[Senate Hearing 114-703]
[From the U.S. Government Publishing Office]
S. Hrg. 114-703
ACHIEVING THE PROMISE OF HEALTH INFORMATION TECHNOLOGY
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HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED FOURTEENTH CONGRESS
FIRST SESSION
ON
EXAMINING ACHIEVING THE PROMISE OF HEALTH INFORMATION TECHNOLOGY
__________
OCTOBER 1, 2015
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.gpo.gov/fdsys/
______
U.S. GOVERNMENT PUBLISHING OFFICE
31-167 WASHINGTON : 2017
COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
LAMAR ALEXANDER, Tennessee, Chairman
MICHAEL B. ENZI, Wyoming PATTY MURRAY, Washington
RICHARD BURR, North Carolina BARBARA A. MIKULSKI, Maryland
JOHNNY ISAKSON, Georgia BERNARD SANDERS (I), Vermont
RAND PAUL, Kentucky ROBERT P. CASEY, JR., Pennsylvania
SUSAN COLLINS, Maine AL FRANKEN, Minnesota
LISA MURKOWSKI, Alaska MICHAEL F. BENNET, Colorado
MARK KIRK, Illinois SHELDON WHITEHOUSE, Rhode Island
TIM SCOTT, South Carolina TAMMY BALDWIN, Wisconsin
ORRIN G. HATCH, Utah CHRISTOPHER S. MURPHY, Connecticut
PAT ROBERTS, Kansas ELIZABETH WARREN, Massachusetts
BILL CASSIDY, M.D., Louisiana
David P. Cleary, Republican Staff Director
Evan Schatz, Minority Staff Director
John Righter, Minority Deputy Staff Director
(ii)
C O N T E N T S
__________
STATEMENTS
THURSDAY, OCTOBER 1, 2015
Page
Committee Members
Alexander, Hon. Lamar, Chairman, Committee on Health, Education,
Labor and Pensions,............................................ 1
Murray, Hon. Patty, a U.S. Senator from the State of Washington,
opening statement.............................................. 4
Burr, Hon. Richard, a U.S. Senator from the State of North
Carolina....................................................... 21
Casey, Hon. Robert P., Jr., a U.S. Senator from the State of
Pennsylvania................................................... 23
Cassidy, Hon. Bill, a U.S. Senator from the State of Louisiana... 25
Franken, Hon. Al, a U.S. Senator from the State of Minnesota..... 27
Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin.. 29
Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode
Island......................................................... 31
Warren, Hon. Elizabeth, a U.S. Senator from the State of
Massachusetts.................................................. 33
Witnesses
DeSalvo, Karen, M.D., MPH, MSc, National Coordinator for Health
Information Technology, Department of Health and Human
Services, U.S. Department of Health and Human Services, New
Orleans, LA.................................................... 6
Prepared statement........................................... 8
Conway, Patrick M.D., MSc, Acting Principal Deputy Administrator,
Deputy Administrator for Innovation and Quality, Centers for
Medicare and Medicaid Services Chief Medical Officer, Centers
for Medicare and Medicaid, College Station, TX................. 11
Prepared statement........................................... 13
(iii)
ACHIEVING THE PROMISE OF HEALTH INFORMATION TECHNOLOGY
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THURSDAY, OCTOBER 1, 2015
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The committee met, pursuant to notice, at 10:01 a.m., in
room SD-430, Dirksen Senate Office Building, Hon. Lamar
Alexander, chairman of the committee, presiding.
Present: Senators Alexander, Burr, Cassidy, Murray, Casey,
Franken, Bennet, Whitehouse, Baldwin, and Warren.
Opening Statement of Senator Alexander
The Chairman. Good morning. The Committee on Health,
Education, Labor, and Pensions will please come to order.
This is our sixth hearing in this Congress on health
information technology and the government's electronic health
records program. Senator Murray and I will each have an opening
statement, and then we'll introduce our panel of witnesses.
After our witnesses' testimony, Senators will have about 5
minutes of questions.
This is a wrap-up session. We've really been working
together, the committee staff on the Democratic and Republican
side, and we've worked with the Administration to see if,
jointly, we could improve electronic health record systems.
Senator Murray and I were just talking a little earlier. I
don't want anybody to think that the committee's goal on either
the Republican or the Democratic side is not to move forward on
electronic healthcare records. We don't want to stop them. We
want to get them right, although we might have different
opinions about how to get it right. I think I can speak for
Democrats as well as Republicans on that.
Over the last 5 years, the taxpayers have spent about $30
billion to encourage doctors and hospitals to adopt electronic
health records systems. The whole purpose of this is to benefit
patients so that they and their healthcare providers have
quicker and better access to their health histories, and their
doctors, hospitals and pharmacists can provide them with better
care. Making electronic health records succeed is essential to
the biomedical research and innovation legislation that we hope
to mark up and finish this year and have ready for the full
Senate to work on.
No. 1, it's especially critical to President Obama's
Precision Medicine Initiative to assemble 1 million genomes and
allow doctors to take advantage of that genomic information to
prescribe the right medications in the right quantity at the
right time. It doesn't make any sense to go to all this trouble
to gather the information if you can't use it effectively.
No. 2, getting electronic health records is also important
to the shared goal between the Administration and Congress
adopted in recent legislation--the doc-fix legislation, we call
it--to change the way the Medicare program pays doctors so that
Medicare is paying providers based on the quality rather than
the quantity of care they give patients.
Under the new Merit-Based Incentive Payment System, 25
percent of the score that determines a provider's penalty or
bonus payment will be based on participation in meaningful use
and how well they comply with the regulations involving
electronic health records. You're not going to be very
successful with a merit-based system if electronic health
records aren't working.
We're now entering a period where the government is
penalizing doctors and hospitals if they do not adopt
electronic health records systems instead of giving them money
as an incentive. Stage 1 of Meaningful Use has been a success.
Stage 2 is not a success. Only 12 percent of doctors and 40
percent of hospitals have been able to attest to Stage 2.
The Administration has revised its rules for Stage 2. Most
people believe it would be a big help to adopt that final rule
immediately. I have urged those rules for Stage 2 be adopted
immediately. I have also asked the government to make the rules
final for Stage 3, to require doctors and hospitals to create
electronic health records, no sooner than January 1 of 2017,
and that the Stage 3 requirements be phased in at a rate that
reflects how successfully the program is being implemented.
Patients need an interoperable system that enables doctors
and hospitals to share their records, but they need time to do
it right. There are no reasons I've found not to do it on the
schedule I've just suggested: Stage 2 now, Stage 3 in a year.
There are five reasons--and I won't go into detail about
them, but I'm going to mention each one--to do it according to
the schedule I've suggested. One is only 12 percent of doctors
and 40 percent of hospitals have attested to Stage 2. Rushing
out Stage 3 seems premature.
No. 2, I've mentioned that within the merit-based payment
system for doctors, 25 percent of the penalties or incentives
depend upon attesting to meaningful use. It's important that
meaningful use be right. Just this week, the Administration
began the process to develop regulations for its value-based
payment system. It makes sense for the final stage of
electronic health records to be developed at the same time you
develop your merit-based payment system records.
No. 3, several of the leading medical institutions in the
country--and I won't name them--have recommended that we take
more time on Stage 3. One of those, one of the finest, said it
was literally terrified of Stage 3. That's no way to have a
success.
No. 4, the Government Accountability Office this week
issued a report saying that complying with the meaningful use
program is taking so much time that it's actually preventing
work on interoperability.
And, finally, we're working on legislation which we hope
that the full Senate and Congress will adopt next year. We'll
finish, we hope, in this committee this year and adopt it next
year with our 21st Century Cures. We want to do in our
legislation what the Administration can't do administratively.
It would make sense to me to do that together.
We're working on physician documentation; giving patients
better access to their own records; encouraging the entire
health team. We're working on things essential to
interoperability; data blocking; certification; improving
standards; security and privacy of patient records. All of
those things help make electronic health records a better
system.
I visited the Budget Director the other day and gave this
advice:
``When I was young and playing the piano, I used to
like to play fast, and my piano teacher would say to
me, `Lamar, play the music a little slower than you can
play it, and you're more likely to get it right when
you have a recital.' ''
Well, my advice to the Administration on this is similar.
You could go ahead with Stage 3, but I would suggest you go a
little slower than you need to go and make sure you don't make
a mistake.
Senator Thune, chairman of the Commerce Committee, and I
wrote a letter to the Administration suggesting the schedule
I've just described. A bipartisan group of 96 Republicans and
20 Democrats in the House did the same. I've got four letters
I'd ask consent to put in the record reflecting that advice
also from doctors and hospitals and others.
[The information referred to may be found in Additional
Material.]
The Chairman. I want to make sure what I'm about to say
isn't misunderstood, and I'll conclude and go to Senator
Murray. We have an opportunity in Congress to carefully review
whatever decision the Administration makes about how we
proceed. One way we can do that is through the innovation
legislation we're working on. Another way is through the
congressional review process if we don't like the rule.
I hope one of the lessons from the Affordable Care Act is
that it's better to move ahead with consensus if you can get
consensus. You can get consensus here. Republicans and
Democrats want electronic health records to succeed for the
benefit of the patients of this country and because it's
critical to at least two of the Administration's major
initiatives, precision medicine and merit-based payment.
Why not move ahead on a schedule that adopts Stage 2 now
and Stage 3 in a year and use the time between now and then to
develop support and build on consensus and get doctors,
hospitals and vendors to buy into what you're doing and go out
of office at the end of the next year with a big success
instead of a big problem? The big problem would be if you
prematurely announce the rule and the people who don't like it
try to repeal it from the day you do it.
Senator Murray.
Opening Statement of Senator Murray
Senator Murray. Well, thank you very much, Mr. Chairman.
Dr. DeSalvo and Dr. Conway, thank you so much for taking
the time to be here and for all you do to help improve the
health and well-being of families across our country.
I also want to thank all of our colleagues who are joining
us today and for the bipartisan commitment all of you have
shown to improving our Nation's health IT infrastructure.
This is the sixth and final hearing in a series intended to
explore ways that Congress can help improve health IT for
patients and providers. Over the course of this conversation,
we've heard striking examples that show how important
electronic medical records are to providing patients with the
care they need.
Whether it's understanding a loved one's full medical
history or being able to look up your own healthcare
information online or using a patient's medical record to catch
a dangerous interaction between medicines, it is very clear
that a strong health IT infrastructure is a critical part of
building a healthcare system that works for patients and
families and puts their needs first.
Hospitals and providers have made great strides over the
last few years when it comes to adopting health IT. Today,
almost 83 percent of physicians use some form of electronic
health record s. That is compared to just 18 percent in 2001.
The HITECH Act that passed in 2009 was a big part of that
transformation, and I am very grateful for the work that so
many doctors and hospitals have done to bring our healthcare
system into the 21st century and improve the value and quality
of care patients receive.
There is certainly more to do, and I'm pleased that over
the last few months, this committee has explored ways to build
on this progress in a bipartisan way. I've been very focused on
a few areas in particular.
I believe that we need to prioritize standards so that,
increasingly, systems developed by different vendors and used
by different doctors are actually able to speak to each other.
In the same way that an email sent from a gmail account makes
sense when it's opened in Yahoo, data in one EHR system should
be structured so that it makes sense in others.
Other industries have been able to converge around common
standards for exchanging digital information. It is important
that healthcare organizations continue to adopt a standardized
approach to sharing and using electronic health information.
These standards would not only support important research but
they would also cut down on the amount of time providers spend
on administrative tasks and allow them to focus resources on
providing care.
We also need to continue supporting the development of a
network of networks so that providers have many options for
trustworthy information sharing and they don't have to reinvent
the wheel every time they need to exchange information with a
new facility. Put simply, this is like making sure that someone
with a Verizon plan can call someone with a Sprint plan.
Many organizations are working hard on this already. They
are developing networks that allow information to be shared
between patients' different health care providers.
One great example is in my home State of Washington, the
Everett Clinic. They have set up an infrastructure to share
information with 121 different providers, helping to make sure
a doctor has as much information as possible on hand about her
patient's health. This is an effort Senator Baldwin is
especially interested in, and I really appreciate her work on
it.
