not rely 
entirely on the invisible hand either. So, in our certification 
program, for example, we have required transparency from the 
vendors in terms of their pricing.
    If a module is going to cost you extra, in addition, you 
need to be transparent about that with the customers. You have 
to be transparent about how you passed the certification test. 
We still hear providers saying, I do not understand how this 
product got certified. We indeed have pulled the certification 
for a vendor who did not respond to repeated questions about 
whether they in fact were doing what they were supposed to be 
doing. We also have requirements around user-centered design so 
that, particularly around safety issues, they meet those needs.
    Senator Stabenow. I was just going to jump in and ask, do 
you think you have enough authority from a regulatory 
standpoint----
    Dr. Mostashari. Yes.
    Senator Stabenow [continuing]. Or do we need to change the 
law?
    Dr. Mostashari. No. No. We have authority from a regulatory 
standpoint. The question is, the judicious exercise of that 
authority. We also need the market, the invisible hand, to work 
too. The customers need to be demanding and tough customers, 
and they need to ask for interoperability. We have regional 
extension centers helping the smallest practices with better 
vendor contracts, better negotiations, and so forth.
    But in between the market competition and regulation there 
is something else, and that is kind of professional business 
norms and the social norms among the vendors. We have asked 
them to step up on that, and, in fact, the vendor association 
did just recently come out with a code of conduct, which I was 
very glad to see, where the vendor is saying there is actually 
a code of good conduct for electronic health record vendors 
that includes things like not blocking information. So I do 
think we are making progress on that. We need to continue to be 
vigilant.
    Senator Stabenow. Let me just say, as my time is up, that 
also related to interoperability, of course, particularly in 
rural areas, is tele-health, which has such an important 
impact. We have a lot of leaders in Michigan, in what we call 
the Upper Peninsula of Michigan. Marquette General Hospital has 
received a lot of recognition for what they are doing. So I 
hope that we are using what we are doing in terms of leveraging 
tele-health with the interoperability standards that we are 
putting together. Particularly for rural areas, that is very, 
very important.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator. Thank you very much.
    Senator Roberts?
    Senator Roberts. Well, thank you, Mr. Chairman. I think I 
am riding drag on this posse. I want to associate myself with 
the remarks of Senator Enzi and the distinguished chairman and 
ranking member. Senator Stabenow pretty well summed it up with 
regards to the word getting out to all of our rural health care 
providers, and for that matter any health care provider. Who 
are you meeting with this Friday, or a week from Friday, in 
terms of the rural providers?
    Dr. Mostashari. We actually meet weekly. Our staff meets 
weekly with----
    Senator Roberts. Who are these folks?
    Dr. Mostashari. It is the National Rural Healthcare 
Association.
    Senator Roberts. All right.
    Dr. Mostashari. It is critical access hospitals, it is----
    Senator Roberts. How many of them are there? Five, 10, 20? 
What? Three?
    Dr. Mostashari. I am sorry?
    Senator Roberts. How many are there?
    Dr. Mostashari. Oh, I would have to get back to you on 
that.
    Senator Roberts. Well, my concern is, I do not think we are 
getting the word west of Highway 81 in Kansas, or for that 
matter, what was it, Ten Sleep in Wyoming? That is 250 people. 
They have to go 40 miles to even see a doctor.
    But I am worried about these folks, because it is a lot 
like Paul Harvey used to be with Page 1 and Page 2. You know, 
Page 1, and I will be back in just a minute. Well, you have 
Phase 1 and Phase 2. If we could just pause and make sure that 
most of the rural providers know what is going on, because I 
get two sides of the story. I talked with the folks in Topeka, 
our capital. They say everything is going as best as it 
possibly can. I get a lot of calls from providers saying this 
is the proverbial wet horse blanket.
    Let me just ask a specific question. Well, my suggestion 
would be to take this show on the road, to go out to places. I 
would recommend probably Hays, KS, or Dodge City, KS. That is 
my hometown. I am not sure I would recommend wearing the bow 
tie in Dodge City, KS. But at any rate, we will let you do 
that. It would be easy. I could say, I cannot answer that 
question; ask the guy with the bow tie. I am not trying to pick 
on you here. [Laughter.]
    But if you could go out and sort of take this, what, 
digital show on the road, I think that might be helpful, or 
maybe have these folks come in. That might be a better thing, 
because I know you are extremely busy. By the way, thank you 
for coming by and visiting with me.
