[Senate Hearing 114-578]
[From the U.S. Government Publishing Office]





                                                        S. Hrg. 114-578
 
    AMERICA'S HEALTH IT TRANSFORMATION: TRANSLATING THE PROMISE OF 
               ELECTRONIC HEALTH RECORDS INTO BETTER CARE

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                                   ON

EXAMINING AMERICA'S HEALTH INFORMATION TECHNOLOGY (IT) TRANSFORMATION, 
 FOCUSING ON TRANSLATING THE PROMISE OF ELECTRONIC HEALTH RECORDS INTO 
                              BETTER CARE

                               __________

                             MARCH 17, 2015

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and Pensions
 
 
 
 
 
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          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, Staff Director

               Lindsey Ward Seidman Deputy Staff Director

                  Evan Schatz, Democrat Staff Director

              John Righter, Democrat Deputy Staff Director

                                  (ii)

  




                            C O N T E N T S

                               __________

                               STATEMENTS

                        THURSDAY, MARCH 17, 2015

                                                                   Page

                           Committee Members

Alexander, Hon. Lamar, Chairman, Committee on Health, Education, 
  Labor, and Pensions, opening statement.........................     1
Murray, Hon. Patty, a U.S. Senator from the State of Washington, 
  opening statement..............................................     3
Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin..     5
Cassidy, Hon. Bill, M.D., a U.S. Senator from the State of 
  Louisiana......................................................     6
Warren, Hon. Elizabeth, a U.S. Senator from the State of 
  Massachusetts..................................................    36
Isakson, Hon. Johnny, a U.S. Senator from the State of Georgia...    42
Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode 
  Island.........................................................    44
Franken, Hon. Al, a U.S. Senator from the State of Minnesota.....    49

                               Witnesses

Adler-Milstein, Julia, Ph.D., Assistant Professor of Information, 
  School of Information, Assistant Professor of Health Management 
  and Policy, School of Public Health, University of Michigan, 
  Ann Arbor, MI..................................................     6
    Prepared statement...........................................     8
Wergin, Robert L., M.D., FAAFP, President, American Academy of 
  Family Physicians (AAFP), Milford, NE..........................    11
    Prepared statement...........................................    12
DeVault, Peter, Director of Interoperability, Epic Systems 
  Corporation, Madison, WI.......................................    18
    Prepared statement...........................................    20
Kennedy, Angela, Ed.D., M.B.A., R.H.I.A, Head of Department/
  Professor, Department of Health Informatics and Information 
  Management, College of Applied and Natural Sciences, Louisiana 
  Tech University, Ruston, LA....................................    28
    Prepared statement...........................................    30

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Peter DeVault, Letter........................................    52
    Response by Julia Adler-Milstein, Ph.D. to questions of:
        Senator Alexander........................................    53
        Senator Burr.............................................    58
        Senator Warren...........................................    58
    Response by Robert L. Wergin, M.D., FAAFP to questions of:
        Senator Alexander........................................    59
        Senator Burr.............................................    65
        Senator Cassidy..........................................    66
        Senator Murray...........................................    66
        Senator Warren...........................................    67
    Response by Peter DeVault to questions of:
        Senator Alexander........................................    68
        Senator Burr.............................................    73
        Senator Roberts..........................................    74
        Senator Cassidy..........................................    76
        Senator Murray...........................................    76
        Senator Warren...........................................    77

                                 (iii)

  


    AMERICA'S HEALTH IT TRANSFORMATION: TRANSLATING THE PROMISE OF 
               ELECTRONIC HEALTH RECORDS INTO BETTER CARE

                              ----------                              


                        TUESDAY, MARCH 17, 2015

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10 a.m. in room 
SD-430, Dirksen Senate Office Building, Hon. Lamar Alexander, 
chairman of the committee, presiding.
    Present: Senators Alexander, Murray, Burr, Isakson, 
Cassidy, Franken, Bennet, Whitehouse, Baldwin, Murphy, and 
Warren.

                 Opening Statement of Senator Alexander

    The Chairman. The Senate Committee on Health, Education, 
Labor, and Pensions will please come to order.
    This morning, we're holding a hearing on America's Health 
IT Transformation: Translating the Promise of Electronic Health 
Records into Better Care. Senator Murray and I will each have 
an opening statement. Then we'll introduce our panel of 
witnesses. After our witnesses, Senators will have 5 minutes of 
questions.
    We have two votes at 11. That should give us plenty of time 
to get through our opening statements and hear from the 
witnesses and some questions. We'll see where we are at about 
11:20 in the first vote, and if we're through, we'll conclude 
the hearing. If there are Senators who still want to stay and 
ask further questions, we'll work it out where some of us go 
vote and some of us come back. We'll work it out so Senators 
will all have a chance to participate.
    Health IT means many different things, everything from 
wearable gadgets that monitor your heart rate to sophisticated 
applications that help physicians track treatments. But today, 
we're focused on electronic health records used by hospitals 
and doctors in their practices.
    Our committee hasn't had a hearing on Health IT since 
January 2009, a month before the $35 billion HITECH Act became 
a part of the stimulus package. The HITECH Act was warmly 
greeted. It was meant to unleash a new IT era where our health 
information would move seamlessly among doctors and hospitals 
to help achieve better, more coordinated care.
    After the bill's passage, doctors and hospitals rushed to 
join the so-called Meaningful Use Program. There were $35 
billion in incentives to encourage that. Adoption rates for 
electronic health records grew dramatically. According to the 
most recent data, 48 percent of physicians and 59 percent of 
hospitals have at least a basic electronic health records 
system, compared to 26 percent and 47 percent in 2009.
    The hope was that the program would improve care, 
coordination, and reduce costs. The evidence suggests these 
goals have not been reached. Half of physicians have not met 
the requirements of the program and are now facing penalties.
    A Medical Economics survey last year found nearly 70 
percent of physicians say their electronic health records 
systems have not been worth it. One physician wrote:

          ``We used to see 32 patients a day with one tech, and 
        now we struggle to see 24 patients a day with four 
        techs. And we provide worse care.''

    Doctors and hospitals have had so much difficulty meeting 
the Meaningful Use requirements that CMS has had to delay or 
change requirements three times. We're here today to find out 
how this happened and what we should do about it.
    Transitioning to electronic health records requires a real 
transformation in how physicians practice. The administration 
seems to have complicated the process by rushing ahead with 
penalties for those who don't adopt electronic health records 
systems. To be specific, doctors and hospitals that don't adopt 
these records systems lose 1 percent of their Medicare payments 
in 2015. That penalty grows to 5 percent by 2019.
    To receive incentive payments, physicians and hospitals had 
to buy systems certified to Federal Government specifications. 
Providers assumed the certified systems would be of high 
quality and meet program requirements. Instead, many providers 
discovered that certified systems have to undergo costly 
upgrades on short timelines to meet new requirements. Providers 
have to pay for these upgrades or pay even more to switch 
vendors.
    Hospitals have spent hundreds of millions of dollars to 
implement and continuously upgrade their systems. For example, 
Wellmont Health System, which operates hospitals in Tennessee, 
went through a complete IT conversion from one system to a new 
one that guaranteed they'd be able to meet the requirements of 
the Meaningful Use Program.
    Wellmont spent $125 million and expects to receive $38 
million in Meaningful Use dollars. Wellmont is also seeing an 
approximately $10 million increase in annual IT costs, but 
hasn't been able to calculate potential savings.
    Many providers are struggling with interoperability.
    Here's another example: Children's National Medical Center 
in Washington spent $400 million on its health IT over the last 
4 years to make a web of 138 different electronic health 
records systems talk to each other and work together. That 
medical center received $28 million in incentive payments.
    The Eye Centers of Tennessee, with five locations, spent 
$731,000 trying to comply with all the programs. Because they 
were not able to meet one measure, they expect a $100,000 
penalty.
    This should have been a really good idea. For some, it has 
been. Vanderbilt, for example, had an award-winning program 
that includes patients' genetic information in their medical 
records. That system prevented a patient in her eighties from 
receiving a blood thinner that would have metabolized poorly 
because of her genetic variation.
    Instead of the government trying to make everybody do this 
by taking away Medicare payments, a better route might have 
been to find ways to enable and encourage their adoption. 
Instead, the Administration seems to have rushed the process 
with its penalties and at the same time made the Federal 
Government the arbiter of IT quality.
    It reminds me of a lesson I learned a long time ago. In 
1980, when I was Governor, I flew out to Palo Alto to meet 
Steve Jobs. I had the idea of having every eighth grader in 
Tennessee computer literate.
    We bought Macs, which then were about 4 tall, and we did 
that for every middle school in the State. We had a mandate 
that every child will become computer literate. I forgot one 
thing: teacher training. It sounded like a good idea to make 
everyone use computers, but I should have spent more time 
finding ways to enable them to use computers.
    Enabling instead of mandates--that appears to be a good 
lesson for Washington policymakers who have rushed ahead with 
penalties in this program that has now created so many unhappy 
physicians and hospitals. I'm interested in learning today how 
we can become enablers rather than mandaters.
    Senator Murray.

                  Opening Statement of Senator Murray

    Senator Murray. Thank you very much, Mr. Chairman.
    Thank you to all of our witnesses for being here today.
    When it comes to our healthcare system, I'm really focused 
on making sure that we expand coverage, make coverage more 
affordable, and, critically, ensuring we continue to improve 
the quality of care that patients receive. Today's hearing 
really is a great opportunity to focus, in particular, on that 
third goal, improving quality, because we all know having more 
and better information about a patient's healthcare can make 
all the difference.
    We have come a long way in this effort. Our country has 
made significant gains in terms of adopting electronic health 
records. In 2001, only 18 percent of physicians used electronic 
health records, and today, 78 percent do. That is a real 
transformation, and I'm proud that the HITECH Act we passed in 
2009 was a big part of that.
    I truly appreciate the work that's been done by so many 
doctors and hospitals to help bring our healthcare system into 
the 21st century and improve the quality and value of care for 
families across the country. This progress does mean that 
doctors can identify health problems sooner and help patients 
get preventive care that will keep them healthy, and it means 
patients can know more about their own health and be better 
equipped to make decisions about the care that they need.
    It also means patients are safer, since electronic health 
records can alert providers to errors that hurt patients. I 
look forward to hearing from Dr. Adler-Milstein and Dr. Wergin 
about the important role health information plays in providing 
high-quality, patient-centered care.
    I'm very proud that in my home State of Washington, 
patients are benefiting from better access to health 
information. For example, a patient at Group Health Cooperative 
in Seattle was able to switch her treatment and avoid serious 
health risks, thanks to electronic medical records that showed 
that a dangerous interaction between two of her medications was 
the problem.
    That's just one story of many across the country that show 
how critical better health information is for patients. There 
is, of course, a lot more that should be done to build on the 
progress we've made so far.
    Many physicians across the country are facing, as the 
Chairman mentioned, a Medicare payment reduction this year 
because they're struggling to meet the requirements for the use 
of these electronic health records. I know that there's a lot 
of frustration about that. I think we need to do more to both 
set high standards and ensure providers have the support and 
flexibility they need to reach them.
    There are also important issues around interoperability 
that I look forward to hearing about from our witnesses today. 
It is critical that as electronic health records become more 
and more integral to our healthcare system, information can be 
securely and efficiently shared between doctors and across 
systems developed by different vendors. This is something that 
Mr. DeVault is deeply involved in, and I look forward to 
hearing his thoughts on best practices to increase 
interoperability.
    As we do more to make sure electronic health information 
can be shared between providers, I think there is much more we 
can do to help patients stay informed about and involved in 
their own care. In addition to our extensive work on health 
information technology, I know Dr. Kennedy can speak personally 
to how important it is that patients have access to their 
medical records.
    Thank you for coming today, Dr. Kennedy, and sharing your 
daughter's story.
    Of course, a critical part of making sure our country can 
fully benefit from health IT is security. Patients and 
providers need to know that their information is safe and 
secure, and I'm glad to be working with Chairman Alexander to 
ensure that that is a top priority.
    Finally, I want to note that progress on health IT is 
especially needed when it comes to the care of our service 
members and our veterans. Those who bravely serve our country 
deserve the absolute best care we have to offer, and that does 
include a state-of-the-art interoperable electronic records 
system. The VA and DoD missed an opportunity to develop that 
infrastructure, and I really hope that both departments will 
continue to work toward a better, modernized electronic health 
records system for our service members and our veterans.
    Again, I want to thank our witnesses for being here today. 
As we continue working to strengthen our healthcare systems for 
patients and families, expanding and improving our Nation's 
health IT infrastructure cannot be more important. I truly 
appreciate everyone's efforts today, and I look forward to 
working with you in the coming weeks and months.
    Thank you very much, Mr. Chairman.
    The Chairman. Thank you, Senator Murray.
    This is another bipartisan hearing, which means that 
Senator Murray and I worked together to invite the witnesses. 
Our purpose is to learn what's going on and figure out what we 
need to do. We want to go straight down the middle and make 
this work and create an environment in which it can work, if we 
can.
    I'm pleased to welcome the four witnesses. I want to thank 
you for being flexible. We got snowed out the last time we 
tried to have a hearing on this, and I know that was 
inconvenient for you, and we thank you for rescheduling and 
coming today. I want to introduce two witnesses, and then I'll 
turn to Senators to introduce two others.
    Our first witness is Dr. Julia Adler-Milstein from the 
University of Michigan, Assistant Professor at the School of 
Information with a joint appointment in the School of Public 
Health. Her research focuses on policy and management issues 
related to the use of IT in healthcare delivery. She has 
expertise in health information exchange. She has conducted 
four national surveys of health information organizations. She 
also studies the productivity and efficiency of electronic 
health records.
    Our second witness is Dr. Robert L. Wergin from Nebraska. 
Dr. Wergin is president of the American Academy of Family 
Physicians where he advocates on behalf of family physicians 
and patients nationwide. Dr. Wergin is a practicing physician 
in the town where he was born and raised, Milford, NE. He 
practices the full spectrum of family medicine, from obstetrics 
to geriatrics, at the Milford Family Practice Center and is 
medical director of Crestview Care Center.
    Senator Baldwin, I believe you have a witness.

                      Statement of Senator Baldwin

    Senator Baldwin. Thank you, Mr. Chairman and Ranking 
Member. I am honored to introduce today Mr. Peter DeVault. He 
is the director of Interoperability at Epic Systems in Verona--
Verona, WI, I might add. He joins us armed with a significant 
amount of industry expertise and experience in electronic 
health records.
    Not only does Peter sit on the Health IT Policy Committee's 
Information Exchange work group, which makes recommendations to 
the national coordinator for health IT, but he also has held 
leadership positions in several interoperability bodies, 
including the Certification Commission for the Health 
Information Technology Interoperability work group, HL7's EHR 
Technical Committee, and the Electronic Health Record 
Association, just to name a few.
    He also works with Healthy Ways Quality Initiative, a 
vendor effort to drive health information exchange to help Epic 
accelerate connections between interoperability networks.
    Peter, welcome to the committee, and thank you for joining 
us to share Epic's story and your expertise in this area.
    The Chairman. Thank you, Senator Baldwin.
    Senator Cassidy will introduce our fourth witness.

                      Statement of Senator Cassidy

    Senator Cassidy. It's my privilege to introduce Dr. Angela 
Kennedy. Dr. Kennedy is from Louisiana, specifically from 
Ruston, a beautiful little town in north Louisiana, where she 
teaches.
    Dr. Kennedy, welcome to you and your daughter. Thank you 
for being here to share your story.
    Dr. Kennedy is a professor and the head of the Department 
of Health Informatics and Information Management at the College 
of Applied and Natural Sciences at Louisiana Tech University in 
Ruston, LA. She is here to share her personal story and her 
daughter, Grace's, story. Grace was not properly diagnosed with 
cystic fibrosis because of, frankly, a foul-up of the 
electronic medical record and the usage thereof. It is both as 
a person with expertise in health informatics, but, more 
importantly, as a mom that she is here to present.
    Dr. Kennedy, we look forward to your testimony, and I thank 
you for coming from Louisiana--where azaleas are blooming and 
the cypress trees are gorgeous--to Washington, DC.
    The Chairman. Thank you, Senator Cassidy, for that 
commercial.
    [Laughter.]
    I agree with you. This is a nice time of year in Louisiana.
    Why don't we start with Dr. Milstein, and then we'll move 
right down the line.

 STATEMENT OF JULIA ADLER-MILSTEIN, Ph.D., ASSISTANT PROFESSOR 
 OF INFORMATION, SCHOOL OF INFORMATION, ASSISTANT PROFESSOR OF 
    HEALTH MANAGEMENT AND POLICY, SCHOOL OF PUBLIC HEALTH, 
             UNIVERSITY OF MICHIGAN, ANN ARBOR, MI

    Ms. Adler-Milstein. Good morning, Chairman Alexander, 
Ranking Member Murray, and members of the committee. Thank you 
for inviting me here today.
    This hearing is coming at a critical time in the evolution 
of our healthcare system. Over the past 5 years, there's been a 
multibillion dollar investment of both public and private funds 
into adoption of electronic health records. This was driven by 
widespread bipartisan agreement that using a first-century 
technology, paper-based records, is not a good way to deliver 
safe, effective, and efficient care.
    The result is that we now have electronic health records in 
place in the majority of hospitals and physician practices 
across the country, and this is remarkable progress. However, 
there are early warning signs that a set of key barriers are 
preventing our investment in EHRs from resulting in the better 
care we so desperately need.
    These barriers can be boiled down into three domains: 
ensuring that EHRs contain accurate data; ensuring that EHRs 
have the capabilities to move data; and ensuring that patients 
and providers can use that data. Careful policymaking can 
tackle each of the barriers in these domains and ensure that 
over the next 5 years, we leverage our new health IT 
infrastructure to deliver the high-quality affordable care we 
all want for ourselves and our loved ones.
    In my remaining time, let me describe these barriers and 
suggest some policy actions that could address them. First, I 
often hear physicians using the technical term, gobbledygook, 
to describe the information that they find was in the clinical 
notes fields of their EHR. They also express frustration with 
the amount of time they have to spend documenting information 
that's not directly relevant to patient care.
    Simply put, the multitude of clinical, billing, and 
regulatory requirements for what must be documented in the EHR 
is compromising the quality of the data in the EHR. And if the 
data isn't good, simply having it be electronic isn't going to 
get us anywhere. CMS is in a position to experiment with 
introducing more flexibility into documentation requirements 
and then assessing the effects.
    Second and perhaps the most critical challenge is enabling 
the data that now sits within the EHRs of healthcare 
organizations across the country to move to where it is needed, 
to providers who cannot provide safe or effective care with 
missing information, and to patients who can use it to better 
understand and manage their health and care and to do so within 
a robust privacy and security framework.
    Instead, only a minority of physicians, as few as 20 to 30 
percent of physicians and hospitals, exchange clinical data 
with other providers electronically. It may be surprising to 
discover that the true barriers to such exchange are largely 
not technical ones.
    An agreed upon set of standards implemented in a consistent 
way would undoubtedly facilitate interoperability. The 
underlying issue is that we don't have the incentives in place 
to make this a reality. EHR vendors do not have a business case 
for seamless, affordable interoperability across vendor 
platforms, and provider organizations find it an expense that 
they often can't justify.
    It is reasonable to ask in exchange for the large amount of 
public funding that has been dedicated to EHR adoption that 
vendors facilitate a robust market of new tools and 
technologies by enabling better access to patient data. The 
mechanisms to do this exist today in the form of EHR 
certification criteria.
    Third, despite the fact that IT is deeply interwoven into 
the fabric of our lives, for most patients, health IT has meant 
very little. This is true to such an extent that provider 
organizations are struggling to meet the Stage 2 Meaningful Use 
criteria that requires that 5 percent of patients view, 
download, or transmit to a third party their health 
information.
    The reason is straightforward. Most patient portals and 
personal health records are not making patient data 
understandable, useful, and engaging. Despite the tremendous 
explosion of patient-generated health and lifestyle data, few 
patients are able to sync that data with their EHR data.
    If we make real progress in patient-centric data sharing 
from providers to patients and patients to providers, there's 
no shortage of smart, creative companies that will work with 
patients to help them make sense of the data and use it in ways 
that are valuable.
    In closing, I think we can all agree that newly adopted 
EHRs have a critical role to play in improving our healthcare 
system. It won't happen on its own. Smart policy interventions 
can push to improve the data, as well as move it to where it is 
needed in order to let physicians, patients, and the broader 
market use it to innovate and create value.
    Many other industries have shown us the power of what can 
happen when high-quality data are at our fingertips and 
incentives are aligned behind innovation. We've made great 
progress in EHR adoption. Now is the time to do the things we 
need to make sure the investment leads to safer, more 
effective, and more efficient care.
    Thank you.
    [The prepared statement of Ms. Adler-Milstein follows:]
           Prepared Statement of Julia Adler-Milstein, Ph.D.
                                summary
    There has been remarkable consensus that the U.S. healthcare system 
needs to adopt and use electronic health records. EHRs have been an 
area of so much agreement because they hold the potential to do two 
things: save lives and save money.
    The good news is that use of electronic health records is 
spreading. In 2008, just 17 percent of American physicians and 9 
percent of hospitals were using EHRs. Since that time--and with the 
passage of the HITECH Act--a majority of physicians utilize EHRs and 60 
percent of hospitals have converted as well. These changes have 
occurred in a wide range of provider groups, from small ambulatory care 
practices to large teaching hospitals. Additionally, safety-net 
providers have largely kept up with other providers, staving off a 
digital divide.
    While these gains are remarkable, we are not yet seeing the large 
anticipated benefits of EHRs: the evidence fails to show consistent 
improvement in patient care or a decrease in healthcare spending 
because of our investment. While in most industries there is a time 
lag--as much as a decade--between when IT is adopted and when we see 
large productivity gains, in healthcare we don't have a decade to wait. 
There is growing consensus about the challenges that need to be 
addressed, and we need to channel the strong momentum behind EHRs to do 
so.
    First, and most critically, we need to enable the vast amount of 
``digital'' data that now sits within EHRs to move to where it is 
needed: to other providers who cannot provide safe or effective care 
with missing information, and to patients who can use it to better 
understand and manage their health and care. Only a small minority--as 
few as 20-30 percent of physicians and hospitals--exchange clinical 
data with other providers electronically. This is not, at its core, a 
technological issue. The interoperability barriers that exist between 
providers are driven by a lack of incentives. EHR vendors do not have a 
business case for seamless, affordable interoperability across vendor 
platforms, and provider organizations find it an expense that they 
often can't justify.
    Patient involvement is also critical to realizing the value of 
EHRs. At this time, EHRs have not developed in a way that is meaningful 
to most Americans. The reason is straightforward: most patient portals 
and personal health records are not making patient data understandable, 
useful, and engaging. There are few opportunities for patients to 
provide the data they generate about their lifestyle and health 
behaviors to create a complete picture of their health.
    We also have work to do to improve the quality of data within EHRs, 
and there is a tension between the information that needs to be 
captured in EHRs for clinical care and the information needed for 
billing (as well as other administrative and regulatory requirements). 
We need to devote more attention to how to resolve this tension.
    In each of these areas, solutions will come from the talents and 
creativity of healthcare providers, entrepreneurs and the broader 
industry. The job of policymakers is to enable those innovations and 
there are concrete things we can do. The HITECH Act has done a 
remarkable job of getting EHRs deployed widely, but our job is not 
done. With smart policy actions that enable greater innovation in the 
healthcare marketplace, we can realize the promise of EHRs--to drive 
value in healthcare for all Americans.
                                 ______
                                 
    Good morning, Chairman Alexander, Ranking Member Murray, and 
distinguished members of the committee. My name is Julia Adler-Milstein 
and I am an assistant professor at the University of Michigan. It is an 
honor to appear before you to discuss how our Nation can ensure that 
the substantial investment we have made in health information 
technology over the past decade translates into improved healthcare for 
all Americans. My research tracks the adoption of health IT in the U.S. 
healthcare system as well as assesses the impact of health IT adoption 
on the cost and quality of care, and it is for this reason that I am 
here today.
    A decade ago, President George W. Bush set an ambitious goal for 
our Nation: by 2014 every American would get their care with the 
support of an electronic health record.\1\ In 2009, President Obama 
reiterated the same goal, calling for universal use of EHRs by 2014.\2\ 
Investing in health information technology has been area of remarkable 
consensus, and the reason is clear: when done right, health IT can have 
a profound impact on improving virtually all dimensions of care. No one 
believes that paper-based records are a good way to deliver safe, 
effective, high-quality care.
---------------------------------------------------------------------------
    \1\ ``President Bush continues EHR push, sets national goals.'' 
Healthcare IT News. April 26, 2004. Available at: http://
www.healthcareitnews.com/news/president-bush-continues-ehr-push-sets-
national-goals.
    \2\ ``Obama: EHRs for Americans by 2014.'' Healthcare IT News. 
January 8, 2009. Available at: http://www.healthcareitnews.com/news/
obama-ehrs-americans-2014.
---------------------------------------------------------------------------
    In response, an array of Federal and State-based strategies has 
sought to spur the adoption and use of electronic health records. They 
have been remarkably successful. Since the last time this committee met 
to discuss health IT, the adoption of EHRs, which include key functions 
known to improve the quality of care, has increased dramatically. Among 
U.S. hospitals, the increase has been from 9 percent \3\ to nearly 60 
percent \4\ in the most recent data (2014). Over the same period, the 
increase among U.S. physicians has also been large: from 17 percent \5\ 
to 48 percent.\6\ These gains can be largely credited to the HITECH 
Act--which provided nearly $30 billion in incentives to physicians and 
hospitals to adopt and meaningfully use an EHR.\7\ For example, if 
today you were to walk into your local hospital, you would find that 
the majority of medications are ordered through the EHR.\8\ This was 
not true only a few years ago, and the evidence is clear that just this 
one use of EHRs avoids errors and saves lives.\9\ There is more good 
news. We have seen EHR adoption among safety net providers mostly keep 
up with everyone else, partly due to the alternative incentive program 
that was created for safety-net providers. The increases in adoption of 
EHRs have been widespread--across all regions of the country, across a 
large variety of provider groups from small ambulatory care practices 
to large teaching hospitals. We should feel proud of these successes.
---------------------------------------------------------------------------
    \3\ Adler-Milstein J, Desroches CM, Furukawa MF, Worzala C, Charles 
D, Kralovec P, Stalley S and Jha A. More than half of U.S. hospitals 
have at least a basic EHR, but stage 2 criteria remain challenging for 
most. Health Affairs (Millwood). 2014;33(9):1664-71.
    \4\ Adler-Milstein J, Desroches CM, Furukawa MF, Worzala C, Charles 
D, Kralovec P, Stalley S and Jha A. More than half of U.S. hospitals 
have at least a basic EHR, but stage 2 criteria remain challenging for 
most. Health Affairs (Millwood). 2014;33(9):1664-71.
    \5\ Desroches CM, Campbell EG, Rao SR, Donelan K, Ferris T, Jha A, 
Kaushal R, Levy D, Rosenbaum S, Shields A, Blumenthal D. Electronic 
health records in ambulatory care--a national survey of physicians. New 
England Journal of Medicine. 2008;359(1):50-60.
    \6\ Furukawa MF, King J, Patel V, Hsiao C-J, Adler-Milstein J, Jha 
AK. Despite Substantial Progress In EHR Adoption, Health Information 
Exchange And Patient Engagement Remain Low In Office Settings. Health 
Affairs (Millwood). 2014;33(9): 1672-79.
    \7\ Public Law 111-5, Title XIII.
    \8\ Hospital Performance on Stage 2 Meaningful Use Measures. http:/
/www.healthit.gov/FACAS/sites/faca/files/
HITPC_Data_Analytics_Update_2014-11-04.pdf. Page 8.
    \9\ Ammenwerth E, Schnell-Inderst P, Machan C, Siebert U. The 
effect of electronic prescribing on medication errors and adverse drug 
events: a systematic review. Journal of the American Medical 
Informatics Association. 2008;15(5):585-600.
---------------------------------------------------------------------------
    Adoption of EHRs is, however, only the first step; EHRs are 
necessary, but not sufficient, to drive large gains in healthcare 
quality. The evidence to date suggests that EHRs do not consistently 
lead to better care or lower healthcare spending. In some ways, this 
should not be a surprise. In most industries, there is a time lag--as 
much as a decade--between when IT is adopted and when we see large 
efficiency and productivity gains. In healthcare, we don't have a 
decade to wait. We need a strategy for figuring out how to use our new 
information technology infrastructure to truly transform healthcare. 
Here, there is growing consensus about the challenges that need to be 
addressed and important places where careful policymaking can make a 
big difference.
    The first challenge is ``liberating'' the patient data that now 
sits within electronic health record systems of healthcare 
organizations across the country. By adopting EHRs, we have made a 
tremendous investment in ``digitizing'' clinical data, and have asked 
busy physicians to take extra time out of their day to enter this data. 
We need to enable the data to move to where it is needed: to other 
providers who cannot provide safe or effective care with missing 
information, and to patients who can use it to better understand and 
manage their health and care. Instead, only a small minority--as few as 
20 to 30 percent of physicians and hospitals--exchange clinical data 
with other providers electronically.\10\ That means that if, in the 
middle of the night, you have to rush your child to the emergency room 
in your community--the chances are very low that the treating physician 
will be able to access all of your child's information. Much of my 
research has focused on identifying the primary barriers to achieving 
broad-based health information exchange and interoperability. It may be 
surprising to discover that the barriers are largely not technical 
ones. An agreed-upon set of standards, implemented in a consistent way, 
would undoubtedly facilitate interoperability. The underlying issue is 
that we don't have the incentives in place to make this a reality. EHR 
vendors do not have a business case for seamless, affordable 
interoperability across vendor platforms, and provider organizations 
find it an expense that they often can't justify.
---------------------------------------------------------------------------
    \10\ Adler-Milstein J, Jha A. Health information exchange among 
U.S. hospitals: who's in, who's out and why? Healthcare. 2014: 2 (1) 
26-32.
---------------------------------------------------------------------------
    We are also struggling to engage patients through health 
information technology and better access to their data. Despite the 
fact that IT is deeply interwoven into the fabric of our lives, for 
most consumers, health IT has meant very little if anything at all. 
Despite much hype that personal health records would engage patients to 
be far more involved in their care, there is little evidence that this 
is happening. This is true to such an extent that provider 
organizations are struggling to meet the Stage 2 Meaningful Use 
criterion that requires that 5 percent of patients ``view, download, or 
transmit to a third party'' their health information. The reason is 
straightforward: most patient portals and personal health records are 
not making patient data understandable, useful, and engaging. The 
difference between getting my lab test result in the mail versus 
viewing it online is small. The ability to sync my exercise and other 
lifestyle data in order to understand how those choices impact my lab 
results is a whole different ball game. If we make real progress in 
patient-centric data sharing, from providers to patients and from 
patients to providers, there is no shortage of smart, creative, 
innovative new companies that will work with patients to help them make 
sense of the data and use it in ways that are valuable.
    There are other key challenges to ensuring that our national 
investment in EHRs improves care. We need to address the competing 
burdens on clinical documentation that are compromising the quality and 
usability of the data captured within EHRs. EHRs serve multiple 
masters, and there is a tension between the information that needs to 
be captured in EHRs for clinical care and the information that needs to 
be captured for billing (as well as other administrative and regulatory 
requirements). We need to think creatively about how to resolve this 
tension, and there is an opportunity for CMS to experiment with 
solutions. Finally, we know that when some physicians adopt EHR 
systems, they are worse off--slower, less efficient, struggling to 
provide high-quality care. For others, the experience is very 
different: they see big gains in productivity and the quality of care 
they provide.\11\ Why do some do so well with technology while others 
struggle? The answers are not as simple as age or tech savviness. It's 
likely much more about how the IT is used, and the context in which it 
is used.\12\ We need to identify these factors and work to spread them 
in order to ensure that all providers translate EHR use into better 
care.
---------------------------------------------------------------------------
    \11\ Adler-Milstein J, Green CE, Bates DW. A Survey Analysis 
Suggests That Electronic Health Records Will Yield Revenue Gains For 
Some Practices And Losses For Many. Health Affairs (Millwood). 
2013;32(3):562-70.
    Kern LM, Edwards A, Kaushal R. The Patient-Centered Medical Home, 
Electronic Health Records, and Quality of CarePatient-Centered Medical 
Home and Quality of Care. Annals of Internal Medicine. 
2014;160(11):741-9.
    \12\ Adler-Milstein J, Scott KW, Jha AK. Leveraging EHRs to Improve 
Hospital Performance: The Role of Management. American Journal of 
Managed Care. 2014;20(11 Spec No. 17):SP511-SP519.
---------------------------------------------------------------------------
    We are at a critical moment for our healthcare system. We are 
nearing the 5-year anniversary of the passage of the Affordable Care 
Act and 6 years after the passage of HITECH. Whatever our beliefs of 
those laws, we can all agree that our healthcare system has to get 
better--and we can all agree that newly adopted health information 
technology has a critical role to play. It won't happen on its own. 
Smart policy interventions can push to improve the data, as well as 
liberate it, in order to let physicians, patients, and the broader 
market use it to innovate and create value. Many other industries have 
shown us the power of what can happen when high-quality data are at our 
fingertips and incentives are aligned behind innovation. Of course, we 
need not be overly coercive or prescriptive. Policymakers won't have 
all the solutions--but if we ask that, in exchange for the large amount 
of public funding that has been dedicated to EHR adoption, vendors be 
willing to facilitate and participate in a robust market of new tools 
and technologies, we will begin to deliver on the promise of EHRs to 
drive improvements in care and to engage patients and their families. 
We have made great progress--now is the time to do the things we need 
to make sure that the investments lead to safer, more efficient, more 
effective care for all Americans.