We should also look for ways to make it easier for
providers to shop for electronic records systems and vote with
their feet when one isn't working or when an organization is,
as we've discussed in the committee, unnecessarily withholding
data. I know that Senators Whitehouse and Cassidy have been
very focused on this last challenge and on ensuring that
providers can speak up about technology that isn't getting the
job done, and I think that's very important.
Security is another critical challenge. As electronic
health record s become more integral to our healthcare system,
we need to prioritize developing technology and best practices
that can stand up to the realities of today's cybersecurity
threats.
Finally, one area that I think is absolutely critical is
patient engagement. If you can easily look up and download your
bank statement, you should be able to do the same with your
medical history. For far too many patients, these experiences
are very different.
In our last hearing on EHRs, I told a story I'd heard about
a woman looking up results of a pregnancy test in her medical
records and finding her hormone levels listed instead of a
simple yes, you are, or no, you're not. We've heard many other
stories about patients seeking their medical records and being
given massive binders, unreadable PDFs, and stacks of CDs. In
the 21st century, we can and must do a lot better than that.
I'm very hopeful we can do more to ensure electronic health
record s are accessible to patients so that they are able to
stay engaged in their care.
I want to close with some news I got recently from
Washington State. A doctor at Swedish Medical Center in Seattle
wrote to my office about how electronic health records have
changed the way her office works. She said that while their EHR
system is far from perfect, it is alerting patients to come in
for important preventive healthcare services, like cancer
screenings.
She said that since the summer, they have identified two
breast cancers, two colon cancers, and one cervical carcinoma
that otherwise may not have been detected. The doctor wrote me
and said,
``There are five people in our clinic that would have
gone undiagnosed and possibly died that now have caught
the disease early and will hopefully see a long, happy
life.''
This really reinforces the importance of the bipartisan
work this committee is doing to strengthen our healthcare
information infrastructure and improve our healthcare system
for patients like these and their families. We've come a long
way. We've got a lot more to do.
I'm looking forward to working with you, Mr. Chairman, on a
bipartisan effort on this.
Dr. DeSalvo and Dr. Conway, thank you again for being here
and sharing your expertise with us.
The Chairman. Thank you, Senator Murray.
I want to thank Senator Murray, as we have been working all
year in a bipartisan way on this. Our hearings have been
bipartisan. Our working groups have been bipartisan.
Our hope is that Senator Murray and I will be able to
present a bipartisan starting point for our medical innovation
legislation to the committee for its consideration that would
include whatever we need to do about electronic health records
that the Administration can't do by Executive order, that can
then be ready for the Senate, passed and be combined next year
with the House 21st Century Cures and enacted. That's the
schedule that we hope to go on, and we're making very good
progress.
We have two witnesses today from the Department of Health
and Human Services. The purpose of the hearing really is to
wrap up the work we've been doing within our bipartisan working
groups and with the Administration to try to identify five or
six steps that we could take to improve the electronic records
system.
First, we'll hear from Dr. Karen DeSalvo. She is the
National Coordinator for Health Information Technology and
Acting Assistant Secretary for Health for the Department of
Health and Human Services. As National Coordinator, she has
spent a lot of time on this issue and worked well with the
committee, and we thank her for that. She's been nominated by
the President to be the Assistant Secretary for Health, and her
nomination has been cleared by this committee already.
Our second witness is Dr. Patrick Conway. He is the Deputy
Administrator for Innovation and Quality and Chief Medical
Officer at the Centers for Medicare and Medicaid Services. He
leads the Center for Clinical Standards and Quality, which is
responsible for all quality measures and standards of Medicare
and Medicaid providers. He is also the Principal Administrator
for the Electronic Health Record Incentive Program, commonly
referred to as meaningful use.
Dr. DeSalvo and Dr. Conway, thank you for coming. If you
would summarize your remarks in about 5 minutes, there are
several Senators here who would like to have a conversation
with you about electronic health records.
Dr. DeSalvo.
STATEMENT OF KAREN DeSALVO, M.D., MPH, MSc, NATIONAL
COORDINATOR FOR HEALTH INFORMATION TECHNOLOGY, DEPARTMENT OF
HEALTH AND HUMAN SERVICES, U.S. DEPARTMENT OF HEALTH AND HUMAN
SERVICES, NEW ORLEANS, LA
Dr. DeSalvo. Good morning, Chairman Alexander and Ranking
Member Murray and distinguished committee members. I'd like to
start by thanking you all for your ongoing interest in
continuing the country's progress toward health information
technology and seeing that we create an open, connected
community of health.
I do appreciate the opportunity to appear here today and
discuss with you the current State of health IT in our Nation
and how we can work together to see that these systems realize
their full potential now and in the future so that health
information is available to the right person, at the right
place, at the right time in a private and secure manner. I do
firmly believe that we have common ground and shared goals.
Under my leadership, the Office of the National Coordinator
for Health IT has been working urgently to ensure that we
realize a return on investment for electronic health records.
Our urgency mirrors your own and hundreds of doctors, consumers
and stakeholders with whom I have spoken during my tenure as
National Coordinator and my own personal experience practicing
medicine in the community.
We have, indeed, achieved a tremendous success in advancing
the digitization of the healthcare experience for Americans.
Nearly three-quarters of doctors and more than 90 percent of
hospitals use electronic health records, and providers do want
this progress to continue.
Our work is only beginning. We continue to work
collaboratively to see that health IT matures and becomes a
more seamless support for doctors and the health system as it
seeks to provide individuals with the kind of safe, person-
centered care that we're all working toward.
As Congress has recognized, the availability of usable
electronic health information through a more connected and
interoperable health system is a major priority. I have made it
ONC's priority since I started my tenure a year and a half ago.
Within months of becoming National Coordinator, we released
a vision document for interoperability and followed up shortly
thereafter with a draft nationwide interoperability road map,
which we have used to establish a dialog with the health IT
community. In the road map, we describe what needs to be
achieved when and by whom to reach the goal of the open,
connected community of health IT so that we can support better
care and efforts like precision medicine.
We have identified that we need to move forward with a set
of shared interoperability standards, to establish an
environment of trust, and to create the right business
environment that will allow data to flow. We have been working
with our Federal and private sector partners since the release
of the draft road map but have not waited for the final version
which will come out in the coming weeks.
Here are some examples of actions that we have taken in the
near term to see that we can advance interoperability. We have
set exact and explicit technology standards. We have promoted
the use of APIs, which are doorways to the data. We are
building an economic case for sharing data through the
Secretary's delivery system reform effort. We are exposing and
discouraging health information blocking.
We have been coordinating with our Federal partners to
enhance education around HIPAA and privacy, and we have
proposed in our certification program to push more
transparency, more competition in the marketplace to encourage
innovation in areas like usability and to help providers know
what systems they are purchasing. We've been working to
increase awareness of the hardship exemption for providers who
might want to switch products and for those who want to stay
with the products they have, offering technical assistance on
the front lines.
We believe that in addition to the actions we can take as
an administration, the private sector needs to continue to
contribute. They can help us make more progress now by agreeing
to make publicly available APIs to allow consumers to have
access and control of their data and share it where they like.
We can agree to not knowingly or unreasonably engage in health
information blocking, and they can agree to a set of federally
recognized national interoperability standards for technology
and policy.
In addition to the steps taken by the Administration in the
near term and in the days to come and our partners in the
private sector, we understand that the committee may be
interested in ways to increase interoperability. We think this
can be achieved by establishing a governance approach for how
technology is used in practice, improving transparency in the
market, and prohibiting information blocking.
A governance mechanism would ensure that those
participating in the exchange and interoperability of health
information can be held accountable, including, for example,
vendors and providers. Improving transparency in the
marketplace by outlining basic expectations would improve
interoperability and exchange of information, making purchasing
decisions easier if doctors and hospitals had a better sense of
the cost, limitations, and other performance characteristics of
their products.
Last, by promoting and prohibiting information blocking and
associated business practices under programs recognized by the
National Coordinator, we would prevent unnecessary impediments
to data flow and interoperability of health IT. Any actions in
this area should balance the need for not only health
information availability, but patient safety and the interests
of the business practices at hand.
Thank you to the members of the committee for this
opportunity to discuss health information technology, which is,
we agree, a critical underpinning of the better health system,
where we have better care, smarter spending, and a healthier
population. I do look forward to a continued partnership so
that, together, we can achieve our shared goals, and I'm happy
to answer any questions.
[The prepared statement of Dr. DeSalvo follows:]
Prepared Statement of Karen B. DeSalvo, M.D., MPH, MSc
Chairman Alexander, Ranking Member Murray, and distinguished
committee members, thank you for the opportunity to appear today. My
name is Dr. Karen DeSalvo and I am the National Coordinator for Health
Information Technology. Thank you for the invitation to be here to
discuss the current state of health information technology in our
Nation and how we can work together to help these systems realize their
full potential now and in the future.
The Office of the National Coordinator for Health Information
Technology (ONC) was established by Executive Order in 2004 and charged
with the mission of giving every American access to their electronic
health information when and where they need it most. In 2009, ONC was
statutorily established by the Health Information Technology for
Economic and Clinical Health Act (HITECH), enacted as part of the
American Reinvestment and Recovery Act (ARRA). HITECH also provided the
resources and infrastructure needed to stimulate the rapid, nationwide
adoption and use of health IT, especially electronic health records
(EHRs). In the 6 years since the HITECH Act was enacted, we have seen
dramatic advancement in the use and adoption of health IT. The
proportion of U.S. physicians using EHRs increased from 18 percent to
78 percent between 2001 and 2013,\1\ and 94 percent of hospitals now
report use of certified EHRs.\2\ The combined efforts of initiatives
like the Regional Extension Centers, the ONC Health IT Certification
Program, use of standard terminologies, and the CMS Medicare and
Medicaid EHR Incentives Programs have brought us past a tipping point
in the use of health IT. Today, we are firmly on the path to a digital
health care system; but, there is still much work to do.
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\1\ http://www.cdc.gov/nchs/data/databriefs/db143.htm.
\2\ http://healthit.gov/sites/default/files/data-brief/
2014HospitalAdoptionDataBrief.pdf.
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Prior to becoming the National Coordinator in January 2014, I
worked in a variety of settings, which provided me with keen insight
into and experience working with health IT systems. My previous
positions include serving as the Health Commissioner for the city of
New Orleans, a Senior Health Policy Advisor to the Mayor of New
Orleans, and a professor of medicine and vice dean for community
affairs at Tulane University School of Medicine. In addition, I have
practiced internal medicine for close to a quarter century. In all of
these positions, I have established, purchased, utilized, implemented,
and studied health IT systems. I not only understand the importance of
health IT to improving the overall health care in this Nation, but I
also understand firsthand the numerous complications and frustrations
that we have faced, and continue to face along the way. I came to ONC
to build on the incredible progress we have made since 2009, and to
move us forward into a new and exciting era of health IT. Thus far, I
have focused my energy and attention on what I believe is a fundamental
piece of the puzzle to moving us forward, and that is a ubiquitous,
safe, and secure interoperable health IT infrastructure.
Since I became the National Coordinator, ONC has been working
intensely to harness the health care industry's energy and consumer
demands for interoperability to drive improvement in health--we feel
the strong sense of urgency and have acted on it quickly. The Nation
asked for a clear strategy to get to interoperability and a learning
health system, and we delivered that plan in ``Connecting Health and
Care for the Nation: A Shared Nationwide Interoperability Roadmap Draft
Version 1.0.'' We received broad feedback and have heard agreement from
critical stakeholders like developers, consumers, providers,
technologists, and others that this plan is the right path forward, and
that they would like to work with us to advance interoperability. The
Roadmap explains that, in order to meet stakeholders' specific
interoperability needs as quickly, securely, and safely as possible, we
must: (1) buildupon the current infrastructure; (2) ensure that
applicable standards are consistently used; (3) foster an environment
of trust where individuals can access their data in a private and
secure manner; and (4) incent, through consumer demand and delivery-
system reform, enduring, self-sustaining interoperable movement and use
of electronic health information.