    You have stated that providers will also be required to 
communicate with patients through secure messaging, like 
encrypted 
e-mail, and make patients' health record information available 
to them electronically. Now, we have not seen any details on 
this, and this is probably premature, but how will this work 
for patients in physicians' offices who do not have 
sophisticated access to a computer or the Internet?
    Dr. Mostashari. So, Senator Roberts, I did find the numbers 
for you. We are working, through our Regional Extension Centers 
that are in the field, modeled after the agricultural extension 
program, with 23,650 rural primary care providers and 1,025 
critical access hospitals, boots on the ground, helping them 
understand what the program is about and to be successful at 
the transition.
    Senator Roberts. Now, I have 83 of those critical access 
hospitals in my State. I am not sure. You are saying you have 
been out there to visit with these folks?
    Dr. Mostashari. Not me personally, but we have----
    Senator Roberts. Well, not you. I understand that.
    Dr. Mostashari. We have funded the Regional Extension 
Center in Kansas to work with them, and they are working with 
207 providers who are working in critical access hospitals in 
Kansas.
    Senator Roberts. I appreciate that. Thank you.
    I want to go to a more specific question. I am running out 
of time here, so I will try to be brief. I have heard a lot 
from providers, more specifically, a radiologist, a 
pathologist, an anesthesiologist, that they fall subject to 
penalties for not participating in the requirements of an 
office-based program where they would simply be collecting data 
to report to the government to avoid a penalty.
    Do we have any plans to improve the flexibility for these 
specialists? It seems a little ridiculous to me that, if we are 
just going to collect data that they would not otherwise gather 
in their practice, that would not be necessary.
    Dr. Mostashari. Yes, Senator. That is feedback that we 
heard from Stage 1 of meaningful use. Many of those specialists 
were originally classified as hospital-based providers, and 
there was a legislative change to include them as eligible 
professionals, which meant that they would be potentially 
eligible for the penalties as well. But we are now hearing 
about the difficulties they may face as users of the hospital-
based system in meeting some of those requirements.
    So we have, in Stage 2, in the final rule that CMS 
promulgated, provided for the opportunity for exceptions for 
hospitalists like anesthesiologists, pathologists, and 
radiologists, whose systems are the hospital systems that they 
use.
    Senator Roberts. What is the length of the comment period 
on the final rule?
    Dr. Mostashari. I can get back to you. I think it is 60 
days.
    Senator Roberts. This is not an interim final rule where 
you have 30 days and then, bingo, you are----
    Dr. Mostashari. We had a Notice of Proposed Rulemaking, and 
we received, I think, a few thousand comments on that, and we 
did a final rule after 60 days of comment.
    Senator Roberts. Is there any comment period after the 
final rule? I mean, is final final?
    Dr. Conway. Once it is finalized, the rule is final. We 
always welcome comment to inform future stages of rulemaking, 
if there are any adjustments that we can make on a 
subregulatory basis. This is an important community that we are 
trying to work with to make sure the program works for them.
    Senator Roberts. I appreciate that. Thank you for your 
answer, and thank you for coming.
    The Chairman. Thank you, Senator.
    Gentlemen, as you know, we are having another hearing with 
vendors and others. What will they tell us; what will their 
complaints be? What will their concerns be, and what is your 
response?
    Dr. Mostashari. I think you are going to hear different 
things, Senator, depending on whom you ask. There will be some 
who will say that we are not moving fast enough, not moving 
hard enough. There are others who will say it is too fast and 
the standards are too rigorous.
    The Chairman. So what category is going to say ``not fast 
enough,'' and what is the category that is going to say ``too 
fast''?
    Dr. Mostashari. Making broad generalizations in terms of 
the comments that we received from the Notice of Proposed 
Rulemaking, the consumer community believes and has written to 
us about needing to keep up the pressure, with purchasers and 
payers included in that group.
    Some of the smaller, more nimble software companies feel 
that this is not that difficult to step up to the next stage of 
certification. On the other hand, the bulk of the larger 
vendors and some of those who have to deal with hundreds or 
thousands of separate----
    The Chairman. So what is going to be the most legitimate 
complaint?
    Dr. Mostashari. Well, they are all legitimate, Senator.
    The Chairman. I said ``most legitimate.''
    Dr. Mostashari. I think one of the lessons that we have 
learned, and one of the ways in which we need to continue to 
evolve the program, continue to make forward progress on the 
program, is going to be moving more towards outcomes, not just 
in our quality measures but also in the program, and aligning 
the program ever more tightly with the needs of delivery reform 
and payment reform.