    The Chairman. Thank you.
    Dr. Wergin.

STATEMENT OF ROBERT L. WERGIN, M.D., FAAFP, PRESIDENT, AMERICAN 
        ACADEMY OF FAMILY PHYSICIANS (AAFP), MILFORD, NE

    Dr. Wergin. Chairman Alexander, Ranking Member Murray, and 
members of the Senate HELP Committee, I want to thank you for 
this opportunity to testify on behalf of the American Academy 
of Family Physicians and over 115,000 members that I represent. 
My name is Robert Wergin, M.D. I'm summarizing my written 
statement and speaking both as president of the American 
Academy of Family Physicians and as a rural practicing family 
physician in Milford, NE.
    Four years ago, my practice implemented an electronic 
health record, and I have to say it wasn't pretty. The 
transition was expensive, time consuming, and resulted in a 
decline of office productivity and loss of patient volume. We 
worked hard at it and learned the system, and productivity 
improved.
    Although our patient volume has never returned to the pre-
EHR levels, I am pleased to say that my clinic is running more 
smoothly. In fact, we met Meaningful Use 2 requirements late 
last year.
    While it's difficult to provide a single characteristic of 
how health IT is working, I can report that my EHR experience 
is not unique. Today's hearing addresses a significant issue 
that is on the mind of every physician across this country, 
regardless of geography, practice size, or years in service.
    Here are a few of my observations. First, technology is 
improving healthcare at a practice level, such as accessing and 
editing patient data, all the way up to advanced EHR functions 
that allow for e-prescribing, clinical decision support, and 
accessing lab results.
    Family physicians were early adopters of health IT because 
we saw its potential for improving patient care, and we still 
see that potential.
    Second, family physicians are excited about innovative 
health delivery models, such as patient-centered medical homes, 
ACOs, and telemedicine, that rely on health IT. For example, 
medical homes that use EHRs have higher quality scores, and 
telemedicine is increasing access to care, especially in rural 
areas like mine, and physicians welcome those changes.
    Third, health IT improves coordination between primary care 
physicians and subspecialists, hospitals, pharmacies, labs, and 
State health departments. But there's still room for 
improvement.
    I've discussed the opportunities and the major challenges, 
and they can be summed up as follows. Regulatory burdens are 
interfering with the doctor-patient relationship. Current EHRs 
are expensive and do not function well within the physician's 
work flow and are not fully interoperable. Payment structure 
does not fully support coordinated care that is time intensive 
and EHR dependent.
    To fulfill the promise of health technology, the AAFP 
respectfully submits the following recommendations. No. 1, 
overhaul the current documentation requirements. The current 
standards are time consuming, lead to bloated EHR, and 
emphasize billing information rather than meaningful clinical 
data exchanges.
    For example, I recently saw a patient for a followup from 
an emergency room visit. After reviewing 18 pages of patient 
notes, all I knew was that her mother was of Mediterranean 
descent, and I was not easily able to ascertain through the 
medical history or relevant patient data why she was seen and 
hospitalized. I didn't think it was because her mother was of 
Mediterranean descent.
    In addition, physicians like me are spending far too much 
time typing on computers instead of face-to-face patient care.
    Second, provide flexibility from the regulatory burdens. 
The Meaningful Use incentive payments encourage health IT 
adoption. The regulatory burdens are tremendous, and we thank 
policymakers who have been supportive of regulatory relief.
    CMS's recent proposal to allow a 90-day reporting period 
for 2015 is a good example of regulatory relief.
    In addition, CMS and Congress should revisit the all-or-
nothing requirement for Meaningful Use. HHS should also 
harmonize quality and reporting standards.
    Third, physicians are also dependent on their EHRs for 
transition to ICD-10. As the deadline approaches, we urge the 
administration to establish an ICD-10 contingency plan to 
anticipate transition difficulties that may result in denials 
and loss of revenue.
    Fourth, Congress and the Administration must step up 
efforts to require interoperability. It has now been 10 years 
since the EHR incentive program was created, yet we still do 
not have adequate levels of interoperability. HHS should 
strengthen its EHR certification requirements, as the AAFP and 
40 other medical organizations requested in a January 21st 
letter. Policymakers should also delay Federal penalties for 
Meaningful Use until interoperability is achieved.
    Fifth, Congress should strengthen consumer and health 
privacy laws to ensure that information is fully protected, not 
hoarded for commercial purposes, and physicians should not be 
at the mercy of their vendors to access patient data.
    And, finally, we urge Congress to pass a permanent SGR 
repeal that supports payment reform in the type of care 
coordination that is health IT dependent.
    Again, I appreciate the opportunity to testify and would be 
happy to answer your questions when appropriate.
    [The prepared statement of Dr. Wergin follows:]
            Prepared Statement of Robert Wergin, M.D., FAAFP
    Chairman Alexander, Ranking Member Murray and members of the Senate 
Health, Education, Labor, and Pension (HELP) Committee, I appreciate 
the opportunity to testify today on behalf of the American Academy of 
Family Physicians (AAFP) and the more than 115,900 members we 
represent.
    My name is Robert Wergin, M.D., FAAFP. I am president of the AAFP 
and a practicing family physician from Milford, NE, a small, rural town 
with a population of around 2,100 residents. I am a meaningful user of 
an electronic medical record and practice in a patient-centered medical 
home (PCMH).
    The AAFP is one of the largest national medical organizations, and 
we represent the largest number of primary care physicians in the 
country. We have members practicing in all 50 States and over 90 
percent of all counties. The AAFP was founded in 1947 to promote and 
maintain high-quality standards for family physicians who are providing 
continuous, comprehensive, and connected health care to the public.\1\ 
Approximately one in four of all office visits are made to family 
physicians.\2\ That is 214 million office visits each year--nearly 74 
million more than the next largest medical specialty.\3\ Family 
physicians provide more care for America's underserved and rural 
populations than any other medical specialty. In addition, family 
physicians provide a diverse range of care that includes pediatric, 
women's health and end-of-life.
---------------------------------------------------------------------------
    \1\ About the American Academy of Family Physicians, website: 
http://www.aafp.org/about/the-aafp/history.html.
    \2\ Ibid.
    \3\ Ibid.
---------------------------------------------------------------------------
    Today's hearing addresses a significant health practice issue that 
is on the mind of every physician across the country regardless of 
geography, practice size or years in service. In recent years, I have 
traveled around the country and talked with dozens of family physicians 
whose experiences adopting health information technology (health IT) 
were much like mine.
    Four years ago, my practice implemented an electronic health record 
(EHR) system. The initial results weren't pretty. Transitioning from 
paper to electronic files was expensive, time consuming, and resulted 
in a decline in the productivity of my office. We worked at it, learned 
the system and productivity has improved. Although our daily patient 
volume has not yet returned to pre-EHR volumes, my clinic is running 
more smoothly than it did initially because my staff and I have 
adapted. We have embraced this change, and the benefits have been 
numerous. In fact, our practice successfully met Meaningful Use (MU) 
Stage 2 requirements late last year.
    So, it is with that perspective, both as an AAFP leader and a 
practicing physician in a rural area that I am speaking with you today. 
Physicians around the country are anxious to know that policymakers 
understand and appreciate the challenges and concerns associated with 
successfully adopting health IT. Physicians also hope that decision 
makers will not simply consider the importance of health regulations 
but the context in which physicians are implementing a myriad of new 
requirements with limited financial resources and available time that 
can distract from the patient-physician relationship and impose 
significant challenges on physicians' quality of life and for some 
threaten the viability of their practice.
   family physicians are early adopters of electronic health records
    Physicians have used computerized medical records for well over 20 
years. Successful utilization of EHRs, also known as electronic medical 
records or EMRs, has long been a vision of family medicine well before 
Congress approved the Health Information Technology for Economic and 
Clinical Health (HITECH) Act, enacted as part of the American Recovery 
and Reinvestment Act (ARRA) of 2009. Over 10 years ago, the AAFP 
encouraged adoption of EHRs as part of its Future of Family Medicine 
initiative.\4\ In addition, the AAFP created a Center for Health IT, 
which is now the Alliance for e-Health Innovation, to educate 
physicians about issues surrounding adoption and to work with IT 
vendors on standards for primary care practice. The AAFP also published 
health IT guides, shared best practices and reported on the most widely 
used EHR systems. We have also worked to create interoperability 
standards, which are represented in meaningful use. The organization's 
leadership boosted EHR adoption among family physicians. In a 2014 
survey conducted by the U.S. Department of Health and Human Services' 
(HHS) Office of National Coordinator (ONC) for Health IT, over 77 
percent of primary care physicians indicated that they were using 
electronic health records and outpacing other medical and surgical 
specialties.\5\
---------------------------------------------------------------------------
    \4\ Sheri Porter, What Factors Influence EHR Adoption?, AAFP News, 
December 10, 2014, http://www.aafp.org/news/practice-professional-
issues/20141210oncbrief.html.
    \5\ Ibid.
---------------------------------------------------------------------------
    We are pleased Congress and the Administration implemented the 
Medicare and Medicaid EHR Incentive Programs within ARRA to provide 
payments to eligible professionals, eligible hospitals, and critical 
access hospitals (CAHs) as they adopt, implement, upgrade, or 
demonstrate meaningful use of certified EHR technology. According to 
the 2014 HHS physician survey, however, lack of financial resources was 
a significant barrier to adopting or upgrading systems, particularly 
for physicians operating in rural, small and solo practices.\6\
---------------------------------------------------------------------------
    \6\ Ibid.
---------------------------------------------------------------------------
    Family physicians are proud to be early adopters and we remain 
committed to pursuing the full potential of EHRs to enhance patient 
care, support new health delivery systems, improve population health, 
increase access through digital health technologies, and reduce the 
costs of health care. Most importantly, family doctors recognize 
successful EHR adoption will be the super highway for 21st century 
medicine. It is a road stakeholders must travel together: physicians, 
insurers, government agencies, patients, hospitals, community health 
centers and other health providers. It also is a road EHR manufacturers 
and vendors must travel with us. It is not enough for them to simply 
build the products and point physicians on their way; they must accept 
their responsibility to travel this road with the physicians and 
hospitals that purchase and rely on their systems. We are not there 
yet, but we are making progress toward that goal. In the final 
analysis, we must not lose focus on how our endeavors may ultimately 
impact patient care.
                       ehrs and health practices
    Electronic health records continue to be an important part of the 
future of health care delivery. There's no going back to paper 
records--we all recognize this even if our levels of acceptance vary. 
EHRs represent the potential for changing physician operations at a 
practice-level and for supporting new health care delivery models. On a 
simple level, EHRs use software that allows physicians to create, 
store, organize, edit and retrieve patient records on a computer or 
other device. An effective EHR is more than just the electronic 
equivalent of paper.
    Advanced EHRs automate a practice's many time-consuming, paper-
driven office tasks. They allow for electronic prescribing and 
medication refills, automatic formulary checking, electronic lab, 
imaging and referral ordering, automated charge capture, automated 
coding advice, intra-office clinical messaging, multiple note creation 
options, remote access to the chart, results flow charting, clinical 
alerts, patient education and disease management.\7\
---------------------------------------------------------------------------
    \7\ Kenneth Adler, MD, Why It's Time to Purchase an Electronic 
Health Record System, Family Practice Management, 2004 Nov-
Dec;11(10):43-46. http://www.aafp.org/fpm/2004/1100/p43.html.
---------------------------------------------------------------------------
    Advanced EHRs and health IT impact every process and individual in 
a practice. Advanced health IT that is interoperable can improve the 
safety of care through clinical decision support, robust data analysis, 
tracking of results, and supporting routine application of evidence-
based medicine. It also has the capacity to improve care coordination 
and the collaboration on patient care by our currently fragmented 
health care system. It can assist in the reduction of duplicative 
services and inappropriate utilization of services. To achieve these 
potentials, we must continue to view health IT as a tool for 
transformative change in health care and not a fancy electronic file 
cabinet.
                  the future of health delivery reform
    Health technology also holds the potential to help physicians 
engage in delivery system reform efforts. EHRs could improve care 
coordination between primary care physicians and subspecialists, 
hospitals, pharmacies, labs and State health departments--but this is 
not possible now in any meaningful way. Common standards are needed 
across all entities to realize this benefit. Technology also is an 
integral part of improving care access reform efforts with advances in 
telehealth and is especially important for improving access to 
preventive and primary care.
    Research shows that preventive care, care coordination for the 
chronically ill, and continuity of care--all hallmarks of primary care 
medicine--can achieve better health for individuals and cost savings. 
Published studies have demonstrated the positive impact of primary care 
on a variety of health outcomes, including decreased mortality from 
cancer, heart disease, stroke, and all causes combined. EHRs are 
essential for many health delivery reforms aimed at improving the 
quality of patient care and increasing primary health care access. For 
example, team-based coordinated care is a foundational piece of the 
patient-centered medical home (PCMH), and, when coupled with the use of 
an EHR system, the primary care practice has the best opportunity to 
improve the quality of care offered to patients.\8\ New research shows 
that organizational changes associated with the PCMH combined with use 
of an electronic health record can boost the quality of care delivered 
in primary care practices of all sizes.\9\ Researchers found that the 
odds of overall quality improvement in PCMH practices with an EHR were 
7 percent higher than in paper-based practices and 6 percent higher 
than in non-PCMH practices with an EHR.\10\ Specifically, improvement 
was seen in 4 of 10 quality measures chosen by six participating health 
plans. Unfortunately, today's EHRs do not yet possess the needed 
functionality to fully support a PCMH.
---------------------------------------------------------------------------
    \8\ Shari Porter, Combine Medical Home Culture, EHR for ``One-Two'' 
Punch, AAFP News, June 10, 2014, http://www.aafp.org/news/practice-
professional-issues/20140610pcmhehrstudy.
html.
    \9\ Ibid.
    \10\ Ibid.
---------------------------------------------------------------------------
    As the health care industry begins to implement new value-based 
payment models, the use of technology will be essential for collecting 
patient data, measuring care quality, engaging patients in their health 
care and evaluating the effective management of chronic care 
conditions. Other health delivery reforms that rely on health IT 
include Accountable Care Organizations and telehealth. These also have 
important implications for our ability to increase access to 
underserved communities, better serve the homebound, and improve health 
at a population level.
                     challenges and recommendations
    So far, I have focused on the great potential we see in health IT. 
The challenge is that this potential is not being realized in the 
majority of physician practices today. A recent RAND survey of 
physicians showed that EHRs are negatively impacting professional 
satisfaction.\11\ The goal of health IT is to make patient care more 
efficient and less costly. For every success story, there are family 
physicians and others struggling to make this a reality. While there 
are many challenges and the testimony will not cover them all or in 
great detail, I have highlighted the major concerns for AAFP's members, 
along with potential solutions.
---------------------------------------------------------------------------
    \11\ Mark W, Friedberg, et al., Factors Affecting Physician 
Satisfaction and their Implications for Patient Care, Health System and 
Health Care, Rand Corporation, September 30, 2013, accessed online: 
http://www.rand.org/pubs/research_reports/RR439.html.
---------------------------------------------------------------------------
    Current Documentation Requirements Distract from Patient Care. 
Physicians are deeply concerned that Federal and State regulations 
associated with EHRs can interfere with patient care and reduce patient 
and physician satisfaction. Instead of interacting with patients, 
physicians are typing into their computers and must spend hours keeping 
up with paperwork requirements. This can be distracting for patients 
and their doctors. In addition, physicians feel it can create a barrier 
to the patient-physician relationship. A 2014 Physicians Foundation 
survey indicated face time with patients care was among physicians' top 
five concerns. A majority of the 20,000 physicians surveyed expressed 
anxiety that patient care was suffering because they are spending more 
time on administrative responsibilities.\12\
---------------------------------------------------------------------------
    \12\ Top Five Concerns Include Consolidation, ICD-10, AAFP News, 
January 14, 2015, http://www.aafp.org/news/practice-professional-
issues/20150114physfdtnwatchlist.html.
---------------------------------------------------------------------------
    When my practice implemented EHRs, I certainly experienced this 
challenge of balancing the need to provide the face-to-face care I know 
patients need and fulfilling my paperwork requirements.
    We need the government to take a new critical look at the current 
medical documentation requirements required for Current Procedural 
Terminology (CPT) coding. The current requirements were developed in an 
era dominated by paper records and fee-for-service models. These 
antiquated requirements are time-consuming for physicians and other 
clinicians and lead to bloated medical records, both of which do not 
lead to better patient care.\13\ The current documentation requirements 
cause the generation of lengthy documents with critical clinical data 
buried within them. Physicians waste their time sifting through pages 
and pages of external ``billing'' documentation to find the critical 
data to inform treatment for the patient.
---------------------------------------------------------------------------
    \13\ Robert A. Berenson, M.D., Revisiting E&M Guidelines--A Missing 
Piece of Payment Reform, New England Journal of Medicine, 2011, page 
1892-95, accessed online: http://www.nejm.org/doi/full/10.1056/
NEJMp1102099.
---------------------------------------------------------------------------
    Encouraging a wider range of patients to view or download their 
data continues to be a challenge. A 2014 Health Affairs study found 
that only 30 percent of physicians reported using secure messaging to 
communicate with patients. Although 40 percent of physicians said their 
systems have the ability to allow patients to view, download or 
transmit information online, only half of those physicians said they 
were using that technology. \14\
---------------------------------------------------------------------------
    \14\ Michael Laff, Basic EHR Use Rising But Data Sharing, Patient 
Engagement Lag Behind, AAFP News, August 22, 2014, http://www.aafp.org/
news/practice-professional-issues/20140822healthaffehrstudy.html.
---------------------------------------------------------------------------
    Patients who have chronic disease and elderly patients whose care 
is being managed remotely by their children are among the individuals 
most likely to use patient portals. When my practice worked to achieve 
Stage 2 Meaningful Use status, meeting the patient portal requirement 
was particularly challenging. We have strong concern with requirements 
for action by those outside the control of the practice to avoid 
financial penalties.
    The AAFP is pleased the Centers for Medicare and Medicaid Services 
(CMS) has announced proposed rules to reduce the reporting period for 
Meaningful Use from 365 days to 90 days, and we hope CMS will provide 
physicians with certainty regarding this decision as soon as possible. 
This type of flexibility will give physicians more time to implement 
the guidelines without compromising patient care. We would like to see 
further flexibility to address the all-or-nothing nature of meaningful 
use. Today if a physician misses a single requirement by a mere 1 
percent, the physician is ineligible for an incentive payment and will 
see a penalty the following year under Medicare.
    EHRs Have Limited Functionality for Physicians. Physicians across 
specialties are deeply frustrated with EHR functionality and the fact 
that systems do not meet their workflow needs. In addition, these 
systems can reduce efficiency and have limited interoperability. These 
concerns are reflected in a January 21, 2015 letter to ONC that AAFP, 
along with 40 other medical and health organizations signed urging a 
serious review of the current certification standards.\15\
---------------------------------------------------------------------------
    \15\ EHRs Fails to Meet Physician, Patient Standards, AAFP News, 
January 27, 2015, http://www.aafp.org/news/practice-professional-
issues/20150127EHRcert.html.
---------------------------------------------------------------------------
    The letter outlined the following recommendations:

    (1) Decouple EHR certification from the Meaningful Use program.
    (2) Re-consider alternative software testing methods.
    (3) Establish greater transparency and uniformity on UCD testing 
and process results.
    (4) Incorporate exception handling into EHR certification.
    (5) Develop C-CDA guidance and tests to support exchange.
    (6) Seek further stakeholder feedback.
    (7) Increase education on EHR implementation.

    The letter stated the urgent need to change the current 
certification program to better align end-to-end testing to focus on 
EHR usability, interoperability and safety. AAFP stands with the 
medical community in urging ONC to address these certification 
standards.
    EHR Systems Lack Full Interoperability. The issue of 
interoperability between electronic health records represents one of 
the most complex challenges facing the health care community as we 
pursue patient-centered health care reform. The ability to share and 
utilize information between two or more information systems is critical 
in today's increasingly interconnected health care environment, yet 
significant challenges have impeded information exchange across the 
spectrum of care.
    To achieve better care, smarter spending and healthier people, both 
patients and physicians must be able to securely access their health 
care information when and where it is needed. When our patients leave 
our practice and go to another--for a subspecialist consultation, for 
example--my EHR most likely will not be able to communicate with the 
subspecialist's EHR.
    This is a major flaw in our health care system, and the AAFP 
continues to push the Office of the National Coordinator for Health 
Information Technology and EHR vendors on this important issue.
    AAFP leaders continue to advocate for requirements that demand 
interoperability from health IT vendors. The Federal Government should 
require that vendors achieve a high level of interoperability before 
expecting physicians and other clinicians to achieve current EHR and MU 
requirements. We have expressed our concern with the lack of 
interoperability and are pleased that the ONC has identified critical 
actions and outlined a timeline for implementation. We are making 
progress, such as with the Direct Project. This project was a 
partnership between the Federal Government and the private sector to 
establish the needed standardization for secure ``email'' in health 
care. We encourage continued support for this exchange and agree with 
many others that more work is needed to define the underlying data 
standards.
    Physicians Face Expensive Regulatory Burdens. Physicians face what 
has been described as a tsunami of regulatory burdens associated with 
health IT that include Meaningful Use, ICD-10, and CMS' Patient Quality 
Reporting System (PQRS). Implementing each requirement requires a time 
commitment, financial investment, and training to integrate into the 
physicians' practices. In addition, physicians face growing Medicare 
payment cuts for non-compliance. A 2014 Washington Post article states 
that paperwork is contributing to physician burnout, particularly among 
primary care physicians. \16\
---------------------------------------------------------------------------
    \16\ Roni Caryn Rabin, A Growing Number of Physicians Are Burning 
Out, Washington Post, March 31, 2014, accessed online: http://
www.washingtonpost.com/national/health-science/a-growing-number-of-
primary-care-doctors-are-burning-out-how-does-this-affect-patients/
2014/03/31/2e8bce24-a951-11e3-b61e-8051b8b52d06_story.html.
---------------------------------------------------------------------------
    We have written numerous letters to CMS calling for improvements to 
the Meaningful Use program to ensure that family physicians can qualify 
and thus avoid the penalties associated with non-compliance. In 
addition, the AAFP has urged the Administration to push implementation 
back to 2017.
    The Federal Government's strategic plan for the future of health 
information technology encompasses worthy goals. It should both seek to 
ease the administrative burden physicians confront and build on goals 
set a decade ago. The AAFP wrote in response to a public request for 
comments on the draft strategic plan that the ONC released in December 
2014 which outlines a working plan for the next 5 years. As the AAFP 
outlined in our comments, we urge greater coordination among agencies 
and efforts to reduce administrative burdens on physicians.
    Another area of concern regarding administrative burden with little 
impact on improved patient care is ICD-10. Many physicians worry that 
even if they successfully transition to ICD-10, they may still face 
potential claims denials or delays. Avoiding a disruption in the 
practice's cashflow remains a serious concern with this transition. 
Physicians heavily depend on electronic system vendors, claim 
clearinghouses, and payment administrators and need to know that 
testing is available and will be conducted to allow for corrections 
prior to the transition date. ICD-10 transition concerns are 
particularly acute for rural, small and solo practices.
    We strongly urge CMS to establish contingency plans or establish 
task forces that include payers, clearinghouses, and software vendors 
to ensure that a system is in place to identify and address unexpected 
process failures. In 2012, CMS mandated the roll-out of Health 
Insurance Portability and Privacy Act (HIPPA) 5010 rule for claims 
submissions. There were major issues across the Nation with payment to 
providers. With many practices operating on very thin budget margins 
and depending on normal revenue cycles, a payment delay of even 2 weeks 
could be harmful to the financial health of a clinic, regardless of its 
size.
    We urge Congress to make sure that legislation includes adequate 
timelines that take into account the complexity of health systems, the 
many competing demands for physicians' time and planning to mitigate 
the unintended consequences that could jeopardize patient care.
    Vendors Engage In Data Hoarding. The AAFP also has written to the 
Federal Trade Commission about anti-competitive practices that hinder 
interoperability. The AAFP is concerned with the utilization of health 
information technology to create competitive barriers against 
physicians and patients. The lack of interoperability makes it 
practically infeasible for a physician practice to switch electronic 
health records should the vendor or health care community use 
anticompetitive methods to limit the practice's access to needed health 
information on their patients. This hoarding of data--this vendor 
lock--negatively impacts care and distorts market forces trying to 
decrease health care costs and improve quality. It is critical that 
health data flow to where patients wish to be treated--in fact, these 
records are the patient's records and should be electronically 
available to any physician or other provider of care at any time. These 
records and data do not belong to the EHR vendor. The current market 
forces for EHR vendors and large (quasi-monopoly) health systems limit 
interoperability to retain customers and patients and to elevate prices 
artificially. We need to make sure the business incentives are aligned 
to ensure continuity of care for patients and appropriate access to 
data by providers.
    Reimbursement for Care Coordination is Inadequate. The biggest 
barrier to usable and interoperable health IT is the Nation's current 
fee-for-service business model that stresses volume rather than value. 
The system we have now is all about getting widgets out the door. In 
this case, those widgets are real live people who depend on their 
family physicians to provide quality care. It takes time and energy to 
improve quality in a busy medical practice. Moving to a value-based 
payment system can set the stage for a revolution in health IT that 
will move us from automating the business of health care to automating 
the delivery of that care. In a value-based payment-driven health care 
system, interoperability is desired not mandated.
    On January 26, 2015, HHS announced that a higher percentage of 
Medicare payment systems would be tied to quality-based systems by the 
end of 2016. Also, Medicare began paying for chronic care management 
(CCM) effective January 1, 2015, recognizing the value that primary 
care brings to health care. In addition, the bipartisan, bicameral 
legislation to repeal the Medicare Sustainable Growth Rate (SGR) 
proposes a payment system that focuses on the value of the health care 
delivered and that supports health care delivery models centered on 
care coordination. We support the Administration's efforts to advance a 
quality-based payment system. We strongly urge CMS to expand this 
program and to eliminate the co-payment requirement. Ultimately, 
physicians need a long-term and permanent solution. Congress should 
repeal and replace the SGR based on the 2014 legislative framework that 
supports value-based payments, encourages health delivery reforms and 
streamlines administrative requirements.
                               Conclusion
    Again, thank you for inviting me to testify before the committee 
today. I would like to reiterate our key recommendations to Congress:

    (1) Overhaul the current documentation requirements. The current 
standards are time-consuming, lead to bloated medical records which 
emphasize billing information rather than helpful and important 
clinical data.
    (2) Provide flexibility from regulatory burdens. The Meaningful Use 
90-day reporting rule is a good example of the type of flexibility 
physicians need. In addition, HHS should establish a minimum threshold 
necessary to meet the Meaningful Use standards instead of its all-or-
nothing requirement. Regulatory implementation is as important, in some 
cases, as the regulation, itself. AAFP urges policymakers and the 
Administration to take a ``do no harm'' approach when considering 
current and future standards that factor in the current physician 
workforce shortages, practice viability and patient care and safety. 
Harmonizing quality and reporting standards across all payers, 
especially for primary care, would also help physicians successfully 
implement Federal standards and similar requirements in the private 
sector.
    (3) The Administration should take steps to put an ICD-10 
contingency plan in place. Although the initial testing reports were 
favorable, physicians have been advised to take out loans to prepare 
for potential billing denials. Rural, small and solo practices may be 
especially hard hit if the transition process is not implemented as 
anticipated and there are weeks or months of claims denials.
    (4) Congress and the Administration must step up efforts to require 
interoperability and functionality. It has been 10 years since the EHR 
incentive program was created, yet we have not reached an adequate 
level of interoperability. This is not acceptable. HHS should use its 
authority to strengthen certification requirements to advance 
interoperability requirements and improve EHR functionality. We also 
believe that Congress should take action to delay Federal penalties for 
Meaningful Use until interoperability is achieved. In addition, until 
national standards are established, EHR vendors should be required, at 
a minimum, to use open Application Programming Interfacing technology, 
which experts indicate would significantly advance interoperability, by 
the end of 2016.
    (5) Review current consumer and privacy data protections. Patients' 
information should be fully protected and not hoarded for commercial 
purposes, and physicians' should not be at the mercy of their vendors 
as they are now. Physicians should not be charged by their vendors for 
accessing their own patients' data. Congress should consider amending 
medical privacy laws to strengthen consumer protections in ways that 
address both patients' concerns as well as physicians' data management 
responsibilities.
    (6) Congress must pass a permanent SGR repeal legislation this 
year. The SGR bicameral, bipartisan legislation included policies that 
help bring the health care industry into the 21st Century through 
value-based payment reform. This level of patient care emphasized in 
the legislation is intensive, but it is not adequately reimbursed right 
now. We urge Congress to enact SGR reform in 2015.
    I appreciate the opportunity to share the perspective of America's 
family physicians on what's working well and what challenges remain in 
implementing successful health IT systems.

