[Senate Hearing 113-290]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 113-290
 
                    HEALTH INFORMATION TECHNOLOGY: 
                        USING IT TO IMPROVE CARE 

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

                                HEARING

                               before the

                          COMMITTEE ON FINANCE
                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 24, 2013

                               __________
                                   

            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...................     3

                               WITNESSES

Marchibroda, Janet M., director, Health Innovation Initiative, 
  Bipartisan Policy Center, Washington, DC.......................     4
Glaser, John P., Ph.D., chief executive officer, health services, 
  Siemens Healthcare, Malvern, PA................................     6
Fattig, Marty, administrator and chief executive officer, Nemaha 
  County Hospital, Auburn, NE....................................     9
Banas, Colin, M.D., M.S.H.A., chief medical information officer 
  and associate professor, Virginia Commonwealth University, 
  Richmond, VA...................................................    11

               ALPHABETICAL LISTING AND APPENDIX MATERIAL

Banas, Colin, M.D., M.S.H.A.:
    Testimony....................................................    11
    Prepared statement...........................................    29
Baucus, Hon. Max:
    Opening statement............................................     1
    Prepared statement...........................................    39
Fattig, Marty:
    Testimony....................................................     9
    Prepared statement...........................................    41
Glaser, John P., Ph.D.:
    Testimony....................................................     6
    Prepared statement...........................................    48
Hatch, Hon. Orrin G.:
    Opening statement............................................     3
    Prepared statement...........................................    56
Marchibroda, Janet M.:
    Testimony....................................................     4
    Prepared statement...........................................    58

                             Communications

American Hospital Association....................................    83
College of Healthcare Information Management Executives (CHIME)..    93
Food Marketing Institute (FMI)...................................    96
InterSystems Corporation.........................................   104
National Partnership for Women and Families......................   107
Pierluisi, Hon. Pedro R..........................................   110
Puerto Rico Hospital Association.................................   112
Secure ID Coalition..............................................   117

                                 (iii)


                    HEALTH INFORMATION TECHNOLOGY: 
                        USING IT TO IMPROVE CARE

                              ----------                              


                        WEDNESDAY, JULY 24, 2013

                                       U.S. Senate,
                                      Committee on Finance,
                                                    Washington, DC.
    The hearing was convened, pursuant to notice, at 10:35 
a.m., in room SD-215, Dirksen Senate Office Building, Hon. Max 
Baucus (chairman of the committee) presiding.
    Present: Senators Nelson, Carper, Cardin, Casey, Hatch, 
Enzi, Thune, and Toomey.
    Also present: Democratic Staff: Mac Campbell, General 
Counsel; Karen Fisher, Professional Staff Member; and Peter 
Sokolove, Robert Wood Johnson Fellow. Republican Staff: Kristin 
Welsh, Health Policy Advisor; and Bryan Hickman, Special 
Counsel.

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

    The Chairman. The hearing will come to order.
    Thomas Edison said that ``vision without execution is 
hallucination.'' When it comes to health information 
technology, or health IT, no one knows Edison's lesson to be 
true more than providers.
    Dr. Jonathan Griffin from Helena, MT summed it up best by 
saying, ``If health care is a car, health IT is the navigation 
system. It tells you where you have been, where you are now, 
and where you need to go. It also helps prevent wrong turns and 
avoid road blocks.''
    We all agree that health IT is a critical instrument to 
improving health care and reducing costs. Last week, 
administration leaders shared their views and said we have made 
progress. Medicare and Medicaid financial incentives are 
encouraging providers to use health IT, but more work needs to 
be done. That work should be focused in particular on ensuring 
that all of the various computer systems seamlessly share 
information.
    Today we will hear from the vendors who build the 
technology and the providers who use it. No one knows better 
than doctors how important it is that technology works well. 
Technology can alert doctors to dangerous drug interactions; it 
can help them avoid duplication; and, most importantly, it can 
help doctors deliver the right care at the right time to their 
patients.
    Health IT has revolutionized the way Dr. Jay Erickson, a 
family practitioner in Whitefish, MT, treats patients who take 
blood-thinning drugs like Coumadin. These drugs prevent life-
threatening blood clots, but the doctor needs to constantly 
monitor a patient's dose to get it right. Simple things like 
the amount of spinach a patient eats can throw off the dose.
    The dose must be high enough to prevent clots but not so 
high as to cause a stroke. Achieving the right level requires 
several blood tests a week. Before his practice starting using 
health IT, Dr. Erickson often had to wait a full day for the 
lab to fax the blood test results.
    Then he would call the pharmacy with the prescription or 
give a handwritten script to his patient. The entire process 
could be repeated up to a dozen times to find a stable level of 
medication. Now, thanks to IT, the lab results are sent to Dr. 
Erickson instantly. He can quickly send prescriptions to the 
pharmacy electronically, and the process is faster and it is 
safer.
    Dr. Erickson is glad he can use this technology, but it has 
required hard work and a major financial investment. He and the 
nine colleagues in his practice spent significant resources for 
the system and hired two full-time employees to maintain it.
    Under a 2009 law called the HITECH Act, Dr. Erickson 
received incentive payments from Medicare and Medicaid for his 
use of the technology, but the incentive payments do not cover 
his costs. His system still cannot talk to the hospital system, 
so, when one of his patients is hospitalized, Dr. Erickson 
needs to send charts and tests back and forth by fax.
    I have also heard from critical access hospitals that face 
their own unique challenges. They have more trouble than other 
hospitals getting the up-front capital necessary to install 
health IT. They cannot afford IT staff, and these small rural 
hospitals have trouble getting IT vendors to come to them.
    Hospital-based rural health clinics are also ineligible for 
incentive payments. Critical access hospitals manage these 
clinics. Rural health clinics are important partners, but they 
cannot get funding for installing the technology they need due 
to their size and location. We must correct this.
    As we discussed in last week's hearing, just implementing 
technology is not the goal. Rather, technology must be used to 
actually improve health care. Vendors need to create the right 
software so that when doctors want quality reports, they get 
accurate results. If the software is not written correctly, it 
may not recognize drug allergies or dangerous interactions.
    Vendors must also create systems that talk to each other, 
even when those systems are not part of the same network. 
Medicare and Medicaid play a role. Their payment policies can 
help provide great incentives to providers to use health IT and 
for vendors to improve quality.
    So, when it comes to IT, the vision is there, but, as our 
witnesses today know, it is the execution that matters. So let 
us ensure that our health IT vision is being executed in a way 
that lowers costs and improves care for all Americans.
    [The prepared statement of Chairman Baucus appears in the 
appendix.]
    The Chairman. Senator Hatch?

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

    Senator Hatch. Well, thank you, Mr. Chairman, for holding 
this hearing as a follow-on to last week's IT hearing. It is a 
good start to this conversation. I think we are all better 
informed of the complexity of the issues involved.
    As I mentioned last week, I have heard from many providers 
and vendors, both large and small, about some of the challenges 
in becoming ``meaningful users'' as defined by the Office of 
the National Coordinator, or ONC.
    I am hopeful that leaders at ONC and CMS are paying 
attention to our hearing this morning and that they will 
consider the thoughtful comments made by our witnesses. All too 
often, Congress creates programs that, despite our good 
intentions, have unintended consequences for those it seeks to 
help.
    In this case, Congress passed a law which provided billions 
of dollars in incentive money for providers to purchase health 
information technology with the hope that it would help 
transform care, increase quality, and lower costs. These are 
all the right goals, so the question becomes, are the 
incentives well-placed and are they making a difference? If 
not, why not?
    We know that unless you provide people with compelling 
reasons to make changes, changes are not going to occur. For 
example, there has to be a compelling reason for hospitals to 
want to share information among non-affiliated providers.
    Likewise, there has to be a compelling reason for vendors 
to want to create technologies that work across various 
systems. It would seem to me that those reasons do not 
currently exist. If they did, we might not struggle with 
achieving interoperability.
    Now, this seems to be the elusive Holy Grail of health IT. 
Everyone is talking about it, and yet it always seems to be out 
of reach. I am most interested in hearing the thoughts of 
today's witnesses about the timing of the various stages of 
meaningful use and the requirements involved.
    Let me be clear. I think we need to hold people's feet to 
the fire so that we continue to make strides in delivering 
high-quality care. If that means making the requirements more 
stringent, then let us have that conversation. However, as I 
said to our witnesses last week, we have to give organizations 
enough time to acquire certified technologies and appropriately 
train staff to use them.
    Ignoring the question of whether providers have the ability 
to keep up will only hurt the cause. This transformation will 
not happen overnight, but having the right time-lines in place 
is nothing short of a necessity for success. Providers cannot 
afford to waste resources on systems that quickly become out of 
date as CMS and ONC change requirements over time, and vendors 
should be afforded very clear instructions as to what is 
expected as part of a certified system. Indeed, when we are 
talking about spending millions of dollars on health IT, 
certainty is a must.
    Mr. Chairman, I want to thank you once again for holding 
this hearing, and I look forward to hearing from especially 
this panel of witnesses, and we will go from there. Thank you.
    The Chairman. Thank you, Senator.
    [The prepared statement of Senator Hatch appears in the 
appendix.]
    The Chairman. I would like to welcome the witnesses. First 
is Janet Marchibroda, who is the director of the Health 
Innovation Initiative at the Bipartisan Policy Center. Next is 
John Glaser, chief executive officer of health services at 
Siemens Healthcare; Marty Fattig, administrator and chief 
executive officer of the Nemaha County Hospital; and Colin 
Banas, chief medical information officer and associate 
professor, Virginia Commonwealth University.
    Thank you all for coming. We really appreciate it. I know 
you spent a lot of time thinking about this hearing and you can 
tell us a lot of things that are pretty important to say, so we 
appreciate it very much.
    Your full statements will be in the record, and I urge you 
to summarize in about 5 minutes.
    Ms. Marchibroda?