We anticipate releasing in the very near future the final
streamlined Version 1.0 of the Roadmap, which will focus primarily on
impactful, near-term actions we all can take by the end of 2017 to
improve interoperability. These actions are detailed in three areas in
the Roadmap. First, ``Drivers,'' which are mechanisms that can propel a
supportive payment and regulatory environment that relies on and
deepens interoperability. Second, ``Policy and Technical Components,''
which are essential items stakeholders need to implement to enable
interoperability, such as shared standards and expectations around
privacy and security. Third, ``Outcomes,'' which serve as metrics by
which stakeholders will measure our collective progress on implementing
the Roadmap.
We are also working across the Department on ways to increase
interoperability. As part of the Department's Delivery System Reform
initiative, HHS is using a variety of policies and programs to achieve
a vision of information sharing and interoperability. A key component
of the Delivery System Reform initiative is expanding the use of
alternative payment models that reward quality over quantity and
linking fee-for-service payments to quality and value. Electronic
sharing of health information is an important element of how care is
delivered under these models. ONC activities are focused on the
Delivery System Reform goal to improve the way information is shared
among providers to create a better, smarter, and healthier system. ONC
is working closely with CMS on certifying that health IT products
adhere to interoperability standards, providing support to stakeholders
focused on sharing health information, and working with other agencies
across HHS to reinforce the use of health information interoperability
and adoption of health IT through a variety of policies and programs.
Achieving interoperability to meet stakeholder needs now, and
throughout the next few years, can help us to realize our vision of a
learning health system--one that delivers high-quality care, lower
costs, a healthy population, and engaged people. It is clear we must
move beyond electronic health record adoption and focus on liberating
health data, so critical information is available when and where it
matters most to transform individual, community, and population health
and care.
In our pursuit of achieving a learning health system, we are also
continuing our work with our other Federal partners. As you know, we
recently issued the Federal Health IT Strategic Plan 2015-20. This
Plan, developed in partnership with over 35 Federal entities,
demonstrates the extensive interest across the Federal Government to
digitize the health experience for all individuals and facilitate
progress toward a learning health system that can improve health and
care. The Plan has been designed to support important changes already
occurring in the health landscape, such as the Precision Medicine
Initiative and the Department of Defense's Military Health System's
acquisition of a new health IT system, as well as longer-range changes,
such as FDA's Sentinel program. The Plan's long-term vision of a
learning health system relies on the use of technology and health
information from a multitude of sources for a multitude of purposes,
and working with our Federal partners, with the Congress, and other
stakeholders, our strategies will evolve to ensure we can meet this
vision for the Nation. In addition, we will continue our collaboration
with the Office for Civil Rights, and the Food and Drug Administration,
both within HHS, and with the Federal Trade Commission to improve
security in health IT and consumer understanding of security risks.
We also understand that advancing health IT requires engagement
beyond the government, which is why we have continued our ongoing
collaborative work with not only this committee, but also outside
stakeholders, patients, hospitals, and providers to name a few. For
example, ONC is currently working with the National Quality Forum (NQF)
to develop multi-stakeholder consensus around health IT safety
measurement priorities, create an organizing framework for health IT
safety measures, and identify potential health IT safety measures and
current gaps in health IT safety measures. In 2014, we participated in
a series of ``Learning What Works'' listening sessions in five cities
across the country with the Robert Wood Johnson Foundation to hear from
local leaders, residents, and professionals from a wide range of
sectors on what information is important to them and how they might use
it to help people lead healthier lives and improve health in their
communities. ONC participated in these listening sessions and heard
feedback about the importance of trust, data access, and how
individuals and communities want to use data to improve overall health.
In addition, last year, Health Level Seven International (HL7)
launched an initiative to accelerate the development and adoption of
HL7's Fast Healthcare Interoperability Resources (FHIR), with support
from 11 organizations, including EHR vendors like Epic and Cerner and
health systems like Mayo Clinic and Intermountain Healthcare. Following
the JASON Report,\3\ our Federal advisory committees urged the Office
of the National Coordinator to focus on an approach involving public
application programming interfaces (APIs) and FHIR, which you see in
our proposed 2015 Edition certification rule and is also addressed in
CMS's proposed rule for Stage 3. I'm optimistic because I am seeing
more collaborations like these from the private sector. For example,
the Argonauts Project, which is a coalition of industry vendors and
providers, is collaborating in an unprecedented fashion. They are
accelerating the maturation of FHIR, to see that we have a safe, but
highly usable new technology that stands to transform the health IT
ecosystem.
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\3\ JASON. (2013). A Robust Health Data Infrastructure. Washington,
DC: MITRE for Agency for Healthcare Research and Quality.
---------------------------------------------------------------------------
Through this ongoing work, as a Department, we have concluded that
to achieve a learning health system, we must buildupon the current
health information infrastructure and work together to focus on three
key areas. We have prioritized and intend to focus on: (1) ensuring
that electronic health information is appropriately available, easily
transferable, and readily usable by the patient, provider, payer,
scientist, and others; (2) improving the safety and usability of health
information technology and allowing the market to function in a way to
incentivize necessary improvements; and (3) simplifying program
requirements to lower administrative burden and create a clear link
between program participation and outcomes. We believe this work will
support providers as they adopt and use health IT and work to deliver
better care for patients. While ONC will support efforts on all three
fronts, we plan to focus our attention most acutely on addressing the
first two.
It is imperative to a functioning health information technology
infrastructure to have data available to the right person, at the right
place, at the right time. ONC can make a big impact in this area by
promoting interoperability, addressing information blocking, and by
empowering providers to engage patients. In 2012, ONC took on the
responsibility for spreading the Blue Button initiative nationwide.
This work was done in collaboration with the Department of Veterans
Affairs, the White House, and a host of other public and private sector
leaders. Patients can securely access their health data from multiple
sources and then choose to download that data to their computer, thumb
drive or smartphone without using any special software, or choose to
share that data with individuals they trust--whether it's their other
physicians or family members. To date, there are more than 600 member
organizations participating in the Blue Button initiative. Meanwhile
our actions over the next year will focus on continuing to build the
economic case for interoperability, including increasing incentives and
improving the regulatory and business environments; coordinating with
health information technology stakeholders to coalesce around a shared
set of technical standards; exposing and discouraging health
information blocking; and ensuring the implementation of robust privacy
and security protections.
We recognize that the current marketplace does not always function
in a way that promotes a learning health system. ONC is committed to
supporting providers as they use health IT for more advanced
applications and encourage the private sector to address this
challenge. For example, we proposed the 2015 Edition rule with the goal
of improving transparency for certified health IT systems. We believe
we can help by driving secure, safe and usable products while also
continuing to offer technical assistance to providers. Through the 2015
Edition proposed rule, we also are continuing to help make the business
case that investments in health IT tools that support better care
coordination and population health management offer an important way to
drive continued innovation as vendors seek to meet the needs of
providers moving toward value-based care.
In addition to taking steps administratively within these important
spaces, we understand that the committee may be interested in ways to
make technology more usable by (1) establishing a governance mechanism
for how technology is used in practice; (2) improving transparency in
the market; and (3) prohibiting information blocking. For example, a
governance mechanism would ensure that those participating in the
exchange and interoperability of health information, including, for
example, health IT vendors, can be held accountable. Defining and
outlining basic expectations would improve interoperability and the
exchange of information. Moreover, providers would be able to make more
informed purchasing decisions if they had a better sense of the costs,
capabilities, limitations, and other performance characteristics of
certified health IT. And, last, prohibiting information blocking and
associated business practices by providers, suppliers, and vendors of
health IT certified under programs recognized by the National
Coordinator would prevent unnecessary impediments to the use of health
IT for the interoperable exchange of electronic health information. Of
course, any action in this area should balance the need for
availability of electronic health information with the need to promote
patient safety, maintain the privacy and security of electronic health
information, and protect the legitimate economic interests and
incentives of providers, developers, and other market participants.
We share the goal of making this technology more usable, and should
the Congress choose to legislate in this area, these actions could
further help health IT reach its full potential. With that in mind, ONC
is committed to moving forward by promoting the use of health IT to
encourage information exchange, not only across the Department and
Governmentwide, but also with outside stakeholders, including the
Congress. We realize everyone has a role to play in moving health IT
systems forward and look forward to the challenge ahead of us.
Thank you again for inviting me today.
The Chairman. Thank you, Dr. DeSalvo.
Dr. Conway.
STATEMENT OF PATRICK CONWAY, M.D., MSc, ACTING PRINCIPAL DEPUTY
ADMINISTRATOR, DEPUTY ADMINISTRATOR FOR INNOVATION AND QUALITY,
CENTERS FOR MEDICARE AND MEDICAID SERVICES CHIEF MEDICAL
OFFICER, CENTERS FOR MEDICARE AND MEDICAID, COLLEGE STATION, TX
Dr. Conway. Chairman Alexander, Ranking Member Murray, and
members of the committee, thank you for the opportunity to
discuss the work of the Centers for Medicare and Medicaid
Services related to health information technology.
When I started practicing medicine, I remember trying to
read hand-scrawled consult notes, struggling to find an x-ray
in the basement of the hospital, and going to the lab to track
down lab results for patients. It was not an effective system.
I practice as an attending physician on weekends in a
hospital with a electronic health record, or EHR, networked
with other hospitals across the region. With the click of a
button, I can pull up lab results, x-rays, or consult notes. I
can even show the radiologic image to a worried family on the
computer screen and explain the treatment.
When I was at Cincinnati Children's Hospital, I led
efforts, using our EHRs, to measure quality across the system.
We used EHRs as an essential tool to measure and improve care
and patient outcomes.
Health IT is an important catalyst for improving care
delivery and can help prepare providers to be successful under
alternative payment models. Earlier this year, Secretary
Burwell announced measurable goals and a timeline to move the
Medicare program and the health system at large toward paying
providers based on quality rather than the quantity of care
they deliver.
In April, Congress passed the Medicare Access and CHIP
Reauthorization Act, or MACRA, which aligns with and supports
the Secretary's goals by requiring implementation of a new
value-based payment system for physicians and other clinicians
in Medicare. We would like to thank those on the committee who
supported MACRA and have helped continue our efforts to
accelerate delivery system reform.
CMS has worked to advance the use of EHRs as an investment
to ensure we can realize the benefits of value-based payment
systems established by MACRA and other initiatives. We are
focused on implementing MACRA in a manner that allows
physicians and other clinicians to succeed in improving their
practice and, most importantly, in delivering high-quality
coordinated care to all people.
CMS will also work to implement provisions in MACRA that
address information blocking by requiring providers to
demonstrate they have not acted to limit or restrict
interoperability of certified EHR technology.
Under alternative payment models, it is essential for
providers to communicate across care settings, reduce
duplication, and engage patients. The effective use of health
IT can help providers achieve those aims. For example, health
IT can help a patient transition safely from the hospital to
home by enabling inpatient and ambulatory providers to quickly
and easily share information.
The Medicare and Medicaid EHR incentive programs provide
incentive payments to eligible professionals, hospitals, and
critical access hospitals in order to encourage the adoption of
health IT to improve care for beneficiaries. Participation in
the program remains strong. As of July 2015, more than 474,000
healthcare providers had received payment for participating in
either the Medicare or Medicaid incentive program. That
represents over 70 percent of eligible professionals and over
95 percent of eligible hospitals.
CMS is working to simplify program expectations and give
providers needed flexibility while advancing important
capabilities such as effective health information exchange and
population health management that are essential to better care
and lower costs. Many of the proposed objectives and measures
for Stage 3 are focused on interoperability. For example, we
have proposed to encourage providers to make available their
EHR's application program interfaces, or APIs.
APIs are like road maps for computer software. Opening them
up allows programmers to design applications that help patients
view and share their health information where and when they
need to. In fact, the majority of the proposed measures in
Stage 3 require interoperability and information exchange,
which is a significant increase from Stage 1 and 2.
In addition, CMS identified redundancies, duplication, and
incidences of measures that were topped out. Based on that
analysis, we proposed the Stage 3 rule focused on an aligned
set of only eight objectives and measures, down from 20 in
Stage 2.
We have also proposed to give eligible professionals
options within several objectives, allowing providers
flexibility to concentrate on factors of health IT
implementation that are most applicable to their practice.