    The Chairman. Thank you.
    Mr. DeVault.

STATEMENT OF PETER DeVAULT, DIRECTOR OF INTEROPERABILITY, EPIC 
                SYSTEMS CORPORATION, MADISON, WI

    Mr. DeVault. Thank you, Senators Alexander and Murray and 
other members of the committee. It's quite an honor for me to 
be here today.
    I've been with Epic for 18 years, and during that time, not 
only has our company grown from a small company to a larger 
one, but we've seen the growth of the electronic health record 
as a simple replacement for paper records to becoming a very 
sophisticated platform for healthcare innovation, population 
management, patient engagement, and the development of the 
learning healthcare system. You have access to my written 
testimony. I'll summarize a few thoughts in the areas of 
adoption, innovation, and interoperability.
    U.S. healthcare organizations have made great strides in 
electronic health record adoption over the last 10 years, and 
that's certainly an area in which the Meaningful Use Program 
has helped. Epic's community of leading healthcare 
organizations actually serves as a model for EHR adoption 
success.
    Epic has never had a customer fail to go live. No hospital 
has ever replaced Epic by choice, and we have never lost a 
customer due to dissatisfaction with our software or our 
services.
    The Epic community of customers represents a very diverse 
cross section of the U.S. care industry, including academic 
medical centers, safety net organizations, and some of the 
world's largest EHR deployments, such as Kaiser Permanente, and 
the care for patients in all 50 States and the District of 
Columbia. By the time our current customers finish rolling out 
the record to all of their users, they will be caring for about 
half of the U.S. population and include more than 310,000 
physicians.
    Our customers lead the industry in objective measurements 
of EHR adoption, including Meaningful Use attestation both for 
hospitals and eligible providers, as well as achieving Stage 7, 
which is HIMSS' categorization of EHR adoption. That's the 
highest level you can achieve, and the majority of 
organizations who have achieved Level 7 are Epic sites.
    Epic's customers are most often large organizations. 
Smaller organizations and smaller physician practices have a 
more difficult time in adopting healthcare information 
technology. One of the ways that we've sought to help with that 
is to open up what we call the Community Connect Program, which 
allows our customers, again, the larger organizations, to 
extend the EHR out to those community physicians and practices. 
More than 70 percent of our customers currently participate in 
that program and have extended to more than 17,000 physicians.
    Healthcare organizations adopt technology for a variety of 
reasons, often several, including increased efficiency; better 
and safer patient care; furthering their clinical research 
missions, which is very important for many of our customers; 
and the ability to adapt to healthcare payment reform.
    Our customers have achieved benefits in a wide variety of 
areas, including decreased wait times for appointments, 
reduction in hospital-acquired infections, elimination of 
duplicate tests, and engaging patients in their own care. 
Today, more than 30 million patients access the MyChart patient 
portal so they have access to their records and their families' 
records, can manage their medications, can incorporate outside 
data from their devices, and communicate securely with their 
care team.
    Increasingly, the ability to achieve these kinds of 
benefits, especially with payment reform and the mobility of 
patients, relies on a sharing ecosystem. It relies on being 
able to get the patient's health information from one point of 
care to another and to be shared among members of the care 
team, whether that's between hospitals and independent 
physicians or between a doctor's office in Wisconsin and an 
emergency department in Florida.
    Our interoperability platform, for which I'm responsible at 
Epic, is called Care Everywhere--and it's in use now by every 
customer in the United States--which gives access to more than 
1,000 hospitals and 23,000-some clinics to the ability to share 
patients' records. That doesn't mean that everybody is 
accessing that capability, and during the course of this 
morning's discussion, it would be useful to talk about what 
further barriers there are to actually using that technology.
    However, even though that is the case, today, our customers 
share more than 8.8 million records a month with different 
healthcare systems, almost 2 million of which are non-Epic, 
whether those are health information exchanges, other vendor 
systems, or Federal agencies on the e-health exchange, such as 
the DoD and the VA and the Social Security Administration. 
Healthy Ways tells us that we exchange more records with the VA 
than users of any other system.
    That being said, interoperability is certainly not a solved 
problem, and there are still barriers to achieving everything 
that it promises. Significant progress has been made, and it's 
important to recognize that progress in the last several years. 
We are certainly committed to sharing what we've learned and 
furthering the adoption of interoperable technology for the 
benefit of our country's patients.
    Thank you, and I'll be happy to answer any questions you 
have.
    [The prepared statement of Mr. DeVault follows:]

                  Prepared Statement of Peter DeVault
    Chairman Alexander, Ranking Member Murray and distinguished 
Senators serving on the Health, Education, Labor, and Pensions 
Committee, thank you for the opportunity to testify before you today to 
help you address, ``America's Health IT Transformation: Translating the 
Promise of Electronic Health Records Into Better Care.'' My name is 
Peter DeVault. I am director of Interoperability for Epic and I would 
respectfully like to share my views on the State of Electronic Health 
Record adoption and interoperability as well as the success healthcare 
organizations have achieved using our software to engage patients in 
their own care. Additionally, I hope my testimony and answers to your 
questions today address any concerns you may have and demonstrate our 
commitment to advancing Interoperability for our Nations' health care 
system.
              electronic health record--state of adoption
    Over the last 10 years, U.S. healthcare organizations have made 
major strides in Electronic Health Record adoption. According to data 
released from the ONC and the National Ambulatory Medical Care survey, 
nearly 80 percent of office-based physicians and about 60 percent of 
hospitals used an electronic health record (EHR) system.
    The community of leading care organizations that use Epic have 
served as a model of EHR Adoption Success. Epic has never had a 
customer fail to go live. No hospital has ever replaced Epic by choice 
and we have never lost a customer due to dissatisfaction with our 
software or services. Our customers serve patients in all 50 States and 
we estimate that when fully rolled out they will provide care for more 
than 54 percent of the U.S. population and support efficient daily 
workflows for more than 300,000 physicians and many more nurses, 
physicians assistants, schedulers, front desk staff and others. They 
include the Majority of U.S. News and World Report's Top Hospitals and 
Top Pediatric Hospitals Honor Rolls as well as the clinical 
organizations affiliated with the top medical schools.
    They represent a diverse cross section of the U.S. care industry, 
from the world's largest non-government electronic health record 
deployment at Kaiser Permanente, to academic medical centers such as 
Stanford, Yale, Cleveland Clinic, and the Mayo Clinic, to faith-based 
organizations such as Mercy health and Providence, to the Nation's 
``Safety Net'' of organizations that run the FQHCs and Critical Access 
hospitals that provide access to care for the most vulnerable patient 
populations.
    More eligible hospitals and professionals have attested for the 
first and second stages of Meaningful Use with Epic than any other 
system. The Healthcare Information and Management Systems Society 
(HIMSS) grades care organizations on a 7-point scale for Electronic 
Health Record adoption. More hospitals and clinics at the highest 
level, the HIMSS Stage 7 award, use Epic than every other Electronic 
Health Record put together.
    We are very proud of what they have achieved with our software:

     In 2014 alone, groups using Epic handled nearly 400 
million ambulatory visits, 34 million Emergency Department visits, 13 
million hospital admissions and 48 million hospital outpatient visits.
     They are using our software to improve patient safety. 
Over 390 million medication warnings were presented in our system, and 
our customers used bar code administration workflows to avoid nearly a 
quarter of a million harmful or fatal events were prevented by stopping 
medication from being administered to the wrong patient.
     They are reducing the cost of care by avoiding duplicate 
tests, unnecessary clinical visits, and hospital re-admissions due to 
complications. Most importantly, they are helping their patients live 
healthier lives and take active decisionmaking roles in their own 
care--keeping patients out of the hospital, helping them manage chronic 
conditions effectively, and ensure important screenings are performed 
to catch minor issues before they become major.

    It would be impossible to share everything our customers have done 
to use the Electronic Health Record to improve quality of care and 
reduce costs so I'll just touch on a few examples:\1\
---------------------------------------------------------------------------
    \1\ Customer statistics are taken from winning HIMSS Davies Award 
Case Studies. These Studies are available at http://www.himss.org/
library/davies-awards.

     University of Iowa Hospitals and clinics saw a 159 percent 
return on investment in the first 5 years following implementation. 
UIHC has netted over $50 million from July 2013 to June 2014 
attributable toward the use of information technology.
     Lakeland Healthcare achieved a 44 percent reduction in 
sepsis mortality rate in one quarter due to adherence to EHR-based 
clinical decision support order sets and analytical review of outcomes. 
They also achieved a 100 percent reduction in transcription-related 
adverse drug events.
     Children's Medical Center of Dallas reduced Emergency 
Department length of stay by 40 percent. They also used the system's 
bronchiolitis and RSV pneumonia\2\ pathway\3\ to achieve:
---------------------------------------------------------------------------
    \2\ Bronchiolitis and RSV Pneumonia is the No. 1 cause of 
hospitalization in the United States and accounts for approximately 
1,000 inpatient admissions every year at Children's.
    \3\ The Bronchiolitis and RSV Pneumonia Pathway was used for 
previously healthy children less than 2 years old with a primary or 
secondary diagnosis of bronchiolitis (ICD-9: 466.11 and 466.19).

          19 percent reduction in median length of stay for 
        bronchiolitis (from 2.4 to 1.95 days).
          34 percent reduction in chest x-rays (59 to 39 
        percent).
          48 percent reduction in bronchodilator use (27 to 14 
        percent).
          22 percent reduction in antibiotic use (32 to 25 
        percent).

   epic's background in innovative healthcare information technology
    Epic is 100 percent focused on developing, implementing, and 
supporting industry-leading integrated software for a small client base 
composed of the world's top academic medical centers, children's 
hospitals and large integrated delivery systems. To ensure their 
success, our staff to customer ratio is over 20 times higher than our 
nearest global competitor. We have a relatively small client base, and 
our development priorities are driven by their goals and vision.
    The first Epic software systems were created more than 30 years ago 
at an academic medical center. Since our founding we have contributed a 
number of innovations to health information technology:

     Groups using Epic were the first in the industry to have 
access to a single system supporting both hospital and ambulatory 
clinical care, patient access (i.e., admissions, registration, 
scheduling), and medical billing.
     Their patients were the first to have a secure web portal 
that is part of the electronic health record. MyChart offers access to 
medical information such as lab results and immunization records along 
with self-service features for appointment scheduling, prescription 
renewal requests, and co-pays.
     Doctors using Epic were the first to be able to access 
patient information, prescription writing, visit notes, and related 
features on smartphone and tablet apps that are part of the same 
electronic health record they use in the hospital and clinic. They do 
it in way that does not store data on the smartphone or tablet, so that 
even if the device is lost or stolen their patients' confidential 
information is safe.

    This level of innovation, coupled with a strong history of 
clinician and IT staff satisfaction with our software and services 
helped us become one of the most widely adopted and well-respected 
health IT vendors. We support the goals and vision of our customer 
community with one of the industry's largest research and development 
commitments. Nearly 54 percent of our annual operating expenses are 
dedicated to development. We conduct all of our development in the 
United States, and we support all U.S. customers with U.S.-based staff.
    KLAS Enterprises has ranked Epic the #1 overall software suite and 
#1 overall practice management vendor based on the results of thousands 
of surveys of U.S. healthcare organizations using major health IT 
vendors' software. Our enterprise products lead the industry in the 
following categories in the most recent Top 20 Best in KLAS report:

     #1 Acute Care EMR
     #1 Ambulatory EMR (75+ physicians)
     #1 Ambulatory EMR (11-75 physicians)
     #1 Practice Management (75+ physicians)
     #1 Patient Accounting/Patient Management
     #1 Health Information Exchange
     #1 Patient Portal
     #1 Surgery Management
     #1 Lab

    Over the past 10-15 years, we have helped drive the evolution of 
the Electronic Health Record from a system used primarily to document 
the care an organization has provided to one that actively supports the 
growth of medical knowledge and improves the health of diverse 
communities of patients. The Epic EHR underlies our customers' 
activities in:

     Medical Research and Discovery. The majority of the top 20 
National Institute of Health grant recipients use Epic, as do most of 
the Nation's most well-respected academic medical centers. Our software 
improves the speed and efficiency of areas including research 
participant recruitment and data analysis, allowing researchers to 
accelerate the pace of discovery and get new knowledge into practice 
faster and at a lower cost than was possible with older methods.
    Our vision is that a research-enabling EHR should not just empower 
the research department. It should empower the curious physician who 
wants to investigate a hunch to make the best decision for the 
patients. With Epic's self-service reporting, physicians can parse a 
large quantity of clinical data and view the results within seconds to 
find trends across patient populations or identify specific sets of 
patients for whom they need to take followup actions.
     Performance-based Reimbursement Models. The healthcare 
industry is in the midst of a shift from volume-based payment models 
where care organizations are paid based on the number of services they 
provide to value-based models that take their quality of care and the 
health of their patients into account. Epic's customers have used our 
software to pioneer models of care that have emerged to address this 
shift such as the Accountable Care Organization and the Patient 
Centered Medical Home.
     Business Intelligence and Population Management. Epic's 
software automatically collects data on each stage of the care process 
and the revenue cycle. This gives healthcare organizations a rich 
source of data for reporting and analytics. Our analytics tools do more 
than show what happened in the past. They include built in benchmarking 
so that each Epic customer can see how they are performing against 
national averages and against anonymized data from their peers in the 
Epic community. They also support predictive modeling that can help 
organizations anticipate and prepare for future trends.
    Healthy Planet, Epic's population health management module, is the 
Nation's fastest growing population health system. More than 115 
million patients have already been added to registries to help 
organizations manage their care. This makes it very easy for clinicians 
and care managers to address the unique needs of diverse groups of 
patients. The system helps them identify and engage patients at risk 
for specific conditions such as diabetes and events such as hospital 
re-admissions. It helps them manage care longitudinally, whether the 
patient is seen in a hospital, clinic, post-acute care setting, retail 
clinic, or at home--and it provides tools to reach patients in new ways 
by taking advantage of emerging technologies for engagement and 
telemedicine.
                  efforts to extend health it adoption
    Epic has taken an active role encouraging health IT adoption, 
serving with healthcare organizations, policy experts, and other 
healthcare software developers in government and industry groups 
dedicated to extending the benefits of the EHR nationwide. We have also 
been an early supporter of the Government's Meaningful Use program, 
becoming one of the first of the major Vendors to offer systems with 
Stage 1 and Stage 2 certification.
    As a program to accelerate health IT adoption, we view Meaningful 
Use as a success. We saw a surge of interest from care organizations in 
making the move from paper to EHRs as well as groups looking to move 
beyond outdated and functionally limited systems.
    One remaining challenge is encouraging health IT adoption among the 
smaller and single-provider practices that deliver care for a large 
percentage of the U.S. population. These groups encounter higher 
barriers to EHR adoption than larger organizations. Even with 
incentives that offset costs of acquiring systems the investment of 
time and IT resources to install an EHR successfully can be prohibitive 
for these groups. Epic is collaborating with its community of customers 
to help address this challenge. Through the Connect program, 
organizations that use Epic can extend their software to other 
practices and hospitals. More than 70 percent of our customers are 
helping boost IT adoption among smaller practices and hospitals through 
the Connect Program--bringing thousands of new providers live on the 
system.
                          engaging the patient
    Advances in telemedicine coupled with a proliferation of affordable 
consumer devices for healthcare monitoring continue to expand the reach 
of the healthcare organization beyond the walls of the clinic and 
hospital. This increases convenience for patients, allows them to 
receive services at convenient times and locations, and helps them take 
a more active role in managing their own care.
    A survey of 12 large organizations using Epic showed that patients 
have become the #1 consumer of EHRs (graphic below), echoing what we 
see in the evolving healthcare industry, and we have aligned our vision 
with this trend. Top MyChart adopters are engaging 65-95 percent of 
their populations and reporting millions of dollars in savings.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    MyChart gives patients access to data from same Epic chart used by 
clinicians. Patients can use MyChart to exchange secure messages with 
members of their care team, review goals and instructions recorded by 
their physicians, add data such as blood pressure readings to their 
charts, see their upcoming preventive care needs, and schedule 
appointments. Patients can access links to education materials curated 
for their specific health issues from MyChart.
    Patients can update their Epic records with data from home blood 
pressure cuffs, glucometers, Fitbits, and other personal devices, 
helping clinicians monitor those patients' health and well-being. Data 
taken from monitoring devices using Apple's HealthKit will populate 
Epic's medical record and similar integration will be available with 
Google Fit in the future.
    For the hospital, we offer MyChart Bedside, a tablet-based system 
that helps improve the care experience for hospitalized patients and 
their families. It provides access to personalized information on the 
patient's treatment team, scheduled procedures, lab results, electronic 
requests for services, and educational materials with support for rich 
content such as streaming video, images and Web sites.
    For the future, we are creating a MyChart dashboard which will 
allow patients to monitor their progress toward their health goals and 
give them access to tools that help them meet their goals. We are also 
developing a ``Companion'' capability that will remind patients to take 
medications, exercise, track blood glucose, or perform other tasks 
according to post discharge instructions or their health maintenance/
disease management plan.
                         the interoperable ehr
    The last concept I'll touch on is Interoperability. There's been a 
lot of focus on the need for interoperable electronic health records 
over the last couple of years, and a lot of confusion and 
misinformation in terms of what Epic's software will support.
    Epic does not own or claim rights to our customers' patient data. 
We do not interfere with their ability to access patient data and we do 
not re-sell patient data. We give our customers access to our source 
code and developer support. We also provide tools that support the free 
flow of information between different system and different 
organizations.
    We have a patient record exchange platform called Care Everywhere 
to support the exchange of patient data between organizations. A 
library of interfaces helps keep Epic systems communicate with hundreds 
of other systems, transmitting billions of messages a year. And last, 
we have application programming interfaces or APIs that we freely 
publish along with testing tools on open.epic to support third party 
innovation and connection to Epic's EHR.
    Our efforts have been validated by independent surveys of live 
customers conducted by KLAS. According to a KLAS survey of healthcare 
organizations in 2014, we were the only vendor to successfully balance 
success and depth of interoperability. We also had the highest ability 
to support interfacing and keep interfacing costs low.\4\
---------------------------------------------------------------------------
    \4\ Source: ``EMR Interoperability 2014'', KLAS Enterprises, 
September 2014.
---------------------------------------------------------------------------
    There are three major components that make up an interoperable 
Electronic Heath Record:

     Secure health information exchange between healthcare 
organizations. Care Everywhere, Epic's standards-based patient record 
exchange platform, debuted in 2005--years before the HITECH Act took 
effect. Today, Care Everywhere uses the Consolidated Clinical Document 
Architecture (C-CDA) as required for Meaningful Use Stage 2 
certification. Epic has installed Care Everywhere in all versions of 
its EpicCare EHR software in live use. One-hundred percent of customers 
who are live with EpicCare also have the ability to exchange patient 
records with any other system that supports the national 
interoperability standards.
    Organizations using Care Everywhere make up the largest active EHR 
exchange group in the United States--over 1,000 hospitals and 26,000 
clinics are live today and last month they exchanged nearly 8.5 million 
records patient with each other and with about 7,500 other 
organizations. This includes healthcare providers using other EHR 
systems, Health Information Service Providers (HISPs), Health 
Information Exchanges (HIEs), and groups connected to the eHealth 
Exchange like the VA, the Social Security Administration and the 
Department of Defense. According to Healtheway in July 2014, 
``Organizations using Care Everywhere exchange more records with the VA 
than any other vendor.''
    Any Epic customer can exchange patient data with third party that 
support national interoperability standards. There is no language in 
Epic's contracts to restrict our customer's ability to exchange data.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

     Interfaces between products. With over 36 years of 
experience creating and maintaining connections to other vendor 
systems, Epic has one of the largest libraries of existing interfaces. 
Each year, billions of data transactions happen between Epic and 600+ 
other systems through 12,500+ standards-based interfaces.
    Along with our interfaces we supply BridgesTM, an 
interface development and runtime toolkit that allows customers to 
write new interfaces and enhance/modify existing ones as well as 
efficiently maintain and monitor all the Epic interfaces they use.
    These interfaces allow healthcare organizations to connect with 
other vendors and outside groups such as pharmacies, specialty and 
immunization registries, and lab systems. Connections to outside 
agencies include public health agencies, research societies, 
immunization registries for 46 States, and research registries.
     An open system that encourages customer and third party 
innovation. For third-party application providers and device 
manufacturers, the open.epic initiative speeds the connection process 
to Epic's systems through public documentation, application programming 
interfaces (APIs), and online testing tools. Epic provides public test 
harnesses for third party developers to test their integration with our 
software using FHIR (Fast Health Interoperability Resources) at http:/
/open.epic.com/Interface/FHIR.
    For healthcare organizations, we have a large set of Web services 
and APIs for them to create add-ons, extensions, and new functionality. 
We also offer them the same tools that we use to develop our systems, 
as well as training for developers and access to source code.
    This year, we debut the Epic app exchange to allow these developers 
to offer their innovations to the Epic customer community.
    We are also continuing our work as a founding member of the 
Argonaut Project launched by Health Level 7, a non-profit driving the 
development of international healthcare informatics interoperability 
standards. Epic is working with healthcare and IT leaders such as Mayo 
Clinic, athenahealth, Cerner Corporation, Intermountain Healthcare, 
Meditech, and Beth Israel Deaconess Medical Center accelerate the 
development and adoption of Health Level 7's Fast Healthcare 
Interoperability Resources (FHIR). This development will enhance and 
expand information sharing among EHR systems and other elements of 
healthcare technology.
              epic's efforts to encourage interoperability
    Along with encouraging adoption, the Meaningful Use program was 
intended to encourage seamless interoperability across electronic 
health records. The goal is that a patient should be able to go to any 
organization using an Electronic Health Record that meets national 
interoperability standards and have their key medical information be 
accessible to the provider treating them. While Epic views the 
Meaningful Use program as a success in terms of encouraging Health IT 
adoption, three key challenges still remain in achieving true 
nationwide interoperability.

     A single nationwide directory of exchange ready 
organizations and providers. It should be fast and simple for a 
provider to determine whether another organization has treated their 
patient in the past. This can be challenging because the organization 
they are looking for could be a member of one of several 
interoperability networks--resulting in a time consuming search every 
time the provider wants to share information. One nationwide network of 
groups able to exchange patient data would make the process much more 
efficient.
     Consistent Standards. Products from light bulbs to cars 
rely on standards, and healthcare is no exception. Healthcare 
information technology has a variety of Standards Development 
Organizations tackling a variety of challenges including: data 
exchange/messaging standards, terminology standards, document 
standards, conceptual standards, applications standards, and 
architecture standards. At times, healthcare has too many options to 
choose from, with multiple standards serving similar purposes. That's 
why you can have multiple interoperability networks adopting different 
standards for exchange of something as fundamental as a patient's 
medications, or using different data exchange methods. One network may 
choose to ``push'' messages to another participant using one standard 
(e.g., Direct messaging), while another may choose to pull messages 
from its participants using another standard (e.g., IHE profiles).
     Legal Framework. Before care organizations can exchange 
data, they must have a legal framework in place governing the use of 
this connectivity. This ensures, for example, that use remains 
consistent with the Health Insurance Portability and Accountability Act 
(HIPAA) requirements. Today, the legal agreements used by one network 
typically are not compatible with other networks. This means that every 
time a care organization wants to connect with another group, they may 
be required to negotiate a new agreement. This is an extremely time 
consuming process and has created the misconception in the industry 
that interoperability is being ``blocked.''

    The result is that while many individual interoperability networks 
have emerged (see graphic), no single network provides universal 
interoperability. No single network attempts to address all 
interoperability use cases and scenarios, and no single technical 
platform operated by a single provider can meet the needs of all the 
diverse players in healthcare. Just as ATMs and cell phones rely on 
multiple, interconnected networks, healthcare must connect its 
interoperability networks to achieve universal connectivity.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    To put this ATM-like structure in place for healthcare, Epic has 
helped found Carequality, a public-private collaboration working to 
create a unifying legal and technical agreement to accelerate 
connection between networks regardless of platform or underlying 
technology. Carequality participants include the largest public and 
private interoperability networks in the United States like the 
Surescripts network (largest e-prescribing network) and the eHealth 
Exchange.
    Carequality's work will build on the success of Epic's Care 
Everywhere network. By providing a single directory of participating 
organizations, one consistent legal agreement governing data exchange, 
and a single set of technical standards, Epic allowed customers to make 
connections with other network participants much faster and at lower 
expense that is possible when making connections to groups outside the 
network. That's what made Care Everywhere the largest open 
interoperability network in the United States, and what allowed us to 
achieve 100 percent adoption across all live customers. The CareQuality 
Vision is illustrated in the graphic below.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    I look forward to answering any questions you may have for me and 
welcome future dialog beyond this hearing. Thank you for this 
opportunity.

    The Chairman. Thank you, Mr. DeVault.
    Dr. Kennedy.