STATEMENT OF JANET M. MARCHIBRODA, DIRECTOR, HEALTH INNOVATION 
      INITIATIVE, BIPARTISAN POLICY CENTER, WASHINGTON, DC

    Ms. Marchibroda. Thank you. Good morning, Chairman Baucus, 
Ranking Member Hatch, and members of the committee. Thank you 
for the opportunity to testify before you today. My name is 
Janet Marchibroda, and I serve as the director of the Health 
Innovation Initiative at the Bipartisan Policy Center. Founded 
by former Senate Majority Leaders Baker, Daschle, Dole, and 
Mitchell, BPC is a nonprofit organization that drives 
principled solutions in a number of areas, including economic 
policy, energy, housing, immigration, and, of course, health 
care.
    Our Health Innovation Initiative conducts a great deal of 
research and engages stakeholders in promoting improvements to 
health and health care through the use of innovation and health 
IT, and my testimony draws upon about six reports we have 
released over the last couple of years.
    First, health IT plays a significant role in improving the 
quality, cost-effectiveness, and patient experience of care. 
Last year we convened a task force, led by former Senate 
Majority Leaders Tom Daschle and Bill Frist, that pulled people 
together and asked the question: what are the attributes of 
high performance health care, new models of care? Then we 
looked out into the field to look at what health IT 
capabilities are required and where are the gaps. Very quickly, 
I will run through those in my few minutes today.
    First, electronic health records are key. We have seen 
adoption move to more than 40 percent among physicians and 
hospitals, but there still are gaps. Small physician practices 
lag behind, as do small and rural hospitals. Also, there are 
many providers, such as long-term care facilities and 
behavioral health care providers, that do not qualify for the 
incentives.
    The second, and probably the most important point in my 
testimony is, in order to improve quality and reduce costs in 
health care, we need information to flow across the settings in 
which care and services are delivered. This is not only needed 
for care, but also to calculate performance measures and to lay 
the foundation for new delivery system and payment models.
    Unfortunately, only 30 percent of hospitals and 10 percent 
of ambulatory practices are participating in operational 
exchange efforts. In order to achieve information sharing, two 
things need to happen. First of all, those EHR systems need to 
be interoperable. I am pleased to say, as we move from Stage 1 
to Stage 2, we have moved from a very small five data types to 
being able to transition fully to 23, so I think we are well-
positioned with Stage 2 to move forward on interoperability.
    But second, providers need to be able to and willing to 
share information. Unfortunately, as you mentioned, Senator, 
the primary barrier to information sharing is the lack of a 
business case for such sharing, given our primarily volume-
based payment system. If there is one message that I can leave 
with you today, it is that we must prioritize electronic health 
information sharing moving forward, in terms of allocation of 
resources and focus of Federal agencies, as well as in the 
industry. We need to merge both the health care conversation 
and the health IT conversation.
    So what is the government's role? First, do not delay the 
start of Stage 2. Second, align expectations for information 
sharing with payment, both inside and outside of meaningful 
use. Lead by example. Expand efforts to enable sharing of 
Medicare data to support new models of care. Assure public/
private sector development of a long-term strategy for data and 
sharing that meets all health care priorities, not just those 
of meaningful use, and address the patient matching issue.
    The third gap area is around effectively engaging patients. 
The world is changing. Since HITECH was passed, 85 percent of 
Americans use the Internet and 91 percent own a cell phone. We 
use electronic tools for everything else in our country, but 
not so in health care. Fortunately, I see change coming. Stage 
2 takes a giant step forward in enabling providers to engage 
with patients electronically.
    I will tell you, I have witnessed this firsthand. Just last 
month, my 16-year-old son had knee surgery, and we were up at 
Johns Hopkins in Baltimore. For the first time--they had just 
installed a system--we were able to see his test results 
online, review his prescribed medications, and even securely 
message with his physician on follow-up questions, without 
having to drive from Virginia to Baltimore to do so.
    It is not just institutions like Hopkins, but also our 
pediatrician's office, which is in Northern Virginia--pretty 
small, unaffiliated with any large health care system--had 
installed within the last year both an EHR and a patient 
portal. So, much progress is being made with Stage 2.
    One final point as I move to close. Since HITECH was passed 
in 2009, we have seen tremendous change in the health care 
system as well as the technology designed to support it. Health 
IT must evolve and change to support rapidly emerging changes 
in the health care system, so future stages of meaningful use 
should prioritize information sharing, number one, but also 
transition towards the achievement of outcomes, moving away 
from things such as features and functions, and that will offer 
flexibility as we move ahead.
    The Federal Government should also consider carefully, from 
a regulatory standpoint, the actions it takes as it relates to 
the development of a regulatory framework for health IT under 
FDASIA, the Food and Drug Administration Safety and Innovation 
Act. We hope that it will be risk-based, flexible, and one 
which promotes, not stifles, innovation, and we have done a lot 
of work in this area.
    In closing, health IT is the necessary and critical 
foundation for higher quality, more cost-effective patient-
centered care. We are at a critical juncture as we embark on 
the second stage of this journey, and we look forward to 
continuing to support your efforts as you consider policy in 
this area.
    Thank you for your leadership, and thank you for the 
opportunity to share my insights today.
    The Chairman. Thank you, Ms. Marchibroda.
    [The prepared statement of Ms. Marchibroda appears in the 
appendix.]
    The Chairman. Dr. Glaser, you are next.