Furthermore, CMS has proposed to modify Stage 1 and 2
requirements to reduce complexity, lessen providers' reporting
burdens, and shorten the EHR reporting period in 2015 to 90
days to accommodate these changes.
In totality, these proposed changes put an end to the
stages of so-called meaningful use and move us forward to MACRA
and comprehensive quality and value programs for physicians,
clinicians, and hospitals. Our primary goal is to ensure
beneficiaries and providers can realize all the benefits of EHR
systems to support high-quality, value-based care.
We will continue our work with ONC, providers, Congress,
and others to improve the interoperability, make health IT more
user-friendly, and simplify program requirements as we work to
transform the healthcare delivery system to achieve better
care, smarter spending, and healthier people.
I have read all three of my older children into the
congressional record, and I am dedicated to a long-term,
affordable, high-quality Medicare program for our new 2-month-
old daughter, Isabelle Ann Conway, who is now also in the
congressional record.
Thank you again for the opportunity to testify. I'd be
happy to answer your questions.
[The prepared statement of Dr. Conway follows:]
Prepared Statement of Patrick Conway, M.D., MSc
Chairman Alexander, Ranking Member Murray, and members of the
committee, thank you for the opportunity to discuss our work at the
Centers for Medicare & Medicaid Services (CMS) related to health
information technology (health IT). CMS is committed to working with
providers and stakeholders to harness the potential of health IT to
improve the quality and reduce the cost of care--and, more broadly,
transform our Nation's health care delivery system.
As a result of the Medicare and Medicaid Electronic Health Record
(EHR) Incentive Programs, adoption of electronic health records
continues to increase among physicians, hospitals, and others serving
Medicare and Medicaid beneficiaries. Higher EHR adoption has helped
care providers evaluate patients' medical status, coordinate care,
eliminate redundant procedures and provide high-quality care. The
proportion of U.S. physicians using Electronic Health Records (EHRs)
increased from 18 percent to 78 percent between 2001 and 2013, and 94
percent of hospitals now report use of certified EHRs. EHRs also will
help speed the adoption of key delivery-system reforms by making it
easier for hospitals and doctors to better coordinate care and achieve
improvements in quality.
Earlier this year, Health and Human Services Secretary Burwell
announced measurable goals and a timeline to move the Medicare program,
and the health care system at large, toward paying providers based on
the quality, rather than the quantity of care they give patients. Such
incentives will help achieve the critical goal of improving care
delivery and access to information. Encouraging the use of health IT is
an important component of HHS efforts to transform the delivery system.
It supports the health information exchange needed to improve
communication and care coordination, promote patient safety, enhance
clinical decisionmaking, track patient outcomes and support payment for
care quality. Health IT helps provide the information needed to
clinicians and patients at the point-of-care.
On April 16, 2015, President Obama signed the Medicare Access and
CHIP Reauthorization Act (MACRA),\1\ which supports the Secretary's
goals by requiring the implementation of new payment systems for
physicians and other practitioners in Medicare by 2019: the Merit-Based
Incentive Payment System and Alternative Payment Models,. Together,
these important steps to transform the way Medicare pays practitioners
will promote a long-term business case for effective health IT adoption
and, in turn, lead to better care and improved outcomes.
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\1\ PL 114-10 https://www.Congress.gov/114/plaws/publ10/PLAW-
114publ10.pdf.
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Health IT is an important catalyst for improving care delivery,
enabling providers to prepare for and be successful under new
alternative payment models. Under new payment models, it is
increasingly critical for providers to communicate effectively across
care settings, quickly and easily share health information, reduce
duplicative and unnecessary care, successfully manage high-risk
populations and engage patients in their care by communicating and
sharing test results electronically. Effective use of health IT can
help providers achieve those aims: helping a patient transition safely
from the hospital to the home by enabling inpatient and outpatient
providers to quickly and easily share key information; helping patients
communicate with providers through secure, electronic messaging; and
helping providers identify and communicate with patients who are in
need of followup care to address their chronic condition(s).
Additionally, many providers now are using clinical and patient-
submitted data from health IT systems to track and improve population
health.
While the use of health IT can promote higher-quality care
delivery, we also recognize that providers face costs when adopting and
implementing new EHRs and other health IT systems, such as the up-front
cost to purchase new technology and the indirect cost of the provider's
time to incorporate that new technology into practice workflow. By
aligning CMS programs and providing flexibility, we aim to ensure that
providers focus their resources on delivering high-quality care for our
beneficiaries.
CMS is focused on efforts to simplify our program requirements to
lower administrative requirements and create a clear link between
program participation and better outcomes. These include providing
provider flexibility in achieving meaningful use of certified EHR
technology and aligning quality measures across payment programs. At
the same time, CMS is supporting the ongoing efforts of the Office of
the National Coordinator for Health IT (ONC) to make electronic health
information more readily transferable and to promote more user-centric
EHR systems. We believe this work will support providers as they adopt
and use health IT and work to deliver better care for Medicare and
Medicaid beneficiaries.
encouraging ehr adoption
Since the passage of the American Recovery and Reinvestment Act of
2009 (``Recovery Act''), CMS has been hard at work implementing
financial incentives and technical assistance to encourage the
widespread use of certified EHR technology to improve quality, safety
and efficiency; reduce health disparities; engage patients and
families; improve care coordination; improve population and public
health; and maintain the privacy and security of patient health
information.
The Recovery Act established the Medicare and Medicaid EHR
Incentive Programs, which provide incentive payments to eligible
professionals, eligible hospitals, and critical access hospitals (CAHs)
as they adopt, implement, upgrade or demonstrate meaningful use of
certified EHR technology. To receive an EHR incentive payment under
Medicare, providers must demonstrate that they are ``meaningfully
using'' their certified EHR technology by meeting thresholds for a
number of objectives and reporting clinical quality measures.
States verify eligibility for the Medicaid EHR Incentive Program.
Several additional types of health care providers are eligible for
Medicaid EHR incentive payments, including nurse practitioners,
certified nurse-midwives, dentists, and physician assistants who
furnish services at a physician assistant-led federally qualified
health center or rural health clinic. There also are patient-volume
thresholds that providers must meet to be eligible for EHR incentive
payments under Medicaid. Children's hospitals, however, are eligible
for Medicaid incentive payments regardless of Medicaid patient volume.
In their first year in the Medicaid EHR Incentive Program, Medicaid
providers also have the option to receive incentive payments based on
whether they adopt, implement or upgrade a certified EHR technology.
The Medicare and Medicaid EHR Incentive Programs have progressed in
stages, moving from basic data capture to advanced functionality of
EHRs, including interoperability, patient engagement, clinical decision
support, and quality measurement and then to increased health
information exchange, interoperability and improved patient outcomes.
This last phase, referred to as ``Stage 3,'' would make changes that
are responsive to stakeholders asking for more time, flexibility and
simplicity in the program.\2\
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\2\ Electronic Health Record Incentive Program--Stage 3 Notice of
Proposed Rulemaking https://www.Federalregister.gov/articles/2015/03/
30/2015-06685/medicare-and-medicaid-programs-electronic-health-record-
incentive-program-stage-3.
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Participation in the Medicare and Medicaid EHR Incentive Programs
remains strong. As of July 2015, more than 474,000 health care
providers received payment for participating in either the Medicare or
Medicaid Incentive Program. More than $20.9 billion in Medicare EHR
Incentive Program payments were made between May 2011 and July 2015. In
addition, more than $9.98 billion in Medicaid EHR Incentive Program
payments were made between January 2011 (when the first set of States
launched their programs) and July 2015.\3\ As of July 2015, over
300,000 unique providers had received Medicare EHR Incentive Program
payments under Stage 1 and over 50,000 providers had received payments
under Stage 2.\4\
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\3\ https://www.cms.gov/Regulations-and-Guidance/Legislation/
EHRIncentivePrograms/Down
loads/July2015_PaymentsbyStatebyProgramandProvider.pdf.
\4\ Ibid.
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reducing administrative requirements and increasing flexibility
CMS is taking several steps to streamline Medicare and Medicaid EHR
Incentive Program requirements and provide flexibility based on lessons
learned from the initial years of operating the programs. For example,
in March we proposed that Stage 3 will be optional in 2017,\5\ giving
program participants and industry more time to implement changes,
update workflows and adopt new technology.
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\5\ Electronic Health Record Incentive Program--Stage 3 Notice of
Proposed Rulemaking https://www.Federalregister.gov/articles/2015/03/
30/2015-06685/medicare-and-medicaid-programs-electronic-health-record-
incentive-program-stage-3.
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CMS also aims to streamline and reduce overall reporting
requirements. We analyzed the objectives and measures of the program to
determine where measures are redundant, duplicative or have ``topped
out.''.\6\ For Stage 3 specifically, based on this analysis, we
proposed an aligned set of eight objectives and measures for eligible
professionals and hospitals, down from 20\7\ in Stage 2.\8\ If
finalized, we believe these changes will focus provider efforts on
objectives that pertain to the advanced use of EHRs, such as using data
to drive improvements in care coordination, care management and
population health outcomes.
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\6\ ``Topped out'' is the term used to describe measures that have
achieved widespread adoption at a high rate of performance and no
longer represent a basis upon which provider performance may be
differentiated. It is commonly used to justify removal of specific
clinical quality measures from public and private sector quality
reporting programs.
\7\ Eligible Providers must achieve 20 Meaningful Use Objectives in
Stage 2; Eligible Hospitals must achieve 19, see Stage 2 final rule
here: http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-21050.pdf.
\8\ Electronic Health Record Incentive Program--Stage 3 Notice of
Proposed Rulemaking https://www.Federalregister.gov/articles/2015/03/
30/2015-06685/medicare-and-medicaid-programs-electronic-health-record-
incentive-program-stage-3.
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Providers have indicated to CMS that they need flexibility in
implementing the objectives and measures of meaningful use in diverse
clinical settings. As a result, we proposed to give eligible
professionals measure options within several objectives to allow
providers to report on measures most applicable to their practice.\9\
In addition, CMS proposed to focus objectives and measures on
interoperability requirements, such as allowing the use of Application
Program Interfaces and focusing on electronic exchange of health
information between providers. In Stage 3, more than 60 percent of the
proposed Meaningful Use measures require interoperability, up from 33
percent in Stage 2.
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\9\ For example, providers must report the numerator and
denominators for all three measures within the Health Information
Exchange objective. However, providers are only required to achieve the
thresholds for two measures to meet the objective. See Electronic
Health Record Incentive Program--Stage 3 Notice of Proposed Rulemaking
https://www.Federalregister.gov/articles/2015/03/30/2015-06685/
medicare-and-medicaid-programs-electronic-health-record-incentive-
program-stage-3.
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Finally, we are aligning clinical quality measure reporting
requirements across payment programs to reduce reporting requirements
and focus provider efforts on high-impact outcomes-based measures.
Today, eligible professionals in the Medicare EHR Incentive Program
that report quality measures to CMS electronically can receive credit
in both the EHR Incentive Program and the Physician Quality Reporting
System.\10\ These results also will be used in calculating eligible
professionals' performance under the physician value modifier and
future value-based purchasing initiatives. The CMS goal is to allow
providers to report once for all applicable quality programs. We also
are working to align CMS quality measures with those used by the
private sector, concentrating provider efforts and lowering the
reporting burden for those providers that submit data to both public
and private payers. While we are removing ``topped-out'' and outdated
measures, we are simultaneously working to fill measure gaps by
developing measures for important health conditions and provider types
where sufficient measures have yet to be created. Over time, these
measures will be added to our quality programs, making them more
relevant to certain specialties and better reflective of the latest
evidence base.
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\10\ Electronic Health Record Incentive Programs Stage 2 Final
Rules: http://www.gpo.gov/fdsys/pkg/FR-2012-09-04/pdf/2012-21050.pdf.
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health it and delivery system reform initiatives
CMS is working hard to implement MACRA, which will promote the
adoption of new payment and service delivery models. The law creates a
value-based physician payment system (Merit-Based Incentive Payment
Systems or MIPS), and the adoption and meaningful use of health IT will
be one of the categories for determining how Medicare provider
performance is assessed--and rewarded--under MIPS. MACRA also
encourages participation in alternative payment models by requiring
eligible professionals participating in such models to use certified
EHR technology.