    So our goal is for this health IT to be truly a foundation 
for your work, to be able to create a higher quality, safer, 
more cost-
effective health care system. The greater the alignment we can 
bring between the health IT and the payment and delivery 
reforms, the more successful both will be.
    Dr. Conway. If I might build on that.
    The Chairman. Sure. Go ahead.
    Dr. Conway. You named one of the groups earlier that I 
think about a lot--and we need to make sure we address the 
issue sufficiently--and that is rural providers, small 
practice, small-town providers. By way of context, I grew up in 
a small town in Texas with a solo practitioner family medicine 
doctor. Many of my family are in small practices across the 
Midwest, including my sister, who is a solo practitioner 
specialist in the Midwest.
    Farzad mentioned a lot of the Regional Extension Center 
work that we are doing that is terrific, but I think we need to 
continue that work, and we need to make sure that the program 
meets the needs of the rural and small practice providers. We 
also need to think about what support looks like in future 
years beyond the Regional Extension Centers.
    The Chairman. I appreciate that. But boy, I urge you to get 
out. That is, out of your offices and get out to rural America 
and see it, smell it, and taste it, and know what it is. It is 
one thing to conceptualize it; it is something else to 
experience it. I mentioned to you, Dr. Mostashari, I do not 
know, but I sense you are a Philadelphia guy, or now you are an 
eastern guy, a big city guy, and there is a huge difference.
    Eighty percent of life is showing up, just getting out 
there, just being there and seeing it. Get out from behind your 
desk. It is well worth it. You are going to make fewer mistakes 
with respect to rural providers if you get out and see what 
they experience.
    Montana, for example. Let me put it this way. I forgot what 
the new data are, but the population density, I think, in New 
Jersey, is over 1,000 people per square mile. In Montana, it is 
about six. There are just huge distances. It is very small 
operations. You mentioned it, that somebody who is doing IT is 
also the person who is maybe the janitor, or might be doing 
something else. So, just get out there, talk to them, feel 
them, taste them.
    Dr. Mostashari. With the bow tie. [Laughter.]
    The Chairman. With the bow tie. I do not care. With or 
without, it makes no difference. Just ask the right questions, 
because people will want to work with you.
    Dr. Conway. I will come to Montana anytime.
    The Chairman. I want you both to go to Montana. I brought 
Bill Roper out when he was CMS Administrator a few years ago. 
Unfortunately, it was during a blizzard. He flew into a small 
town, Lewistown, MT. As we were flying out, he was literally 
white-knuckled. He was scared to death. It worked. We got a 
little bump-up in reimbursement, I suppose. [Laughter.]
    He saw what we are going through.
    My time has expired. Senator Thune, go ahead.
    Senator Thune. Thank you, Mr. Chairman.
    When you go to Montana, I think the bow tie is all right as 
long as you are wearing cowboy boots. That will be the ultimate 
equalizer.
    Without beating this to death--and we have covered it a 
lot--I understand the aspiration you have to have all the rural 
providers being able to participate in this and to move along 
at the same rate as some of those in more urban areas, but as a 
practical matter, that is just probably an unrealistic thing to 
hope for. So I guess the only thing I would say is, I think we 
need to really carefully balance accommodating those rural 
needs, while not holding back those who are ready for a more 
advanced data exchange.
    So I guess the only thing I would say in response to your 
earlier response, when I asked the question about whether or 
not you could give rural providers more time, is that you 
really should take a realistic approach to accommodating those 
needs, because I think, just practically speaking, the area 
that the chairman represents and the area that I represent are 
very remote, very rural, and these things are just, practically 
speaking, going to take a little bit more time.
    Stage 1 of the meaningful use required no actual cross-
platform exchange of information. Stage 2 requires one instance 
of information sharing, and that can be with a dummy server set 
up by the government. In 2013, how is it possible to 
meaningfully use information technology without actually 
sharing information outside of a proprietary network? So the 
question really is, has the bar really not been set too low for 
those who are ready for an advanced level of exchange?
    Dr. Mostashari. We do have, I think--again, listening to 
the community and everybody who is affected by this, including 
some rural providers who said that they do not have means of 
exchanging information, I think the challenge that you raised 
is exactly right. How do we not hold back those who want to be 
the trailblazers and yet make accommodations for the diversity 
that we have in our country?
    The other observation that we have had with setting 
thresholds, Senator, is, we fight a lot and have a lot of 
discussions about what the threshold should be, and what we 
actually find is that, when the data comes in, when the 
providers actually do the workflow changes, they do not just do 
it for 10 percent or 20 percent or 30 percent of their 
patients. They do it consistently.