 STATEMENT OF JOHN P. GLASER, Ph.D., CHIEF EXECUTIVE OFFICER, 
        HEALTH SERVICES, SIEMENS HEALTHCARE, MALVERN, PA

    Dr. Glaser. Chairman Baucus, Ranking Member Hatch, and 
distinguished members of the committee, it is an honor to 
testify before you today.
    As was mentioned, I am the chief executive officer of the 
health services' business of Siemens Healthcare, Siemens being 
a leading medical technology company with a portfolio comprised 
of medical imaging, laboratory diagnostics, and health care IT.
    Health services develops enterprise-level health care IT 
solutions that help providers coordinate care in a variety of 
settings, including hospitals and physician practices. We are 
pioneers in the HIT industry, having served our customers for 
over 40 years. Before joining Siemens about 3 years ago, for 20 
years I was a CIO in a large health care system in Boston on 
the implementation side of electronic health records, provider 
order entry, and interoperability, so I have lived those 
battles and those accomplishments.
    I also spent a year working for David Blumenthal as a 
senior advisor involved in the early formation of the 
meaningful use Stage 1 criteria and the formation of the grant 
programs that led to health information exchanges, the regional 
extension centers, et cetera.
    Now, Siemens applauds the committee for holding this 
hearing to highlight the importance of health care IT as a tool 
to improve the delivery of care. We also appreciate the work of 
Senators Roberts, Enzi, Thune, and Burr for their published 
report, ``Reboot: Reexamining the Strategies Needed to 
Successfully Adopt Health IT.''
    Today's IT solutions, as you know and have heard from the 
panel and cited in your opening comments, have a wide variety 
of abilities to improve health care, reducing errors, improving 
the efficiency of the delivery of care, and overall elevating 
quality, such that the care that we deliver to citizens in this 
country has dramatically and materially improved.
    We are fully committed to helping our customers achieve the 
objectives outlined in the EHR incentive program. The program 
was thoughtfully designed and has been quite effective in a 
number of different ways. We all can point to the significant 
increases in the number of hospitals and physicians that have 
attested to the program, and I am sure that Drs. Mostashari and 
Conway mentioned that and covered that in their commentary last 
week.
    However, I think the program is reaching an inflection 
point, and these are some comments drawn from the multiple 
perspectives that I have had over my 30-odd years of career 
here. I think the requirements for Stage 2 are more stringent, 
and there are a number of complicating factors, such as delayed 
delivery of testing tools, confusion over criteria, and 
inconsistent auditing approaches. Optimizing EHR technology is 
a fundamental element, both in the episodic treatment of an 
individual, and also in the care delivered to them over time 
and over multiple venues.
    Implementing an EHR is a massive undertaking, even for our 
most sophisticated of providers and health systems. For small, 
rural, and critical access hospitals that do not have adequate 
financial resources and staff resources, it may be on the edge 
of impossible. So we run the risk of creating and exacerbating 
a have and have-not series of systems and providers, those that 
are able to use the technology and those for which the 
technology is outside of their reach.
    Further compounding this, in the next 15 months health care 
organizations, in addition to meaningful use Stage 2, are 
dealing with the mandatory, massive overhaul of their systems 
and operational processes that results from ICD-10,* and in 
addition to their own strategic and operational needs and 
challenges, must prepare themselves for payment reform, new 
care models, and other changes that will be coming in the years 
ahead.
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    * The 10th revision of the International Statistical Classification 
of Diseases and Related Health Problems (ICD), a medical classification 
list by the World Health Organization (WHO).
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    We may be creating a perfect storm that has the potential 
to over-burden eligible hospitals and providers of all sizes. 
Hospitals and providers may choose to opt out of the program. 
There is evidence of this. As more hospitals and providers have 
indicated, they will not attest to Stage 2, and fewer rural and 
critical access hospitals participate at all.
    We could arrive at a situation in which the participation 
rates that we have seen to date in the Medicare portion of 
meaningful use represent a plateau rather than a point along a 
greater journey of adoption, and we would not regard this a 
success if we actually have, at the end of this program, a 
minority, a significant minority, of participating 
institutions.
    Moreover, many hospitals and providers are rushing into 
their implementations. They are trying to say, I have 15 months 
to get this, and I also have to do ICD-10, I have to do this, 
that, and the other, and I am going to get it in and get my 
check, and in the process of that they are short-changing a lot 
of the process, reengineering, and clinical engagement work 
that needs to occur.
    The result can be that we will look back on the $19 billion 
or whatever we wind up spending on this program and say, what 
did we get in terms of care improvement, and be quite 
disappointed with the results, because the time needed to 
change the health care system was not taken, because there was 
no time to go off and do that.
    Similarly, we could wind up in unsafe conditions where, 
because of hurriedness, the workflow changes were not done as 
well as they should have been, nor was the training done as 
well as it should have been. Therefore, I propose a couple of 
recommendations.
    The first is, I would give hospitals and providers the time 
needed to properly and effectively implement electronic health 
record systems. It is a complicated task that involves every 
aspect of care in every department in the hospital and in the 
outpatient setting. It takes a lot of work and a lot of 
reengineering.
    I would recommend that you extend this Stage 2 deadline 
until October 1, 2015. Those who can take advantage of it in 
the time frame of 2014, fair enough. Those who need more time, 
give them the time to do it right. This would give them the 
time to accomplish what we want them to accomplish.
    The second is, I would modify the program to be less 
proscriptive and more flexible by, for example, providing a 
menu of requirements with a minimal set that must be met rather 
than all of the current 16 requirements of Stage 2. The ones 
that I would keep would focus on interoperability and give more 
latitude regarding the remaining set. This would allow 
providers to select those requirements that reflect their own 
strategic and operational objectives in terms of improving 
their care, their quality, and the service that they provide to 
their community.
    The third thing that I would do is have the Stage 3 
meaningful use requirements support the transition to new care 
models and reimbursement by placing less emphasis on future 
function and more emphasis on our true goal, improving care 
outcomes.
    Fourth, we should consider provisions for rural and 
critical access hospitals, such as grants, loans, and advanced 
payment of incentive monies, to enable them to better finance 
the undertaking of the journey that we would like them all to 
engage in.
    Then last but not least, we should strengthen the program 
to focus with more vigor and more force on the 
interoperability, to achieve the development of standards and 
the enforcement of the standards. I realize, as mentioned by 
Janet, that a lot this involves the business case. That being 
said, we can be more aggressive and more effective at getting 
the standards in to the industry and ensuring that they are 
complied with.
    I have run out of time. I have a brilliant closing, but I 
will not use that at this point. We will save that for the 
comments. [Laughter.]
    Thank you.
    The Chairman. Thank you, Dr. Glaser. We look forward to 
your brilliant closing. [Laughter.]
    You have put a lot of pressure on yourself.
    [The prepared statement of Dr. Glaser appears in the 
appendix.]
    The Chairman. Mr. Fattig?

 STATEMENT OF MARTY FATTIG, ADMINISTRATOR AND CHIEF EXECUTIVE 
          OFFICER, NEMAHA COUNTY HOSPITAL, AUBURN, NE

    Mr. Fattig. Chairman Baucus, Ranking Member Hatch, members 
of the committee, thank you for holding this hearing and 
inviting me to testify.
    My name is Marty Fattig, and I am the chief executive 
officer of Nemaha County Hospital, a 20-bed critical access 
hospital in Auburn, NE. In addition, I also serve as an 
appointed member of the Meaningful Use Workgroup of the HIT 
Policy Committee, and I am proud to represent small and rural 
hospitals on this group.
    I would like to say at the outset that I believe 
policymakers will need to make changes to the meaningful use 
program to narrow the digital divide and ensure that small and 
rural hospitals are not left behind as we make transitions to 
Stage 2 of meaningful use, and as the positive incentives 
quickly turn to significant payment penalties.
    Our hospital went live with our EHR in January of 2004. We 
have been recognized as one of the most wired hospitals in 
America 7 of the last 8 years. We are also one of 15 site visit 
hospitals for our HIT vendor, which means that they bring 
potential customers to our hospital to show them how their 
software works in the live environment.
    As I look beyond my own experience to that of my rural 
colleagues, I see a strong commitment to provide the highest 
quality care to their communities, including the use of EHRs. 
Progress is being made, but the digital divide between urban 
and rural hospitals persists, and most rural hospitals have yet 
to meet Stage 1.
    All the critical access hospitals in Nebraska have had a 
computer system for some time, but very few have had an EHR 
before 2009. Some are now discovering that the EHR provided by 
their current vendor will not meet their needs, so they are 
changing vendors. Another group of 33 hospitals in our State 
all use the same vendor, and they are extremely concerned that 
it will not be certified for Stage 2 by the time these 
hospitals need to be utilizing it.
    Rural hospitals often find it more difficult to get timely 
attention from vendors. For instance, our vendor has over 600 
hospitals that all need some software upgrade in order to meet 
the Stage 2 objectives. This is an extremely difficult task if 
there are no problems. If bugs are discovered in the software, 
it becomes impossible.
    We purchased a piece of software from our vendor in May 
that we will need for Stage 2, and we were told that it would 
be 9 months before they would be able to complete the install 
because they are so busy. So, based on my experience and that 
of my colleagues, I do not believe HHS has provided sufficient 
time for the transition to Stage 2.
    In 2014, all providers will have to install a new version 
of their EHRs, regardless of where they are. In addition, the 
2-year cycle is too short for us to move beyond simply 
installing the required elements to improving patient care.
    The 2014 time crunch also raises concerns about patient 
safety. One of the main reasons that we installed our EHR when 
we did was to improve patient safety, and it has done just 
that. Our closed-loop medication administration system has all 
but eliminated medication errors in our hospital. However, 
these systems, especially when they are upgraded under severe 
time constraints, can, and unfortunately do, introduce risks 
that things can go wrong.
    We installed a software upgrade some time ago, and all the 
allergies listed in our patient record disappeared. We were 
able to catch this problem before the patients were harmed, but 
this is the kind of thing that can happen. Combine this with a 
mandate to transition to ICD-10 by October 1st of 2014 and the 
changes created by the Affordable Care Act, and the challenge 
to maintain a safe patient environment becomes even more 
difficult.
    I believe that the administration could, and should, take 
steps to provide more flexibility in the transition to Stage 2 
and address the challenges faced by small and rural hospitals. 
If done correctly, the changes can alleviate the time crunch 
but still keep the program moving forward.
    The establishment of a reliable mechanism for health 
information exchange is key to the future progress. In 
Nebraska, we have one health information exchange, and that is 
working quite well. My concerns are that I do not think we will 
be able to connect to the State to report the public health 
measures by the time the hospital is required to do so, and I 
am also worried about its financial sustainability.
    When the grant money is exhausted, will they remain 
financially viable through subscription fees alone? It is my 
belief that we need to reassess the program in light of the 
reasons that Congress chose to support the adoption of 
electronic health records. The first goal was to have an 
electronic record, the second goal was to ensure that we could 
share data, and the last thing was to build on the system to 
make it more and more robust.
    We are making great progress on the first two goals, but we 
have yet to fully achieve them. It is my opinion that we are 
trying to make the system more robust before the first two 
steps are anywhere near complete. We should re-focus our 
efforts on achieving widespread adoption and efficient 
information exchange before rushing ahead.
    Thank you again for the opportunity to participate in 
today's hearing. I look forward to working with the committee 
and all who are committed to the shared goal of widespread 
adoption of EHRs, whether they live in the largest city in 
America or the smallest rural community. Together, we can 
achieve the triple aim of better health, better health care, 
and lower costs for all Americans. Thank you.
    The Chairman. Thank you very much, Mr. Fattig. I appreciate 
that.
    [The prepared statement of Mr. Fattig appears in the 
appendix.]
    Dr. Banas. I want it noted that I believe in technology so 
much that I am going to try to do this entirely without paper.
    The Chairman. I hope it works! [Laughter.]