Adopting health IT enables capabilities--like efficient
communication across care settings, safe prescribing and managing
overall population health--that are central to improving care and
lowering costs. In addition to implementing MACRA, CMS is supporting
the business case for EHR adoption through targeted initiatives that
encourage health care providers to deliver high-quality, coordinated
care at lower costs. These reforms enable us to pay based on value
while promoting patient safety and better care coordination across the
health care delivery system.
CMS initiatives include Accountable Care Organizations (ACOs)--
groups of doctors and other health care providers that have agreed to
work together to treat individual patients and better coordinate their
care across care settings. They have the opportunity to share in
savings generated from lowering the growth in health care costs while
improving quality of care, including a measure that promotes use of EHR
technology. Medicare ACOs have already demonstrated significant cost
savings and improvements in quality. In 2014, 20 Pioneer and 333 Shared
Savings Program ACOs generated more than $411 million in savings.
Pioneer ACOs also showed improvements in 28 of 33 quality measures and
experienced average improvements of 3.6 percent across all quality
measures. Shared Savings Program ACOs that reported quality measures in
2013 and 2014 improved on 27 of 33 quality measures.
Another example is the Comprehensive Primary Care Initiative
(CPC),\11\ which is a multi-payer partnership between Medicare,
Medicaid, private health care payers and primary care practices in four
States\12\ and three regions.\13\ CMS requires all participants in CPC
to use ONC Certified EHR Technology. A few of the ways the practices
use such certified technology include: (1) reporting their practice
results for all electronic clinical quality measures; (2) risk-
stratifying their patient populations to focus on patients likely to
benefit from active intensive care management; (3) ensuring patients
can reach a member of their care team who has real-time access to their
EHRs 24 hours a day; and (4) achieving meaningful use. Results from the
first year suggest CPC, on average across seven regions, has generated
nearly enough savings in Medicare health expenditures to offset care
management fees paid by CMS, with hospital admissions decreasing by 2
percent across all sites and emergency department visits decreasing by
3 percent.
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\11\ http://innovation.cms.gov/initiatives/comprehensive-primary-
care-initiative/.
\12\ Arkansas, Colorado, New Jersey and Oregon.
\13\ New York's Capital District and Hudson Valley, Ohio and
Kentucky's Cincinnati-Dayton region, and Oklahoma's Greater Tulsa
region.
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Finally, CMS is testing bundled-payment models,\14\ which link
payments for multiple services beneficiaries receive during a single
episode of care, encouraging doctors, hospitals and other health care
providers to work together on delivering coordinated care for patients.
CMS recently proposed the Comprehensive Care for Joint Replacement
initiative that would buildupon other bundled-payment models already
being tested by the Centers for Medicare and Medicaid Innovation.
Providers and suppliers in the proposed joint replacement initiative
would be paid under the existing payment systems in the Medicare
program for services provided during episodes of care for hip and knee
replacements. Following the end of a model's performance year, actual
episode spending for beneficiaries who receive certain joint-
replacement surgeries in a participant hospital would be compared to
the Medicare episode price. Depending on the participant hospital's
quality and episode spending performance, the hospital may receive an
additional payment from Medicare or, beginning in the second year of
the model, may need to repay Medicare for a portion of the episode
spending. This proposed initiative, like other bundled-payment models,
incentivizes the type of close collaboration among inpatient and
outpatient providers and suppliers that is made easier with the
effective use of health IT.
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\14\ http://innovation.cms.gov/initiatives/bundled-payments/.
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Although designed for different providers and care settings, all of
these initiatives promote well-coordinated, high quality care and build
the business case to adopt health IT systems that help providers manage
population health and share information across care settings.
conclusion
CMS will continue to support the adoption and effective
implementation of health IT that supports better care and lower costs
for Medicare and Medicaid beneficiaries. While health IT alone does not
make care better, it is an essential ingredient to improvement of care
and supporting providers as they transition from volume-based to value-
based payment models. Health IT moves us away from illegible notes and
prescriptions, reams of paper charts, x-rays that cannot be found and
lost faxed lab results toward a health system where relevant
information is available for providers at the point of care and for
patients when they need it at home or at the pharmacy. As a practicing
physician, I have experienced the power of health IT to improve care
and patient safety, and I also realize that we need to continue to
improve the programs and products so they support clinicians and
patients in achieving better outcomes.
CMS's primary goal is to ensure that beneficiaries and providers
can realize all of the benefits of EHR systems without unnecessary
costs. Providers should be confident that their time and resources will
be spent caring for patients rather than unnecessary or duplicative
administrative requirements. CMS will continue our work with ONC to
improve interoperability, make health IT more user-friendly, and
streamline program requirements as we work to transform the health care
delivery system and promote high-quality care.
The Chairman. Well, we welcome all four children into the
congressional record.
[Laughter.]
We'll now begin a round of 5-minute questions. Let me
repeat what I said earlier. At least, speaking for myself, I
want to move forward, not backward, on electronic health
records. There's no doubt in my mind that that's where we're
headed.
Dr. Conway, it is correct, isn't it, that the merit-based
payment system, or moving to paying doctors for value, is a top
priority of the Administration?
Dr. Conway. Yes.
The Chairman. I gather from Secretary Burwell that she is
bound and determined to get that done in the next year. Am I
correct about that?
Dr. Conway. Yes, sir. Implementing the MACRA legislation
and the merit-based incentive program and alternative payment
models is an extremely high priority.
The Chairman. It has broad support in Congress. You began
the process of making regulations on that this week. Is that
correct?
Dr. Conway. We released a request for information to get
public input and engagement on the rulemaking process.
The Chairman. Right. When do you expect to have those
regulations completed?
Dr. Conway. We are aiming to put out those regulations next
year, most likely in the late spring timeframe.
The Chairman. Next spring. Isn't it true that 25 percent of
the incentive payment or the penalty for doctors under your new
payment system would depend upon how well they complied with
meaningful use?
Dr. Conway. Yes. The good news is that Congress, in passing
the statute for MACRA, enabled significantly more flexibility
in the EHR incentive portion or meaningful use. In the RFI, we
asked questions around the issue of the so-called all-or-none
phenomenon from providers in terms of meaningful use. We
believe the MACRA statute provides us more flexibility for that
25 percent in terms of how we consider successful use of
electronic health records, and we want to thank Congress for
that flexibility.
The Chairman. The most important thing would be the better
the electronic health record system is and the easier it is for
doctors to comply with it, the more effective your new value-
based system will be. Right?
Dr. Conway. We are committed in the value-based system for
electronic health records----
The Chairman. No, but is it right or wrong?
Dr. Conway. Yes, sir. We are committed in the electronic
health record systems that they be usable----
The Chairman. A yes would be adequate. What I'm getting at
is why wouldn't you want to develop the final rules for the
electronic health record system at the same time you're
developing your rules for your value-based system? Why would
you go ahead with finalizing Stage 3 and then have to do what
you did with Stage 2, which is then to say, ``OK. This is our
final rule, but it's not very good, so we're going to spend the
next 2 or 3 years changing it.''
Why don't you go ahead and do Stage 2, which you're ready
to do, and then you've got Stage 3 out there, and work with
doctors and hospitals and vendors and make your changes before
you make it final?
Dr. Conway. We are committed to work with Congress,
doctors, and other providers to improve the program over time.
We're committed to work with you both on legislative and
administrative options----
The Chairman. That's not an answer. That's not an answer.
Let me ask you, Dr. DeSalvo. If Proctor and Gamble was
going to introduce a new soap or a new product, it surely
wouldn't introduce it in the whole country to test it out. They
would make sure it was right. If McDonald's was introducing a
new sauce or gravy or hamburger, they would test it out.
Most businesses would do things that way, and as a result,
we have in our private sector things like ATMs that actually
work all over the world. We have an amazing system for making
airline reservations. That's the kind of system we'd like to
have for our electronic health records.
Why wouldn't it be a good idea to take my music teacher's
advice and play it a little slower than you can play it and go
ahead and do Stage 2 now? Only 12 percent of doctors can comply
with Stage 2 the way it is now and only 40 percent of
hospitals.
Let them do that, and then say, ``We're going to do Stage 3
in a year. Count on it. Between now and then, we're going to
work with you on all these issues.'' How can we reduce
physician documentation? What other things can we do to
encourage interoperability? Get buy-in and broad support in
Congress for it, and then have a big success in a year, rather
than spend the whole year defending a rushed-up program.
Dr. DeSalvo. Senator, as Dr. Conway shared, we do want to
get this right, and that means that we've taken a lot of time
to listen and receive feedback for ONC's rule, the
certification rule. An example of where we did, of course,
correction is, for example, last summer, we realized that some
of the approaches to technology we were taking needed to be
fixed so that interoperability would be better. We have been
willing to make changes where it was necessary along the way.
Similarly, with respect to flexibility, some year and a
half ago, we worked with CMS on making adjustments so that if
docs weren't ready to upgrade to a new product, if they needed
more time to get used to their product and make it work better
on the front lines, that flexibility rule has given them that
additional time. Our track record reflects that we are willing
to work with the private sector.
We do understand firsthand what that's like to be in the
clinical environment and working with our electronic health
records. Our certification rule, as proposed, itself has some
of the protections and advancements that I believe are shared
interests with this committee--so better security, more access
to data for consumers through these APIs, better opportunities
to address blocking, and opportunities to advance the
marketplace so that docs and others know what they're buying,
to make more transparency.
The proposals in our certification rule reflect the input
and the guidance that we received through not just abstract
conversation, but meaningful day-long conversations with docs
and others to see how we could better serve them through this
program.
The Chairman. Thank you.
Senator Murray.
Senator Murray. Dr. DeSalvo, I'm really pleased to see the
hard work your office has done to advance the interoperability
of health IT. Time and time again, we've had witnesses before
this committee that testified that systems need to be
interoperable to unlock the full potential of electronic
medical records.
The interoperability road map that you developed with
providers and developers includes some both short- and long-
term objectives for achieving interoperability. This committee
has heard about how the lack of interoperability really impedes
care coordination and quality improvement.
Can you share with us what your plans are for working with
healthcare providers and health IT companies to accelerate the
adoption of common standards and business practices that are
needed to improve interoperability?
Dr. DeSalvo. Thank you, Senator Murray. It is our approach
and our philosophy that to get to interoperability, we have to
do this with the private sector and with consumers as our goal,
them having control of their data. They're right at the center
of this.
All of our actions reflect their input and our cooperation
with them to advance new technologies like something called
FIRE--great name--a nice new way to have data be accessed in
systems. That's the result of a collaboration between us and
the private sector to see that that's moving along as quickly
as possible, faster than we might be able to do it federally.
More importantly, what it's going to do is give consumers
an opportunity to be able to pull their data out of the record
at their--Sunday evening, I'm filling out the immunization
record for my kid's camp. I can go online and do that in a way
that's not going to be quite as clunky as it might be today for
some families.
On the other hand, we see remarkable examples of how
interoperability is already working, and we want to learn from
those and buildupon it. Right here in DC, in Maryland, there
are systems where you can do a Google type search to find a
patient and understand their last visit to the ER and the
information that's necessary for the care in that doctor's
visit.
New York, Nebraska--so many great examples of where this
works. We've seen even within systems, like at Vanderbilt,
they've been able to leverage what they've done with meaningful
use around smoking and improve their smoking programs for the
patients that are within their system.
The excitement is that we know the private sector is using
the technology to create solutions around quality and safety
and better care and information flow. As people move through
the care system, it's giving them more access to data. Our goal
is to catalyze that to accelerate it, but at the same time make
certain that we're being clear that we all need to move to some
federally recognized national standards, that we have to have
the right trust environment, and we need to push on these
drivers to make sure that the system is working on behalf of
the consumers.
Senator Murray. Dr. Conway, there's a lot more work to do.
Health IT really is supporting some improvements in the quality
of care. Providence Health, which is in my home State, is using
their electronic health record now to prevent a common form of
hospital-acquired infection associated with catheters. Early
results from that show their system is helping to implement
clinical best practices that may eventually lead to shorter
hospital stays, even reduce mortality.