 STATEMENT OF ANGELA KENNEDY, Ed.D., M.B.A., R.H.I.A, HEAD OF 
  DEPARTMENT/PROFESSOR, DEPARTMENT OF HEALTH INFORMATICS AND 
    INFORMATION MANAGEMENT, COLLEGE OF APPLIED AND NATURAL 
        SCIENCES, LOUISIANA TECH UNIVERSITY, RUSTON, LA

    Ms. Kennedy. I'm very honored to be here today. Certainly, 
I don't want to over-simplify my testimony as Professor of 
Health Informatics and past president of the American Health 
Information Management Association. I will answer questions 
related to policy and technical questions as appropriate. 
Today, I really want the voice of the consumer to be heard, and 
the importance of interoperable health IT for the consumer to 
be shared with you.
    As a parent of two adopted children, my desire for complete 
and accurate medical information rests at the top of my to-do 
list. My children, Zach and Grace, are siblings, adopted at the 
ages of 2 and 4 from the State of Louisiana.
    State laws vary on the provision of medical information and 
the provision of family medical history to parents of adopted 
children. We acquired a limited medical history for each child 
and almost no family medical history. Through diligent 
searching, I have been able to access additional information 
and recreate missing medical information through claims data 
and limited hospital medical records.
    Many of the medical records for my children have been 
destroyed by both hospitals and clinics. My children have been 
treated for asthma and allergies for most of their lives. With 
each visit, I'm quick to tell every physician that we encounter 
that my children are adopted and that I do not have a family 
medical history for them.
    This is a statement that I've always believed to be 
valuable to the care and treatment of my children. Recently, 
the impact of that statement and the importance of carefully 
maintaining their personal health information has become 
paramount.
    In January 2014, at the request of my physician, we changed 
asthma and allergy specialists. After a review of Grace's past 
medical history, the physician requested a followup appointment 
for additional testing. The second visit changed our world 
forever, and my daughter, Grace, was diagnosed with cystic 
fibrosis at the age of 11.
    Armed with a thumb drive and a 5-inch binder of medical 
information, which included copies of every pulmonary function 
test and every doctor's visit since the age of two, we 
presented for our first visit with the pediatric pulmonary 
specialist. When we returned for the second visit, our 
physician had analyzed the data and concluded that Grace never 
had asthma or allergies and removed her from medications that 
she had been taking for 9 years.
    Grace is just one example of why the commitment to the 
consumer must be made that we can provide health information 
where and when we need it, a guarantee that information will be 
available, accessible, accurate, and complete. I experienced 
many frustrations in my attempt to gather my child's medical 
records.
    Due to an inaccurate entry in my daughter's medical record, 
the inheritable condition was overlooked. The records included 
an inaccurate statement that had been copied and pasted into 
subsequent records for 9 years. Copy-paste and copy-forward 
pose risks to patient care.
    In my daughter's case, perhaps if the information had been 
reviewed or audited for accuracy, she would have received an 
earlier diagnosis. If information governance practices would 
have been in place, things could have been different.
    Information governance is not just a program for hospitals. 
It should be thought of as the gold standard for health 
information and documentation practice across the healthcare 
ecosystem. From creation to deletion, information governance 
policies created and enforced by the provider can support a 
data and information infrastructure that is as critical to 
patient care as the care that is provided.
    Governance policies must clearly define the legal health 
record and address retention standards. Consumers shouldn't 
have to recreate care from claims data or worry about their 
data being stolen or destroyed. Things are rapidly changing, 
but we must navigate that change in ways that drive better 
decisionmaking for patients and the providers who treat them.
    As healthcare professionals, we have been applying data 
analytics and informatics techniques for many years. The 
difference now is that the data is electronic with multiple 
users at multiple settings applying multiple guidelines for 
collection, creation, storage, use, and deletion. Care is 
important, but the information generated is what remains when 
the care is complete. We cannot neglect this consumer's legacy 
that is left for us to preserve and to protect.
    Healthcare professionals encounter healthcare consumers 
daily. We know the benefits that access and use of personal 
health information can bring to the consumer and their 
families.
    But consider this. Over the past year, I've written 
numerous appeals to our insurance company to pay for an $18,000 
vest for my daughter, and I've lobbied for prescription 
medicine coverage and coverage for supplements, all of which 
are vital to her care. I am a healthcare professional. What 
about the average consumer who is just overwhelmed by a 
diagnosis and just trying to make it to the next day?
    As we address these barriers, we also must keep in mind 
health literacy levels of healthcare consumers. Health literacy 
can be defined as the degree to which individuals have the 
capacity to obtain, process, and understand basic health 
information and services needed to make appropriate decisions. 
Only 12 percent of adults have proficient health literacy, 
according to the National Assessment of Adult Literacy.
    On our journey to remove barriers to accessible health 
information, we must ensure that this is understandable and 
actionable by consumers. It is our challenge to educate 
consumers and local communities on the importance and value of 
personal health information and educate consumers on the 
importance of the opt-in and interoperability for continuity 
for care.
    For my daughter, personal health information is saving 
Grace.
    [The prepared statement of Ms. Kennedy follows:]
     Prepared Statement of Angela Kennedy, Ed.D., M.B.A., R.H.I.A.
                                summary
    As a parent of two adopted children, my desire for complete and 
accurate medical information rests at the top of my ``Mom to-do list.'' 
My children, Zach and Grace, are siblings, adopted at the ages of two 
and four from the State of Louisiana. State laws vary on the provision 
of medical information and the provision of family medical history to 
parents of adopted children. We acquired a limited medical history for 
each child and almost no family medical history. Through diligent 
searching, I have been able to access additional information and 
recreate missing medical information through claims data and limited 
hospital medical records. Many of the medical records for my children 
have been destroyed by both hospitals and clinics.
    My children have been treated for asthma and allergies most of 
their lives. With each visit I'm quick to tell every physician that we 
encounter that my children are adopted and I don't have a family 
medical history for them. This is a statement that I have always 
believed to be valuable to the care and treatment of my children, but 
recently the impact of that statement and the importance of carefully 
maintaining their personal health information has become paramount.
    In January 2014, at the request of my physician, we changed asthma 
and allergy specialists. After a review of Grace's past medical 
history, the physician requested a followup appointment for additional 
testing. The second visit changed our world forever. Grace was 
diagnosed with cystic fibrosis at the age of 11.
    Armed with a thumb drive and a 5" binder of medical information--
which included copies of every pulmonary function test and every 
doctor's visit since she was two--we presented for our first visit with 
the pediatric pulmonary specialist. When we returned for the second 
visit, our physician had analyzed the data and concluded that Grace 
never had asthma or allergies and removed her from those medications.
    Gracie is just one example of why a commitment to the consumer must 
be made . . . that we can provide health information where and when 
they need it; a guarantee that information will be available, 
accessible, accurate, and complete. I experienced many frustrations in 
my attempt to gather my child's medical records. Due to an incorrect 
entry in my daughter's medical record, the inheritable condition was 
overlooked. The records included an inaccurate statement that had been 
copied and pasted into all subsequent records for 9 years. Copy paste 
and copy forward pose risks to patient care. In my daughter's case, 
perhaps if the information had been reviewed or audited for accuracy, 
she would have received an earlier diagnosis. If information governance 
practices would have been in place, things could have been different. 
Information governance is not a program just for hospitals. Information 
governance should be thought of as the gold standard for health 
information and documentation practice across the healthcare ecosystem. 
From creation to deletion, information governance policies can support 
a data and information infrastructure that is as critical to the 
patient as the care that is provided. Governance policies must clearly 
define the legal health record and address retention standards. 
Consumers shouldn't have to recreate care from claims data or worry 
about their data being stolen.
    Things are rapidly changing, but we must navigate that change in 
ways that drive better decision making for patients and the providers 
who treat them. As healthcare professionals, we have been applying data 
analytics and informatics techniques for many years. The difference now 
is that the data is electronic, with multiple users at multiple 
settings, applying multiple guidelines for collection, creation, 
storage, use, and deletion. Care is important but the information 
generated is what remains when the care is complete, and we can't 
neglect the consumer's legacy that is left for us to preserve and 
protect. Healthcare professionals encounter healthcare consumers daily. 
We know the benefits that access and use of personal health information 
can bring to the consumer and their families. But consider this: over 
the past year, I have written numerous appeals to our insurance company 
to pay for an $18,000 vest for my daughter, and I have lobbied for 
prescription and supplement coverage, all of which are vital to her 
care. I am a healthcare professional. What about the average consumer 
who is overwhelmed by a diagnosis and just trying to make it to the 
next day?
    As we address these barriers, we must also keep in mind the health 
literacy levels of healthcare consumers. Health literacy can be defined 
as the degree to which individuals have the capacity to obtain, 
process, and understand basic health information and services needed to 
make appropriate decisions.\1\ Only 12 percent of adults have 
proficient health literacy according to the National Assessment of 
Adult Literacy. On our journey to remove barriers to accessible health 
information, we must ensure that it is understandable and actionable by 
consumers. It is our challenge to educate consumers and local 
communities on the importance and value of personal health information. 
For my daughter, personal health information is ``saving Grace.''
---------------------------------------------------------------------------
    \1\ U.S. Department of Health and Human Services. 2000. Healthy 
People 2010. Washington, DC: U.S. Government Printing Office. 
Originally developed for Ratzan SC, Parker RM. 2000. Introduction. In 
National Library of Medicine Current Bibliographies in Medicine: Health 
Literacy. Selden CR, Zorn M, Ratzan SC, Parker RM, Editors. NLM Pub. 
No. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S. 
Department of Health and Human Services
---------------------------------------------------------------------------
                                 ______
                                 
    As a health informatics and information management (HIIM) 
professional and a parent of two adopted children, my desire for 
complete and accurate medical information rests at the top of my ``Mom 
to-do list.'' My children, Zach and Grace, are siblings, adopted at the 
ages of two and four from the State of Louisiana Office of Family and 
Child Services.
    State laws vary on the provision of medical information and the 
provision of family medical history to parents of adopted children. We 
acquired a limited medical history for each child and almost no family 
medical history. Through diligent searching, I have been able to access 
additional information and recreate missing medical information through 
claims data and limited hospital medical records. Many of the medical 
records for my children have been destroyed by both hospitals and 
clinics.
    My children have been treated for asthma and allergies most of 
their lives. With each visit I'm quick to tell every physician and 
medical professional that we encounter that my children are adopted and 
I don't have a family medical history for them. This is a statement 
that I have always believed to be valuable to the care and treatment of 
my children, but recently the impact of that statement and the 
importance of carefully maintaining their personal health information 
has become paramount.
    In January 2014, at the request of my physician, we changed asthma 
and allergy specialists. After a review of Zach and Grace's past 
medical history, the physician requested a followup appointment for 
additional allergy testing. The second visit changed our world forever. 
With no known family history of autoimmune disease, Grace was sent for 
a sweat test as a precaution when she failed to respond to the allergy 
testing.
    Grace was diagnosed with cystic fibrosis at the age of 11. Cystic 
fibrosis is usually diagnosed shortly after birth. Grace was 
immediately seen by a pulmonary pediatric research specialist at Texas 
Children's Hospital. Armed with a thumb drive and a 5" binder of 
medical information--which included copies of every pulmonary function 
test and every doctor's visit since she was two--we presented for our 
first visit.
    When we returned for the second visit, our physician had analyzed 
the data and concluded that Grace never had asthma or allergies and 
removed her from those medications. Her analysis of the data also 
helped her determine a correlation between seasons and when Grace's 
pulmonary functions declined, finding that past episodes that were 
labeled ``upper respiratory infection'' were due to her lungs not 
clearing properly during periods of lower activity. Genetic testing 
revealed that she has a rare form of cystic fibrosis.
    Her plan of treatment focuses on wellness. Grace wears a Nike 
FuelBand to track her levels of activity. The data collected helps to 
keep Grace well. Grace journals and keeps records on her activity, 
diet, and how she's feeling. All of the data that she collects is 
shared with her care team and becomes a part of the medical record. 
Grace reviews her electronic medical record and is aware when additions 
are made to the documentation. Records that are not available 
electronically are collected and added to the personal health record we 
keep at home. Copies of those records are shared with her specialist on 
each visit.
    Grace communicates with her care team and is actively involved in 
making decisions about her care. Personal health information is saving 
Grace. When you meet my daughter, she appears to be the picture of 
wellness. That's a picture that we want to see every day, a picture 
that tracking data helps us to keep.
    It is important to note that a comprehensive past medical history 
enabled Grace's physician to quickly assess and create a plan of 
treatment specific to her needs. A complete medical record, cradle to 
current medical history, was not available electronically and was not 
easy to obtain. I went to every care provider that has seen my daughter 
since the age of two. I requested copies of complete medical records. 
For those medical records prior to her adoption, I went to local 
clinics and hospitals near the location where my children were placed 
in foster care for the first few years of their lives and requested any 
available medical or claims data. Most early medical records had been 
destroyed but the claims data and with associated charges and ICD-9-CM 
diagnosis codes remained. From claims data, I was able to reveal an 
early history of acute and chronic respiratory illness and the 
treatment that was provided.
    Acquiring medical data from local family physician and pediatrician 
was fairly easy. I requested the medical information and it was printed 
from the electronic record on the day of request. All x-rays were 
placed on a CD and the information was provided to me and sent directly 
to the pediatric pulmonary specialist in Texas. While the critical 
access hospital/clinic utilizes an electronic medical record, 
interoperability between the two facilities was not possible. Not all 
documentation was stored in the electronic record. Both a paper and an 
electronic record existed for my daughter. While these records were 
easy to obtain others were not.
    The asthma and allergy clinic, where my daughter had been seen 
every 6 months since the age of two, delayed the release of her medical 
records. The office immediately provided me a copy of every pulmonary 
function test since the age of two, but refused to release physician 
notes. The office manager stated that the physician would need to 
verify the notes and then information would be sent to the specialist 
after review.
    The office promised to fax to my husband's office and the research 
clinic the following day (Saturday). The records were never received 
and the office was closed on Saturday. On Monday, I requested the notes 
be faxed directly to me at the hotel where we were staying and to the 
research clinic. The office manager told me that the fax on Saturday 
had been sent but to the wrong location. The first fax that was sent to 
the hotel also went to the wrong location. On the third attempt the 
records were received. The records were never sent from the physician 
to the research clinic. After receiving the information I quickly began 
to collate and review. Upon review, I found this statement this 
statement in the family medical history: ``the mother states that there 
is no family medical history of genetic disease.'' The statement was 
entered on the first visit at the clinic. It was clearly a copy paste/
copy forward in the electronic record and the entry was made on every 
visit that followed. That one statement ruled out cystic fibrosis as a 
diagnosis for that care team and possibly any care team that utilized 
that record.
    Gracie is just one example of why a commitment to the consumer must 
be made that we can provide health information where and when they need 
it. We need a guarantee that information will be available, accessible, 
accurate, and complete. Copy paste and copy forward pose risks to 
patient care. In my daughter's case, perhaps if the information had 
been reviewed or audited for accuracy, she would have received an 
earlier diagnosis.
    This audit is not just the responsibility of the care giver but 
also the responsibility of the patient. Patients should routinely 
access and review records for accuracy. Since 2003, the Federal HIPAA 
privacy rule has given individuals the right to examine and obtain 
copies of their health records, yet there is still widespread 
misunderstanding about these rights in the healthcare community, and 
barriers still exist for patients and families seeking full access to 
health records and information.
    For example (and anecdotally), the ``HIPAA law'' is still given as 
the reason a patient or another provider cannot be provided with copies 
of or access to health records or information--although this could not 
be further from the truth.
    Without full access to their health information, patients and 
consumers are unable to make informed care decisions and the status 
quo--care that is not patient-centric--continues. There is a need to 
ensure that barriers to accessing health information are removed--both 
through education of providers about patient rights and how to 
administer HIPAA, and through increased implementation and effective 
leveraging of health information technology to make information more 
accessible to patients, consumers, and all providers caring for the 
patient.
    If information governance practices would have been in place, 
things could have been different. Information governance is not a 
program just for hospitals. Information governance should be thought of 
as the gold standard for health information and documentation practice 
across the healthcare ecosystem. From creation to deletion, information 
governance policies can support a data and information infrastructure 
that is as critical to the patient as the care that is provided. 
Governance policies must clearly define the legal health record and 
address retention standards. Consumers shouldn't have to recreate care 
from claims data or worry about their data being stolen.
    Effective implementation of regulations and laws and leveraging of 
health information technology for sharing of health information with 
both consumers and other providers highlights the need for ``rules of 
the road'' or information governance. Without governance mechanisms 
that are agreed upon across the larger healthcare ecosystem, the United 
States will not be able to receive full benefit from its multi-billion 
dollar investment in health IT, let alone advance patient-centric care. 
Governance is needed to have high-integrity, reliable health 
information that can be trusted for healthcare decisionmaking.
    The American Health Information Management Association (AHIMA) 
defines information governance as a framework for managing health 
information throughout its lifecycle and which supports strategy, 
operations, regulatory, legal, risk, and environmental requirements. It 
includes the processes, standards, and tools necessary for establishing 
decision rights, valuation of information, and improvement of data 
quality and integrity. Most importantly, information governance is 
based on principles. AHIMA has identified the set of Information 
Governance Principles for Health Care as:

     Accountability: Senior leadership oversight and 
responsibility for information management.
     Transparency: Information management practices and 
processes that are open and verifiable.
     Integrity: Reasonable and suitable guarantee of the 
authenticity and reliability of information.
     Protection: Appropriate levels of protection against 
breach, loss, or corruption of information.
     Compliance: Information complies with applicable laws, 
regulations, standards and organizational policies.
     Availability: Maintenance of information in a manner that 
ensures timely, efficient, accurate retrieval.
     Retention: Maintenance of information for the period of 
time that takes into account its legal, regulatory, fiscal, 
operational, risk and historical requirements.
     Disposition: Secure and appropriate disposal of 
information no longer required to be retained by law or organizational 
policies.

    Many of the current challenges in the healthcare industry 
associated with health IT have been the result of inattention to these 
principles at higher levels of the healthcare ecosystem--not just at 
the level of the individual healthcare entity or organization.
    In addition to principles, the adoption and use of functional, 
semantic, and technical standards to support the interoperability 
necessary for stakeholders to share information is a critical 
information governance issue. This includes the ability to properly 
identify patients as well as locate information about them. It also 
includes ensuring the proper incentives are in place to encourage their 
adoption, implementation and use.
    If we continue with a narrow focus on technology and without a 
focus on information governance processes and principles, the United 
States will continue to experience daunting challenges related to 
health information exchange and sharing, patient identification, and 
privacy/security. Patients will continue to be at a disadvantage in 
trying to manage their health without appropriate, trusted information. 
Information governance is the new imperative for advancing the use of 
health IT and health information to support patient-centric care. And 
what about claims data? It was critical to providing a complete medical 
history for my daughter and the codes that remained and the charges 
associated with her visits helped to recreate the encounter.
    Addressing the current classification system is important, too. We 
should have been talking about the value of patient information and the 
classification of disease for population health long before now. The 
ICD-10 implementation delay presents implications for providers, health 
plans, and State and Federal agencies, but we must continue to advocate 
for ICD-10 implementation. ICD-10 will have tremendous value and impact 
on population health data and the consumer. It is imperative we clearly 
articulate to the consumer the value of accurately coded data.
    Things are rapidly changing, but we must navigate that change in 
ways that drive better decisionmaking for patients and the providers 
who treat them. As healthcare professionals, we have been applying data 
analytics and informatics techniques for many years. The difference now 
is that the data is electronic, with multiple users at multiple 
settings, applying multiple guidelines for collection, creation, 
storage, use, and deletion. Data are being generated by mobile health 
and personal health devices. We have to make certain that we are using 
clean data to create health intelligence. Care is important but the 
information generated is what remains when the care is complete, and we 
can't neglect the consumer's legacy that is left for us to preserve and 
protect.
    Healthcare professionals encounter healthcare consumers daily. We 
know the benefits that access and use of personal health information 
can bring to the consumer and their families. Consider this: over the 
past year, I have written numerous appeals to our insurance company to 
pay for an $18,000 vest for my daughter, and I have lobbied for 
prescription coverage for a $1,500 monthly prescription and supplement 
coverage for my daughter, all of which are vital to her care. I am a 
healthcare professional; I know how to get these things accomplished. 
What about the average consumer who is overwhelmed by a diagnosis and 
just trying to make it to the next day?
    As we address these barriers, we must also keep in mind the health 
literacy levels of healthcare consumers. Health literacy can be defined 
as the degree to which individuals have the capacity to obtain, 
process, and understand basic health information and services needed to 
make appropriate decisions.\1\ Only 12 percent of adults have 
proficient health literacy according to the National Assessment of 
Adult Literacy. Fourteen percent of adults (30 million) have below 
basic health literacy. These people were more likely to report their 
health as poor when compare with those with proficient health 
literacy.\2\ In our journey to remove barriers to accessible health 
information, we must ensure that it is understandable and actionable by 
consumers.
---------------------------------------------------------------------------
    \1\ U.S. Department of Health and Human Services. 2000. Healthy 
People 2010. Washington, DC: U.S. Government Printing Office. 
Originally developed for Ratzan SC, Parker RM. 2000. Introduction. In 
National Library of Medicine Current Bibliographies in Medicine: Health 
Literacy. Selden CR, Zorn M, Ratzan SC, Parker RM, Editors. NLM Pub. 
No. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S. 
Department of Health and Human Services.
    \2\ Kirsch IS, Jungeblut A, Jenkins L, Kolstad A. 1993. Adult 
Literacy in America: A First Look at the Results of the National Adult 
Literacy Survey (NALS). Washington, DC: National Center for Education 
Statistics, U.S. Department of Education.
---------------------------------------------------------------------------
    Today's models of healthcare demand a commitment to wellness. It is 
our challenge to educate consumers and local communities on the 
importance and value of personal health information. There is so much 
each and every one of us can do to make an incredible difference.

    The Chairman. Thank you, Dr. Kennedy.
    Senator Murray. Mr. Chairman, if I could just say, I have 
to go to the floor, and we have numerous Senators here. If I 
could, I would like to submit my questions for the record. I 
just want to thank all of the witnesses here today, and I will 
allow one of the other Senators to take my time.
    The Chairman. If you would like to go ahead and ask 
questions, you're welcome to do that.
    Senator Murray. No, that's OK. I'll submit mine for the 
record. We have a lot of people here who want to ask questions.
    The Chairman. All right. We have two votes. The first is at 
11. What we'll do is we'll begin a round of 5-minute questions. 
I'll go vote at 11, and then I'll come back, and we'll make 
sure that as long as Senators want to ask questions, we'll keep 
going until about noon. We'll work it out so someone is 
presiding while I'm gone.
    Thank you, Senator Murray.
    We'll begin a round of 5-minute questions.
    Dr. Wergin, about half the doctors, half the physicians who 
are participating in Medicare and are eligible for the 
electronic health records program aren't participating, and 
they're about to be penalized this year. Why are they not 
participating, and why are they willing to accept a penalty 
rather than participate?
    Dr. Wergin. Senator Alexander, that's a good question. A 
lot of it has to do with the regulatory requirements to meet 
Meaningful Use, and I'll use a personal story again.
    I met Meaningful Use in the last day of the 90-day 
reporting period when my staff came up at 3 o'clock--the 
reporting period was going to end at 5 o'clock--and said, 
``You're two patients short of having a patient send you a 
question through the portal.'' I stopped what I was doing, 
called two patients that I'd seen--``Could you send me a 
question about your labs?'' They were a little confused. I met 
it by the skin of my teeth.
    The all-or-nothing quality of that--those two patients 
allowed me to participate in Meaningful Use and avoid the 
penalties. If they had not, I would not have met Meaningful Use 
and got the penalty.
    All or nothing, 100 percent or 0 percent. Many of the 
providers, in terms of their work flow and the reporting 
requirements, particularly small practices--I don't have an IT 
support team. My staff and I worked very hard on this, spent 
many hours, and, in fact, if I had calculated the hours I spent 
on meeting Meaningful Use, it may have been a wash in terms of 
the benefit, but also the penalty.
    Many practices, as they look at it, say, ``We're engaged. 
We were early adopters.'' About 77 percent that have electronic 
health records say, ``The time, expense, and the effort it 
takes makes it not worthwhile, and I'll have to take the 
penalty.''
    The Chairman. The penalty starts out at 1 percent, but it 
will eventually go up to 5 percent. It gets to be a pretty 
significant penalty for about a quarter of a million doctors. 
Right?
    Dr. Wergin. Yes, and that's significant. Again, in primary 
care--and I can speak for my family physicians--we're in the 
trenches, in day-to-day practice that--it's really small margin 
care. We don't have large procedures with high margins, and we 
have overhead to meet. You're exactly right. It becomes kind of 
a business decision--the efforts to do that.
    We, as an academy, try to provide them tools and support to 
help them meet Meaningful Use. I'll use another example. I 
practice in a Mennonite community. My Mennonites don't have 
TVs, newspapers, or radios, so they surely don't have 
computers. That removes them from the pool.
    The Chairman. Let me go to Dr. Adler-Milstein. We live in 
an era where it seems like almost everyone has a smart phone, 
and we imagine all of these wonderful advances that could 
happen with this sort of useful information. You mentioned 
other industries that have done a good job of dealing with 
data. What industries do you have in mind? Who has done 
something like this better?
    Ms. Adler-Milstein. Sure. I think there are two components 
to it. One is if you look at industries that are sort of 
regularly using data to improve the value that they deliver, we 
look to technology service companies. Amazon, on a day-to-day 
basis, is making decisions about its business strategy based on 
the data that they see.
    But that's just within Amazon. Amazon is certainly not 
sharing their data with their competitors and other 
organizations. When we look to the data sharing piece of it, 
then we turn to the financial and banking industry, where you 
do see that there is a national system that's been created that 
allows you to put your ATM card into any ATM machine.
    I don't want to say that the two scenarios are equivalent. 
In healthcare, we're dealing with much more complex data. It is 
very different from the financial industry, but we can at least 
see that it is possible to achieve that level of information 
sharing of a basic set of data.
    The Chairman. You study this. You don't receive incentives 
for all this.
    Do you believe the penalties should be deferred until the 
government does a better job of enabling physicians and 
hospitals to use electronic healthcare data?
    Ms. Adler-Milstein. That's a tricky question, because on 
the one hand, we want to keep the pressure on to keep doctors 
and hospitals from demanding more from these systems. We want 
to keep that market demand piece there.
    If we pull the penalties back, there's a risk that we'll 
sort of accept the status quo and that pressure won't be there. 
That's a reason to think carefully about it. If we were to pull 
back penalties, we need to think carefully about how to make 
sure that the market incentives are in place to make sure that 
the systems continue to improve.
    The Chairman. Senator Warren and then Senator Cassidy.