    STATEMENT OF COLIN BANAS, M.D., M.S.H.A., CHIEF MEDICAL 
     INFORMATION OFFICER AND ASSOCIATE PROFESSOR, VIRGINIA 
             COMMONWEALTH UNIVERSITY, RICHMOND, VA

    Dr. Banas. Chairman Baucus, Ranking Member Hatch, and 
members of the committee, thank you for the opportunity to 
discuss our work at the Virginia Commonwealth University 
Medical Center in Richmond, VA related to our successes in the 
arena of health information technology.
    I am the chief medical information officer for the VC 
Medical Center, an actively practicing internal medicine 
hospitalist, and an associate professor of medicine. In my 
career, I have been fortunate to experience the care of my 
patients using a multitude of health information systems, 
including paper-based, electronic vendor-based, hybrid, and 
even the federally created Veterans Administration system. To 
be clear, I would never go back to paper.
    The VC Medical Center has a proud history of leveraging 
health information technology to improve patient care that 
spans decades. We benefit from near 100-percent computerized 
physician order entry or CPOE adoption in our hospital, and 
fully electronic clinical documentation for all providers, 
including nurses and physicians, in our outpatient and 
inpatient settings. We are proud to have successfully attested 
for almost 500 eligible providers, as well as our hospital, for 
the first year of meaningful use.
    I would like to share a number of health IT success stories 
framed in three categories of next-order benefits: clinical 
decision support, handoffs, and innovations, all of which are 
made possible by the foundation of data ubiquity. These 
represent years of effort in improving people and process 
workflows. It was only after the processes had been refined 
that the application of technology became the secret sauce to 
improving outcomes.
    In fact, I have also experienced the premature application 
of technology, causing very detrimental results which can harm 
and erode the trust of both patients and providers.
    VCU employs a number of clinical decision support 
methodologies to support patient care. We have over 650 rules 
and alerts to help promote delivery of best practice. For 
example, in the arena of core measures, we have improved our 
compliance rate with the timely removal of urinary catheters to 
prevent hospital-acquired infections for our surgical patients. 
Our EMR now recognizes urinary catheters which are placed in 
the operating room and schedules their removal automatically in 
concert with physician guidance.
    Years of education in process improvement could only yield 
compliance in the 80-percent range. It was the thoughtful and 
actionable integration of technology that finally pushed us 
above 98 percent. I cannot stress this enough. It is the triad 
of people, process, and then technology that proves to be the 
recipe for success.
    VCU launched its patient portal in December of 2012, and, 
in just 7 months, we have already enrolled 11,000 patients who 
now have access to core elements of their electronic medical 
record. Inefficient phone tag has been replaced by an e-
exchange between patients and providers, and we have only 
started to scratch the surface of this technology.
    While the patient portal was always an institutional vision 
on our health IT planning road map, it was the meaningful use 
program that gave it the much-needed activation energy and 
directional framework for success.
    We have created innovative and custom dashboards to augment 
our patient population management strategy by repainting large 
sums of data into easy-to-consume graphical and interactive 
formats. We help our providers deal with the information 
overload that has become common as the data stored in the 
electronic medical record grows.
    The most recent and exciting example of innovation is our 
home-grown medical early warning system dashboard. This gives 
our rapid-response team a real-time monitoring system that 
continuously measures patient acuity and severity. The 
dashboard has been adopted by the team as their compass to 
guide them to the bedside of our most sick patients.
    The team no longer waits to get a call from a nurse or 
doctor with a patient in distress. Instead, they are accessing 
the dashboard on mobile devices and arriving at the bedside to 
assess and intervene, sometimes ahead of the primary team and 
nurse. Since launching this dashboard, our analysis has shown a 
5-percent reduction in in-house mortality and a significant 
reduction in cardiopulmonary arrests outside of the intensive 
care unit.
    The landscape and requirements for health IT are constantly 
and rapidly changing. We are drowning in a sea of competing 
priorities and clinical needs to ensure that the EMR remains 
usable and meaningful. The combined tsunami of the ICD-10 
mandate collides precisely with our medical center's need to 
attest for the first year of meaningful use Stage 2.
    The talent pool for this mountain of work that faces our 
industry has become sparse. For the first time, I am noticing a 
legitimate inability to onboard the talent requisite to make 
these initiatives successful. I believe there is a creative 
opportunity to be thoughtful about the timing of the meaningful 
use program, especially the impending penalties, while 
preserving the momentum we have worked so hard to achieve.
    The examples offered here are emblematic of the power of 
health IT and data fluidity. VCU purposely pursued internal 
data ubiquity as a preliminary strategic goal. There were 
immediate and tangible results from simple data availability. 
Only once this was achieved were we then able to pursue the 
next order of benefits described here.
    I believe the VCU experience is relatable to the true power 
of even the most basic health care data interoperability, a 
benefit that is echoed by many of my colleagues who recommend a 
higher focus for these measures within the meaningful use 
program.
    I do wish to applaud the ONC and the meaningful use program 
for the successes to date. I credit the program with helping to 
provide our industry a shared vision and road map, as well as 
providing the activation energy to help accelerate the journey. 
A sincere ``thank you'' for their leadership is indeed 
warranted and offered here.
    I am proud to be a part of the training of the next 
generation of care providers who do not know a non-digital 
health care world. There are students and residents who have 
never written an illegible paper prescription or scrawled onto 
paper the chicken scratch progress note.
    The next generation has come to expect and demand a safer 
digital health care world and will prove to be a valuable asset 
in continuing to push the industry and our Nation forward into 
digital success.
    Thank you for the opportunity to testify before you today. 
VCU Medical Center stands ready to serve as a resource and work 
with this committee and all members of Congress to improve the 
quality of health care in this Nation.
    The Chairman. Thank you, Doctor.
    [The prepared statement of Dr. Banas appears in the 
appendix.]
    The Chairman. I would like to get your reaction, the four 
of you, on what we can do to give hospitals and providers the 
business incentives to provide the technology. My sense is that 
health is way behind, and has been. It is not new. Everybody 
knows it is way behind others in the private sector. Some 
private sector businesses know the value of technology and have 
pursued it almost ruthlessly, to be efficient, to help their 
bottom line, et cetera. In health, it has been very slow 
because the incentives are just not lined up.
    So how can we help providers build a better business model 
to want to implement more HIT and more quickly? Any thoughts? 
Or on the other hand, CMS could require them to do it, with 
penalties if they do not. That seems like a backwards way. You 
would think that companies, the providers, would understand for 
their businesses, for themselves, this is a great thing to do, 
and they should do it. So what can we do to help make that 
happen? Anybody? Dr. Glaser, this is your chance to do your 
closing. [Laughter.]
    Dr. Glaser. We will have a little session after for the 
brilliant closing. I think it is a fair question. You are 
right: when you see it happen in other industries, it is 
because the business incentives are quite strong, and they will 
make investments, the vendors will be supportive, et cetera.
    I think there are three parts to this. One is that the 
payment method must change to reward quality and efficiency and 
safety in a material way. It does not have to be 100 percent of 
your payments, but it has to be more of a percent of your 
revenue than it currently is today. It does not have to be for 
all patients, because quality measures are harder in some areas 
than in others. It is harder to have quality measures in, for 
example, emergency care than it is in management of people with 
asthma. So I think that it is the continued movement, perhaps 
more aggressive movement, to changes in the payment system, 
that folks will respond to. They will respond with the IT 
needed to thrive in that environment, including the 
interoperability. So that is part A.
    Part B is to realize that all markets have failures, and 
motivations that are purely economic will not work. So the 
contribution of data to public health will not necessarily work 
because of payment methods, and there may need to be a 
regulatory mechanism that says you have to contribute to the 
public health mechanisms of the world because we have a public 
interest here that occurs. So the regulation will be a critical 
counterpart to that.
    The third part is, as we get smarter and industry gets 
better, that the energy required and the hurdles required to 
get to it are lowered, such that it will still be work, it will 
be work on big organizations and small organizations, but we 
will help with that. Regional extension centers are an example 
of helping providers get choices of vendors, get 
implementations, et cetera. So the third part is to work on it 
with the industry, but also government, to say, are there 
things that we can do to make the path easier, knowing that it 
will not be trivial to accomplish this thing, but nonetheless 
to make it less daunting, less problematic, than it currently 
is.
    The Chairman. Anyone else? Mr. Fattig?
    Mr. Fattig. Yes. I would certainly like to address this. 
First of all, I thank you for the question, because I think it 
is imperative that we get this right. First of all, I think we 
should consider that a health information exchange network can 
be very similar to our interstate highway system.
    We need to do this at a national level; we need to have 