    There was just a paper published this week that found that, 
whatever the threshold was, the actual median level of 
accomplishment on the part of hospitals was between 92 and 100 
percent of the threshold. So for me, one of the lessons has 
been to focus a little bit less on fighting over the threshold 
and to just get folks to begin making that transition.
    I think the menu items, the menu optional approach, was one 
way that we allowed for people in Stage 1 who were ahead to get 
credit for information exchange use, and for Stage 2 we said, 
now everybody has to be able to do it. So I would love to 
continue to work with you and with the committee on how we can 
continue to keep the pressure on interoperability and care 
coordination while accommodating the diversity we have in our 
country.
    Senator Thune. The Stage 3 rules have not been written. I 
am wondering how we achieve those goals that you have laid out 
between now and the end of Stage 3 in a reasonable way. I am 
also wondering what your plans are for after Stage 3. Are you 
planning future stages? If so, what do those stages look like?
    Dr. Conway. Maybe I will start, and then Dr. Mostashari can 
build on. We plan to write the Stage 3 rule in 2014. To the 
previous question on interoperability, we put out a Request for 
Information on how we push interoperability forward, so we are 
taking that input in, both for Stage 3 rulemaking and for any 
other changes outside of meaningful use rulemaking. So we plan 
to propose Stage 3 in 2014.
    Senator Thune. Go ahead.
    Dr. Mostashari. In terms of the road map for meaningful 
use, I think I was just visiting Virginia Commonwealth 
University last week with Patrick and Jon Blum. Their journey 
is very similar, I think, to what many other providers are 
facing, where their first priority was making sure that within 
their practice, within their hospitals, all across their 
different sites and specialties, they can share the information 
and the information is available when they need it. That is 
kind of Stage 1, and that was their first priority the first 
few years of their journey.
    The next priority for them was, now how do we reach out to 
our affiliated providers that we work closely with all the 
time? How do we make sure those referrals get to them, get back 
and forth, the laboratory results are getting where they need 
to go, the EKG results are going where they need to go? That is 
Stage 2, and much of what we have in place will support that 
sort of local coordination of care: planned care referral 
exchange, laboratory exchange, public health exchange, pharmacy 
exchange, the network of providers that are within your local 
community that you exchange information with.
    For Stage 3, and where they are not quite there yet is, how 
do I allow someone else to query my system? There are lots of 
concerns that providers have before allowing that to happen. 
They are technical issues, but they are also issues of, how do 
I know that you are authorized to do this query? How do I know 
that you are going to get the right patient? What if I release 
information on the wrong patient? How do I know to trust you?
    I think, if we look at the road map for where we are going 
in interoperability, the goal is always the same. The goal is 
that patient information is available when and where it is 
needed, but the staged approach accounts for the realities of 
where we are and where individual providers will be in their 
progression: first, let me get my own house in order; next, let 
me exchange information with those I talk to all the time in my 
local community; and then the next stage will be enabling what 
we all hope for, that, wherever we are, if we have a problem, 
our information can be accessed.
    I will say that the other thing that Stage 2 permits is 
this: Stage 2 permits every patient, every family member, every 
caregiver who chooses to accept more responsibility and be 
empowered with their own information, to get their own 
information and share it with whomever they want to share it 
with. I believe this is going to be a major step forward, if 
health care providers also embrace that relationship, that new 
relationship, with the patient.
    The Chairman. Good.
    Senator Thune. Thank you, Mr. Chairman.
    The Chairman. Thank you.
    Senator Thune. Thank you, gentlemen.
    The Chairman. What happens when someone tries to access 
John Smith's record but there are a million John Smiths? How do 
you handle that?
    Dr. Mostashari. That is one of the barriers toward enabling 
the sort of exchange that we hope to see. I was at Metro Health 
in Cleveland, and I saw a patient sitting next to a doctor who 
said, I got my care at Cleveland Clinic.
    They went and they queried Cleveland Clinic, and they got 
the patient's records back, because it was not a query to the 
world asking, does anyone have information on the patient? The 
patient told them his records were at Cleveland Clinic. So they 
only asked Cleveland Clinic, and the universe of potential 
wrong matches is dramatically lower if you know who you are 
asking and they know whom you are responding to.
    The Chairman. And if you do not?
    Dr. Mostashari. If you do not, it is much more challenging.
    The Chairman. So what is the solution?
    Dr. Mostashari. We are going to continue to work on finding 
ways to improve the quality of patient matching, improve the 
data quality that is used to do that matching, and have 
guidance on what constitutes an adequate match and what are, 
frankly, the liability issues and protections in the case of 
incorrect matches.