                      Statement of Senator Warren

    Senator Warren. Thank you, Mr. Chairman.
    As a result of the 2009 HITECH Act, most providers have 
electronic health record systems right now. Many still can't 
exchange patient information. For example, when a patient goes 
to a new doctor for the first time, all of their background 
information and their tests have to be collected from scratch, 
even if it was collected just down the street a week earlier.
    This leads potentially to unnecessary testing, to lost 
time, to wasted money. A 2014 study performed by Dr. Adler-
Milstein and other University of Michigan researchers found 
that emergency rooms connected to a regional health information 
exchange ordered fewer duplicate tests. Patients in these ERs 
were 59 percent less likely to have a redundant CT scan, 44 
percent less likely to get a duplicate ultrasound, and 67 
percent less likely to have a duplicated chest x-ray compared 
with patients who went to unconnected hospitals.
    In 2015, when cell phones can text pictures instantly 
around the globe, it just doesn't make sense that potentially 
lifesaving health information can't be transferred across the 
street. The problem doesn't seem to be a lack of technology. 
Instead, it seems that there must be other barriers that are 
holding up the exchange of health information.
    Mr. DeVault, you represent Epic, the largest electronic 
medical record vendor in the country. You have testified that 
you can set up systems that talk to each other. Doctors report 
that it can cost tens of thousands of dollars for a single 
office to set up a connection to another system.
    The Department of Health and Human Services is working with 
the industry to address one of the three key remaining 
challenges that you identified in your testimony, and that is a 
lack of consistent data standards. I want to ask once we have 
uniform standards, can we expect that health information 
exchange will be easier and cheaper?
    Mr. DeVault. Thank you, Senator Warren. It's a very good 
question. Often, I hear that the problem with interoperability 
is the lack of standards, and I would argue that that's a minor 
problem compared to some of the others. We've had standards for 
several years now for being able to interoperate with some 
kinds of data.
    Senator Warren. I'm sorry. Let me just make sure I'm 
following you. You're saying we already have uniform standards?
    Mr. DeVault. We don't have standards for everything. We 
have standards for being able to exchange some information, 
such as medications, laboratory results----
    Senator Warren. We saw the business here--x-rays, blood 
tests----
    Mr. DeVault. Absolutely. There's much more work to be done. 
However, we can do a lot of important----
    Senator Warren. The question I'm asking is when we get 
standards, would we expect that the cost of creating 
interoperability among systems would decline?
    Mr. DeVault. It will eventually decline. Here are some of 
the costs that----
    Senator Warren. I just want to focus right now on this 
question about what standards will do for us and how it is that 
we get this cost down. I assume having better standards means 
we get these costs beaten down, at least some. There may be 
other issues going on here.
    Mr. DeVault. Once they're implemented.
    Senator Warren. Let me ask about some of these other 
issues.
    Dr. Adler-Milstein, even once we have consistent standards, 
what barriers will stand in the way of health information 
exchange?
    Ms. Adler-Milstein. One of the key ones are these issues 
around competition. Some of my research has shown that in more 
competitive markets, hospitals are less likely to share data 
with each other. It's, in some ways, an obvious point, which is 
when you say, ``This is an entity you're used to competing 
with. Now share all your data with them,'' most organizations 
are going to say that makes no sense.
    Senator Warren. Wait. Why do they not want to share the 
data?
    Ms. Adler-Milstein. Because they're competitors. They're 
competing for the same patients. If you share the data, it 
makes it easier for patients to go get care from your 
competitor.
    Senator Warren. Basically, it's a way to tie a patient to a 
system, to say the system is not going to share data anywhere 
else.
    Ms. Adler-Milstein. Exactly, and I actually think it gets 
factored in on the margin. When interoperability is expensive, 
you have to justify that expense, and it makes it hard to 
justify when there are these potential competitive implications 
that get played in. The two barriers relate to each other.
    If interoperability were cheap, it may be--hospitals and 
doctors may be more willing to take that risk. As long as it's 
expensive, as I said, It's an expense that becomes hard to 
justify.
    Senator Warren. Thank you. The Federal Government has 
invested nearly $30 billion in electronic health records, 
because exchanging health information in real time improves 
patient safety, it saves lives, and it can reduce healthcare 
costs.
    We now have the technology, as you rightly point out, to 
create an electronic records system that lets one part talk to 
another. Soon we're going to have data standards that will make 
the connection to the system both easier and cheaper. It seems 
past time to eliminate the perverse incentives and 
administrative barriers and just get this done.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Warren.
    Senator Cassidy.
    Senator Cassidy. Mr. DeVault, we're hearing over and over 
again about the cost. You all have a 50 percent market share, 
so I guess that kind of looks at you. How much do you all 
charge each practice for each patient to interface with the--if 
you will, to put each patient into Epic and to share their 
data?
    Mr. DeVault. Thank you, Senator. One thing that's important 
to note is that we do not sell our systems at the practice 
level. Most of our organizations are very large.
    Senator Cassidy. If I work for Our Lady of the Lake 
Hospital in Baton Rouge when I go see patients, and I have a 
patient's data I'm entering, and imagine the Lake wants to send 
that data someplace else, how much does the Lake pay for the 
cost of that transaction?
    Mr. DeVault. There are two costs that go into creating the 
connection to begin with, and then the licensing cost for the 
actual software. Creating the connection to begin with to that 
other system can vary widely. We charge for that based on an 
hourly fee.
    Senator Cassidy. Let me ask, because it seems as if to a 
certain extent there is common ground between all these 
different interfaces.
    Mr. DeVault. To some extent.
    Senator Cassidy. It almost seems like you could plug and 
play a little bit.
    Mr. DeVault. It's getting there. It's not quite--with some 
vendors, we've done it so many times that it is plug and play. 
For example, when we connect to a Greenway, we've done that 
many times----
    Senator Cassidy. Now, back to the question. We have 1,000 
patients that they are sending data elsewhere. How much is 
charged on a per-patient basis, if you will, to send that data?
    Mr. DeVault. We charge on a per-patient, per-year basis, so 
it's not per transaction, and it's the same whether that 
patient is sent to 100 different places or one other place, and 
that charge is $2.35----
    Senator Cassidy. Does both the receiver and the sender----
    Mr. DeVault. No. We only have a relationship with the Epic 
side of that, so we charge our customer.
    Senator Cassidy. How much do the upgrades typically cost?
    Mr. DeVault. We don't charge for our upgrades. All of our 
customers have a perpetual license to the software. We did not 
charge anything for the Meaningful Use upgrade. I know many 
other vendors did. We didn't raise our licensing rate, so 
somebody who bought our system last year paid the same with 
differences in----
    Senator Cassidy. The Office of the National Coordinator for 
Health IT speaks of a cost of $15,000 to $70,000 per provider 
to bring in an electronic medical record. Dr. Wergin is nodding 
his head yes.
    Can I ask how much your practice had to pay for your EMR?
    Dr. Wergin. Easily in that range. I would say a little 
more.
    Senator Cassidy. It's a big range. So you paid more than 
$70,000?
    Dr. Wergin. Yes. Probably per provider, including training 
and implementation, not counting reduced patient volume and 
stuff, it was probably in that $70,000 to $80,000 per provider.
    Senator Cassidy. Per provider?
    Dr. Wergin. Yes, per provider.
    Senator Cassidy. My gosh. How much was offset with the 
Federal subsidies?
    Dr. Wergin. It did not offset the entire amount, and one of 
the----
    Senator Cassidy. Substantially, or 20 percent, 100 percent, 
90 percent--ball park.
    Dr. Wergin. It was $44,000, so roughly half.
    Senator Cassidy. Per provider.
    Dr. Wergin. I'd say probably half of it. Also to meet 
Meaningful Use, as Senator Alexander was saying, we didn't 
often upgrade. Our vendors kind of had us hostage. We had to 
pay for upgrades to meet Meaningful Use. Some chose not to do 
that.
    Senator Cassidy. So that was over and above the $80,000?
    Dr. Wergin. Oh, yes.
    Senator Cassidy. Somebody in one of the testimonies spoke 
about the doc who formerly saw 30 patients a day--maybe you 
mentioned this to Mr. Alexander--and is now seeing 24--was with 
one tech, and now has four techs. Are you including the cost of 
the extra personnel to maintain all this?
    Dr. Wergin. No, but that's a standard story I hear as I 
travel around the United States--lower patient volumes and more 
cost.
    Senator Cassidy. Mr. DeVault, this is an incredible 
problem. I can tell you that we've just decreased productivity, 
and frankly--by the way, I still teach. When I see medical 
students--and we have Epic at the hospital--they're not talking 
to the patient. They're entering data.
    And as Dr. Adler-Milstein pointed out, sometimes the data 
is data bloat. I'm thinking, ``I'm a doggone hepatologist''--
which is liver disease--``why in the hell am I asking about 
cigarette smoking?'' Because I've got that much time with the 
patient----
    Mr. DeVault. It's not because the vendor wanted you to do 
that.
    Senator Cassidy. So who's driving that?
    Mr. DeVault. That's often billing requirements or 
Meaningful Use requirements.
    Senator Cassidy. The Federal Government has said, ``Listen, 
you've got to have this in order to have Meaningful Use, and so 
the Federal Government is here to help you,'' and that's the 
problem?
    Mr. DeVault. That's a significant problem, yes. We take it 
on the chin from our customers all the time, and it's not 
because we have an interest in people filling out all those 
fields.
    Senator Cassidy. I'll also say I was told that the 
interface--again, the interface is so 1990. You know what I'm 
saying? I'm sitting there typing into a screen as opposed to 
looking into someone's eyes.
    Mr. DeVault. Oh, the user interface?
    Senator Cassidy. Someone told me that that in part is 
driven by the lack of venture capital. The HITECH Act basically 
prescribed the interface, and, therefore, there's been no 
investment in how to make that more efficient or friendlier to 
the provider. Again, Dr. Wergin, who's kind of on the front 
lines, is nodding his head.
    Mr. DeVault. Speaking for us, we invest an incredible 
amount of research and development on user interface design.
    Senator Cassidy. It still seems to be, though, the screen--
and I'm using a keyboard, correct?
    Mr. DeVault. Often, yes. There is an art to learning how to 
do that with a patient, as you probably know.
    Senator Cassidy. I'm told that by your data, it's about 17 
minutes more per patient to enter electronically as opposed to 
paper. Is that right?
    Mr. DeVault. I don't have that information, but I can 
followup with your----
    Senator Cassidy. Somebody told me it's now 17 minutes per 
patient.
    Mr. DeVault. I can't imagine that's the case.
    Senator Cassidy. I can. It's just incredible how much time 
you spend on that.
    Mr. DeVault. We have documented practices that have reduced 
the amount of time that they spend per visit.
    Senator Cassidy. Really?
    Mr. DeVault. Yes.
    Senator Cassidy. Dr. Wergin, relative to paper, how much 
more are you spending per patient to enter data?
    Mr. DeVault. Again, I don't have----
    Senator Cassidy. No, I'm asking the doc.
    Dr. Wergin. I would say it's 10 to 15 minutes per patient, 
and that's why I've never gotten back to the same volume pre-
EHR. I hear that story pretty consistently across the country.
    Senator Cassidy. I yield back.
    Mr. DeVault. It is harder for family practitioners. I will 
grant you that.
    Senator Cassidy. I yield back, and I will say we have a big 
problem here. Anyway, our productivity for the front lines is 
down by 25 percent.
    Thank you.
    The Chairman. Thank you, Dr. Cassidy.
    I'm going to go vote, and Senator Isakson is going to 
preside. I'll be right back, so every Senator who is here will 
have a chance to ask questions. The next Senator is Senator 
Baldwin, then Senator Isakson, and I'll be back by the time he 
is finished.
    Senator Baldwin. Thank you, Mr. Chairman. Our health system 
has made tremendous gains in the use of electronic health 
records, and I'm proud to represent a constituent who has 
played a major role in our health IT transformation, Epic 
Systems in Verona, WI.
    You mentioned, Mr. DeVault, in your testimony that in just 
the last month, Epic users exchanged almost 8.5 million records 
with each other and almost 7,500 with other organizations. We 
all know that more work needs to be done, and our system has 
not yet achieved the goal of being fully interoperable, which 
is why, Mr. Chairman, I'm very glad that we're having this 
constructive discussion here today about how we move forward.
    We've all heard stories from providers arguing that some 
vendors won't allow them to easily exchange patient records 
with health systems that use a different EHR company. Mr. 
DeVault, can you please address some of the issues and help us 
understand what interoperability means, including why all 
providers today can't seamlessly share and access data as part 
of their workflow between healthcare settings?
    Mr. DeVault. Thank you, Senator Baldwin. Interoperability 
does mean different things to different people, and if you talk 
to the Googles and the Facebooks of the world, they're 
interested in data for different purposes than clinicians might 
be interested in. I'll narrow that focus down to what we often 
call health information exchange, getting a patient's record 
from one point of care to another.
    We have seen a lot of progress on this in the last few 
years for a few different reasons. One, Meaningful Use 2 did 
put a focus on health information exchange. It was not a focus 
of Meaningful Use 1, so things have taken some time.
    We have seen a large up-tick in the last year and a half of 
our customers being able to connect easily to non-Epic systems. 
Previously, that was not the case. Different implementations of 
standards was an impediment, and now some of that has shaken 
out. That's reducing the cost of those connections 
significantly and the time to implementation.
    There are some other things that were not anticipated by 
ONC that are important for interoperability. There's a whole 
ecosystem that needs to be in place. If we went back 150 years 
ago and gave everybody a phone, that would not allow us to talk 
to each other, because there's no operator, there's no 
information, there's no white pages.
    We need provider directories. We need the ability to find 
resources. Those are starting to appear. We're starting to have 
an ecosystem with provider directories where you can actually 
look up somebody's phone number, which is obviously important 
in order to be able to send somebody something.
    The other thing that's made our Care Everywhere 
interoperability platform so successful among the Epic groups 
is something that we've shared with ONC over the last several 
years and suggested that they take very seriously--and I'm 
happy to see it's in their roadmap--which is the role of 
governance.
    People need to understand what are the rules of the road, 
have common understanding of their rights and responsibilities 
with regard to their patients' data, and they need to have 
recourse to somebody when they believe that there is a bad 
actor. We've had that in place within our Care Everywhere 
network, and that is what has allowed us to, for one thing--and 
I wanted to address something else.
    Senator Baldwin. I do have another question that I'd like 
to ask.
    Mr. DeVault. I'll wrap that up, then.
    Senator Baldwin. In your written testimony, you identify 
several different networks of interoperability that operate 
today, such as Commonwell, and, of course, you've just been 
talking about Epic's Care Everywhere. Can you please elaborate 
on how these networks are different, including why Epic is not 
a member of Commonwell, and then discuss the work that Epic is 
doing with other vendors to connect these various networks?
    Mr. DeVault. Yes. Great. Thank you. There are different 
networks, and there should be different networks, just like 
there are different banking networks, and there are systems 
that are out there to connect all of them together. Things work 
best when there's a robust ecosystem, and there are multiple 
players involved. Care Everywhere is one such network.
    Commonwell is what I would call an aspiring network. They 
aspire to be a nationwide network with a record locater service 
that will tell you where every part of a patient's record is. 
They are not that today. According to their latest report that 
I've seen, they have four different sites live on their 
network, fewer than 1,000 physicians, compared to 100,000 
physicians in Care Everywhere and almost 10 million records 
exchanged a month now.
    That having been said, in terms of what they're doing, 
architecturally, there's not a problem with that. When we were 
approached by them and asked to join, we were told that it 
would be multiple millions of dollars for us to join, and that 
we would have to sign an NDA. And, to us, the only reasons to 
have an NDA are if they're going to tell you something that 
otherwise they wouldn't want people to know, for example, the 
possibility that they might sell data downstream, or that they 
want to make sure that their intellectual property doesn't 
conflict with ours. That kind of lack of transparency did not 
sit right with us.
    Instead, we have engaged Commonwell through Carequality. 
Carequality is meant to be that fabric that connects all of the 
networks together. You've got health information exchanges. 
You've got the Care Everywhere network. You will eventually 
have Commonwell. Carequality then will be the fabric that 
stitches all of that together. We hope that they will join 
Carequality.
    Senator Baldwin. Thank you.

                      Statement of Senator Isakson

    Senator Isakson [presiding]. Thank you, Senator Baldwin. I 
want to followup on your line of questioning, and I want to ask 
a question to Dr. Wergin and Dr. Adler-Milstein. I want to 
preface it by saying I'm not a physician. I'm not a high-tech 
person. I was a salesman all my life before I came to Congress, 
and I guess I still am if I'm in Congress.
    I learned in business, though, that scarcity and 
exclusivity drive cost and drive price. Is the interoperability 
a competitive advantage for the people who sell the different 
software for IT?
    Ms. Adler-Milstein. It certainly is, because when you have 
that, it makes it harder to switch vendors and much more 
expensive to switch vendors. I do think the reality is that 
that's playing a factor, because if you protect the data within 
your system, it makes it harder for people to switch systems if 
they were to decide that there's a better system on the market 
for them.
    Senator Isakson. Dr. Wergin, do you agree with that?
    Dr. Wergin. Yes, I would. What I see in a pragmatic sense 
as a practicing physician is the vendors are siloed, and you're 
held somewhat hostage by the vendor you have, because it's very 
difficult to change. Who owns the data is a point that makes it 
difficult to make those changes.
    It does make it difficult, and I think it does give them a 
competitive advantage, plus updates are for your system. That 
makes it difficult, and we're charged for updates. I'm glad to 
hear Epic does not. You have to pick and choose with the small 
margin care that we do. Yes, we have difficulty with those 
kinds of exchanges or who owns the data.
    Senator Isakson. Mr. DeVault, let me ask you a question. 
I'm assuming it's to nobody's advantage, yours or Cerner's or 
any of the others in the business, to try and create an 
interoperable system because nobody would cooperate. Is that 
correct? I don't mean that in a negative way. I mean that in a 
factual way.
    Mr. DeVault. I'm not sure I follow the question.
    Senator Isakson. Let me preface it--would it not take the 
cooperation of all the vendors, including sharing intellectual 
property, in order to create an interoperable system?
    Mr. DeVault. Not necessarily intellectual property, but it 
certainly does require the participation of at least a core set 
of vendors, and that's why we participate in HL7, which is a 
standards development organization. We participated in the 
development of Direct. I was actually the chair of the user 
case work group that created the protocol for doing the 
exchange. We participate in the EHR Vendors Association, now 
called the EHR Association.
    Senator Isakson. Let me interrupt you real quick.
    Mr. DeVault. Yes.
    Senator Isakson. I don't want to run out of time. What 
would be a catalyst to cause you to get together with Cerner 
and the other people and find a way to be interoperable?
    Mr. DeVault. We already have, and another example of that 
is what's called the Argonaut Project in HL7 right now, which 
is developing state-of-the-art, web-based application 
programming interfaces that will make it even easier for new 
systems to talk to each other. In my opinion, it's not a 
technological problem to create these standards.
    The deficiencies in the system are--the ecosystem, as I 
mentioned earlier--things like provider directories, and then 
provider incentives, which is one reason why even though we 
developed our Care Everywhere application in 2005, we did not 
go live with it until 2008. That was how long it took for us to 
find customers who were willing to say, ``We are not going to 
compete over data.''
    And we have a rule in our governance structure that says, 
``If you're going to share data, you're going to share with 
everybody,'' and I'm happy to say that all of our customers now 
do that.
    Senator Isakson. Does provider incentives mean incentives 
to the physicians?
    Mr. DeVault. Yes, or the hospitals or the health system, in 
general.
    Senator Isakson. To cooperate in sharing the data?
    Mr. DeVault. That's right.
    Senator Isakson. To a certain extent, that's a competitive 
advantage right now for them as well, is it not?
    Mr. DeVault. It could be, depending on the payment model. 
There are lots of things that could influence what those 
incentives are. Different kinds of payment models have 
different kinds of incentives for data sharing. In an ACO, for 
example, an Accountable Care Organization, you are highly 
incentivized to share information with the other parts of your 
network.
    Senator Isakson. I am told that some people have a fear of 
security--cyber security in terms of data----
    Mr. DeVault. Well, they should, yes.
    Senator Isakson [continuing]. And they should. We in 
Congress have been reluctantly moving toward finally getting to 
a cyber security bill, which, hopefully, we'll do pretty soon. 
Is there anything we should be aware of or cognizant of in 
terms of cyber security in terms of medical IT?
    Mr. DeVault. Absolutely. I've seen draft legislation from a 
variety of areas and heard lots of conversations about 
radically opening up patient health information to a variety of 
actors, and we need to think very carefully about who these 
actors are and what kinds of security needs to be in place to 
make sure that some foreign actor or a nefarious actor doesn't 
have access to that information. That needs to be done at the 
same time that we have these discussions about opening up 
systems further.
    Senator Isakson. Thank you all very much for your 
testimony.
    Senator Franken.
    Oh, I'm sorry. Senator Franken disappeared or lost a lot of 
weight, one of the two.
    [Laughter.]
    Senator Whitehouse.

                    Statement of Senator Whitehouse

    Senator Whitehouse. Thank you for that comment, Chairman 
Isakson. I agree with what a number of my colleagues have said, 
that it's time for a reboot of the Meaningful Use Program. It's 
been run for quite a while now.
    It started from a little bit of a disability, which was 
basically the equivalent of subsidizing cars or penalizing 
people for not buying cars, and then figuring out that they're 
all going to go and build the roads on their own. That's not 
the way we do highways, and it's a pretty fair analogy for what 
the problem has been with health information exchange.
    We have put some money into health information exchanges. 
Mr. DeVault, as you know, Rhode Island has worked very hard to 
have CurrentCare, which is a very good health information 
exchange, perhaps best in show, and we've been really fighting, 
I feel, very much on our own, without much help from the 
Federal Government. If you get the exchange part right, so much 
of the rest falls into place.
    We're doing this, very inefficiently, focusing on the most 
remote parts of the system, the physicians' desks, without 
building the internal infrastructure and supporting the State-
built, in our case, internal infrastructure that allows those 
points to all connect. If you get that right, then people will 
have to connect, because there'll be a value proposition from 
the system, and you won't have to make an artificial value 
proposition of subsidy and punishment. We need to reboot that.
    I also think that we need to reboot the failure to include 
behavioral health and nursing homes into it. I see lots of 
heads nodding here. If you're looking at the expensive people 
in the healthcare system, a lot of them are going back and 
forth, cycling between nursing homes and the healthcare system. 
I see more heads nodding here. If you don't capture that, and 
if you don't require the nursing home to meet the Meaningful 
Use standard or cooperate, then you've made a really stupid 
tactical error in the rollout of health information technology.
    Ditto if you are a patient who has a significant behavioral 
health issue. Your behavioral health provider--guess what--is 
your medical home. They're the ones who help you deal with the 
rest of the healthcare needs that you have. When you cut out 
the behavioral health provider from Meaningful Use, you've made 
another stupid decision, and we refuse to fix those decisions.
    I would love to work with my colleagues on rebooting 
Meaningful Use in those directions and, particularly, 
empowering the local information exchanges that have come up. 
I'm tired of being a lead dog, carrying a huge load, and having 
floods of money go into this in a whole bunch of different 
areas, but having to struggle for support at trying to get 
CurrentCare up and going, and we have.
    To Epic's credit, Epic, through life-span, has just created 
its CurrentCare link, and so it will be linked into our health 
information exchange. Care New England, our second biggest 
hospital chain in Rhode Island, is also an Epic customer. We 
stand a real possibility of having our two largest hospital 
chains and our health information exchange all linked in a very 
meaningful way. As others have said, it's incredibly important 
that we gather this data and that we use it to empower the 
reforms that we need in healthcare.
    I do think that there are some vendor business practices 
that we need to be worried about. We need to be worried about 
vendors who don't put the connecting fees into their pitch to 
their clients, and then you find out, once you've budgeted what 
you think your cost is to the vender, that now to hook you up 
will cost tens of thousands of dollars more. That's just a bad 
business practice.
    We have not really resolved the question of ownership of 
data, and as big data begins to move more and more, people want 
less and less to share the data that they have with other 
competitors. That data should be ultimately the property of the 
patient, not of anybody else. These artificial divisions of 
``you can have the data'' and ``you can't have the data'' do 
none of us any good in the long run. They just provide 
immediate private advantage in the short run.
    Finally, there is a business model in which not being 
interoperable is to the advantage of the company, because it 
means you have to link up with them. You can try to get the 
advantage of being the Microsoft operating system, that you're 
everywhere, and then you can charge high prices because you're 
the dominant player in the marketplace. That should not be a 
factor. There's a role for government in protecting against 
some of the abuses that are possible here.
    And the last thing I'll say is that it's really important 
that we solve the question of ownership of this data, so that 
it's clear how privacy is protected, and it's clear that we 
maximize the extent to which this data is available to the 
patient and, on an anonymized basis, to anybody who is doing 
really important research that will save lives and improve our 
healthcare system. We've got a lot at stake.
    I've used up my whole time and 1 minute more just saying 
those things. I've been kicking at this for a while now, and so 
thank you, Chairman, for allowing me to vent here. We can agree 
as a panel that we have important work to do on this topic. We 
are a long way from where we should be. The possibilities are 
immensely positive, and the hazards, are solvable and 
negotiable.
    Thank you for the hearing, Mr. Chairman.
    The Chairman [presiding]. Thank you, Senator Whitehouse.
    Senator Franken wants to come back, so I'll wait a few 
minutes and see if he does.
    This is a sufficiently important issue, and there's 
sufficient interest in the committee--Senator Cassidy, Senator 
Whitehouse, and others--that we ought to focus--Senator 
Whitehouse, I wonder if you agree, we ought to focus some extra 
time on this and maybe organize a way to see how we can help 
get a result.
    Senator Whitehouse. I think we should. It might even be 
helpful to have a group of us kind of meet on a regular basis 
offline and try to put something together for the committee to 
consider.
    The Chairman. Yes.
    Senator Whitehouse. This is a bipartisan issue. It's about 
doing it right versus doing it wrong, doing it stupid versus 
doing it smart, and we ought to be able to work together on it.
    The Chairman. I agree with that. So we will do that. This 
has been a helpful hearing. It's been 5 years since we've 
really taken a look at this. We're moving into an era where, 
after providing a lot of money, $30 billion, for incentives and 
grants, we're now going to start collecting penalties.
    Mr. DeVault, do you charge an hourly labor fee for 
upgrades?
    Mr. DeVault. If the customer needs assistance in the 
upgrade, which often they do not, yes, we do.
    The Chairman. Often they do?
    Mr. DeVault. I'm sorry. Let me take that back. Not for 
upgrades. That's part of the maintenance cost that's built into 
the licensing fee. I misunderstood your question.
    The Chairman. You do not charge an hourly labor fee for 
upgrades.
    Mr. DeVault. That's right. For creating those new 
connections, we do. That's what I thought you were asking 
about.
    The Chairman. Let me ask a question in this way. Assuming 
we on the committee wanted to spend the next several months 
trying to fix the problem here, my own sense of it--and this 
shows a bias about government--is that the Federal Government 
does a much better job when it is an enabler or an encourager 
rather than a mandater, and that there are also some things the 
Federal Government just doesn't do as well as the private 
sector.
    Also, it's just an evitable law, whether it's Republicans 
or Democrats, that regulations just pile up over time. Let me 
ask each of you now if you would reflect on this, and then 
maybe you could think about it after the hearing and either 
provide in writing or in the subsequent activities so that we 
have your thoughts.
    If you were in our shoes, and you looked at the $30 billion 
that's been spent, and you looked at the promise of the idea, 
and if you looked at the fact that about half the doctors who 
are a part of Medicare reimbursement would rather take a 
penalty this year than be involved with electronic healthcare 
records, what are the first two or three things that you would 
do to try to realize the potential of expanding the use of 
electronic health records for more physicians and more doctors 
to the advantage of patients?
    Let's start with you, Dr. Adler-Milstein.
    Ms. Adler-Milstein. Sure. In the category of enabler, I 
would begin with focusing on transparency, and this is really 
about transparency in terms of how the frontline physicians 
experience both the usefulness and usability of the system, the 
connectivity of the system, and the cost associated with these. 
Part of the challenge has been that it's been very hard to get 
information on this, and, therefore, we have uninformed 
consumers.
    The Chairman. Information from whom?
    Ms. Adler-Milstein. From the frontline physicians. It would 
be great to be able to say we have a consumer report style set 
of information that really compares the system, compares the 
cost, compares the value. We don't have that basic information, 
and we, therefore, can't have a robust market around these 
tools.
    The Chairman. Dr. Wergin.
    Dr. Wergin. Well, a couple of suggestions I'd make is 
interacting and having electronic health records that work with 
the workflow of my day-to-day operation of what I do, 
particularly in family medicine. We as an organization started 
a task force that included an efficiency engineer we hired from 
outside at the American Academy of Family Physicians to look at 
just that instead of just complaining about how can we do it--
if there were standards that said that.
    Regarding interoperability, I do want to say that it 
shouldn't just be a data dump. I mentioned that patient I had 
that I had to call and get a fax copy of the record. It was 18 
pages long, and I wasn't sure why she was seen in the ER.
    My own small system that I operate in, a 20-bed critical 
access hospital, has a different EHR than mine. I have to log 
out of mine, go to theirs, in my own system to find out if one 
of my partners----
    The Chairman. Where do we start to change that?
    Dr. Wergin. I would say if there's some certification 
standard--we're working on making specific suggestions on how 
the interaction can take in workflow. From my standpoint--and 
that's what this is all about, patient outcomes--the electronic 
health record is a tool. It's not delivering care. It's helping 
me deliver the proper care. Having meaningful data that I can 
get from my partner to me, or from me to my other partner, and 
set standards and move away from bullets on billing which is 
what we have now.
    The Chairman. Mr. DeVault.
    Mr. DeVault. Thank you. The first few things that come to 
mind are to be descriptive rather than prescriptive. The 
Meaningful Use Programs were meant to be an adoption in an 
interoperability program, as I understand it, largely 
successful on the adoption front. Rather than focusing on 
interoperability and describing the kinds of outcomes that 
people wanted, it ended up becoming an EHR design session by 
committee.
    I would much rather see an incentive to have the kinds of 
outcomes we all want to have. Then there will be incredible 
innovation, both at the clinician level and at the vendor level 
to make that happen in a variety of ways.
    I agree with Dr. Wergin here, that we don't need just data 
dump. That was also something that was very prescriptive, that 
this is the data that needs to be shared, no matter what the 
use case was. There are also very artificial incentives to do 
that sharing.
    You mentioned the fact that you had to get a patient to 
send you a message about nothing so that you could qualify, or 
send all of the information that you have on a patient because 
you're transitioning their care, and for an electronic 
transition of care, you have to send everything.
    So getting rid of artificial incentives by incentivizing 
the kinds of outcomes that we want to see and refocusing MU on 
interoperability.
    The Chairman. Dr. Kennedy.
    Ms. Kennedy. I agree with the previous comments. I do have 
one comment, though, the road to interoperability is long, and 
it's a journey that we have to--it's critical that we continue 
on. At some point, while I understand the business of business 
is business, we have to stop leveraging profits at the expense 
of the care that's given to the patient.
    In my daughter's case, I created the record that is carried 
across State lines to the provider. Both providers or all of 
the providers did have electronic health records, yet none of 
them could share the data. It was shared via fax, or it was 
copied and given to me. We have to make sure that we can 
exchange data in a way that providers receive the information 
that they need to care for the patient.
    In my daughter's case, two faxes went to organizations that 
were not healthcare organizations before it ever arrived in my 
hands. Had I not been diligent to copy and carry the records, I 
don't think that they could have diagnosed or been able to take 
my daughter off of some of the medications that she had 
received for 9 years.
    In looking at this from the consumer's perspective, it is 
important, and while not every consumer is going to go in and 
demand a copy of their information, certainly, they do own the 
data, and they are entitled to it, because that data, wherever 
it is created, is going to lead to better continuity of care 
that's provided to me, you, everyone in this room.
    It's critically important that we continue to work toward 
interoperability and remove the barriers, whether they're on 
the side of the developer, the provider, even maybe with the 
consumer. I don't think that it should be prescriptive in terms 
of what interoperability looks like. That is going to present 
with another barrier to innovation, and we want companies to 
continue to be innovative.
    The current portal that my daughter uses is a widely used 
electronic health records system. The information that is in 
that portal is not adequate to support care across the line. If 
we were to go in as a family and pull that information from 
that portal, it is not every piece of information that we need 
to continue her care when we cross the State line 6 hours away 
and she needs something. I still continue, even with electronic 
records, to copy and carry records with us wherever we go.
    So much work needs to be done in this area. I don't 
disagree with any of the comments. However, I don't think we're 
moving fast enough on the issue.
    The Chairman. Thank you.
    I see Senator Franken, and we'll let him take 5 minutes of 
questions, and then we'll wind up the hearing, and I'll wind it 
up after Senator Franken has a chance to comment.
    Senator Franken.