national standards. We need to be able to set something up so 
that all these highways connect, as they do in the interstate 
system. We need to do that digitally for health information 
technology.
    The other things that I think are coming--I think there are 
some financial incentives that are in place that will help 
drive this, if in fact we get the network in place. As we move 
toward participating in community health initiatives where we 
are responsible for the health of our community and not just 
providing care when someone is sick, I think we will have a 
motivation to collect all that data from the clinics and the 
pharmacies, from public health, from the tertiary care 
providers, as well as from the critical access hospitals. 
Another thing that is coming in is, of course, what we call 
clinical care coordination, where we are going to be more 
responsible for the entire care of patients.
    The Chairman. I would like to ask another question. My time 
is expiring.
    Mr. Fattig. Sure.
    The Chairman. Last week, this committee met with government 
witnesses on this subject, and I asked them, I said, we are 
going to have a hearing the following week with a bunch of 
private folks. They are going to be vendors and so forth. What 
are they going to say, and what is your response to what they 
are going to say? They said, well, they are going to say slow 
down, too much, too fast. I have heard a lot of that today. 
Someone mentioned the potential perfect storm; someone else 
mentioned how you just cannot do it at all, and you have to do 
it right the first time, so slow down.
    So my question then is, people tend to like to slow down 
sometimes, so what assurances are there that the slow-down is 
not just an excuse for not doing what needs to be done? First 
of all, how much should be slowed down, and second, how do you 
reassure everybody here that we are going to get this better 
and right in addition to just words?
    Dr. Banas. I think the assurance that we will get it right 
comes from the fact that there is still a stick at the end of 
this carrot. I think slowing down is prudent, simply because I 
think literature and experience have shown that these things 
take time. Nine women cannot have nine babies in one month, 
that sort of thing. That is the analogy that our CEO sometimes 
uses. I think that the fact that there will be a stick at the 
end of this program provides the much-needed motivation that 
follows the carrot.
    The Chairman. By asking the question, I do not mean to 
imply that we should slow down, but I do hear concerns. My time 
has expired, but I think it is a fundamental question that has 
to be addressed. That is, you guys want to slow down a little 
bit. I do not know if you all do. Maybe you do not, Ms. 
Marchibroda, but others seem to suggest that we should slow 
down slightly. It is a basic question that we are going to have 
to figure out an answer to.
    Senator Hatch?
    Senator Hatch. Well, I have appreciated your testimony here 
today. Accurate and efficient matching of individual patients 
to their health records across settings is a wonderful thing if 
we can do it right. Enabling a clinician to view a 
comprehensive picture of the patient does require accuracy and 
efficient matching.
    Now, incorrectly matching a patient to a health record may 
have patient safety, privacy, and security implications, such 
as disclosing confidential information to the wrong patient or 
wrong doctor, even.
    Dr. Banas, what do you think are the obstacles in solving 
this problem of patient matching? I might add, as a former 
medical liability defense lawyer, I can see all kinds of 
problems that might arise if this is not done right.
    Dr. Banas. Yes. I think it is difficult when we lack a 
single identifier. I know that is a hot topic. But there are 
intensive algorithms that are matching on a variety of data 
points to get it near a 100-percent success rate. So I think, 
in the balance between patient privacy in the form of a 
national identifier and these intensive algorithms, something 
has to give. I think if you can accept that it is a difficult 
thing to match without such a unique identifier, than you will 
understand the results that we are seeing thus far.
    Senator Hatch. Dr. Glaser, let me just ask you this. In 
light of the current expectation that almost every eligible 
professional and hospital will need to upgrade in order to 
comply with Stage 2 requirements, is the vendor community 
adequately resourced to meet this unprecedented demand for 
assistance, and are smaller community hospitals and 
professionals, many of whom are located in rural communities, 
getting adequate attention from the vendor community?
    Dr. Glaser. Yes. I think the industry overall is challenged 
to address the demands of Stage 1, 2, and 3, so the vendors are 
challenged with staff, as are a lot of the providers. One of 
the key elements initially of the grant program under HITECH 
was the workforce development to sort of create all the 
centers.
    Particularly in the case of Stage 2, one of the challenges 
is the October 1, 2014 deadline--you have to have it done by 
then--and then the time required to actually solidify the 
requirements, to get the testing tools, took longer and longer, 
and all of a sudden there is a very compressed window in which 
a lot has to happen. The software has to be developed, the 
software has to be certified, the implementations have to 
occur, and whatever workflow changes are necessary have to 
occur.
    So, in a way, there are resources, but at some point you 
cannot resource if the window gets too narrow. It is a 
challenge for the vendors, but it is also a challenge for those 
who are providing care. Plus, they have ICD-10 to resource and 
a variety of other things. I think it is one of the fundamental 
reasons why--my concern anyway--the delay by a year is a 
critical thing to do because of the late start in being ready 
for Stage 2.
    I think, increasingly, organizations of the vendors are 
addressing the smaller community hospitals. There is still a 
little ways to go. I think we are being helped as a vendor 
community by the advent of cloud technology, which means that 
you can deliver software services to organizations and not 
require a computer room on their part, or IT staff on their 
part.
    The vendors are increasingly getting better at 
implementation methods that are shorter, less intense, and 
hence do not require this amazing consumption of the resources 
that are often scarce in the community hospitals.
    So we, for example, at Siemens have customers who have 17 
beds, 25 beds, 43 beds, and we are not alone in terms of the 
vendor community getting better there. There is still a ways to 
go to where we can deliver it efficiently, but also deliver it 
over distances that recognize this dispersal of caregivers 
across the country.
    Senator Hatch. All right. Thank you.
    Ms. Marchibroda, you advocate, it seems to me, a risk-based 
regulatory approach in the area of mobile medical devices in 
particular. Which agency or governmental entity should be 
charged with doing this type of work?
    Ms. Marchibroda. Senator, back in February we released 
recommendations for the principles of how this oversight 
framework would be developed. We recommended that it leverage 
existing patient safety and quality organizations where we have 
accreditation today, so that it reflects shared responsibility.
    We did say that the current medical device regulation as it 
exists today is not appropriate for a majority of health IT; 
however, we did not state which agency--we did not gain 
agreement on your question, but laid out a set of principles.
    Senator Hatch. You will let us know as soon as you get some 
sort of consensus on that?
    Ms. Marchibroda. Certainly.
    Senator Hatch. We would just like to know a little bit more 
about it.
    Ms. Marchibroda. Thank you.
    Senator Hatch. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator.
    Senator Enzi?
    Senator Enzi. Thank you, Mr. Chairman. Thank you for 
holding this hearing.
    Last week, I noted that more than 10,000 providers that 
participated in 2011 did not do so in 2012, and the government 
witnesses last week considered that a small number.
    Mr. Fattig, in your testimony you wrote that policymakers 
will need to make changes to the meaningful use program to 
ensure that small and rural hospitals are not left behind. I am 
from Wyoming. We have small and rural hospitals.
    So can you please explain in more detail why these 
providers are being left behind by the current program and what 
changes could be made to immediately improve the program, and 
does that have anything to do with the 10,000 dropping out?
    Mr. Fattig. It may have something to do with the 10,000 
dropping out. In my understanding, in working with small and 
rural hospitals across the Nation, a number of things come into 
play. One of the reasons they are left behind is a pure lack of 
resources, financial resources, to begin with. It costs a lot 
of money to install an electronic health record. The last 
figure I heard was about $67,000 a bed. That is a lot of money, 
regardless the size of your hospital.
    The second thing is the lack of human resources. For 
instance, our health care informaticist in our hospital serves 
in that position 2 days a week, and she serves as a staff nurse 
the other 3 days of the week, so we have limited time that this 
person can actually do this.
    The other thing is, of course, the vendor supply. There are 
a lot more small hospitals than there are large hospitals, but 
there are less small vendors that market to small hospitals 
than there are those that market to large hospitals. So you 
have a large number of hospitals with a small number of 
vendors, and you end up with this backup of capacity. It is not 
the vendor's fault, it is not the hospital's fault, it is just 
the way things are. We need more time.
    Senator Enzi. Thank you.
    Dr. Glaser, you noted in your testimony that the 
administration should offer providers greater flexibility in 
adopting the requirements, and you suggested a delay of some of 
Stage 2's requirements. Why, in your opinion, were these 
problems not anticipated by the administration at the start of 
the program, and what can Congress and the administration do 
better to ensure a smoother roll-out?
    Dr. Glaser. I think we should recognize--and I am sure that 
you do--a number of things here. One is, the individuals who 
are working on the meaningful use program, both at ONC and CMS, 
and the wide variety of volunteers who support that--my 
colleague being one of those--are smart and working hard to get 
this thing right. But this is an undertaking which has 
certainly no parallel in the health care IT industry, in which 