You noted in your testimony that Medicare and Medicaid are
rapidly changing how they pay providers based on quality, value
of care they deliver to patients. Reduced hospital-acquired
infections is just one of the ways that these new models will
help improve quality for patients.
Can you talk a little bit to us about how critical health
IT is to helping providers adjust to new models of care
delivery?
Dr. Conway. Yes, Senator Murray. Thank you for the
question. First, on Providence, I know the system relatively
well--just incredible work in patient safety, patient
engagement. Thank you for sharing that example.
Just a few other tangible examples to bring home the power
of health information technology. One, in our Comprehensive
Primary Care Initiative, a large focus is using electronic
health records for advanced primary care and managing patients.
A practice in rural Arkansas, using their electronic health
record, measure their patient population and figure out who's
not getting preventative screenings, which you mentioned
bringing those patients in for prevention; using remote
technology to interact with patients to prevent exacerbations
of diseases like diabetes and congestive heart failure; using
various tools connected to their EHR to really achieve those
better health outcomes for the patient population they serve in
a small rural practice.
Another example in some of our accountable care
organizations is using their electronic health record to track
and coordinate care for patients across settings, across
nursing homes, across primary care offices, et cetera, and
really understanding what services that patients needed. And,
last, true patient engagement, allowing patients access to
their information to help manage their own care. It's a
critical foundation to our delivery system reform efforts.
Senator Murray. Thank you.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Murray.
Senator Burr.
Statement of Senator Burr
Senator Burr. Dr. DeSalvo, welcome. Dr. Conway, welcome.
I've got to be candid with you guys. I really do thank you for
the job you do. I wouldn't do it. You're stuck in a
bureaucratic structure that has no hope of succeeding. Let me
explain why.
Technology is changing at a pace that nobody in government
envisioned ever would be this fast. I would only say this, that
you're going to continually play a catch-up game, late to the
party of change that the private sector makes because
technology allows them to do it faster, cheaper, and better,
and the whole of government is making no effort to structurally
change to be able to respond to what your customers are doing
day in and day out, or hoping to do, and that's to take
advantage of that technological change.
I've got three questions. They're jump balls. If one of you
or both of you don't take them, I will assign them.
[Laughter.]
The first one is why is interoperability so difficult to
achieve? Second, how do you define the term you use, a safe and
secure information system? And, third--this will probably be
yours, Dr. DeSalvo. You said in your testimony to us that you
have implemented some things along the way since the April
deadline of comments on the road map. Well, this is 5 months
later, and the testimony says in the near future, we're going
to see the road map. I sort of get the impression that we're
like deer in the headlights.
Five months is a significant technological shift in the
marketplace. The information you heard 5 months ago may or may
not be relevant today from a standpoint of what doctors shared
with you, what hospitals shared with you, what their data has
suggested that they ought to do.
The question is, if the guidelines don't change, if there's
not enough flexibility, how in the hell do we expect them to
perform at the highest level of quality and execution, when
it's, in fact, our regulations that stand in the way of doing
it? The floor is yours.
Dr. DeSalvo. Thank you, Senator. I actually really
appreciate the questions, because I believe it reflects the way
that we've been approaching this challenge as the Office of the
National Coordinator. In the last year and a half since I've
been National Coordinator, we have taken a shift and been
working in a more open fashion with the technology private
sector.
For example, the interoperability standards advisory, which
is an action that we have taken as a result of the road map we
developed with the private sector, with the technology
industry. It's sub-
regulatory so not regulatory, so that we can continue to
iterate it and keep up the times, as you say. We are already on
our second version in the last 6 months of putting out that
document, and we'll have another turn of the crank in December
as we are continuously getting feedback and making that better.
An example of how we work directly with the private sector
to help spur new technology and/or make sure that we're ready
for them is FIRE, which I mentioned earlier. I'm sorry to get a
little wonky, but it's the sort of new thing--that everybody is
looking forward to making the system more internet-like and
making data more available.
We commissioned a report that we then handed to our
advisory committee, who then pulled together a private sector
team called the Argonaut, who have been working in concert to
come up with this new technology that they have to mature.
They've now matured it, and we are ready to receive on the
other side as we're thinking about our certification program,
or even as the DOD is thinking about how it's going to
implement its records.
We are continuously in conversation and trying to make
certain that we're doing our work in as much of a sub-
regulatory fashion as possible so that we're giving guidance
and setting guardrails but not getting in the way, because what
we want to do is raise the floor. We want to get everybody on a
set of shared standards that make sense, that are common, but
not get in the way of innovation, because we really need to see
the marketplace advance in such a way that it's going to meet
the needs of the providers on the front lines.
Dr. Conway. The only two brief things I'll add on
interoperability--we have significantly reduced the total
number of measures and requirements, tried to simplify the
program and really focus on high-level requirements to not
stifle innovation, and those that are left are--the vast
majority are focused on interoperability.
Second, on the new payment models, to give you another
example, in our bundled payment initiative, where these
providers are caring for an episode of care across settings--
they figure out, to your point--in the marketplace, they figure
out how to share information, because it's critical to be
successful in these alternative payment models. Those are two
tangible examples.
Senator Burr. I'll let you answer what your definition of
safe and secure is, but let me just say this. It's amazing that
they can figure it out, yet we can't figure out how to design a
structure, because you're right. The private sector has total
flexibility.
I hope you understand. I'm not being critical. I'm
expressing something that every member hears. The healthcare
community comes to us and says, ``How are we going to do
this?'' We're supposed to be the road map, and if the road map
takes 7 months to do, after you've gotten all the input, 7
months is an eternity to them.
Do you want to address safe and secure for the information
system?
Dr. DeSalvo. Yes, sir. I'd like to just reemphasize that
our milestones along the way of updating that road map is a
reflection of the continuous conversation. It's not that we go
in a room and then put out a new road map. We're continuously
acting on it in partnership with the private sector.
The privacy and security components, particularly security,
are a major focus for us. We have been working with the
Administration--wide efforts around cyber security, and we tend
to follow NIST recommendations, NIST recommendations about
making certain that the systems are secure and that
authentication works, and have used our certification program
to--every time--maturations, but are encouraging the private
sector to keep moving and not to--they don't always have to
wait for us. We really want to see them continuously update.
Senator Burr. Thank you.
Dr. DeSalvo. Thank you.
The Chairman. Thank you, Senator Burr.
Senator Casey.
Statement of Senator Casey
Senator Casey. Thank you, Mr. Chairman.
I want to thank you both for your testimony, also for your
public service. This is hard to get right, and we've got a ways
to go.
I did note in Dr. Conway's testimony in the first page some
numbers that I know others have mentioned but it bears
repeating. The proportion of U.S. physicians using electronic
health records increased from 18 percent to 78 percent between
2001 and 2013, and 94 percent of hospitals now report using.
There is progress, but I know we've got a whole host of
problems to work through and to consider today.
I wanted to focus on the question of flexibility as it
relates to care settings and to really zero in on those care
settings as they relate to children.
Dr. Conway, we've all heard the expression for years that
kids are not small adults. They have to be treated differently.
They need different treatment regimens and approaches. Based
upon the unique aspects of their care, are there ways that the
electronic health records, both in terms of implementation and
use, can be tailored to meet those specific needs? Can you
speak to that in terms of the different settings that we have
for children?
Dr. Conway. Yes, Senator Casey. Thank you for that question
and thanks for your dedication to child health. As a
pediatrician, it means a lot.
I'll speak to a few aspects. With the CHIP reauthorization
act, it gave us the opportunity to work on an electronic health
record format, but was a joint effort between the Agency for
Healthcare Research and Quality, ONC, and CMS. Through that
work, we're able to develop standards adjustments for
pediatrics, things like weight-based dosing, which are critical
for children but not as critical for adults.
We've now tested that in several States. We've tested it
with various vendors, and we're really working with the vendor
community, with States, and with the pediatric community to
make sure there are vendor products that meet their needs.
I alluded to Cincinnati Children's. At that time, this
didn't exist. I did the implementation prior to that work, and
we had to modify an EHR that was largely based on adults to our
system. Over time, we'd like that to not be the case, where
pediatric practitioners and hospitals have the ability to
utilize the EHRs that have already been modified in a way that
they're useful in pediatrics.
Senator Casey. Just an additional question, and I'm going
to be out of time. One issue that's surfaced is with regard to
minors, the varying confidentiality restrictions. Can you tell
us more about how to strike that balance between facilitating
the use of electronic records among adolescent patient
populations and balancing that with ensuring confidentiality?
Dr. Conway. Yes. I'll start, and Dr. DeSalvo may add more
from the certification perspective. There are some of the same
key principles from paper records that apply in an electronic
environment. Then it's how do you adjust those in an electronic
environment.
I'll give you some tangible examples. We have worked with a
network of pediatric specialists who are actually using their
EHR and social networking to engage their patients in a much
more real way, in this case, for inflammatory bowel disease, a
chronic condition.
That work has actually shown decreased hospitalizations,
increased growth in better outcomes for patients. It's a
critical example of not just using the EHR as a recordkeeping
system, but how do you use that information to really engage
patients, in this case, adolescents, in their own care and
improving their care, including feeding data back into the
electronic health record.
Senator Casey. Dr. DeSalvo, anything on this question of
confidentiality?
Dr. DeSalvo. Just to add that today, across town, we're
having an eConsumer Health Summit, where hundreds are in person
and thousands online, of consumers who tell us not just
themselves, but through their own data and others, that they
have an expectation that providers are sharing their electronic
health data on their behalf to improve their care and, in many
cases, to improve the care of others like them with similar
chronic diseases or other diseases.
In general, consumers are expecting and wanting information
to be shared with their consent. Getting that right is what
really matters. It needs to be informed consent, and we need to
be able to protect their data when they don't want it shared.
Those are the kinds of efforts we're always engaged in. Thank
you.
Senator Casey. Thank you.
The Chairman. Thank you, Senator Casey.
Senator Franken.
Senator Cassidy. We're not going to this side?
The Chairman. I made a mistake. Excuse me.
Senator Cassidy.
Statement of Senator Cassidy
Senator Cassidy. I was going to thank my chairman, but
never mind.
[Laughter.]
I do want to thank the Chairman and the Ranking Member.
Obviously, we've spent a lot of time on electronic medical
records. As a physician, I know just how fundamental this is to
how we're going forward. Thank you all for your kind of dogged
determination to make sure we get this down. Thank you.
I'd also like to announce today, as Senator Murray referred
to, that Senator Whitehouse and I will introduce legislation
this coming Tuesday to enhance interoperability. I think that
Senator Whitehouse asked we share that with you all, and in the
spirit of trust, we have shared it with you. Please don't
backstab me. Senator Whitehouse and I thank you all for your
partnership in this effort, and I look forward to working with
him on that.
Let me pick up something--both Senator Casey and Senator
Alexander just said things that kind of triggered with me.
Senator Alexander started off by saying why don't we get the
meaningful use right. I'm going to speak not as a Senator. I'm
going to speak as a physician colleague. You'll understand what
I'm about to say.
I had this kind of weird experience. I still see patients.
I'm seeing a guy who had vomited blood the week before from
varices. His belly is full of fluid. He's as orange as orange
can be.
As I'm trying to get his medicines right so he doesn't re-
bleed, talk to him about not drinking, get his ascites down to
make sure that it's not infected, and get him down to a liver
transplant unit, I'm supposed to take a minute of my precious
time and ask him, ``Have you stopped smoking?'' The absurdity
of that in this situation is evident even to those who don't
know physicians.
One of the suggestions that we have had in these hearings
from a subspecialist is why don't we allow subspecialists to
define what their meaningful use Stage 3 is? What a pediatric
endocrinologist is going to ask is far different from an
orthopedist.
You've mentioned, Dr. Conway, that you're trying to make
this more relevant. The ultimate in relevance is to allow the
specialty societies to define, No. 1. And, No. 2, as Senator
Alexander said, why don't we do that on the front end as
opposed to kind of attaching it to the back? I hope you're
about to tell me that, yes, you've already decided to do that.