                      Statement of Senator Franken

    Senator Franken. First, I'd like to thank the Chairman for 
stalling until I got here, and thank you for holding this 
hearing.
    The HITECH was great, because it really spurred this 
investment in health records. I have a hospital in New Ulm, MN, 
and they're doing a thing with Allina called Heart of New Ulm, 
and they wouldn't be able to do it if it hadn't been for 
HITECH. Yet we've been hearing about all the barriers to 
getting this done smoothly. It's incredibly essential that we 
do this, because it helps operations, things like Accountable 
Care Organizations and patient-centered medical homes and 
bundled payments.
    Ms. Adler-Milstein, in response to Senator Warren, you 
talked about some of the barriers to data sharing between 
healthcare organizations because of economic incentives which 
discourages communitywide data sharing. Is that because they'll 
worry that--and I've heard this before--they worry that you'll 
steal your healthy patients? Is there anything to that?
    Ms. Adler-Milstein. I don't know if it's so much stealing 
the healthy patients. It's actually stealing the sick patients, 
because those are the ones that need the care on which you have 
the higher margins. It's a concern----
    Senator Franken. An Accountable Care Organization would 
want to steal your healthy patients.
    Ms. Adler-Milstein. So true. That's what I think Dr. Wergin 
was referring to.
    Senator Franken. This is for Dr. Kennedy. How can we 
leverage some of the new pay for performance reimbursement 
models to create a business case for providers to connect and 
actively share health information with each other, even their 
competitors, to ensure the patients can receive the best 
possible care?
    Ms. Kennedy. You have to reduce some of the penalties that 
are imposed on providers, and you have to encourage the use of 
electronic health records. Maybe there are other incentives 
that need to be given to our providers.
    Also, in terms of payers, payers are receiving the data. We 
know that the exchange is there. Some of my daughter's records 
were recreated from claims data, and we had to rely on that 
solely to get a picture of the care that was provided at that 
time. Incentives to providers are probably going to enable 
adoption or further adoption. Right now, we say we have 
interoperability. However, that doesn't exist in every case.
    Senator Franken. Dr. Adler-Milstein, we can have access to 
everything, theoretically, right? I've heard that they do this 
in other countries, and it's a lot easier. I remember when we 
had--well, OK, I don't like that, so I'll ask what that meant, 
but I'm human and I know kind of what that means, which is, 
``yes, but''--right?
    When we were having the discussion about ACA, I heard, 
``Well, we have the best healthcare system in the world.'' I 
heard that in Minnesota. And we have Mayo. Look at Mayo. It's 
the best--we have the best healthcare in the world, but I'm not 
sure we have the best healthcare system. I'm not even sure we 
have a healthcare system.
    It depends on--if you're getting Medicare, you're in the 
Canadian system. If you're in the VA or Indian health services, 
you're in the British system. If you get it through your 
employer, you're in the German system. If you're paying for it 
yourself, you're in the Cambodian system--is what we had. We 
didn't have a system.
    What do other countries do differently to be successful on 
this front, and then--because you went like that, which for--is 
someone taking a record of this? He imitated her doing what she 
did.
    [Laughter.]
    What do some countries do better, and what don't they do 
better?
    Ms. Adler-Milstein. Sure. I sit on an OECD task force that 
has looked at--first is trying to benchmark adoption of health 
information technology in various countries so we can truly say 
where we stand and from which countries we have an opportunity 
to learn.
    Senator Franken. Good.
    Ms. Adler-Milstein. I will say that health information 
exchange has been the common challenge across countries, and 
that is despite the way they pay for care, despite the way they 
deliver care. There have been real challenges with getting the 
data to move across the systems and to be in front of the 
providers when they need it.
    I don't think that there's a country that we can point to 
and say they have gotten it right, and the United States should 
look toward that model. There are countries that I think have 
done a better job of trying to centralize some of the data and 
get patient-controlled access to that data. Again, I don't 
think that there is a sort of silver bullet here, and it's been 
a real challenge.
    Senator Franken. Since you held this for me, and I'm the 
last person, can I go over this? Or is that the reason for us 
to go? It's one way or the other.
    The Chairman. We've got to go vote again.
    Senator Franken. Well, let's go vote again.
    The Chairman. No, go ahead.
    Senator Franken. I was wondering--like in France, I thought 
that you have on your card a chip that basically has your 
healthcare records in it. Is that not true, or is that a 
limited thing?
    Ms. Adler-Milstein. There are places--and Germany is 
experimenting with it as well--where you have a basic set of 
your information, and that at least gives the provider the 
ability to see that when you go from place to place. They've 
had relatively low patient opt-in rates, and even when the 
provider goes to see that information, it doesn't always 
seamlessly connect with that.
    So if the provider wants to then keep that information in 
their system from there on out, they would need to spend time 
entering it. Again, there are solutions to this, but no one has 
the sort of vision of seamless--I show up and my data is there 
when it's needed.
    Senator Franken. Thank you.
    Again, Mr. Chairman, thank you for this important hearing, 
and thank you for holding it for me.
    The Chairman. Thank you for making the special effort to 
get here.
    I want to thank the witnesses for coming and, again, for 
adjusting your schedules for our snow day. You've gotten the 
interest of the committee. I anticipate additional hearings or 
at least additional activities.We'd like to also hear from the 
administration about this in a subsequent hearing. They have 
some things they'd like to say.
    What I'd like to ask you to do as you reflect on this is to 
be very specific about what you think we should do. You have 
been in some cases. To give you an example, four of us, two 
Democrats, two Republicans, asked a group of higher education 
people, who were complaining about over-regulation, to give us 
a number of things, specifically, that we could do, and give us 
the 10 that would make the most difference.
    They actually did that, and it's very helpful, and we're 
preparing bipartisan legislation to actually get it done. If 
you could help us think of ways to get specific suggestions of 
how we're going to fix the problem--start one, two, three, 
four--that's what we need to know. Not everything needs to be 
done by the Congress. Some of it can be done administratively, 
and if that's the case, that can be said as well.
    We've been focusing on this for a couple of years. We have 
Senators like Senator Franken, Senator Whitehouse, Senator 
Cassidy, Senator Burr, and others who want to pursue it. We'll 
be spending more time on this issue as we go forward.
    The hearing record will remain open for 10 days. Members 
may submit additional information within that time if they 
would like.
    Thank you for being here. The committee will stand 
adjourned.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

                          Epic Systems Corporation,
                                          Verona, WI 53593.

    Dear Senator Alexander, I thank you for the opportunity to testify 
on March 17th during the HELP Committee's hearing entitled, 
'``America's Health IT Transformation: Translating the Promise of 
Electronic Health Records into Better Care.'' At the end of the 
hearing, you asked the witnesses to send you a list of ideas that could 
help the government in its efforts to increase interoperability and 
foster adoption of electronic health record (EHR) technology by 
``enabling rather than mandating.'' Below are four suggestions that we 
believe will help:

    1. Use the existing cross-industry definition of interoperability 
rather than support new definitions based on complete and open access 
that are unmanageable, unsafe and unnecessary to achieve national 
goals.
    2. Support public-private initiatives that are already working on 
solving key interoperability problems; don't support new government-
centered governance.
    3. Push to normalize public health reporting across the States.
    4. For maximum adoption and benefit, be descriptive rather than 
prescriptive

    Use the existing cross-industry definition of interoperability 
rather than support new ones that are unmanageable, unsafe and 
unnecessary to achieve national goals.

    To improve safety, the coordination of care and bring down costs, 
we need providers to be automated and interoperable. There is already a 
good definition of interoperability that is used by HHS and the FCC and 
which was put forth by The Institute of Electrical and Electronic 
Engineers (IEEE). It provides the generally accepted definition of 
interoperability as ``the ability of two or more systems or components 
to exchange information and to use the informatiom that has been 
exchanged.''
    In the healthcare context, this means the ability for different 
systems to exchange data and for that data to appear meaningfully in a 
care provider's workflow as actionable information. The data could be 
part of a patient's record exchanged between an EHR and an ancillary 
system or device. Or the data could be a more complete patient record 
exchanged between two EHRs or an EHR and a personal health record 
system managed by a patient.
    This simple definition built around the ability to exchange and use 
data is manageable, reportable and enforceable. Expanded definitions of 
interoperability are not.
    Recently there has been a push to redefine interoperability in 
healthcare as access to patient health information. For example, the 
draft legislation put forth recently by Congressman Burgess (some of 
which appears in the SGR Bill) attempts to redefine interoperability 
variously as ``open access,'' ``complete access'' and ``does not block 
access.'' However, access and interoperability are different concepts. 
Attempts to radically open up EHR systems to a wide variety of actors 
has serious implications for privacy, cybersecurity oversight, 
infrastructure costs, and the public's trust.
    By focusing on interoperability as opposed to access, we can avoid 
introducing unwieldy expectations that create either dangerous 
scenarios or marginal value.

    Support public-private initiatives that are already working to 
solving key interoperability problems.

    The healthcare industry has realized that beyond technical 
standards, appropriate governance of interoperability networks is 
critical to their success. This has been borne out in the development 
of our network, Care Everywhere, with Healtheway's eHealthExchange, 
which includes the DoD, VA, and Social Security Administration, as well 
as in numerous State and regional health information exchanges. What is 
also clear is that ubiquitous, nationwide interoperability will require 
national governance so that all of the networks can interoperate with 
each other. We were pleased to see this recognition in ONC's recently 
published Interoperability Roadmap.
    What was not mentioned in the Roadmap is that there is already a 
public-private collaborative well down the road of creating such a 
national governance framework: Healtheway's Carequality. On the 
contrary, based on the Roadmap itself and a roundtable ONC recently 
held on governance, ONC seems poised to create a governance 
superstructure from scratch. If they were to do so, this would create 
market confusion as well as perpetuate a reliance on government to 
administer interoperability networks.
    We were pleased to see the ONC recognize Healtheway at the recent 
Health Information Management Systems Society (HIMSS) conference. The 
ONC should support the activity already underway in Carequality and 
other existing bodies and public-private collaboratives.

    Push to normalize public health reporting across the States.

    Bidirectional communication between Electronic Health Records and 
State and Federal registries, such as immunization registries, is 
necessary to deliver safe and efficient care and to better manage the 
health of populations. However, there are no common standards and 
capabilities that registries in different States currently have. This 
requires EHR developers and care providers to build and maintain dozens 
of different interface formats at great ongoing expense. Additionally, 
some registries can be queried for information by an EHR while others 
are only an information destination. The Federal Government should 
recommend standards and minimum capabilities for State registries and 
incentivize their adoption.

    For maximum adoption and benefit, be descriptive rather than 
prescriptive.

    Rather than mandate how systems are built and used, describe the 
results you want and incentivize the desired outcome. For example, one 
way to reduce costs of care is to eliminate duplicate laboratory and 
radiological testing. A prescriptive measure might be to mandate the 
use of EHR technology that alerts a physician when she is about to 
place an order for a test that the EHR knows is a duplicate. This may 
or may not solve the problem: the EHR may not know about a prior test 
performed at another facility. And if the physician bypasses the alert, 
there's no downstream check (for example in the lab itself) to make 
sure that the test is not performed unnecessarily.
    A descriptive approach with appropriate incentives might be for CMS 
to declare that they no longer will pay for duplicate testing. This 
would incentivize the entire health system to innovate ways to avoid 
such tests. It would also incentivize EHR developers to find novel ways 
to support clinical decision making. Further, it would incentivize care 
providers to use the interoperability technology many of them already 
have in order to find tests that took place in other facilities.
    I hope these recommendations are helpful. As always, please do not 
hesitate to call on me to contribute further in any way.
            Sincerely,
                                             Peter DeVault,
                                              Vice President, Epic,
                                                     [email protected]
                                                    (608) 271-9000.
                                 ______
                                 
  Response by Julia Adler-Milstein to Questions of Senator Alexander, 
                    Senator Burr, and Senator Warren
                           senator alexander
    Question 1. With the rapid digitization of health data, is the 
industry effectively protecting personal health information?
    (a) What additional resources would be valuable in encouraging 
organizations to prioritize health data security?
    (b) Is the government offering proper guidance and/or resources to 
inform industry decision making relative to data security?
    (c) Is threat information readily shared throughout the industry? 
Or with other industries?
         (i) If so, is the information useful?
         (ii) If not, what incentives could be offered for 
        organizations to share threat information with other 
        organizations?
    Answer 1. Health data security is not my area of expertise and so 
these questions are best answered by someone better versed with the 
current state of practice. I do know that it is an area in which the 
Office of the National Coordinator for Health IT (ONC) is offering 
guidance and they have issued a ``Privacy and Security Guide'' with 
resources for provider organizations.\1\ In addition, the most recently 
issued Stage 3 Meaningful Use criteria include a domain that seeks to 
ensure protection of patient health information through appropriate 
technical, administrative, and physical safeguards. Specifically, 
attesting providers must conduct an annual security risk analysis to 
ensure that data security, including encryption of stored data, meets 
standards set by Federal regulations. This is estimated to take 6 hours 
and, since providers are not data security experts, its success seems 
heavily dependent on whether the guidance can be both robust and simple 
to follow.
---------------------------------------------------------------------------
    \1\ http://www.healthit.gov/sites/default/files/pdf/privacy/
privacy-and-security-guide.pdf.
---------------------------------------------------------------------------
    Overall, my sense is that there is more that could be done to 
prevent PHI breaches, but it is not clear whether these actions are 
cost-effective. This is because of limited evidence that breaches 
result in harm. While the number of breaches reported to HHS has 
increased over time and is expected to continue increasing, the effects 
of these breaches, and subsequent costs to identify and repair the 
security problem, are difficult to estimate. Currently, all breaches of 
PHI must be reported to HHS. Reports for breaches involving 500 or more 
individuals must include detailed information to pinpoint the data 
security vulnerabilities. To date, the vast majority of breaches seem 
to be occurring as a result of ``poor data hygiene'' (i.e., theft of 
portable electronic equipment, unauthorized access, or improper 
disposal) as opposed to intentional data hacking.\2\ This is to be 
expected given the large number of healthcare professionals who come 
into contact with PHI. Addressing the human behavior element is, 
unfortunately, far more challenging than addressing a purely technical 
problem.
---------------------------------------------------------------------------
    \2\ Liu V, Musen MA, & Chou T. (2015). Data breaches of protected 
health information in the United States. JAMA, 313(14), 1471-73. http:/
/doi.org/10.1001/jama.2015.2252.

    Question 2a. Half of the Nation's physicians have chosen not to 
participate in the Meaningful Use program to date. How can this change?
    Answer 2a. If we look at the trends in terms of physician adoption 
of EHRs and meaningful use (MU) attestation rates, it does not appear 
that we are on the flat of the curve.\3\ In fact the number of Medicaid 
eligible physicians who have registered for MU has been increasingly 
linearly from January 2011 to January 2015, showing that there is a 
steady growth of eligible professionals who seem to intend to attest 
each quarter.\4\ Given this, I don't think we are at the point of 
needing to say that the MU program needs a wholesale overhaul. But we 
do need to consider why so many physicians have chosen not to 
participate, in order to try to speed the rate of response.
---------------------------------------------------------------------------
    \3\ http://dashboard.healthit.gov/quickstats/pages/FIG-Medicare-
Professionals-Stage-One-Meaningful-Use-Attestation.php.
    \4\ http://healthit.gov/FACAS/sites/faca/files/
HITPC_Data_Analytics_Update_2015-04-07_FINAL.pdf.
---------------------------------------------------------------------------
    When assessing physician participation in MU, it is important to 
differentiate between those who cannot attest due to cost/resource 
reasons and those who could but choose not to because they do not find 
it valuable to do so. Solving the first problem is, relatively 
speaking, easier. We could make available more resources to help 
physicians to adopt. This strategy has proven successful with programs 
like the Regional Extension Center Program. And I feel that there is 
more that could be done to take what we've learned from past 
implementations and better deploy it to reduce the cost of future 
implementations. Addressing the second problem--how to make MU 
participation feel more valuable--is trickier because the MU program 
has to balance the need to identify a national set of criteria (both 
for simplicity of understanding and administering the program, and 
ensuring societal benefits from it), with the greater physician 
response that is likely to emerge from allowing more customization of 
the criteria to better meet the varied needs of physicians 
(particularly for specialists). With the Stage 3 criteria, CMS/ONC are 
trying to structure them in a way that allows more customization (i.e., 
picking 2 of 3 possible criteria), and this could perhaps go even a bit 
further (i.e., expanding the possible criteria).

    Question 2b. Continually, physicians call for the all-or-nothing 
nature of the program to be rethought. Why are rulemakers so hesitant 
to adjust this rigid mandate?
    Answer 2b. First, I think it is important to acknowledge that there 
is a reasonable degree of flexibility built into the program, evident 
in the core versus menu measures, a qualification period that gives 
organizations the flexibility to meet requirements within any 90-day 
window, and staging the criteria to ramp up over time. I also think 
that there is strong justification for having attestation thresholds; 
they define a minimum level of utilization that is needed in order for 
there to be a real shift from paper to electronic processes, and for 
EHR benefits to be realized at a meaningful level. For a subset of 
measures, thresholds are also needed to realize network effects--in 
particular, for health information exchange. In addition, having a set 
threshold reduces the complexity of administering the program (for CMS) 
and understanding it (for providers). Finally, data from Stage 1 MU 
attestations reveal that very few attesters are right at the threshold. 
Most of those attesting well exceed the thresholds.
    That said, we can all agree that it feels profoundly unfair for a 
provider to get no compensation for being just shy of a cutoff for a 
single measure. It would be worth exploring whether there could be a 
provision that allows a provider to fall just short (e.g., within 5 
percent) of the threshold on a single measure, and still receive the 
full incentive.

    Question 2c. Are there any additional resources, other than 
additional incentive payments, that the Federal Government should 
provide to increase physician participation?
    Answer 2c. We have heavily invested in Regional Extension Centers 
and they have the most experience with helping physicians adopt EHRs. I 
think it would be valuable to pursue Regional Extension Centers version 
2.0 in which there are stronger incentives for them to take what they 
have learned over the past 4 years, and demonstrate that they can help 
providers adopt EHRs more quickly, less expensively, and with less 
disruption. A second factor that is likely to help is to continue the 
push to streamline requirements of various Federal programs. This is 
proposed in Stage 3 MU and is included in the new SGR approach. If MU 
is clearly tied to broader healthcare delivery reform efforts that 
physicians are pursuing, this will help it feel more valuable. To the 
extent that this could be done more broadly across payers, it would be 
even better.

    Question 3a. The goal of HITECH was to improve patient care while 
decreasing costs--has there been a change in the cost to health care 
because of HITECH?
    Answer 3a. It is very difficult to attribute the healthcare cost 
reductions we have seen over the past few years specifically to HITECH. 
Because HITECH is a national program, there is no ``control'' group to 
which to compare outcomes. In addition there are many other health 
reform (and broader economic) changes occurring in parallel, notably 
the ACA. If the experience in other industries, most of which adopted 
IT in the 90s, is any indication, the answer to this question is that: 
(1) benefits from IT take time (up to a decade), and (2) during that 
time, some organizations figure out how to use IT well and others do 
not. So we will undoubtedly get some benefit from the HITECH 
investment, but it could be greatly increased by figuring out how to 
minimize the number of provider organizations that never learn how to 
take advantage of EHR capabilities to improve the care they deliver.

    Question 3b. Since EHRs have become more common place, are there 
any metrics of public health improvement being observed?
    Answer 3b. If we limit our evaluation to the subset of measures 
that specifically characterize public health domains (e.g., disease 
surveillance, immunization rates, cancer and lab data), there is scant 
evidence of improvement in ``hard outcomes'' from EHRs. The greatest 
impact of EHRs so far is on key processes that we would expect to 
facilitate improvement in outcomes. Most notably, there has been a 
large increase in the volume of data reported to public health 
departments. Electronic reporting of public health data greatly 
improves the timeliness and completeness of data, while reducing 
variability in data quality and error. Public health data is used 
primarily to identify and track disease outbreaks (including contact 
tracing) and track disease trends over time. However, there are still 
some gaps to close in terms of the ability of public health departments 
to receive electronic public health data. As of 2014, 21 percent of 
hospitals attesting to Stage 2 MU were unable to submit syndromic 
surveillance data electronically because their local public health 
department was unable to receive them, 15 percent were unable to submit 
lab results electronically, and 9 percent were unable to submit 
immunization data.\5\
---------------------------------------------------------------------------
    \5\ http://www.healthit.gov/sites/default/files/
databrief22_hospitalreporting.pdf.
---------------------------------------------------------------------------
    EHRs also have the ability to enhance public health by allowing 
providers to access repositories that include public health data. This 
two-way exchange of data may be extremely effective for clinical care 
in public health clinics for certain chronic conditions such as 
tuberculosis or STDs, or identifying resistance patterns to certain 
drugs. It may also assist providers in identifying which of their 
parents are in need of immunizations.\6\ However, significant 
improvements in EHR interoperability and usability are necessary for 
these benefits to be fully realized.\7\ In addition EHR data can be 
used to assist in emergency situations. For example, in the aftermath 
of Hurricane Sandy, patients leveraged the New York State Health 
Information Exchange to easily grant permission for providers to access 
their health records.\8\
---------------------------------------------------------------------------
    \6\ Shapiro, J.S., Mostashari, F., Hripcsak, G., Soulakis, N., 
Kuperman, G. Using Health Information Exchange to Improve Public 
Health. American Journal of Public Health. [Article]. 2011;101(4):616-
23.
    \7\ Dombkowski, K.J., Clark, S.J.. Redefining Meaningful Use: 
Achieving Interoperability with Immunization Registries. American 
Journal of Preventive Medicine. 2012;42(4):e33-e5.
    \8\ Shapiro, J. S., Mostashari, F., Hripcsak, G., Soulakis, N., & 
Kuperman, G. (2011). Using Health Information Exchange to Improve 
Public Health. American Journal of Public Health, 101(4), 616-23. 
http://doi.org/10.2105/AJPH.2008.158980.
---------------------------------------------------------------------------
    The primary challenge to leveraging EHRs for public health purposes 
is assisting public health departments to modernize their health IT 
infrastructure. Under HITECH, public health departments were not 
provided with the resources to do so, and 72 percent of local public 
health departments identified funding as a significant barrier to 
system development.\9\ This is particularly problematic because as they 
receive an increasing amount of data, they may not be able to fully 
leverage it to improve public health. For example, in 2005, only eight 
State public health departments had the ability to electronically 
report lab results related to public health issues (e.g., lead, HIV, 
STD). By 2014, 48 States supported this capability.\10\ However, we do 
not have evidence that this increase in reporting has had any impact on 
public health outcomes.
---------------------------------------------------------------------------
    \9\ Linert, L. & Sundwall, D. (2012). Public health surveillance 
and meaningful use regulations: A crisis of opportunity. American 
Journal of Public Health, 102(3), e1-e7.
    \10\ http://www.healthit.gov/sites/default/files/phissuebrief04-24-
14.pdf.

    Question 3c.  What can government do to further the goal of using 
this technology to decrease costs?
    Answer 3c. If the target is specifically cost reduction, I believe 
that the most effective way to use HIT to reduce wasteful spending is 
to facilitate health information exchange. If done well, HIE would help 
reduce duplicative utilization (such as redundant lab tests), prevent 
avoidable errors, and improve care coordination. However, as you know, 
HIE progress has been slow and there are a range of barriers that need 
to be addressed.
    In addition, clinical decision support (CDS) can also be tailored 
to targeted cost reduction. Thus far, CDS has largely focused on 
ensuring appropriate care (i.e., recommending immunizations, preventing 
medication errors) but it could be instead focused on detecting misuse 
and waste, as well as on promoting cost-effective treatments, both of 
which would reduce costs. A related idea is using EHR data to profile 
physicians as this feedback may lead to changes in practice patterns 
that could reduce spending. Many physicians do not realize that they 
are higher than their peers in terms of how often they order high-cost 
tests, or admit patients from the ED into the hospital. This could be 
bolstered by not only showing physicians their relative performance 
data, but also using algorithms to help them identify when they are 
making a decision that might deviate from their peers.

    Question 4a. What are the biggest barriers inhibiting nationwide 
interoperability?
    What is the biggest barrier blocking providers from sharing 
information with each other?
    What is the biggest barrier blocking patients from sharing their 
information with different providers?
    Answer 4a. At the highest level, the challenge stems from two 
interrelated dynamics: EHR vendors earn substantial revenue from the 
lack of interoperability (they can design their systems however they 
think best, and then charge for custom interfaces) and provider 
organizations don't have a clear business case for being interoperable 
(therefore, they are not willing to pay the high costs or demand 
interoperability out of the box). Patients simply haven't shown much 
interest in being the stewards of their own health information--so 
patient-facing solutions such as portable personal health records do 
not appear to be a viable national alternative to work around the lack 
of interoperability among providers. We therefore have to decide if we 
want to tackle the problem by changing the incentives for the EHR 
vendors, for the provider side, or for both. Targeting vendors seems to 
be the most effective option--there are policy levers in place and it 
is a more clearly defined, manageable group. ONC has proposed a good 
set of first steps, as outlined in their recent report on health 
information blocking.\11\ There are some challenges, however, in 
operationalizing the steps described in the report. Nonetheless, there 
is an opportunity for Congress pass legislation that gives ONC and 
other Federal agencies more ability to reign in the behavior of those 
engaging in information blocking.
---------------------------------------------------------------------------
    \11\ http://www.healthit.gov/sites/default/files/reports/
info_blocking_040915.pdf.

    Question 4b. Is ONC's nationwide Interoperability Roadmap a 
reasonable guide to widespread interoperability?
    Answer 4b. The Interoperability Roadmap offers a set of guiding 
principles that ONC has committed to follow when designing policies to 
promote interoperability. Efforts are currently underway to figure out 
how best to operationalize these principles. Currently, the ONC is 
focusing on key issues of data governance, but much work remains in 
terms of gaining agreement on next steps and turning it into a true 
``guide.''

    Question 4c. The lack of enforceable, consistent standards has been 
an industry concern. Does the 2015 Interoperability Standards Advisory 
fill the void? If not, what else can or should the Federal Government 
do to ensure a single set of standards is used within the industry?
    Answer 4c. I would also encourage you here to consult someone with 
deep expertise on standards. In my opinion, the issue seems to be more 
related to generating broad consensus on an effective set of standards, 
not just a consistent set of standards. Effective standards need to be 
detailed and prescriptive enough to enable receipt of data without 
extensive customization; however, standards that allow for flexibility 
and optionality are easier for vendors to implement. A single set of 
effective standards would have to balance both of these needs, and 
could be developed through closely coordinated work among various 
participants to make key decisions on the tradeoffs. To do this, key 
use cases for interoperability must be identified and the diverse needs 
and interests of stakeholders have to be addressed to achieve 
consensus. Furthermore, there must be a mechanism through which 
participants are held accountable for their decisions, such that they 
have an incentive to adhere to the consensus solution.\12\
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    \12\ Email Correspondance with Dr. Walter Sujanky, Sujanski & 
Associates; see Sujansky, W. V., Overhage, J. M., Chang, S., Frohlich, 
J., & Faus, S. A. (2009). The development of a highly constrained 
health level 7 implementation guide to facilitate electronic laboratory 
reporting to ambulatory electronic health record systems. Journal of 
the American Medical Informatics Association: JAMIA, 16(3), 285-90. 
http://doi.org/10.1197/jamia.M2610.

    Question 4d. Patient matching is a consistent concern raised by 
industry. How can government and industry ensure that patient data can 
be reliably shared across care settings?
    Answer 4d. Patient matching is another area in which ONC is issuing 
guidance.\13\ Specifically ONC has identified consistent implementation 
of best practices across healthcare organizations as key to successful 
patient matching across systems. These best practices include: 
standardizing patient identifying attributes (possibly by enforcing 
these standards through EHR certification criteria), encouraging 
patients to keep their identifying information up to date, and 
systematically verifying patient identifying information. ONC also 
recommends exploring the use of other types of patient information as 
alternative options for patient identifiers. These are good areas, but 
the key is consistent use and ensuring that all stakeholders put effort 
into maintaining data integrity. As with data security, this requires 
organizational and individual behavior change, which is not easy. 
Another suggestion is to make clear that HHS is allowed to experiment 
with national patient identifiers, which (somewhat counter-intuitively) 
have the potential to be more secure than the current approach of using 
name, birth date, etc.
---------------------------------------------------------------------------
    \13\ http://www.healthit.gov/sites/default/files/
patient_identification_matching_final_
report.pdf.

    Question 5. Physicians consistently voice concerns with product 
usability. What can be done to foster user-centered design rather than 
technology built to meet regulatory and billing mandates?
    In the near term, we should consider including in EHR certification 
a key set of usability metrics, and either require that they be met, or 
publicly report on their performance. I feel that user-centered design 
is tricky because it is not clear that there is consensus across users 
(particularly in different specialties, with different patient panels, 
etc.) on what constitutes optimal design. A promising medium-term 
direction is to work toward a substitutable app-based model for EHRs, 
like the one advocated by SMRT (smarthealthit.org). This would allow 
users to configure displays and functions to a much greater extent 
(like we have a choice of map applications on our smart phones). 
Ultimately, we don't want a single vendor to be in charge of the user 
experience. We want each physician to be able to choose what they like 
best and have a robust ``market'' for creating the best apps to improve 
user experience. Thinking longer term, I think we could learn a lot 
from allowing CMS to experiment with relaxing regulatory and billing 
mandates (i.e., creation of safe harbors) to see what can happen in 
terms of improving EHR usability when EHRs can be wholly focused on 
supporting clinical care.

    Question 6. A lack of a ``business case,'' both for vendors and 
providers, is often cited as a hindrance to information sharing. What 
can be done to create the ``business case'' to generate 
interoperability?
    Answer 6. We need to decide if we want to tie incentives to the 
process (like MU) or the outcome (stop paying for outcomes that we 
think could be avoided with good interoperability). Right now we are 
doing a bit of both but neither approach has been very effective. Going 
back to answer (1), I think the key to promoting the business case for 
interoperability is bringing down the cost for providers. I think we 
are clearly on a path toward stronger pay-for-value incentives, and 
while in theory, this should lead to higher provider willingness to pay 
for interoperability, if the cost of interoperability is high, 
providers may decide to invest in other areas. Bringing down the cost 
of interoperability could also speed provider willingness to take on 
more risk-based contracts.

    Queston 7a. Stakeholders often voice concerns that the electronic 
health record product as certified is quite different from the products 
deployed in individual care settings. How can we ensure that the 
certification program delivers capable technology not just upon initial 
testing but once deployed in the field?
    Answer 7a. This is important and there is a lot to be said for 
considering extending certification to include post-market 
surveillance. Some of these ideas are discussed in the health 
information blocking report. Currently, ONC implements post-market 
surveillance through ONC-Authorized Certification Bodies (ONC-ACBs). 
ONC-ACB's have been asked to prioritize the monitoring of EHR safety-
related capabilities and assuring that vendors have processes in place 
for addressing user concerns.
    One option that has been suggested for improving post-market 
surveillance of EHR products is to implement a centralized reporting 
system where end-users can report issues with their EHR systems, 
especially those concerning patient safety, for further analysis and 
followup by an ONC committee. In this way, issues that are common 
across EHRs can be identified and addressed, and individual vendors can 
also be held accountable for addressing user concerns.\14\ Random 
auditing seems like another approach to post-market surveillance that 
could be quite effective and create minimal opportunity for vendors to 
meet the certification standards while failing to deliver a well-
functioning product in the field.
---------------------------------------------------------------------------
    \14\ Sittig DF, & Classen DC. (2010). Safe electronic health record 
use requires a comprehensive monitoring and evaluation framework. JAMA, 
303(5), 450-51. http://doi.org/10.1001/jama.2010.61.