you are trying to aggressively move a broad swatch, a very 
complex industry, into the 21st century with IT.
    So I think we are going to get some things right and some 
things wrong as we go along here, and the prudent thing to do 
is understand that, as smart as one is and as inclusive as one 
is and as transparent as one is, we need to have conversations 
like this from time to time, to let us take a look and see 
where we are, what needs tuning, what needs correcting, et 
cetera.
    So I think, going back to at least the time when I was 
there in the summer of 2009, I do not know that anybody really 
knew where we would be on the adoption. There was a lot of 
estimating about where that would be or what the barriers would 
be at that point in time.
    Some were anticipated, hence regional extension centers, 
hence state health information exchange grants, but a lot of 
things were not. So these kinds of committee conversations, 
other conversations, that let us step back, take stock, keep 
the program moving but tune where we need to tune, are the 
right thing to do as we go forward.
    I do think one of the things that I would advise my 
government colleagues on is that the Stage 2 requirements ought 
to sort of migrate from being a feature/function prescription 
to saying, let us move to the outcomes. That is why we are 
here. We are not here for meaningful use per se; we are here to 
improve care.
    So let us move into more centricity on the outcome, that 
which we are after, and move into more focus on the 
interoperability, and worry less about whether this feature is 
present or that function is present, where we are in this sort 
of inertia of over-engineering the electronic health record and 
in a way forgetting why we are here, which is to improve care.
    So relaxation of requirements is intended partly to shift 
into the outcomes orientation, partly to give those who are 
making decisions about whether to participate or not, and to 
participate effectively, greater flexibility in bringing these 
technologies in. And all of this is a recognition that, 
collectively as a country and as a industry, we are learning as 
we go forward about what is working, what is not, and what 
needs to be tuned.
    Senator Enzi. I know that the outcome that we had 
envisioned--speaking of the committee and under Senator 
Baucus's leadership when we were working on health care 
reform--was to eventually have some kind of a card that 
everybody could carry that would have their entire medical 
history on it, so, if they are from Wyoming, and they come out 
here and they get in an accident and they break their leg, they 
can just put in a code and release all of the information to 
their doctor so it would be possible to treat them. I think 
that is where we wanted to go. So the interoperability question 
is a really important one, and I will be submitting that in 
writing for each of you because I think that is the real key to 
it.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator, very much.
    Senator Casey?
    Senator Casey. Mr. Chairman, thank you very much. I want to 
thank our panel for being with us today. I apologize I was not 
here earlier for your testimony. If you would permit me a home 
State courtesy, Doctor, I probably will focus a question on you 
first, and I will try to get to your colleagues, but I have to 
be Pennsylvania-focused for this question. I know you do not 
mind that.
    Dr. Glaser. Not at all. I look forward to that.
    Senator Casey. And I know some of what I will ask about 
might be by way of reiteration or repetition, but around here 
it is important to repeat ourselves, so it will not hurt.
    We have had, under the chairman's leadership, a number of 
health care hearings this year about implementation, and a 
repeat visitor has been Jonathan Blum from CMS. He has said on 
a number of occasions that if we can continue what I think is 
already a strategy that has been implemented to reduce 
hospital-acquired infections and reduce readmissions, we can 
save, by his estimate, according to his testimony, 65,000 
lives.
    I know in your testimony, on page 2, you talk about the 
Chester County Hospital in Westchester in our home State, and 
you say that this Chester County Hospital ``has used our 
solutions and our clinical workflow technology to reduce 
hospital-acquired MRSA by 60 percent,'' and then you go on to 
say MRSA infections are identified by CMS as a preventable 
``never event.''
    I know you have already probably addressed this, but, in 
addition to what is happening right now, what additional steps 
can we take to ensure that there are more hospitals like that 
or more examples like that across the country? You also 
mentioned the MedCentral Health System in Mansfield, OH. So, if 
you could expand upon that.
    Dr. Glaser. Certainly, Senator. I appreciate the home field 
nod. I think there are a couple of things. Those are examples, 
and there are lots of those, of both the people who buy the 
technology from us, but also buy from others. Certainly when I 
was a CIO years ago, I saw those often in the organization that 
I served.
    So I think there are a couple of things. You say you would 
like to see that broadly. So what do we do to make sure that 
that is a common occurrence and not particularly noteworthy? 
Everybody ought to be doing that, and it should not be an 
exception. I think there are a number of things, some of which 
we are doing.
    One is to continue the programs that encourage the 
adoption, so we just have to get the fundamental systems in 
place and used effectively. A number of folks, and certainly I 
do, believe that we ought to give them a little more time, but 
we have to lay the foundation that has to occur here.
    We also ought to encourage, although they will do a lot of 
this on their own, that those who deliver care talk to their 
colleagues and say, how did you do that? So there should be 
colleagues talking to colleagues, often supported by 
associations, such as the American Hospital Association, to 
encourage this discussion so people learn from each other.
    The third part would be, as mentioned in a couple of the 
comments, the continued movement of the payment system, such as 
the payment system reward, so that Chester County sees a 
revenue increase, and, hence, whatever costs were incurred in 
making that happen, they have a means to recover, because they 
still have a margin target that they need to fulfill in order 
to continue to deliver on the mission that they are obligated 
to deliver to their community.
    So I think it is a variety of things. It is to make sure we 
lay the foundation effectively, encourage the natural 
conversations between colleagues where they teach each other, 
and continue to work on a payment system, as complicated as 
that is, that continues to incent and reward those kinds of 
behaviors and outcomes across the board.
    None of those is necessarily easy, and none of those is 
necessarily accomplished in a very brief period of time. They 
will take time across the board. So, in a way, it sounds very 
simple. Those are the three things that we have to do, but, as 
we all know, those are complicated things to do and not easy to 
carry out.
    Senator Casey. I want to invite anyone else on the panel, 
if you want to comment on this particular question about this 
strategy. Anyone else?
    Dr. Banas. I think the VCU experience is very similar, in 
that we spent many years laying the foundation before we could 
start to really enjoy a lot of the successes that I displayed 
in my testimony.
    I would echo the importance of sharing and organizations 
like the AHA or AMDIS, the Association of Medical Directors of 
Information Systems. Those collegial relationships that are 
formed in those venues have proved vital to sharing successes 
and strategies. As our vendors mature, they are starting to 
pick up on best practices and hopefully starting to apply them 
from the top down so that we all do not have to reinvent the 
wheel 15 different times.
    Senator Casey. Thanks very much. My time is up.
    The Chairman. Thank you, Senator.
    Senator Thune?
    Senator Thune. Thank you, Mr. Chairman. Welcome, panel. 
Nice to have you here. Thanks for your answers to our 
questions. I want to direct this to Mr. Glaser and Mr. Fattig. 
I want to mention your testimonies, that you had talked about 
the need for extending Stage 2. I think last week we had an IT 
hearing with the administration where I asked them about 
extending Stage 2 to give more time to address some of the very 
issues that you raise in your testimonies.
    The administration would not commit to it at the time, and 
I am concerned that they do not have a realistic view of the 
problems that are facing this program, particularly in rural 
areas. So my question is, do you think there is a way to design 
such an extension to give some providers and hospitals 
additional time in Stage 2 while allowing more advanced 
providers and hospitals to be able to move on to Stage 3?
    Dr. Glaser. When I was a chief information officer, in my 
22 years of being a chief information officer, I implemented 
provider order entry 11 times and did the inventory record for 
4,000-plus physicians across the board. That has taught me to 
have an extraordinarily healthy respect for the challenges of 
implementing these systems.
    These are hard; these are difficult. You have to be careful 
with them. You have to bring the medical staff along and be 
thoughtful about the workflow, have a healthy respect. So, 
Senator Baucus, back to one of your comments, I think I would 
hold feet to the fire. I might give them more time, but we have 
to recognize this is really difficult to do, and we want them 
to do it right in lots of ways.
    So what I would do is say, if you want the additional year, 
take the additional year, but that is it. It is not 5 
additional years, it is 1 additional year. If you are ready and 
on course and things are going well and this, that, and the 
other, terrific. Go ahead and meet the deadline and carry 
forward and move on to Stage 3. But for those who need the 
extra time, let us give it to them, respecting the magnitude of 
the challenge that they have and the criticality of getting it 
right in a lot of ways here.
    I think my colleagues are right, there is going to be a 
special set of considerations for the rural, the critical 
access hospitals, and, in addition to time, they might need 
some resource help. It is not just a question of time, it is a 
question of whether it is people, or money, or whatever. So, 
even with the extra year, they can stay on course and make the 
care improvements that have been cited a couple of times during 
our comments today.
    Senator Thune. All right.
    Mr. Fattig. Thank you for the question. I think it is 