Dr. Conway. There's a couple of points to bring up, and
thank you for the question, Senator. One, with the proposal for
the modifications, it does lessen the number of measures and
provides more flexibility, including flexibility to specialists
in terms of what they focus on, in terms of care.
Senator Cassidy. Does it allow the specialists to define
for their own specialty that which should be meaningful?
Dr. Conway. It does to a large degree, and then let me try
to explain. In the clinical quality measure arena, for example,
we have increasing of flexibility, and as we move to MACRA, an
implementation of a merit-based incentive system, we're working
closely with specialty societies so we have measures relevant
to their practice and give them the flexibility so if we don't
have sufficient measures relevant to their practice, they can
report that. They can say, ``These measures are pertinent to my
practice. I don't have''----
Senator Cassidy. The impression I get of what you're
saying, though, is as opposed to the specialty societies
saying, ``Listen, this is what only 30 percent of our
colleagues are doing, 100 percent should, and this is maximally
relevant,'' it is rather CMS saying, or your office saying,
``Listen, this is what we're going to have you do, and you have
latitude within this as to what you do, but let us know if we
didn't do it right.''
It seems better to have them tell you whatever you should
be doing and isn't. You see where I'm going with that?
Dr. Conway. I do, sir. In terms of--to give another example
where it is not us defining for the specialties, specialties
can now use electronic health records and report via qualified
clinical data registries to CMS. These are registries that are
linked to the EHR, typically----
Senator Cassidy. I get that, but that's not quite the
question where I was. Are we going to allow specialty societies
to define what meaningful use is? Just yes or no.
Dr. Conway. Specialty societies are allowed to define
within meaningful use the measures that are most applicable to
their practice.
Senator Cassidy. Not those which should be applied. There's
a difference there, and I think the difference is critical. One
is they're being told to select from a smorgasbord that we have
decided is relevant. This is--no, let us tell you what is
relevant, and that would make it most meaningful. I gather
that's not what you've done. Let me just say as a practicing
physician that that's what we've heard in our testimony, and
that's what we should do.
Let me ask--because I'm going to run out of time. The other
thing we've heard is that absent a unique identifier, it's
going to be very hard for the comatose patient being seen in
New Orleans, who previously was seen at some hospital in
Missoula--how does a doc in New Orleans figure out what the doc
in Missoula ordered that would be relevant to the comatose
patient now before her?
I guess my question--and we've heard how unique identifiers
is like the only way, really, to get there, unless the patient
can volunteer. Civil libertarians obviously are concerned about
unique identifiers, and yet you've just told us that in e-
health, there's an expectation that doctors are sharing
records.
Without going further into the kind of obstacles there,
what do you think of a global entry type situation? I bypass
the long lines at the airport because I've given all my
personal data to TSA, who figured out that I'm an OK guy and
then allows me to kind of go in with an expedited screening.
This is voluntary, so the civil libertarians can't say, ``Well,
heck, it's big brother.'' Any thoughts about that?
Dr. DeSalvo. Senator, let me begin just by thanking you and
your staff and Senator Whitehouse and his staff. You've been
great partners as we've been talking about this technology work
that you're doing. This whole committee has gotten so steeped
in it. It's exciting for us at the Office of the National
Coordinator.
With respect to identifying the right patient, you and I
experienced this after Katrina. Somebody is displaced to
Missoula or wherever, and you want to make sure that that's the
right Jim Smith, that you're giving the right drug or pulling
up the right medication history for them.
There are models that work in the field right now that have
been, to Senator Burr's comment, developed by the private
sector and get pretty close to matching well so that we can
maximally reduce harm within the constraints of being able to
match. Are you the right person? I'm going to a bunch of
algorithms to make sure that we have that right. We have been
working very----
Senator Cassidy. That's different from a unique identifier.
Dr. DeSalvo. It is. That is the technology in hand, and we
have been accelerating that, working aggressively to work on
getting to a place where we have been making recommendations
that everybody is going to move to a more safe system. That's
one pathway. Since it's what we have today, and with working in
places like Maryland, DC, New York and Nebraska, we need to
keep advancing that.
There are private sector groups working on a unique
identifier model, and we appreciate the work that they're
continuing to do. We have partnered with them in some cases,
just to be a part of the conversation so we can listen. It's
possible that some may decide to go in that direction. In the
meantime, we've certainly been making certain that everybody is
being as aggressive as possible about getting the patient right
so that we can reduce as much harm.
Senator Cassidy. I yield back. Thank you.
The Chairman. Thank you, Senator Cassidy, and thanks for
your contribution to the certification bill and for bringing
your medical experience to the committee. We appreciate that.
Senator Franken.
Statement of Senator Franken
Senator Franken. Thank you, Mr. Chairman. I am not a
doctor, but I played one in a sketch.
[Laughter.]
I want to make sure I understand Dr. Cassidy's question,
because he created a scenario in which someone was basically in
an emergency situation. In an emergency situation--just let me
make sure of this--don't you have some discretion as a
physician to say, ``This is not the time I have to follow
certain protocols in terms of electronic medical records.''
Also, aren't there--emergencies actually create--haven't we
seen where in emergencies, electronic medical records are very,
very beneficial because you can get records much faster?
Dr. Conway. I'll start if it's OK, and Dr. DeSalvo may add
more. No. 1, yes, in emergency situations, we would want
physicians and clinicians to deliver the appropriate care. We
would not in any way want to regulate that, and it is
appropriate. I practice in a hospital medicine environment
where there are emergencies. You deliver the appropriate care.
Whether it's a paper-based or electronic environment, you can
document it after the delivery of that appropriate care, and
that's what we would want.
No. 2, we actually do have examples. One patient, or the
wife of a patient, spoke very eloquently at one of our events
that the EHR prevented a safety event and literally saved her
husband's life, because that information--he came in
unconscious, not with information--had the ability for
electronic health record information to be transferred. That
was a life-saving event. I don't have specific data on how
often that happens, but it can certainly occur, and we have
instances where electronic health records have saved lives.
Senator Franken. The Hennepin County Medical Center, when
the bridge collapsed, used electronic medical records and found
that they were extremely helpful in that situation.
Dr. Conway. Yes.
Senator Franken. I just wanted to understand something,
unusual as that is in a hearing. I'm co-chair of the bipartisan
Senate Rural Health Caucus, so I want to talk about rural and
small practices. I've been meeting with providers and health
systems in rural communities across Minnesota to learn about
the challenges that they face.
In previous hearings, I've talked about the resource
constraints and sort of the asymmetrical bargaining power that
tend to make it more difficult for rural providers to
successfully adopt the EHR systems. They want to implement EHR
systems and are striving, often struggling, to meet the
meaningful use requirements.
Dr. DeSalvo, my question is: What is the agency doing to
help rural and small practice providers be successful? We've
talked a lot about carrots and sticks, but what are the
agency's plans for providing continued support and technical
assistance throughout the process, this transformational
process?
Dr. DeSalvo. Thank you, Senator. We share a policy goal
that no provider, no patient, no person should get left behind.
That means we have to, in some cases, pay special attention to
smaller practices, small hospitals, small group practices, and
those in rural areas to see that they have the technical
assistance and the supports they need.
The Senator may be aware that our office, in partnership
with HRSA and with USDA, over time has leveraged additional
resources for broadband access, for additional technical
assistance on the front lines. We did this with CMS in the
meaningful use program. They were very successful early
adopters, they being rural providers and critical access and
small providers--keeping them in the program, but, more
importantly, keeping them having a digitized care system so
that information will flow and follow.
Their constituency is important, and it's increasingly
important to the VA and the DOD. I's a part of the work we're
going to do going forward to see that soldiers and veterans
have access to their information as they're moving through
those systems.
I had the experience of--it wasn't a rural, but it was
close. It was a small 80-bed hospital that I was on the board
of and led the development of our health IT purchase and
started the implementation before I came to Federal Government,
and it was--it's a challenge when you're that small. We had no
IT shop. We were borrowing--parts of staff we were contracting
out from nearby hospitals just to try to get the pieces back
together.
I know it acutely, because I was on a hospital board when I
was commissioner, trying to build a hospital and get it
rolling. It's in my mind every day about how we make sure that
they don't get left behind in this really critically march
forward, because the people that they serve deserve to have as
much access to data and information as those in urban areas.
Senator Franken. Well, I'm out of time. Let me just put a
word in for rural broadband, because if we're talking about
tackling electronic health records, rural providers need that
broadband.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Franken.
Senator Baldwin.
Statement of Senator Baldwin
Senator Baldwin. Thank you, Mr. Chairman and Ranking
Member.
It's clear that we still have more work to do with
interoperability. Recently, industry stakeholders have made
really significant progress in coming together to solve some of
the IT infrastructure problems. For one, a diverse group of
stakeholders from providers to EHR vendors, even competitors,
are developing a unifying agreement to connect the existing
exchange networks. This could serve as a national structure to
ensure that all of the networks can securely share patient
records with each other.
Just like we've heard with other examples--ATMs, et cetera,
cell phone networks--it shouldn't matter what network your
doctor belongs to. They should all be able to talk to one
another.
Dr. DeSalvo, much if not most of the work in this space has
been done for us. How can we ensure that patients and providers
and developers benefit from all this effort that is ongoing and
has already been done? What can the ONC do to both leverage and
implement the work of these public-private collaborations?
Specifically, I'm looking at--you were talking about
guardrails, but nudges versus mandates, leveraging.
Dr. DeSalvo. Well, Senator, thank you for the question, and
I'm so encouraged in the last year, especially, by the work the
private sector is doing to come together to set some shared
rules of the road, to agree on privacy and security and,
increasingly, standards. That's the reason that efforts like
our interoperability standards advisory--it's a document, but
it's really a process. It's a way that we've been working with
them to come up with a federally recognized list of national
standards, many of which are developed in the private sector.
This helps us, as the Federal partners who purchase and pay
for and deliver care and make IT systems, also be on the same
page with them so that we're using the same rules of the road
and that we're using the same standards as we all move forward.
We consider ourselves partners with them.
At the end of the day, the guardrails are necessary in some
cases because, unlike the private sector, I believe that we
have the responsibility to protect everyone, no matter their
geography, where they live, the color of their skin, the source
of payment, the kind of provider that they have. If you think
about rural America, making sure that all those connections are
made and also that that data is available to consumers and for
public good, public health preparedness and public health
everyday.
There are additional--outside of the healthcare sphere that
some of the conversations have been occurring. It's important
for us to remember that we have a responsibility to consumers
and to the community beyond. I agree with you. I'm encouraged
by their advancements. I want to see that continue going. I
want to see that we're holding them accountable and that we're
setting, the right guardrails, governance expectations, that
the data is there for the consumer when and where it matters in
disaster and every day.
Senator Baldwin. Following on for both of you, Dr. DeSalvo
and Dr. Conway, we have throughout these hearings identified a
number of areas where we need to do better to realize the full
benefits of health IT. In both of your testimonies, you outline
a number of initiatives that each of your organizations are
planning to further advance interoperability as well as
enhancing patient engagement and reducing the burden that we've
all been talking about that providers have shared.
We, universally on this committee, are committed to these
goals. I'm curious to know whether you believe that your
agencies need specific new legislative authority to
successfully achieve these goals, given the planning that
you've outlined to us today.
Dr. DeSalvo. Senator, we really do appreciate the
partnership this committee has brought forward, this
conversation into the public mind, and it's actually really
helping to accelerate what's happening in the private sector.
Thank you all for that.
We are looking across the Administration at every
opportunity we have as an administration to see that systems
are more usable, that data blocking is not occurring, and that
interoperability is happening in a consistent and equitable
way. There may be some opportunities where the committee could
help to give us more opportunities to approach governance, so
setting rules of the road, business practices and
implementations in the marketplace, in some cases around
blocking and in some cases just around consistent data sharing.
There may be additional opportunities for us to make the
market more transparent, to be able to share business
practices, costs, et cetera, of products so that docs and
others know what they're buying. When they go shopping, it's
more clear what they're getting and if the batteries are
included, if you will. We have noted some of those. I have in
my written testimony that was given, and I would really look
forward to the opportunity to provide some ongoing technical
assistance to the committee about that.