    Question 7b. How can we create transparency in cost, satisfaction 
and vendor responsiveness?
    Answer 7b. As mentioned above, this issue could be addressed 
through systematic data collection and public reporting. A public 
reporting model, coupled with consequences for bad vendor behavior 
(such as financial penalties for not addressing consumer concerns with 
a certain time period) are likely to incentivize vendors to increase 
responsiveness.

    Question 7c. Does ONC have the proper resources to employ enhanced 
testing capabilities relative to the Certification Program?
    Answer 7c. The testing is performed by ONC certified labs, and so 
it seems that with more resources, their scope could be extended to 
include post-market surveillance.
                              senator burr
    Question. Your testimony states that even though there has been a 
large uptake of EHR systems, only 20 to 30 percent of physicians and 
hospitals exchange electronic health data with other providers. What 
are the biggest barriers to the interoperability of these systems? What 
incentives need to be in place that are not today?
    Answer. Please see answers 4 and 6 above.
                             senator warren
    Question 1. As you know, our electronic health record systems often 
have trouble matching a particular scan or a test result to the right 
patient, and those mismatches endanger patients. As more providers move 
to electronic health records and databases contain records for more 
patients, the risk of mismatching information to patients only goes up. 
A 2008 RAND Corporation study estimated that even with database 
management software and personnel dedicated to preventing these 
mistakes, hospitals mismatch patient information about 8 percent of the 
time. A 2012 survey conducted by The Council of Health Information 
Management Executives found that one in five physicians encountered 
mismatched information that that put a patient at risk at least once 
over the previous year. Accurately matching health information to the 
correct patient record is critical to creating an electronic health 
information exchange that works. How can we reduce these errors? 
    Answer 1. Please see answer 4D above.

    Question 2. Today, 90 percent of hospitals have certified that they 
meaningfully use electronic health records. And in some areas, 
hospitals and providers have taken the next step of creating regional 
health information exchanges to share patient information. This sharing 
has enormous benefits to patients. A 2014 study performed by University 
of Michigan researchers found that Emergency Departments that were 
connected to a regional health information exchange ordered fewer 
duplicate tests--patients in these Emergency Departments were 59 
percent less likely to have a redundant CT scan, 44 percent less likely 
to get a duplicate ultrasound, and 67 percent less likely to have a 
duplicated chest x-ray compared to patients who went to hospitals that 
were not connected to a regional health information exchange. We've 
made real progress, but we can't get the full value of electronic 
health records until hospitals and providers from around the country 
can exchange patient information with each other. To what extent would 
expanding these small regional systems to a nationally interoperable 
electronic health record system reduce duplicative tests and how much 
money could that save our health care system?
    Answer 2. There have been two estimates of the savings from 
nationwide interoperability. A 2005 Rand study found that fully 
interoperable EMR systems could generate savings of $142-$371 billion 
nationwide; this estimate includes efficiency and safety savings, as 
well as short- and long-term effects on patient health and 
productivity. Of that estimate, $1.3-4.6 billion would be generated 
from efficiency savings in lab tests.\15\ A 2005 Partners HealthCare 
study estimated savings of $77.8 billion a year that could be generated 
through the implementation of a nationwide interoperable exchange 
network that includes payers and public health departments as well as 
labs, radiology centers, pharmacies, physicians, and hospitals. This 
study estimated that an average of $17.41 per person could be saved 
from reductions in redundant lab tests per year.\16\
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    \15\ Hillestad, R., Bigelow, J., Bower, A., Girosi, F., Meili, R., 
Scoville, R., & Taylor, R. (2005). Can Electronic Medical Record 
Systems Transform Health Care? Potential Health Benefits, Savings, And 
Costs. Health Affairs, 24(5), 1103-17. http://doi.org/10.1377/
hlthaff.24.5.1103-17.
    \16\ Walker, J., Pan, E., Johnston, D., Adler-Milstein, J., Bates, 
D. W., & Middleton, B. (2005). The Value of Health Care Information 
Exchange And Interoperability. Health Affairs. http://doi.org/10.1377/
hlthaff.w5.10.
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    What is not clear is how to best realize these savings--and how to 
interconnect the varied regional systems. ONC has laid out a nationwide 
interoperability roadmap, but we are in the early stages of 
operationalizing it. Response to Question 4B above speaks more to the 
roadmap.
   Response by Robert L. Wergin, M.D., FAAFP to Questions of Senator 
 Alexander, Senator Burr, Senator Cassidy, Senator Murray, and Senator 
                                 Warren
                           senator alexander
    Question 1a. With the rapid digitization of health data, is the 
industry effectively protecting personal health information?
    Answer 1a. Privacy of health information is of the utmost concern 
to family physicians. A confidential relationship between physician and 
patient is essential for the free flow of information necessary for 
sound medical care. Only in a setting of trust can a patient share the 
private feelings and personal history that enable the physician to 
comprehend fully, to diagnose logically, and to treat properly. The 
American Academy of Family Physicians (AAFP) supports full access by 
physicians to all electronic health information. Medical information 
may have legitimate purposes outside of the physician/patient 
relationship, such as billing, quality improvement, quality assurance, 
population-based care or patient safety. However, the AAFP believes 
that patients and physicians must authorize the release of any 
personally identifiable information to third parties.
    Electronic health information communication systems must be 
equipped with appropriate safeguards (e.g., encryption, message 
authentication, user verification) to protect the physician-patient 
confidentiality. Individuals with access to electronic systems should 
be subject to clear, explicit, mandatory policies and procedures 
regarding the entry, management, storage, transmission and distribution 
of patient and physician information.
    The AAFP supports the use of patient record information for primary 
care research, biomedical and pharmaceutical research and other health 
research, provided there is appropriate protection for research 
subjects, i.e., Institutional Review Board approval.\1\
---------------------------------------------------------------------------
    \1\ AAFP Policy Confidentiality, Patient/Physician Relationship, 
2013, http://www.aafp.org/about/policies/all/patient-
confidentiality.html.
---------------------------------------------------------------------------
    In a January letter to the U.S. Department of Health and Human 
Services (HHS), the AAFP indicated that we have seen a significant 
increase in adoption of health information technology (HIT) by family 
physicians and we are beginning to see a robust network of secure, 
interoperable exchange via Direct, supported by a security and trust 
framework, accreditation programs, and trust anchor services 
established by DirectTrust under the Exemplar Health Information 
Exchange (HIE) Governance Program's Cooperative Agreement with the HHS 
Office of the National Coordinator for Health IT (ONC).\2\ More could 
always be done, but we must balance confidentiality and integrity of 
data with appropriate access.
---------------------------------------------------------------------------
    \2\ Blackwelder, Reid, AAFP letter to Karen DeSalvo, January 15, 
2015, http://www.aafp.org/dam/AAFP/documents/advocacy/health_it/
interoperability/LT-ONC-HITPlan-011515.pdf.

    Question 1b. What additional resources would be valuable in 
encouraging organizations to prioritize health data security?
    Is the government offering proper guidance and/or resources to 
inform industry decisionmaking relative to data security?
    Answer 1b. Physicians would benefit from resources that help 
promote security in ways that do not reduce efficiency or work flow. 
The Federal Government could better support physicians, and small 
practices, in particular by sharing best practices and providing simple 
tools that would help physicians learn from mistakes or implement 
secure HIT in a cost-effective manner. For example, a 2013 article 
published in Family Practice Management discussed many of the concerns 
physicians face and pitfalls to avoid.\3\ The article noted that many 
physicians believe sharing brochures would encourage patients to use 
the portal, but ultimately other methods proved more effective. Also, 
some practices learned how an electronic messaging set up can ensure 
that offices follow the best methods for ensuring patient information 
will not be compromised. Providing resources for effective ways to 
satisfy Meaningful Use requirements regarding the use of the patient 
portals and secure messaging would also be helpful.
---------------------------------------------------------------------------
    \3\ Rachel Franklin, M.D., Fam Pract Manag. 2013 Jan-Feb;20(1):21-
24.

    Question 1c. Is threat information readily shared throughout the 
industry? Or with other industries?
    If so, is the information useful?
    If not, what incentives could be offered for organizations to share 
threat information with other organizations?
    Answer 1c. Currently, there is no system for sharing threat 
information among organizations. Perhaps the creation of an information 
working group might provide a forum for greatly needed dialog on 
privacy and security issues. Such a forum should include vendors, 
medical associations, and patient advocates.

    Question 2a. Half of the Nation's physicians have chosen not to 
participate in the Meaningful Use program to date. How can this change?
    Answer 2a. Several published reports indicate that many physicians 
opt-out of the program due to the administrative burden of the 
requirements they are required to satisfy. These views were reflected 
in a 2014 Medspace Electronics Health Record (EHR) poll.\4\ The survey 
data suggest that physicians are concerned that Meaningful Use 
requirements interfere with the doctor-patient relationship and 
interfere with how they can effectively and efficiently practice 
medicine.
---------------------------------------------------------------------------
    \4\ Medsape EHR Report, July 14, 2014, accessed online: http://
www.medscape.com/features/slideshow/public/ehr2014#24.
---------------------------------------------------------------------------
    As an AAFP leader, I travel across the country and consistently 
hear physicians. concerns about cost and workflow. As I mentioned in my 
testimony, lowering the Meaningful Use requirements and reducing 
penalties would help alleviate some of those concerns. In addition, for 
those physicians who are later in their careers, the program is simply 
viewed as too burdensome and expensive for their practices.
    This issue could be addressed by requiring certified EHR systems to 
be organized in cooperation with physician experts. In addition, HHS 
could use its authority to ensure that systems achieve greater degrees 
of usability and interoperability. Both will be important issues to 
consider as the Meaningful Use Stage 3 regulatory process moves 
forward. Under current proposals regarding Stage 3, physicians will 
face more complex requirements, and some will be attesting for the 
first time. Also, new certification requirements will be in place, 
which will require costly upgrades to their EHRs. In addition to these 
challenges of achieving Stage 3, there is uncertainty on what will be 
required to successfully participate in the Merit-Based Incentive 
Payment (MIPS) approved as part of the Medicare Access and CHIP 
Reauthorization Act (MACRA). Given these challenges and uncertainty, a 
strong consideration of delaying Meaningful Use Stage 3 is needed until 
the MIPS regulations are written and approved.
    Although MIPS adjustments will not go into effect until 2019 and 
Meaningful Use penalties will sunset in 2019, implementing the new law 
presents an opportunity to address numerous HIT priorities. Currently, 
ONC is reviewing both the proposed rule for Meaningful Use Stage 3 and 
the EHR certification requirements. New standards will be in place that 
will harmonize Meaningful Use, Physician Quality Reporting System 
(PQRS) and the Value-Based Modifier.
    MACRA also requires HHS to establish metrics by July 1, 2016, for 
measuring how hospitals and providers progress in moving toward the 
goal of widespread interoperability of EHR systems. The new law 
requires the administration to submit a report to Congress if this goal 
has not been met by December 31, 2018. In this report, HHS would be 
required to make recommendations for achieving this goal, such as 
adjusting payments and decertifying certain EHR technology. MACRA also 
requires the Meaningful Use Program to require attestations by eligible 
hospitals and physicians that they have ``not knowingly and willfully 
taken action (such as to disable functionality) to limit or restrict 
the compatibility or interoperability of the certified EHR 
technology.'' Finally, HHS is also required to submit a report to 
Congress (within 1 year from the date of enactment of MACRA) on methods 
to aid providers in comparing and selecting certified EHR technology. 
This new policy is a welcome change to help harmonize requirements with 
new Medicare policies. While physicians and hospitals work to prepare 
for a myriad of policy and regulatory changes focused on patient care 
coordination, the administration and Congress should strongly support 
Meaningful Use Stage 3 delay.

    Question 2b. Continually, physicians call for the all-or-nothing 
nature of the program to be rethought. Why are rulemakers so hesitant 
to adjust this rigid mandate?
    Answer 2b. AAFP officials have been informed that there is limited 
executive branch authority to relax certain Federal standards. We urge 
Congress to authorize the Centers for Medicare and Medicaid Services 
(CMS) to allow for partial credit for achieving components of 
Meaningful Use by eligible professionals. Congress should also 
encourage HHS to incorporate more flexibility into the requirements.

    Question 2c.  Are there any additional resources, other than 
additional incentive payments, that the Federal Government should 
provide to increase physician participation?
    Answer 2c. Any changes that would make EHR/Health IT use less 
burdensome would increase physician participation. While eligible 
professionals are penalized for not performing health information 
exchange under Meaningful Use, HIT vendors are not. Eligible 
professionals are dependent on their HIT vendor to be interoperable and 
support health information exchange. We believe that vendors should 
also see penalties if they are not interoperable. We would urge 
Congress to explore how vendor financial penalties could be used to 
further interoperable HIT.
    We urge Congress to request that current Medicare documentation 
policies, which were developed in an era of paper records and fee-for-
service, be updated to reflect the new era of electronic records and 
value-based payment.
    We would urge Congress to consider funding additional research into 
the science of practice for primary care with the purpose to better 
understand how best to design, implement, and use HIT in practices 
focused around the new goals of value-based payment.
    During the hearing, Senators mentioned a desire to ``reboot'' the 
Health Information Technology for Economic and Clinical Health Act 
(HITECH). The AAFP agrees with that sentiment, particularly regarding 
Clinical Quality Measures (CQM). It is an AAFP principle for physician 
performance measurement that the purpose of performance measurement 
should be to identify opportunities to improve patient care so that 
these programs lead to better-informed physicians and consumers.\5\ Our 
policy on electronic health records is such that we believe every 
family medicine practice should leverage health information technology, 
such as EHRs and related technologies needed to support the patient-
centered medical home.\6\ These capabilities can support and enable 
optimal care coordination, continuity, and patient centeredness, 
resulting in safe, high-quality care and optimal health of patients, 
families, and communities. Physicians remain concerned that the current 
CQM fail to reflect why HIT is meaningful for facilitating care 
coordinate and improving health outcomes. The CQM should be updated to 
improve the clinical discipline that the measures evaluate, rather than 
meeting an arbitrary reporting requirement imposed by either the 
quality improvement program or a vendor data submission process.\7\
---------------------------------------------------------------------------
    \5\ Stream, Glen, Letter to Margaret Tavenner, April 5, 2013--
http://www.aafp.org/dam/AAFP/documents/advocacy/health_it/emr/LT-CMS-
ClinicalQualityMeasures-040513.pdf.
    \6\ Stream, 2013.
    \7\ Ibid.

    Question 3a. The goal of HITECH was to improve patient care while 
decreasing costs--has there been a change in the cost to healthcare 
because of HITECH?
    Answer 3a. The evidence is unclear if HITECH has changed healthcare 
costs. New research, however, does suggest that it can help facilitate 
team-based systems that have shown to produce modest reductions in 
healthcare spending.\8\ In addition, a study published in the Annals of 
Internal Medicine indicated that physicians who implemented a medical 
home and used electronic health records experienced improved quality 
scores compared to physicians who used paper records.\9\
---------------------------------------------------------------------------
    \8\ Porter, Shari, AAFP News, April 18, 2014, ``Modest Changes Can 
Lead to Better Quality, Lower Costs in Health Care.'' Accessed online: 
http://www.aafp.org/news/practice-professional-issues/
20140408continuityofcare.html.
    \9\ Lisa M. Kern, M.D., MPH; Alison Edwards, MStat; and Rainu 
Kaushal, M.D., MPH, Annals of Internal Medicine, Ann Intern Med. 
2014;160(11):741-49. doi:10.7326/M13-1798.
---------------------------------------------------------------------------
    Indeed, we know that the potential exists to lower costs and 
improve quality. A study to further evaluate the HITECH's impact on 
healthcare costs would be beneficial. Furthermore, we need an 
infrastructure to establish a research agenda around the science of 
practice (i.e., what makes for an effective and efficient work 
environments and system designs).

    Question 3b. Since EHRs have become more common place, are there 
any metrics of public health improvement being observed?
    Answer 3b. The AAFP cannot report specific public health 
improvements at this time, but the Center for Medicare and Medicaid 
Innovation (CMMI) is examining patient-centered health innovations and 
the use of technology.\10\ For example, its Comprehensive Primary Care 
initiative is engaging 500 practices and 2.5 million patients. During a 
recent meeting, health experts observed that programs are lowering 
costs and improving health outcomes, including reductions in mortality 
rates.\11\ Further, there are two observations worth highlighting. 
First, electronic records are capturing crucial patient data that is 
not being extracted. Second, technology is lagging behind reforms in 
healthcare delivery. As I mention in my testimony, technology still 
holds tremendous potential for health delivery. CMMI may possess 
evidence to demonstrate public health improvements.
---------------------------------------------------------------------------
    \10\ Laff, Michael, AAFP News, Panel Considers Health Care 
Innovations in Technology, Payment, April 28, 2015, http://
www.aafp.org/news/practice-professional-issues/20150428inno-
vation.html.
    \11\ Ibid.
---------------------------------------------------------------------------
    The AAFP also is concerned that the discussion about practice 
transformation has been limited to technology. HIT is a tool for 
increasing access to services. We should focus on how to improve the 
capabilities of the physician's practice. For example, quality 
improvement efforts should mean looking for ways to engage patients in 
their healthcare rather than simply pushing for the adoption of patient 
portals. Practice transformation requires thinking about workflow, 
personnel, content and the technology that supports those elements of 
the sociotechnical system. For example, using HIT to promote more 
telehealth services, such as e-consultations, online health evaluation 
and coaching and tele-visits hold tremendous potential for improving 
health outcomes.

    Question 3c.  What can government do to further the goal of using 
this technology to decrease costs?
    The Federal Government can help decrease health costs by continuing 
to align financial incentives with value-based services that are time-
intensive but rely on or utilize health technology. Essentially, the 
healthcare community should consider how to make basic healthcare more 
accessible to the patients. The AAFP applauds Congress' support for 
alternative payment models within MACRA.
    As implementation moves forward, HIT will be essential for 
physicians. Telehealth helps increase access without compromising care. 
Policymakers should consider ways to eliminate barriers to telehealth 
services, particularly for primary care services to address chronic 
health conditions, like diabetes, and for certain patients who lack 
transportation to followup medical appointments.
    We are pleased that Section 106(c) with MACRA requires the 
Government Accountability Office (GAO) to draft two reports to evaluate 
and report on telehealth programs, barriers, potential healthcare 
outcomes and patient monitoring technology. The evaluation may provide 
some valuable input into the ongoing debate about HIT, the value of 
these services is well-documented. We urge policymakers to push for 
expedited GAO review. Physicians need concrete policies to eliminate 
barriers, particularly for primary care services.

    Question 4a. What are the biggest barriers inhibiting nationwide 
interoperability?
    Answer 4a, Achieving interoperability requires the ability to 
exchange information in real time, but the ultimate goal is to achieve 
optimal care coordination for patients.
    The biggest barrier to achieving interoperability and care 
coordination is the system of incentives. The financial incentives for 
HIT vendors are misaligned. Instead of promoting interoperability, 
vendors focus on locking in practices, which will find it too expensive 
and burdensome to change EHRs after a current system has been 
installed. In addition, ending the current reliance on documentation 
requirements for Evaluation and Management services from the paper era 
could produce positive results. These regulations lead to bloat in the 
EHR, which interferes with patient care and interoperability. They 
decrease the signal-to-noise ratio in the patient's record and 
exchanges of health information, where the signal is the clinically 
relevant information. The requirements are administratively burdensome 
and are not helpful in today's practice environment. We urge Congress 
to communicate that message to CMS.
    Our position from the onset has been that true interoperability 
will not be achieved without fundamental changes in healthcare payment 
reform. We are excited to see the acknowledgment of this position by 
both the private sector and CMS. A good example of the latter is the 
recent announcement by Secretary Burwell on the desired deployment of 
value-based payment by CMS. Also, MACRA supports payment reform that 
incentivizes value-based care. We believe that payment reform is the 
keystone to a nationwide interoperable healthcare delivery system.
    HITECH incentives helped accelerate the adoption of HIT through 
incentives. In 2013, 59 percent of hospitals and 48 percent of 
physicians had at least a basic EHR system, respective increases of 47 
percentage points and 26 percentage points since 2009, the year HITECH 
was signed into law.\12\ As of June 2014, 75 percent (403,000+) of the 
Nation's eligible professionals and 92 percent (4,500+) of eligible 
hospitals and CAHs had received incentive payments.\13\ As we examine 
healthcare interoperability, we must turn our focus on ways to support 
care coordination across health sectors and among stakeholders.
---------------------------------------------------------------------------
    \12\ Office of the National Coordinator for Health IT, Annual 
Report to Congress, October 2014, http://www.healthit.gov/sites/
default/files/rtc_adoption_and_exchange9302014.pdf.
    \13\ Ibid.
---------------------------------------------------------------------------
    While eligible professionals are penalized for not performing 
health information exchange under Meaningful Use, HIT vendors are not. 
Eligible professionals are dependent on their HIT vendor to be 
interoperable and support health information exchange. We believe that 
vendors should also see penalties if they are not interoperable. We 
would urge Congress to explore how vendor financial penalties could be 
used to further interoperable HIT.

    Question 4b. What is the biggest barrier blocking providers from 
sharing information with each other? What is the biggest barrier 
blocking patients from sharing their information with different 
providers?
    Answer 4b. The biggest barrier for physicians is often their 
practice's HIT systems. Physicians often purchase a system that they 
believe will be an effective means of communication. It is difficult to 
know if the system will work and communicate across diverse platforms 
until after physicians invest the time and money into an EHR. The 
investment and costs for moving data that has been warehoused into a 
new system also create significant barriers for physicians who want to 
change vendors.
    In its letter to HHS regarding the nationwide Interoperability 
Roadmap, the AAFP highlighted this concern and recommended a process to 
collect real-world feedback of certified electronic health record 
technology in use. ONC should create a resource to accept complaints 
from users when real world use of certified technology does not allow 
for the interoperability required by certification criteria. This 
feedback would be used to inform the certification testing tools and to 
inform ONC of bad actors as far as the interoperability is 
concerned.\14\
---------------------------------------------------------------------------
    \14\ Blackwelder, AAFP letter to Karen DeSalvo, January 15, 2015.

    Question 4c. Is ONC's nationwide Interoperability Roadmap a 
reasonable guide to widespread interoperability?
    Answer 4c. Overall, the Interoperability Roadmap is a good 
framework for advancing this important issue. The AAFP agreed with ONC 
on several points such as the principles for an interoperable health 
ecosystem. The AAFP also agreed with the plan's recommendations for 
establishing common clinical data sets. Further, there also was 
consensus about the nationwide privacy and security framework.
    The AAFP, however, identified several areas that need improvement. 
First, AAFP strongly urged ONC to address workflow and documentation 
requirements. Also, AAFP expressed concerns about the lack of a 
detailed short-term plan for how its goals would be achieved. In 
addition to interoperability, standards need to address the real-world 
environment in which HIT systems are utilized.\15\
---------------------------------------------------------------------------
    \15\ Ibid.

    Question 4d. The lack of enforceable, consistent standards has been 
an industry concern. Does the 2015 Interoperability Standards Advisory 
fill the void? If not, what else can/should the Federal Government do 
to ensure a single set of standards is used within the industry?
    Answer 4d. The AAFP has dedicated significant resources over the 
last decade to support the achievement of healthcare interoperability. 
We have worked on key clinical and transport standards and participated 
in the national policy dialogs. Our position from the onset has been 
that true interoperability will not be achieved without fundamental 
changes in healthcare payment reform. We are excited to see the 
acknowledgment of this position by both the private sector and CMS. A 
good example of the latter, as stated previously, is the recent 
announcement by Secretary Burwell of the desired deployment of value-
based payment by CMS. We believe that payment reform is the key to a 
nationwide interoperable healthcare delivery system.

    Question 4e. Patient matching is a consistent concern raised by 
industry. How can government and industry ensure that patient data can 
be reliably shared across care settings?
    Answer 4e. Proper patient identification is essential for wide-
scale interoperability. The support of consistent, unambiguous patient 
identification is needed. According to a 2014 Health Affairs study, 
only 40 percent of physicians reported having electronic exchanges of 
any sort with other providers. To further break down the numbers, only 
one of seven physicians shared data with providers outside their 
organization. Privacy concerns and incompatible technology systems were 
cited as the two primary reasons for the slow growth of information 
exchanges.

    Question 5. Physicians consistently voice concerns with product 
usability. What can be done to foster user-centered design rather than 
technology built to meet regulatory and billing mandates?
    Answer 5. There is a discipline of industrial and systems design 
that includes the human factors that could be applied to healthcare and 
HIT. Support is needed to establish an infrastructure to study the 
science of practice, which would include user-centered design.
    On a separate track, we must continue to make progress on real-time 
interoperability. The AAFP has been active in efforts to develop 
standards for packaging of data; e.g., Continuity of Care Record (CCR), 
and Consolidated Clinical Document Architecture (C-CDA). Additionally, 
the AAFP has worked on the development of standards for the transport 
of data (e.g., Direct Project). These efforts must continue alongside 
CMS' efforts to make claims data available.
    As outlined in the testimony, EHR usability is an area of 
significant concern. Often, physicians must sort through pages of 
documentation to access information that is often not relevant to 
patient care. The Medicare Documentation guidelines are out of date and 
structured around billing data versus patient information. Amending 
these standards would change how EHR systems are created. In addition, 
physicians should have significant flexibility to delegate requirements 
to qualified staff as members of the healthcare team.
    To change product usability, the AAFP recommends the following: (1) 
Incentivize value not documentation; (2) Support more research into the 
science of practice by supporting research in the application of 
industrial and systems engineering to healthcare; (3) Simplify 
regulatory requirements that have been created over many years which 
require significant effort by providers and vendors to modify and 
expand the work of providers without positive impact on patient care, 
quality or cost.
    Some key areas of regulatory simplification include the following:

     Elimination of requirement dictating who within the care 
team (i.e., physician, nurse, medical assistant, patient, etc.) can and 
cannot perform certain tasks. With the support of HIT, the roles in the 
care team can change, and team-based care is needed to be efficient and 
effective.
     Elimination of documentation requirements that were 
designed for cost control and not for supporting care delivery.
     Ease external reporting requirements. We have heard from 
many members about the hours of extra work needed to report for 
Meaningful Use. We also heard about the added checkboxes and restricted 
workflows in HIT just to ensure the external reporting is performed.
     Harmonize programs. Each Federal program is created in a 
silo yet they have overlap in goals and requirements. It is a struggle 
for practices to understand the varied regulations and rules. These 
programs need to be integrated to ease the administrative burden to 
understand and comply with these multiple programs. We appreciate the 
changes included with MACRA, but harmonization needs to be a systemic, 
ongoing and serious endeavor.

    Question 6. A lack of a ``business case,'' both for vendors and 
providers, is often cited as a hindrance to information sharing. What 
can be done to create the ``business case'' to generate 
interoperability?
    Answer 6. The best business case for interoperability would be the 
creation of a system in which physicians can see notable improvements 
in clinical efficiency, patient care, and revenue. Physicians' major 
priority is to provide high-quality patient care. The creation of an 
interoperable system that facilitates patient visits and supports 
meaningful data exchanges across different platforms would benefit 
physicians and their patients. Two-thirds of physicians work in a small 
or solo practice. Helping these small practices implement best 
practices and maintain financial viability would also be an important 
return on investment.
    EHR adoption requires a high initial investment and ongoing 
maintenance fees. The costs combined with the regulatory burdens are 
creating a highly diminished sense of return on investment at this 
time. If Congress and the administration aligned physician payment with 
technology-driven and high-value care, it would certainly represent a 
strong business case for many primary care physicians. Doing so would 
require stronger interoperability standards and systems that complement 
physicians. workflow.

    Question 7a. Stakeholders often voice concerns that the electronic 
health record product as certified is quite different from the products 
deployed in individual care settings. How can we ensure that the 
certification program delivers capable technology not just upon initial 
testing but once deployed in the field?
    How can we create transparency in cost, satisfaction and vendor 
responsiveness?
    Answer 7a. The AAFP recommends a quality rating system to create 
greater transparency in cost, satisfaction, and vendor responsiveness. 
In addition, field testing would help ensure that only interoperable 
products are being utilized. Also, we strongly recommend that 
policymakers establish penalties for vendors that do not meet quality 
and interoperability standards.

    Question 7b. Does ONC have the proper resources to employ enhanced 
testing capabilities relative to the Certification Program?
    Answer 7b. No, it is our view that ONC lacks sufficient resources 
to employ enhanced testing relative to the Certification Program. This 
is an issue that Congress must address.
                              senator burr
    Question 1. Please expand on the suggestion in your testimony that 
physicians not be charged by their vendors for accessing their own 
patients. data. Is this occurring for existing patients, new patients, 
or both?
    Answer 1. In my testimony, I mentioned that a patient's data should 
not be restricted because of the vendor's business practices. Concerns 
about these practices apply to both new and existing patients within a 
physician's panel. We have heard of members being required to pay to 
have their data extracted from the EHR if they wish to use that 
information in other information systems. Recent analysis indicate that 
because the market for creating new electronic records is saturated, 
vendors require physicians to pay a range of different fees to access 
their patients' data.