critical that, first of all, we stretch out the time-line to 3 
years at each stage regardless of which stage it is, because 
all hospitals and all the vendors need at least 3 years at each 
stage so that we can do this right.
    I do not believe we just need an extension at Stage 2, I 
think we need an extension at Stage 1 so that those hospitals 
that have not met Stage 1 objectives can meet them. Sixty-five 
of the hospitals in Nebraska are critical access hospitals.
    If we are going to have an electronic record that includes 
all the data on these patients, we have to move the vast 
majority of those 65 critical access hospitals forward and not 
leave them behind with this digital divide. Stretching out 
Stage 1 so that those hospitals that have attested in 2012 have 
an additional year to get Stage 1 right before they move on to 
Stage 2, I think would be very, very helpful.
    Also, maybe we need a grant program or a loan program for 
these programs, something so hospitals have the resources to 
get the initial investment so that they can move forward and 
help increase the compatibility of all these records across the 
Nation.
    Senator Thune. A lot of those critical access hospitals in 
Nebraska are like the ones in South Dakota that I am thinking 
of when asking this question. This, I would direct to anybody 
who would like to take a shot at it. But Stage 1 of meaningful 
use required that there was no actual cross-platform exchange 
of information. Stage 2 requires only one instance of 
information sharing, and that can be with a dummy server set up 
by the government.
    Do you think the administration puts sufficient pressure on 
vendors through the certification process to advance cross-
platform exchange of data? A follow-up to that would be, what 
else could the administration be doing to encourage vendors to 
exchange data?
    Dr. Glaser. I think there should be more pressure on the 
vendors to do this, and I count myself as one, to show that we 
can meet the standards, comply with the standards, and are 
certified relative to the standards. So I think that is part A.
    We should realize that that, in and of itself, is not 
sufficient. What also should be occurring across the board is 
continued movement of the payment model which will incent, not 
only the fact that you can technically do it, but that you can 
clinically do it, so there is motive to go off and to do those 
kinds of things, et cetera. So I think there is continued 
movement on the reform efforts broadly speaking, to change the 
payment mechanisms to reward quality and efficiency.
    Third, and I realize this can be tricky, is to give ONC and 
CMS more authority to move on the standards. At times they are 
stuck in a consensus process. I would give them more clout to 
call it a day, because sometimes they have to stop short of 
full, definite standards and leave too much ambiguity, or are 
unable to call it and say, you need to do this.
    So I would think there are three points: first, pressure on 
us as vendors; second, working with the payment model so that 
there are reasons for the organizations to comply--and it is 
not just connecting things, there is workflow that has to be 
changed, and who does it, who deals with the data, how do they 
do this, and how do they do that, et cetera; and third, giving 
my colleagues at ONC and CMS more authority to further the 
standards development and codification process.
    Senator Thune. Do you think that there is a sufficient 
business case for continued progress on interoperability and 
exchange of data between unaffiliated providers? I mean, is 
there something else that can be done to ensure that there is, 
from a hospital standpoint and from a provider standpoint, a 
sufficient business case to do this? I mean, apart from the 
government incentives. Do you know what I am saying?
    Mr. Fattig. I believe there is. I believe there is, 
especially with the changes that are coming down with the 
Affordable Care Act. When we form our ACOs or value-based 
purchasing groups or our clinical collaboration, we are going 
to have to be able to share data in order to meet those models. 
So the business sense is growing as we speak.
    Senator Thune. Ms. Marchibroda?
    Ms. Marchibroda. I would agree. I think the private sector 
is already moving forward considerably on these new accountable 
care arrangements, and they are already needing to share 
information. So aligning those information sharing 
conversations and methods with what we are seeing here in 
meaningful use would be very important.
    Even as we wait for those to take broader hold, hopefully 
through the Medicare program, through all of the performance 
measures that are being used today, I think there are 
opportunities to improve the use of electronic data that comes 
from electronic health records in order to populate those. So, 
there are other ways to incentivize this in the system.
    Dr. Glaser. Yes. I think you do see it now, so I might say, 
as a health provider, I want to work with you two to form a 
clinical affiliation to deliver cancer care, or whatever it 
might happen to be, and with your two separate organizations in 
my community, and we need to set up an exchange in order to 
manage this population. So you will see that clinical 
affiliations and relationships will lead to this.
    You see health systems that say, I need to fill my beds, 
and so I am going to have connections out to this doctor and 
that doctor to facilitate the admission process, and I want 
them to use my lab and radiology department, so I am going to 
get results back out there. So clearly there is an exchange 
going on, and in fact the health information exchange market, 
if you just look at sales of these things, is really growing 
quite rapidly.
    The problem with it is that it is idiosyncratic, it is 
patchwork. So I have worked with you two, but I have not dealt 
with you guys because I do not have a clinical relationship 
with you, and one of your patients might arrive here. It beats 
me what went on there.
    The Chairman. So what do you do about that?
    Dr. Glaser. Well, I think right now it is about the 
motives. It goes back to the motivational structure. So I think 
part of what you do is you say, listen, I am going to change 
payment, whether it is accountable care, et cetera, so it 
covers all of this stuff. It is not just this cancer 
arrangement, it is the broad coverage of care and 
accountability for care that occurs. So I would move market 
incentives that increase the broader value to adoption and 
bringing people in here.
    The Chairman. And what would those incentives be?
    Dr. Glaser. Well, I think it is like a lot of what is being 
experienced. It is accountable care, and I am going to hold you 
accountable for the population. Even if they go there, there, 
and there, you are still accountable for the quality, you are 
still accountable for the costs, and that will motivate you to 
do the exchange in addition to whatever you might do for a 
targeted cancer arrangement.
    The Chairman. Go ahead, John, if you have more questions.
    Senator Thune. No, I am done. Thank you, Mr. Chairman.
    The Chairman. It dawned on me during this hearing today the 
degree to which, besides going to Stage 1, 2, and 3, you start 
at 3, trying to figure out what you want the outcomes to be and 
how to measure the outcomes, and then go back to 2 and 1. You 
mentioned, Dr. Glaser, that you might want to push 3 into 2 or 
something like that, if I understood you correctly.
    But to your point about how we are not just doing this for 
the sake of technology, we are doing this for the sake of 
patients, are we giving enough emphasis on what 3 is, that is, 
outcomes? Maybe it is ACOs, maybe it is sharing, maybe it is 
patient-centered care. But as we go back and work on Stage 1 
and Stage 2, I am just curious if you have any reaction to that 
off-the-wall observation.
    Dr. Glaser. I do not think it is off-the-wall. Even if I 
did, I would not say it publicly. [Laughter.]
    But nonetheless, I think it is a fair part of it, and ONC 
and the policy committees are working on that. I think it is 
appropriate to have a philosophy regarding Stage 3, which is to 
say it ought to be outcomes-oriented, it ought to be focused on 
interoperability, less focused on future function. So those are 
guidelines about how to frame it that need to occur here.
    So I think it is important to begin to really crystallize 
for the industry, what is 3? One is that it makes sure that we 
are continuing along the journey that we would like to 
continue, and the other is that both vendors and those whom 
they serve want some level of road map so they can say, we see 
where we are heading. Even if Stage 3 is 2015, 2016, whatever 
the timing is, at least I have a game plan and a road map. So I 
think that that conversation is a very important one, an 
important one for you all on this committee to have, to make 
sure you understand it and are contributing to and guiding it.
    The Chairman. Do you feel comfortable that we know how to 
measure outcomes in Stage 3, and if not, what do we have to do?
    Mr. Fattig. I believe we do. I am the eternal optimist and 
the idealist and joust with windmills all the time, so I do 
believe that we do know what the outcomes should look like. I 
also believe that it would be vital for all of us to engage the 
private sector in this, because I think big business is going 
to drive this as much as government as we move forward. They 
are going to demand better outcomes from us, and we are going 
to have to have the data to show them that we are doing the 
right thing. So I think it is there.
    The Chairman. There is a little bit of a sense among three 
panelists maybe to slow down a little bit, maybe at the rural 
level, maybe at Stage 2. But, Ms. Marchibroda, do you agree or 
disagree with that?
    Ms. Marchibroda. So this is the thing. Stage 2, as we have 
discussed, advances considerably engagement of patients and 
electronic information sharing. You do not see that much of it 
in Stage 1. It is hardly there. The information sharing is the 
primary driver of reduction in costs that we will see through 
investments in health IT, and we recognize and have reported 
about how difficult it is to move this forward.
    So we need to find a way--and I think John described a 
way--to let those, particularly the many, many organizations 
that are coordinating care and moving forward on these 
accountable care arrangements, be able to have the 
interoperable systems that Stage 2 provides as a foundation for 
interoperability and sharing, while perhaps providing more room 
for those that need it. But I would hate to see us not benefit 
from those important patient engagement and information sharing 