    The Chairman. So how do you build in trust? You mentioned 
some providers may not want to divulge information. They do not 
know if they can trust the person making the query.
    Dr. Mostashari. Correct.
    The Chairman. How do you develop trust?
    Dr. Mostashari. So trust builds up, I think, over time in 
the people whom you work with, in sharing care for patients. 
That is first-name-basis trust. But we can also create 
institutional supports for that trust.
    So one of the things that we are funding and working with 
are governance entities that can say, let us all agree to a 
common set of rules of the road in terms of how to treat 
patient information, how we authenticate the users, whether we 
get patient consent and how. Having different organizations 
that follow the same rules of the road can increase that trust, 
but it is no substitute for actual experience.
    The Chairman. Yes. I am not nearly sufficiently technical 
to know how to ask the next question, but it is basically, what 
is the goal here? Is the goal here that all patients, all 
providers, will be able to access records?
    Dr. Mostashari. It is a staged approach, and our goal after 
Stage 2----
    The Chairman. Is that the goal? Is that the end goal here?
    Dr. Mostashari. The end goal is that every patient care 
setting makes use of all the world's knowledge in taking care 
of that patient, and that that patient encounter then 
contributes to the world's knowledge. That is the end goal. How 
we get there is going to be an interactive process.
    It is going to take time to get there. But we should start 
with just making sure that patient information is available 
within a practice, within a hospital, within an ACO, within a 
community, and work towards resolving the significant technical 
and policy barriers to the ultimate solution.
    Dr. Conway. Sorry. May I----
    The Chairman. Go ahead. Sure.
    Dr. Conway. So, to try to build on that and sort of drill 
down to specifics, I think our health system's end goal is 
better health, better care, and lower cost. Underneath that I 
think you have measures of health care and cost. Underneath 
that, I think health IT is a foundational building block, but 
it is hard to get there without health IT. If you are my boss, 
Administrator Tavenner or Secretary Sebelius, I think our 
focus, as Farzad knows and is a key part of, is a focus on how 
we improve health outcomes for all Americans.
    The Chairman. How can all this be gamed? There are a lot of 
nefarious people out there. Most are good people, but there are 
a few who are not. So, if you are a bad guy, put yourself in 
the shoes of somebody who wants to game this thing, make money 
he or she should not make off the system. How do you do it? How 
are you protecting against it?
    Dr. Conway. I think we at CMS are always concerned about 
the potential for gaming or improper payments. Let me tell you 
what we are doing to date on that. One, based on feedback we 
got on the program, we have now instituted, not just pre-
verification but also pre-payment audits, especially when there 
is abnormal data and random audits. So, pre-payment audits will 
try to ensure that we are not improperly paying.
    We also have post-payment audits to focus on and try to 
eliminate any improper payments or gaming of the system. As you 
move to submitting data, we also will have actual data to 
analyze coming in in 2014, which will increase our ability to 
detect fraud and gaming of the system.
    The Chairman. What about hackers? When you are building 
this up, I assume you design systems that tend to prevent or 
minimize hacking.
    Dr. Mostashari. The HITECH legislation gives eight 
responsibilities to the National Coordinator. The first one is 
to protect the privacy and security of the health information 
infrastructure, and it is one that I take very seriously.
    The HITECH legislation also created the Chief Privacy 
Officer for ONC, Joy Pritts, who makes sure that we bake 
privacy and security into everything we do, and we coordinate 
with the Office of Civil Rights, which has undertaken a much 
more aggressive measurement of audits and enforcement, as well 
as education for providers. It is a shared responsibility.
    One of the biggest security problems we have is health care 
providers, small and large, not paying enough attention to the 
security in the local setting: whether they encrypt the laptop, 
whether they put things on a thumb drive, whether they put 
passwords on a sticky note, whether they lock the server room. 
So it starts there, and patients need to be able to trust their 
providers to keep their information secure. You do not need to 
have a hacker get in if you can just steal a laptop from a car 
and have all those breaches.
    The Chairman. Right. But a day does not go by these days 
where you do not see some new article about some hacking 
somewhere. There was an article in one of today's papers about 
hacking in the university systems. I know you are doing your 
best, but I would just urge you to think really carefully.
    You are doing a good job, both of you. Clearly you are 
working as hard as you can; clearly you are very competent and 
have your hearts in the right place. We want to help. So, thank 
you very much for your service.
    The hearing is adjourned.
    [Whereupon, at 11:55 a.m., the hearing was concluded.]
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
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