Senator Baldwin. Dr. Conway.
Dr. Conway. We would agree with Dr. DeSalvo on the issues
noted around information blocking, oversight of certification,
et cetera, and we're happy to work with the committee if
there's other ideas that you would like technical assistance
with.
Senator Baldwin. I see that I have run out of time.
The Chairman. Thank you, Senator Baldwin.
Senator Whitehouse.
Statement of Senator Whitehouse
Senator Whitehouse. Thanks very much, Chairman, and thank
you for yours and Ranking Member Murray's continued initiative
and effort in this area. It's going to be very productive for
our committee.
Thank you to Dr. DeSalvo, particularly, but both of you for
your work and your leadership in this area. Thank you for the
support you've given for my efforts with Senator Cassidy to try
to improve the certification piece.
If I take a step back from this, I see a need--if health
information technology is going to be really effective--for
there to be very good health information exchange. One of the
ways very good health information exchange happens is through
very good health information exchanges, like CurrentCare in
Rhode Island, like the exchange up in Maine. There are a number
of them.
One of the continuing concerns and questions that I have is
that meaningful use tees up an enormous amount of resources and
directs them at supporting the purchase of health information
equipment and kind of, in an indirect, like pool table bank
shot type way, tries through the certification process and the
standards to back encourage health information exchange. Having
lived the life of Rhode Island's health information exchange of
CurrentCare, I don't think that's adequate.
I don't think that having these big national companies that
are clawing at each other for market share and that in some
cases appear to be engaged in some pretty unfortunate
practices, like data blocking and hiding costs in the contract
that doctors get clobbered with later--they're not, I don't
see, incented in any way to focus on going to a particular
location, like Rhode Island or Maine, and supporting the
development of a really robust local exchange. A really robust
local exchange is a really important piece of this equation.
When you look at the amount of support--and, by the way,
thank you for the support CurrentCare has gotten. They've won
everything that's available out there. Even so, you put that up
against the absolute avalanche of money that's going into
meaningful use, and it seems very, very disproportionate.
What can we do to further encourage and support the
development of health information exchanges at a local level? I
would carve out of that the exchange of information within
either a hospital system or a corporate system or a particular
company that provides a service in health information exchange,
because that doesn't work. It's not good enough to get health
information exchange within your hospital chain or within
everybody who buys this particular product. That, in fact, is
really adverse to the public interest.
The place where you get across all those problems is when
there's a public health information exchange. How do we make
that work better? How do we tip the huge Mississippi River of
money that's flowing into meaningful use so that a bigger
trickle of a creek comes off of it for information exchange?
Dr. DeSalvo. Senator, I wish I had 3 hours to talk about
that with you. Let me be brief because I have about a minute
and 37 seconds.
Senator Whitehouse. It won't be these 3 hours, but I'm all
in.
Dr. DeSalvo. Rhode Island is a model example of how the
investments that the Office of the National Coordinator made
through the HITECH funding in local health information exchange
can take off and be successful. There's one in every State, and
some are more successful than others. It is a part of the
fabric of how data is going to move. Senator Baldwin mentioned
some of the private sector efforts, which are also part of that
fabric.
In the public interest, I agree, is for information to not
stop at the artificial barriers between private sector network
service providers and health information exchanges that may be
run by the public sector or at the local level. That means that
we need to see, first of all, that the artificial barriers of
different standards don't exist, so we move to a shared set of
standards so the data flow is easier.
We have a set of rules of engagement, rules of the road,
that will be agreed to, and there is an accountability
mechanism. The Senator asked about additional opportunities
that we might need to be able to get into the space that you're
describing, the certification program, and other opportunities
that the Office of National Coordinator has. We have been
pushing that through our proposed rule, but there may be
additional opportunities for us to see that the public's
interest is met in that space.
With respect to the business sustainability, what I want to
see is that there is a sustainable business model that works
for everybody in this country and is not a pay-to-play.
Senator Whitehouse. My time is running out, but I really
want to make this point. If you're really doing health
information exchange through a public facility that brings in
all comers and isn't picked off by a particular private sector
company to emphasize its own business, if it's truly across the
board, then, really, what you've done is develop a piece of
infrastructure, a piece of safety, hardware, and I view it as
akin to air traffic control at an airport.
Dr. DeSalvo. Yes.
Senator Whitehouse. We don't ask for our air traffic
control system to have a sustainable business model. We know
that it provides safety and supports the business models that
are out there of the airlines. I really push back hard on the
notion that a CurrentCare or the Maine information exchange or
any of these need to show a sustainable business model. They
don't. They support everybody else's sustainable business
model.
Dr. DeSalvo. We actually agree, sir.
Senator Whitehouse. Great.
Sorry to go over the time, Mr. Chairman, but I sometimes
get a head of steam up on this.
The Chairman. No, that's good. Thank you, Senator
Whitehouse.
Dr. DeSalvo. I'll catch you a little bit later and we can
go over this.
Senator Whitehouse. By the way, I think Dr. DeSalvo is
terrific.
The Chairman. Senator Warren.
Statement of Senator Warren
Senator Warren. Thank you, Mr. Chairman.
We all know that one way to get the cost of healthcare
under control and to improve quality is to change the way that
we buy care. Instead of charging for each test, for each
procedure, for each followup visit, we need a better way to
pay.
Secretary Burwell has set the goal of transitioning 30
percent of Medicare payments away from fee-for-service by the
end of 2016. One alternative payment model is bundled payments,
a lump sum payment that covers all the costs of a procedure and
the followup care. For example, BayState Health in
Massachusetts has been bundling payments for hip and knee
replacements and the necessary followup care for years, and it
has improved quality and saved an average of $2,700 per
patient.
The data are clear. Bundles can help us move toward better
outcomes at lower costs, and it's good to see that CMS recently
announced their intent to use bundled payments, like
Baystate's, in 750 hospitals across the country, starting next
year through the comprehensive care for joint replacement
model.
Dr. Conway, can you explain why interoperability, making
sure that the electronic medical records can actually talk to
each other, is important to facilitate alternative payment
models like bundled payments?
Dr. Conway. Senator Warren, thank you for the question. I'm
familiar with some of the work of BayState. I was in
Massachusetts last week and it's just tremendous work.
On bundled payments, interoperability--thanks for your
comments on the comprehensive joint model. We're very excited
as well. We're getting comments on rulemaking now. I'm
actually, this afternoon, talking to hundreds--and we actually
have over 1,500 providers in our voluntary bundled model, and
hip and knee replacement is actually the most common condition.
Interoperability is a critical underpinning. The key to
effective care, in these bundled payment arrangements, is to
truly coordinate care for that patient for the entire episode.
What we hear when we interact with providers in bundled
payment is they're sharing information from the hospital to the
physician group, to the post acute care provider, even home and
remote monitoring technology. Some of them are very successful
by getting patients in their home and then caring for them in
their home, which is a lower cost setting and, generally,
patients prefer.
The interoperability piece is critical to the success of
bundled payments. As you said, we believe bundled payments are
a critical piece of the overall picture of alternative payment
models and delivery systems.
Senator Warren. Thank you. That's very helpful.
This is the sixth hearing that this committee has held on
health information technology, and one point that I think has
come across in every single hearing is despite the success of
Federal incentives in getting doctors and hospitals to
implement electronic health records, most still can't exchange
basic patient information.
Dr. DeSalvo, the Office of the National Coordinator for
Health IT is charged with advancing interoperability of
healthcare technology, which, as Dr. Conway said, can help
advance alternative payment models. Is the reverse also true?
Do payment models that require cooperation across care settings
help promote interoperability?
Dr. DeSalvo. Senator, it is absolutely true that moving to
a changed business environment, moving to alternative payment
models, ones that reward value and population-based care,
requires us to have a health IT infrastructure that works, that
provides the data necessary to the docs and the hospitals and
the other care team members and the consumer, to know what
information is there so they're not doing redundant tests, and
that they're able to save money, reduce harm, and improve the
quality of care.
These two concepts are so tightly linked. It is one of the
reasons that the department's delivery system reform effort has
been so tightly linked, that when we change the way we pay for
care and deliver care--but it requires a new information model
that we want to advance. System after system that's highly
successful, whether it's in Massachusetts or--I was just at
Intermountain yesterday. They can show you clearly that when
they have better data, a better dashboard, they know where
they're going, it helps them to reduce costs and improve
quality.
Senator Warren. Thank you. This is very helpful. I fully
support CMS moving forward with the mandatory joint replacement
model. The Congressional Budget Office estimates that
widespread use of bundled payments could save our healthcare
system $46.6 billion. We need to continue to build
interoperable health IT infrastructure in order to realize
those savings.
That means setting common standards for transferring
information and developing a way to accurately link medical
records to patients. It also means creating incentives that
encourage information sharing. Like Dr. DeSalvo and Dr. Conway
have said today, alternative payment models are one way to
create those incentives.
Moving forward with these new models and improving
interoperability go hand-in-hand, just as you've said, tightly
linked. I hope that the Office of the National Coordinator,
CMS, and this committee will continue to coordinate on these
initiatives so we can move toward a healthcare system that
gives us better outcomes at lower costs.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Warren.
Senator Murray, any other thoughts?
Senator Murray. I just want to thank both of our witnesses
today for their incredible work on this. This has been a really
important series of hearings.
Mr. Chairman, we've heard a lot about how critical the role
of information technology is in making sure that we have a
strong healthcare system for patients, families, and everyone.
I just want to thank you for this, and I look forward to
working with you.
The Chairman. Thank you.
I want to thank the Senators here for their participation.
This has been a pretty heavy focus on a target, but that's one
way to get a result. Your active participation in this has made
a difference.
I want to thank Dr. DeSalvo and Dr. Conway for the work
you've done with our staffs over the last several months. We've
tried to identify five or six steps we can take to get an
electronic health record system that had really gotten in the
ditch back on track so that it helps patients and realizes all
the promise that all of us have talked about.
I hope that everyone listening understands that I believe
it's unanimous on the committee--that's kind of a bold
statement to make on a committee this diverse--that we all want
to go forward. Nobody wants to go backward. We want our country
to have a system of electronic health records, and we want to
create an environment in which that can succeed.
A couple of thoughts. A group of Senators met with a group
of Nobel laureates earlier this week, and one of the Nobel
laureates said something that fit into what Senator Whitehouse,
Senator Burr, and others have said. She said that she thought
it was likely that some disruptive technology would come along
that we don't really anticipate and provide most of the answers
for how we have an electronic health system that works the way
we hope it will work. Maybe that's right. Maybe it's wrong.
What we want to get is a system that works as well as our
airline reservations, as our ATM cards, and we would guess that
there will be some Google-like or Apple-like entrepreneur that
will come in and provide some answers to that. I guess what
we're saying is in our regulatory structure, we need to leave
room for that, and you've said that you understand that. That's
a very important thing. None of us are wise enough to guess how
that will happen.
Creating a platform which attracts applications and
solutions is much better than trying to figure out what the
applications or solutions are here. The government historically
hasn't been that good at doing that. I hope that's a part of
it, and I thought that was pretty good advice from the Nobel
laureate.
My final advice is my starting advice from my piano teacher
who said, ``play it a little slower than you can play it, and
you're less likely to make a mistake.'' You've got broad-based
support for what you're doing, and recommendations have come
from a number of us, not all of us, but a number of us that the
wiser approach would be to adopt the Stage 2 rule now and get
that percent of doctors up from 12 percent who comply with
meaningful use and spend the next 12 months getting the
meaningful use Stage 3 rule right and use the year to align it
with the merit-based payment system rule that will be coming
out this next year and with the legislation that will be coming
out this next year.
That is more likely, it seems to me, to help get it right
for patients than to go ahead and rush something out and run
the risk that you're going to have people in Congress try to
overturn the rule and spend the next year arguing about that
rather than working together to try to have a big success by
the end of next year.
I thank the Senators. I thank the witnesses. We look
forward to the promise of an electronic health record system
that works perfectly some day for the benefit of patients.
The hearing is adjourned.
[Whereupon, at 11:28 a.m., the hearing was adjourned.]
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