requirements in Stage 2 as soon as we can.
    The Chairman. There might be some hospitals and providers 
that might see a real advantage in being aggressive in their 
business model with their patients, et cetera. For the four of 
you, very, very briefly, drilling down a little bit, where can 
we urge the administration to speed up a little bit, where not, 
where are we going about the right speed, and where maybe 
should we slow down a little bit? I mean, more separately 
instead of just generally.
    Dr. Banas. In terms of the meaningful use program?
    The Chairman. Yes.
    Dr. Banas. I think everyone is echoing that the 
interoperability patient engagement piece is by far the most 
important piece contained inStage 2, and it is a piece I can 
get behind, and it is a piece that I can comfortably implement 
and advance in my organization. The pieces that become more 
difficult are de novo new technologies that I have to put in, 
such as bar code meta-administration for a hospital. That could 
take us 1 to 2 years to do and might miss the time-line.
    Full order entry in the outpatient clinics--we do very well 
with e-prescribing. There is a great benefit to reducing 
adverse drug events from e-prescribing, but now we are having 
to throw on laboratory and radiology testing, which gets into 
an entire spaghetti of scheduling and future orders and things 
of that nature.
    So patient engagement, interoperability, as I testified, we 
have a portal. I would love to be able to focus even more 
energies into that portal to the benefit of our patients and as 
a by-product to our community.
    The Chairman. Anyone else?
    Mr. Fattig. I would encourage speeding up and redoubling 
our efforts on interoperability, but I still think it is very, 
very important that we bring the late bloomers, those small 
rural hospitals that have not implemented a complete EHR and 
attested to Stage 1, to bring them along so that we do not 
leave them in the dust.
    The Chairman. And I think Dr. Glaser suggested we bring 
them along by giving them a little more time and more 
resources.
    Mr. Fattig. Yes, more time and resources.
    The Chairman. Yes.
    Dr. Glaser?
    Dr. Glaser. Just one other comment, if I may. I would go 
back to one of the points you made, which is that I would like 
to see more movement on how it is we are going to move from the 
current Stage 1 and 2 to the outcomes. So tell me what that 
path looks like. It is not just the definition in the form of 
Stage 3, it is, if I need to help these folks, how long will 
that go on and in what form? So what does that pathway look 
like? We need to get some clarity to make sure it is taking us 
in the direction that we would all like it to take us.
    The Chairman. Ms. Marchibroda?
    Ms. Marchibroda. I would concur. As noted in our testimony, 
that focus on interoperability and patient engagement is 
critical and needs to maintain its current pace with Stage 2, 
and it ties in with your question about outcomes and do we know 
what they are.
    I think a couple of weeks ago, 3 weeks ago, you had a 
hearing on quality. We have a number of outcomes. One of the 
problems is that there are so many different measures. I think 
beginning to move these things together and aligning them with 
health IT will be important as well.
    The Chairman. All right. Thank you all very much.
    Senator Carper has joined us. He and I are due at the same 
location very soon.
    Senator Carper. Maybe we should just have lunch here; what 
do you think?
    The Chairman. We should.
    Senator Carper. We could eat, they could talk.
    The Chairman. Exactly.
    Senator Carper. Thanks very much. Each of us serves, as you 
know, on several different committees. I have been trying to do 
the other part of my day job, and I appreciate you all being 
here and the chance, Mr. Chairman, to ask a question or two.
    One of our main objectives, really one of my main 
objectives in the Affordable Care Act, was to try to reorient 
our Nation's health care system so that we would reward quality 
over just quantity and try to improve health care outcomes 
while trying to get better outcomes for less money.
    With Accountable Care Organizations, with medical homes, 
and penalties for unnecessary hospital readmissions, we are, I 
think, moving in a direction of paying hospitals and doctors 
based, hopefully, more on performance instead of the number of 
procedures that are performed.
    But I would like to say we cannot manage what we cannot 
measure. For 4 years after we created this incentive-based 
program for increasing the use of health IT, I am concerned 
that we still do not have the right public health indicators 
and quality measures in our health IT systems to evaluate the 
performance of our health care system.
    So, with that as a prelude, let me just ask a question. 
This could be for the whole panel, but do existing quality 
indicators and reporting requirements have credibility with 
doctors and health care providers on your staffs? A follow-up 
to that would be, do health IT systems in your hospitals 
capture quality measures and public health indicators, such as 
obesity and smoking rates, accurately and in a meaningful way? 
Those two questions.
    Dr. Banas. So, to your first question, I think the quality 
measures that have been chosen are certainly clinically valid. 
Where I lose buy-in from my physician and clinician population 
is that they are not easily capturable in the current state of 
workflow for our clinicians. So, the EMR vendors need to catch 
up with what I like to term ``usability,'' to make it sort of 
seamless in how I do my job.
    A lot of these clinical quality indicators result in me 
creating more check-the-box phenomena in order to capture this 
data somehow. That is where I lose my physicians. That is where 
they start to turn on the EMR, if you will: wow, you are making 
me check another box.
    So I think the quality measures that have been chosen to 
date are very aggressive, and there are a lot of them, and 
there are a lot of different quality programs that do not 
necessarily align, which also causes a little confusion. I 
think there are steps being made to rectify that, but clinical 
quality measurement is one of the things that also has me 
worried simply for the phenomenon I have just described.
    Senator Carper. All right. Thank you.
    Mr. Fattig, please. Do you agree with anything he said?
    Mr. Fattig. I do. I agree with everything he said.
    Senator Carper. All right.
    Mr. Fattig. Imagine that!
    Our sizes are entirely different, our scopes are entirely 
different, but the problems are the same. The clinical quality 
measures that are there have been collected for years, and our 
physicians agree with them. They are mostly process measures; 
they are not outcome measures, but we have determined that 
these processes give you better outcomes.
    The problem is that we have for years extracted this data 
manually, and now we are into an electronic extraction, and 
that creates a whole different set of problems about where the 
data is entered, and does it pull directly to the numerator and 
denominator of the calculation to make sure that these measures 
are accurate now and that we are getting credit for what we are 
actually doing.
    Senator Carper. All right. Thanks. Dr. Glaser?
    Dr. Glaser. In addition to Janet's earlier comment about 
the plethora of measures--and there is a need to rationalize 
those--I think the challenge is that the standards, while good, 
and measures, while good and important and critical in lots of 
ways, impose a cost to collect. Who bears that cost? Sometimes 
you turn it over to the doctors.
    They enter four or five more things and say, geez, you are 
killing me. You are adding time, I am already busy, et cetera. 
Sometimes we say, oh, we are not going to do that, we are going 
to pay some army to go extract it, either from the chart or 
from the records. So there is an organization that bears the 
cost to collect those things.
    So I think the basic point is, if we are going to capture 
additional data, there is a cost somehow, and how do you 
distribute that, through the doctors, or this, that, or the 
other. We can make things faster, more usable, but I do not 
think we can finesse the issue and make it a non-existent cost.
    Senator Carper. Thank you.
    Last word, Ms. Marchibroda.
    Ms. Marchibroda. Yes. The Bipartisan Policy Center released 
a report back in April and referenced quality measures in that 
report, sort of echoing--there are a number of them. They are 
creating a lot of burden. They are not derived from where care 
is delivered. So getting agreement or alignment across States, 
even Federal agency programs and the private sector, is 
important.
    In terms of, does health IT support these measures, I think 
actually this is an area that needs significant review and 
improvement. I think as we make this journey--and I think about 
the comments made earlier about the value of health IT--
clinicians and providers would like nothing better than to be 
able to generate these measures coming out of the systems, but 
we are just not there yet. Specifications are developed very 
quickly. They need to be tested before being implemented, so 
that is a great area of review in the coming months.
    Senator Carper. All right.
    Ms. Marchibroda. And it will help to create the business 
case.
    Senator Carper. Good. Thank you all.
    Mr. Chairman, I would just say in closing that, in 
Delaware, one of the last things we did in my second term as 
Governor was, we stood up and we said, why don't we create a 
Delaware health information network?
    The idea was to create a health information exchange that 
doctors' offices, hospitals, nursing homes, medical labs, and 
so forth, would provide information to and then from which 
information could be drawn to provide a continuum here and a 
collaborative delivery of health care in our State. In a little 
State like Delaware, it is actually working.
    When I was in the National Governors Association, we had a 
clearinghouse for good ideas within the National Governors 
Association, and this was just one of those good ideas. We are 
hopeful that other people will take heart and maybe take a look 
to see what we have done, and maybe do it even better going 
forward.
    Thank you so much. Thanks, Mr. Chairman.
    The Chairman. Thank you for that good idea. I appreciate 
that.
    Thanks, everybody, very much. The good news here is, we all 
tend to agree on the goal. The question is just the execution, 
how do we do it right. But thanks very much. You have been very 
helpful.
    The hearing is adjourned.
    [Whereupon, at 11:55 a.m., the hearing was concluded.]



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