    Question 2. According to a warning the FBI issued to healthcare 
providers last year, the healthcare industry has the highest volume of 
cyber threats and the slowest response time. What are your suggestions 
of steps that could be taken to make this information more secure?
    Answer 2. Patient safety is of the utmost concern to physicians. To 
address this issue, physicians need access to best practices and the 
highest quality support to protect patient data. To respond to the 
FBI's concerns, the AAFP recommends ONC and other entities focus on 
assisting providers rather than penalizing those that happen to get 
breached. Physicians and hospitals want to avoid data breaches and are 
willing to implement reasonable safeguards.
                            senator cassidy
    Question 1. As a physician, I have concerns that mandated 
``Meaningful Use'' of health information technology such as EHRs, while 
providing useful medical data, has complicated physician-patient 
encounters and distracted the physician from what they have been 
trained to do--provide patients with personalized care and give 
patients their undivided attention.
    In over 46 States and in a variety of settings--emergency rooms, 
hospitals, urgent care clinics, and practices including OB/GYN, 
cardiology, orthopedics, and oncology--medical scribes are used as a 
means of significantly reducing the healthcare practitioner's burden of 
entering data into the EHR. The scribe accompanies a provider into the 
exam room and documents the physician-patient encounter into the EHR in 
real-time and at the point of service. This relationship allows the 
physician to spend more time delivering care directly at the patient's 
bedside and less time in front of a computer screen navigating EHRs. 
The use of a scribe allows a physician to focus on the patient and 
think clinically, not clerically. One of the unintended consequences of 
the ACA is that ED volumes have risen, some argue this is due to access 
to care issues. Scribes could help provide greater access to 
appropriate levels of care. Has adoption of EHRs altered the physician-
patient encounter?
    Answer 1. The AAFP shares your concerns about the negative impacts 
Meaningful Use and poor HIT implementation has had on the patient-
physician relationship. The organization is currently undertaking a 
study to measure this impact on patient care by Meaningful Use. We are 
hopeful to have results to share in mid to late summer of 2015.
    The AAFP has heard of the positive impacts of scribes. One concern 
we have is that this is treating a symptom and not the underlying 
problem. Hiring scribes or re-tasking clinical support staff would 
increase the cost of practices. We would like to see reforms in the 
documentation requirements to update those requirements from an era 
dominated by paper records to one leveraging HIT. That said, we also 
think that practices should have the ability to determine the best 
personnel to perform the work (within the constraints of State law). 
Federal requirements that dictate who can and cannot perform tasks do 
not support a team-based approach to care and these unnecessary 
requirements must be eliminated. Team-based approaches are needed to 
achieve the Triple AimTM and to help with the shortage of 
primary care.

    Question 2. A recent study of using scribes in a cardiology clinic 
in St. Paul, MN, found that scribe-use produces improvements in 
physician-patient interaction and results in large increases in 
physician productivity. Specifically, patients seen per hour increased 
by 59 percent, from 2.2 patients per hour to 3.5, and the amount of 
time that physicians interacted with patients increased. Based on your 
clinical experience incorporating EHRs into your practice, do you agree 
that a physician could deliver care to more patients per hour if they 
did not have to navigate an EHR while also examining a patient? If the 
provider is seeing more patients per hour then are they driving greater 
access to care?
    Answer 2. Currently, the EHR does not work well with the work flow 
of a practice. The note created has more to do with ``bullets on 
billing'' than sharing meaningful clinical information with other 
providers. Some practices do use scribes with an extra expense to the 
practice and overhead. While this may be an option for large-margin 
consultation practices, it may not be a viable business option for 
small primary care practices with smaller margins per visit. If one is 
employed by a healthcare system, the extra expense in personnel has to 
be justified to the bottom line of the practice.
                             senator murray
    Question. Since 2009, physicians and hospitals have made an 
unparalleled investment in HIT. In Washington State, providers have 
received over $500 million in HITECH incentive payments to help with 
the cost of adopting electronic health records. Yet many providers are 
reporting that the cost of implementing HIT doesn't end with 
installation in the hospital or clinic. Is the AAFP aware of providers 
who have paid substantial sums to connect their electronic health 
record with other systems? How commonplace are these fees? Are they a 
barrier to helping providers and families make full use of electronic 
health records?
    Answer. Health data ultimately belongs to the patient, not to EHR 
vendors, and an EHR vendor should not be permitted to ``hoard'' patient 
data in order to gain a business advantage.
    There is typically an interface fee, which is in the neighborhood 
of $5,000, and some also charge a service fee requiring a monthly or 
yearly payment. A practice's current vendor holds a monopoly over 
interoperability for the practice. That monopoly is preventing 
reduction of the price of connectivity. More study and transparency 
around these costs are needed and this vendor ``lock'' should not be 
allowed.
                             senator warren
    Question 1. Today, 90 percent of hospitals have certified that they 
meaningfully use electronic health records. And in some areas, 
hospitals and providers have taken the next step of creating regional 
health information exchanges to share patient information. This sharing 
has enormous benefits to patients. A 2014 study performed by University 
of Michigan researchers found that Emergency Departments that were 
connected to a regional health information exchange ordered fewer 
duplicate tests--patients in these Emergency Departments were 59 
percent less likely to have a redundant CT scan, 44 percent less likely 
to get a duplicate ultrasound, and 67 percent less likely to have a 
duplicated chest x-ray compared to patients who went to hospitals that 
were not connected to a regional health information exchange. We've 
made real progress, but we can't get the full value of electronic 
health records until hospitals and providers from around the country 
can exchange patient information with each other.
    To what extent would expanding these small regional systems to a 
nationally interoperable electronic health record system reduce 
duplicative tests and how much money could that save our healthcare 
system?
    Answer 1. With most healthcare being delivered in a local or 
regional manner for the vast majority of patients, extending to a 
nationwide exchange likely would not dramatically impact those 
duplicative costs like a regional exchange does. A model more like 
Direct Exchange would support those cost reductions without the large 
expense of maintaining a nationwide health information exchange.

    Question 2. It is important that HHS is developing data standards 
for providers covered by the Meaningful Use Incentive Programs, but not 
all providers are covered by these standards and not all providers 
receive incentives for setting up Electronic Health Records. For 
example, nursing homes, independent laboratories, and behavioral health 
providers are exempt, and many of these providers have no electronic 
records system at all.
    Answer 2. The AAFP has been vocal in its advocacy for the need to 
develop data standards. It is clear that the amount of health data will 
continue to grow geometrically. Ultimately, this data will be most 
useful if it is standardized, i.e., encoded in a standard vocabulary 
(in the way that SNOMED CT and CPT are standard codes for diagnoses and 
procedures, respectively). The task of fully standardizing health data, 
however, is a monumental one and represents a very long process that 
will be achieved incrementally.
    Until a national consensus on data standardization emerges, at a 
minimum, EHR vendors should be required to use open application 
programming interfaces (open APIs). Open APIs facilitate the move 
toward interoperable health records by allowing developers to assist 
providers and patients to access and interpret health data that 
otherwise would be inaccessible. The committee's leadership in this 
area is critical--we cannot wait for data to be fully standardized 
before achieving interoperability. Health data ultimately belongs to 
the patient, not to EHR vendors, and an EHR vendor should not be 
permitted to ``hoard'' patient data in order to gain a business 
advantage. Of course, a mandate for a vendor to have an API does not 
redirect the business drivers against interoperability and subsequent 
data hoarding.

    Question 3. Is the ability to exchange information electronically 
with labs, residential care facilities, and behavioral health providers 
important to improving patient outcomes?
    Answer 3. Exchanging information among numerous stakeholders is a 
goal the AAFP shares with ONC.\16\ Having accurate information helps 
with care transition when patients are discharged from the hospital. In 
addition, it helps coordinate drug prescriptions and lab work. Many 
family physicians are using health information technology to partner 
with their subspecialists to integrate and improve patient care, 
including behavioral health providers.\17\
---------------------------------------------------------------------------
    \16\ Stream, Glenn, AAFP Letter to Farzad Mostashari, M.D., ScM, 
April 18, 2013, http://www.aafp.org/dam/AAFP/documents/advocacy/
health_it/interoperability/LT-ONC-Interoper-
abilityHealthInfoExchange-041813.pdf.
    \17\ Arvantes, James, AAFP News, Health IT Forges Medical 
Neighborhoods as FPs Collaborate with Subspecialists, August 6, 2013, 
http://www.aafp.org/news/practice-professional-issues/
20130816hietechnology.html.
---------------------------------------------------------------------------
    Health information exchanges (HIE) allow family physicians to join 
with local subspecialists and hospitals to create medical neighborhoods 
that provide seamless healthcare transitions and a more effective 
healthcare foundation. These HIEs represent a model for effective 
interoperability and continuity of care. Managing chronic health 
conditions require a behavioral health approach. HIT programs are 
helping promote the integration of primary and behavioral health, an 
important priority for patient-centered health improvements.
                                 ______
                                 
                          Epic Systems Corporation,
                                          Verona, WI 53593.

    Dear Senator Alexander and the honorable members of the HELP 
Committee: I thank you for the opportunity to testify on March 17th 
during the HELP Committee's hearing entitled, ``America's Health IT 
Transformation: Translating the Promise of Electronic Health Records 
into Better Care.'' Below are responses to the questions you sent me 
following my testimony.
    Please do not hesitate to contact me at [email protected], 608-271-
9000, if I can be of any further assistance.
            Sincerely,
                                             Peter DeVault,
                                                    Vice President.
                                 ______
                                 
 Response by Peter DeVault to Questions of Senator Alexander, Senator 
  Burr, Senator Roberts, Senator Cassidy, Senator Murray, and Senator 
                                 Warren
                           senator alexander
    Question 1a. With the rapid digitization of health data, is the 
industry effectively protecting personal health information?
    Answer 1a. The healthcare industry shares the cyber-security 
challenges that have affected other industries, such as banking and 
retail. We believe that healthcare, and every other industry, is at the 
beginning of an intensifying cyber-threat era that will require strong 
public-private partnership to ensure that we are protecting patient 
information.
    Healthcare data is much richer than financial or credit card 
information. For example, it can include Social Security numbers, 
illnesses, medical vulnerabilities, medical device information, 
birthdays, addresses, email and employment information and income data 
for customers and employees. In addition to data theft, there is also 
the threat of intentional disruption of medical devices.\1\ Malicious 
altering of electronic health record data could threaten lives.
---------------------------------------------------------------------------
    \1\ Healey, Pollard and Woods, ``The Healthcare Internet of Things: 
Risks and Rewards'' Atlantic Council in partnership with Intel Security 
http://www.mcafee.com/us/resources/reports/rp-healthcare-iot-rewards-
risks.pdf.
---------------------------------------------------------------------------
    The expanding value of healthcare data on the black market 
alongside increased hacker sophistication has made 100 percent 
effective cyber security in healthcare elusive. As we have seen in the 
recent attacks on Premera Blue Cross \2\ (11 million records), Anthem 
\3\ (80 million records), and Community Health Systems Inc.\4\ (4.5 
million records), we are an industry under attack by sophisticated 
domestic and foreign State-sponsored hackers.
---------------------------------------------------------------------------
    \2\ Finkle ``Premera Blue Cross breached, medical information 
exposed'' Reuters March 17, 2015 http://www.reuters.com/article/2015/
03/17/us-cyberattack-premera-idUSKBN0MD2FF201503
17.
    \3\ Abelson and Goldstein, ``Anthem Hacking Points to Security 
Vulnerability of Health Care'' The New York Times February 5, 2015 
Industry http://www.nytimes.com/2015/02/06/business/experts-suspect-
lax-security-left-anthem-vulnerable-to-hackers.html?_r=3.
    \4\ Bosshart, ``Data Breach Notification'' Community Health 
Services http://www.chs.net/media-notice/.
---------------------------------------------------------------------------
    According to the Identity Theft Resource Center, about 44 percent 
\5\ of all registered data breaches in 2013 targeted medical companies. 
Between 2013 and 2014, the number of breaches increased 60 percent 
\6\--almost double the increase seen in other industries--according to 
PricewaterhouseCooper's (PwC) Global State of Information Security 
Survey 2015.
---------------------------------------------------------------------------
    \5\ Li ``The Next Cybersecurity Target: Medical Data'' The 
Atlantic, March 2015 http://www.theatlantic.com/technology/archive/
2015/03/the-next-cybersecurity-target-medical-data/388180/.
    \6\ Harries, ``The prognosis for healthcare payers and providers: 
Rising cybersecurity risks and costs'' December 2014 http://
usblogs.pwc.com/cybersecurity/the-prognosis-for-healthcare-payers-and-
providers-rising-cybersecurity-risks-and-costs/.

    Question 1b. What additional resources would be valuable in 
encouraging organizations to prioritize health data security?
    Answer 1b. We encourage membership in the Health Information Trust 
Alliance (HITRUST) which is the most active cyber threat intelligence 
and incident coordination center in the industry.
    HITRUST \7\ is a group of healthcare, business, technology and 
information security leaders helping to ensure the security of personal 
information. Their programs \8\ help healthcare organizations 
understand current and probable threats, prioritize their cyber 
security efforts and share best practices for cyber threat defense and 
response. HITRUST is a federally recognized cyber Information Sharing 
and Analysis Organization (ISAO) and has partnered with the U.S. 
Department of Health and Human Services to conduct cyber threat 
briefings \9\ and preparedness exercises.\10\
---------------------------------------------------------------------------
    \7\ https://hitrustalliance.net/.
    \8\ https://hitrustalliance.net/content/uploads/2015/03/
HiTrustKeyPrograms.pdf.
    \9\ http://hitrustalliance.net/cyber-threat-briefings/.
    \10\ http://hitrustalliance.net/cyberrx/.
---------------------------------------------------------------------------
    HITRUST is best known for their Common Security Framework (CSF) 
\11\ which is now in its 7th major release. It is the most widely 
utilized approach by healthcare organizations and third-party risk 
assessments--adopted by 83 percent of the hospitals and 82 percent of 
the health plans. The Common Security Framework provides organizations 
with the needed structure, detail and clarity relating to information 
security tailored to the healthcare industry. The framework, along with 
sound risk management practices, harmonize with the requirements of 
existing healthcare standards and regulations including Federal (HIPAA, 
HITECH), third party (PCI, COBIT) and government (NIST, FTC).
---------------------------------------------------------------------------
    \11\ http://hitrustalliance.net/common-security-framework/
understanding-leveraging-csf/.
---------------------------------------------------------------------------
                  Standards Incorporated Into the CSF
     HIPPA: Security, Breach, and Privacy Rules
     ISO/IEC 27001, 27002, 27799
     CFR Part 11
     COBIT 4.1, COBIT 5
     NIST SP 800-53 Revision 4
     NIST SP 800-66
     NIST Cyber Security Framework
     PCI DSS version 3
     FTC Red Flags Rule
     JCAHO IM
     201 CMR 17.00 (State of Mass.)
     NRS 603A (State of Nev.)
     CSA Cloud Controls Matrix v1
     HHS Secretary Guidance
     CMS IS ARS
     MARS-E v1
     IRS 1075
     Texas Health and Safety Code (THSC) 181
     Title 1 Texas Administrative Code (TAC) 390.2

    Question 1c. Is the government offering proper guidance and/or 
resources to inform industry decisionmaking relative to data security?
    Answer 1c. The government could substantially improve private-
private and public-private cooperation by changing the current approach 
to health information security. More coordination is warranted, as 
opposed to more regulation, penalties, or the prospect of unlimited 
liability for those organizations whose data is breached. Much like the 
Patient Safety Act,\12\ we need to create a safe environment where 
groups who follow best practices can openly share safety issues so the 
whole industry can learn and aren't publicly and financially devastated 
by an attack.
---------------------------------------------------------------------------
    \12\ http://archive.ahrq.gov/news/newsroom/press-releases/2008/
psoact.html.
---------------------------------------------------------------------------
    Congress could create a better environment by (1) encouraging 
providers and health information technology vendors to adopt the 
HITRUST Common Security Framework (CSF), (2) creating a protected place 
to disclose breaches (HITRUST or AHRQ \13\), (3) declaring attackers 
who breach a CSF compliant organization to be a common enemy and beyond 
reasonable control, and (4) removing the legal liability of HITRUST CSF 
compliant organizations that are breached.
---------------------------------------------------------------------------
    \13\ http://www.ahrq.gov/.

    Question 1d. Is threat information readily shared throughout the 
industry? Or with other industries?
    Answer 1d. Yes, threat information is shared through HITRUST. Other 
organizations also receive threat information, publish recommendations 
and standards like the National Institute of Standards and Technology 
(NIST) \14\ and the combined effort of the International Organization 
for Standardization (ISO) and the International Electro-technical 
Commission (IEC) to support a family of mutually supporting information 
security standards (ISO/IEC 27000).\15\
---------------------------------------------------------------------------
    \14\ http://healthcare.nist.gov/.
    \15\ http://www.itgovernance.co.uk/iso27000-
family.aspx#.VTfd6JMyY9Q.

         If so, is the information useful?
          Answer. We have found participation in HITRUST very useful.

          If not, what incentives could be offered for 
        organizations to share threat information with other 
        organizations?
           Answer. Eliminating liability and fines for CSF-complaint 
        organizations would encourage the sharing of threat and breach 
        information.

    Question 2a. Half of the Nation's physicians have chosen not to 
participate in the Meaningful Use program to date. How can this change?
    Answer 2a. Simplicity and flexibility are the keys to encouraging 
participation.
    Over 70,000 physicians have participated in Meaningful Use (MU) 
using Epic's software, which is evidence that widespread participation 
is possible with good support. However, while our customers are on 
track in their attestations, portions of MU are burdensome and go 
beyond the definition of the meaningful use of an EHR. For many, 
especially those in smaller practices, the administrative costs 
outweigh the returns.
    On April 10th, we were encouraged by the Centers for Medicare & 
Medicaid Services (CMS) Proposed Rule \16\ with Meaningful Use changes 
for 2015 through 2017. As summarized by HIMSS, ``the new rule is 
attempting to reduce reporting burden, eliminate redundant and 
duplicative reporting, better align the objectives and measures of 
meaningful use, and focus Stages 1 and 2 of the Electronic Health 
Record (EHR) Incentive Programs on advanced use of EHR technology. Most 
importantly, this proposed rule would change the Medicare and Medicaid 
Incentive Program reporting period in 2015 to a 90-day period aligned 
with the calendar year rather a full-year reporting period.''
---------------------------------------------------------------------------
    \16\ https://s3.amazonaws.com/public-
inspection.federalregister.gov/2015-08514.pdf.

    Question 2b. Continually, physicians call for the all-or-nothing 
nature of the program to be rethought. Why are rulemakers so hesitant 
to adjust this rigid mandate?
    Answer 2b. We can't say what has caused their hesitation, but from 
the looks of the Proposed Rule, they are trying to adjust the program 
to provide more flexibility and simplicity.

    Question 2c. Are there any additional resources, other than 
additional incentive payments, that the Federal Government should 
provide to increase physician participation?
    Answer 2c. No. We do not believe additional resources are 
necessary. The resources that are already in place should evaluate the 
existing Meaningful Use requirements, eliminating those that have not 
been shown to improve patient care or decrease healthcare costs in 
proportion to the additional effort they require.
    Some requirements in Meaningful Use are not core to the 
individualized care of the patient, or in some cases apply an 
inappropriate one-size-fits-all approach. Although requirements are 
designed with good intentions, a number of them do not add value to the 
provider workflow. In some cases, Meaningful Use creates complications 
that inhibit usability and provider efficiency.
    CMS could also move to reimburse telehealth workflows and 
coordinated care beyond specific advanced payment programs such as 
Accountable Care Organizations (ACO), both of which necessitate the 
meaningful use of an EHR to be successful.

    Question 3a. The goal of HITECH was to improve patient care while 
decreasing costs--has there been a change in the cost to health care 
because of HITECH?
    Answer 3a. We have observed numerous examples statistically and 
anecdotally of our electronic health record system (EHR) reducing 
costs, increasing quality and access, and improving efficiency. This is 
caused by provider and patient adoption which was seen before, during, 
and after HITECH, both domestically as well as in countries that are 
not under Meaningful Use regulation.
    Examples include:

     The University of Iowa Hospital & Clinics saved $9.5 
million by using EHR decision support to reduce unnecessary blood 
transfusions.
     Lakeland Healthcare in St. Joseph, MI, used their EHR to 
reduce their average cost of care by $1.6 million.
     Sentara Healthcare in Virginia used EHR medication safety 
tools to avoid 117,400 potential med errors and saved $14.7 million.
     Kaiser Permanente achieved an estimated $1 billion in 
savings from reduced office visits and lab tests.

    HITECH reduced costs by increasing automation; Meaningful Use on 
the other hand has probably increased costs in certain domains by 
increasing software development, physician documentation, and reporting 
burdens.

    Question 3b. Since EHRs have become more common place, are there 
any metrics of public health improvement being observed?
    Answer 3b. Yes, we have observed numerous examples of our EHR 
enabling improved population health. MetroHealth, a safety net health 
system in Cleveland, OH, increased immunization compliance 54 percent 
over baselines and reports this data to the Ohio Impact Statewide 
Immunization Information System and the CDC.
    Essentia Health in Duluth, MN, uses Epic and home monitoring scales 
to prevent congestive heart failure (CHF) patients from being 
readmitted. Their 30-day readmission rate for CHF patients is less than 
2 percent, compared to a national average of 25 percent.
    Reliant Medical Group in Massachusetts uses our EHR for a rigorous 
diabetes management program. Their diabetes control is up 6 percent 
while costs per patient are $1,200 less than the average Massachusetts 
ACO.

    Question 3c. What can government do to further the goal of using 
this technology to decrease costs?
    Answer 3c. The government could simplify the Meaningful Use program 
to spur adoption and reimburse coordinated care and telehealth 
workflows which necessitate this technology.
    It has also been widely accepted that utilization costs will be 
reduced in tandem with payment reform. Likewise, health information 
exchange, which can reduce duplicative healthcare utilization and 
adverse medical events, can best be incentivized by value-based 
reimbursement arrangements (cf. Accountable Care Organizations) as 
opposed to fee-for-service arrangements.

    Question 4a. What are the biggest barriers inhibiting nationwide 
interoperability?
    Answer 4a. There remain four main barriers to increased nationwide 
interoperability:

     Technical capabilities: Not all providers are technically 
ready to exchange records. With so many eligible providers not 
participating in Meaningful Use, especially those not affiliated with 
large practices or integrated delivery networks, they likewise do not 
have systems that are Meaningful Use certified, or are not on the 
required version of that software, and therefore are incapable of 
robust health information exchange.
    In contrast, 100 percent of Epic EHR users are live with our Care 
Everywhere patient exchange platform, and 89 percent are interoperating 
with providers on other vendor platforms.

     Payment models: The move to value-based payment models 
where providers are compensated for coordinated care will likely 
increase the use of interoperability capabilities.

     National Rules of the Road for information sharing: 
Neither technical capability nor economic or clinical incentives can 
overcome the lack of a universally adopted national ``rules of the 
road'' and governance framework. In this absence, individual providers 
or healthcare organizations must forge individual data sharing 
agreements with each other, which may take months of legal discussion 
between the two entities.
    This problem was recently acknowledged in the ONC's 
Interoperability Roadmap. We are pleased that ONC has recognized 
Healtheway \17\ as a potential convener on the issues of national rules 
of the road and governance.
---------------------------------------------------------------------------
    \17\ http://healthewayinc.org/.
---------------------------------------------------------------------------
    Healtheway's Carequality \18\ initiative is the broadest collation 
of public-private healthcare stakeholders that include the United 
States' largest active exchange networks as well as smaller networks 
like CommonWell. In early April this year, Carequality released their 
national trust framework \19\ to accelerate national interoperability. 
In mid-April, 11 exchange networks,\20\ including Epic, agreed to 
rollout the national interoperability framework to connect over 200,000 
physicians. (CommonWell has been participating in the Carequality 
initiative but did not elect to be one of the early rollout 
participants.)
---------------------------------------------------------------------------
    \18\ http://healthewayinc.org/carequality/.
    \19\ http://healthewayinc.org/carequality-news/carequality-
introduces-trust-principles-for-secure-interoperability-among-u-s-data-
sharing-networks/.
    \20\ http://healthewayinc.org/carequality-news/carequality-
launches-national-framework-for-inter-network-interoperability/.

    Question 4b. What is the biggest barrier blocking providers from 
sharing information with each other? What is the biggest barrier 
blocking patients from sharing their information with different 
providers?
    Answer 4b. In addition to those items identified above, Stage 2 
being delayed from 1 year to 90 day reporting has delayed 
interoperability by 9 months; creating hardship exemption allowing 
organizations to attest to Stage 1 instead of Stage 2 which required 
interoperability caused further delays.
    If we simplify Meaningful Use to encourage more physician 
participation and reduce hardship exemptions and program delays, we 
would be on the doorstep of broad interoperability, enabling the 
healthcare ATM for patient records.

    Question 4c. Is ONC's nationwide Interoperability Roadmap a 
reasonable guide to widespread interoperability?
    Answer 4c. Yes. The core of the ONC Roadmap provides a reasonable 
guide to widespread interoperability. ONC should avoid over-regulation 
in this emerging space and instead encourage support of existing 
public-private partnerships that will foster creativity and lead to 
competition for low-cost, widespread interoperability.

    Question 4d. The lack of enforceable, consistent standards has been 
an industry concern. Does the 2015 Interoperability Standards Advisory 
fill the void? If not, what else can/should the Federal Government do 
to ensure a single set of standards is used within the industry?
    Answer 4d. Yes, assuming ONC focuses on the exchange of patient 
health information among providers. ONC should not mandate specific 
architectures, technologies, or design approaches, as these would 
inhibit innovation, openness, and competition. The industry has already 
coalesced on reasonable standards that allow providers to share records 
and continues to develop more robust standards and capabilities.

    Question 4e. Patient matching is a consistent concern raised by 
industry. How can government and industry ensure that patient data can 
be reliably shared across care settings?
    Answer 4e. A single, national patient identifier would be the best 
approach to addressing this issue. The industry has done reasonably 
well navigating the challenges of patient matching given the lack of 
such an identifier.

    Question 5. Physicians consistently voice concerns with product 
usability. What can be done to foster user-centered design rather than 
technology built to meet regulatory and billing mandates?
    Answer 5. Much of what the market is experiencing is not actually 
due to a lack of user-centered design. Rather, physicians are 
increasingly frustrated by regulatory requirements that dictate their 
workflows. Physicians we work with in other countries routinely express 
shock at the documentation requirements created to meet the regulatory 
and billing rules of the U.S. healthcare system.
    Fewer regulatory and billing mandates would lead to more satisfied 
users.

    Question 6. A lack of a ``business case,'' both for vendors and 
providers, is often cited as a hindrance to information sharing. What 
can be done to create the ``business case'' to generate 
interoperability?
    Answer 6. The current Meaningful Use incentive for interoperability 
in Stage 2 was not a sufficient step to encourage the adoption of 
interoperable electronic healthcare records systems. It required the 
technical capability to interoperate without changing the incentive 
structure that hinders it. Payment reform is the instrument that is 
needed to alter this incentive structure.
    As we move from process measures to outcome measures, methods to 
compensate providers for coordinating care across organizations will 
further increase the demand for and use of interoperability.
    All of Epic's customers have the technical capabilities to 
interoperate with other systems above and beyond what is required by 
the Meaningful Use program.

    Question 7a. Stakeholders often voice concerns that the electronic 
health record product as certified is quite different from the products 
deployed in individual care settings. How can we ensure that the 
certification program delivers capable technology not just upon initial 
testing but once deployed in the field?
    Answer 7a. We may not be in the best position to answer this 
question. This is not feedback we've received about our software, 
although we have heard it about other vendors. Our customers are 
leading the Nation in EP and EH attestations. We ensure all customers 
have the capable MU technology deployed.

    Question 7b. How can we create transparency in cost, satisfaction 
and vendor responsiveness?
    Answer 7b. This is already being done by impartial industry 
reviewers, such as KLAS, which survey healthcare organizations to 
evaluate vendors in many areas including user satisfaction, vendor 
responsiveness, and cost transparency.
    We fully disclose our costs prior to purchase and our users report 
high levels of satisfaction, as reported by KLAS, which ranks us #1 in 
health information exchange and highly for responsiveness and avoiding 
``nickel-and-diming'' (cost transparency).

    Question 7c. Does ONC have the proper resources to employ enhanced 
testing capabilities relative to the Certification Program?
    Answer 7c. Yes, we believe so.
                              senator burr
    Question 1. Please provide some insight into how products certified 
as being interoperable are not interoperable in every sense of the 
word. Why would an electronic health record, in many cases in which a 
doctor or hospital has already made a significant investment and that 
is certified to be interoperable, require additional interfaces with 
other health care providers outside of their facility?
    Answer 1. A purchaser of a certified EHR as certification is 
performed today should have the technical capabilities necessary for 
interoperability. The purchaser may still wish to contract for 
assistance in configuring the interfaces. Typical configuration may 
include initial setup, consent workflows, and implementation of State 
or local data sharing requirements. Additionally, a purchaser may need 
to contract with other third parties for connections to healthcare 
information service providers (HISPs), State or local HIEs, to obtain 
and load provider directories, or for certificate-granting authorities 
which enable secure authentication of parties exchanging healthcare 
information.

    Question 2. Will we reach a point in which the significant 
investments already made in health IT will realize lower costs? Or will 
the maintenance costs associated with EHRs prevent the overall cost 
savings from ever being realized?
    Answer 2. Yes. The vast majority of our EHR customers already 
report savings and lowered costs. As mentioned above, they experienced 
this before, during, and after HITECH. Former Kaiser CEO, George 
Halverson said that he attributed nearly $5 billion of savings a year 
to their Epic and other IT projects. Sentara's CIO, Burt Reese 
attributes over $53.7 million in savings in 2011 alone. Hawaii Pacific 
CIO, Steve Robertson, attributes Epic to saving their health system 
from bankruptcy. For Epic customers that may need more return on their 
investment, we have several programs to help assess their system use 
and create targeted plans to realize more savings.
    In our customers' experience, the overall savings and benefits of 
our EHR exceed their long-term maintenance costs. This is one of the 
reasons that many customers have moved to Epic's acute care EHR, but 
none have gone the other direction. For example, Cooper University, in 
New Jersey, chose Epic to lower their long-term maintenance costs. They 
calculated that by year three after implementation, the system will 
have paid for itself, saving the health system over $700,000 per year 
in IT savings alone.

    Question 3. In Dr. Wergin's testimony he states that,

          ``HHS should use its authority to strengthen certification 
        requirements to advance interoperability requirements and 
        improve EHR functionality.''

    In what ways could certification requirements be improved?
    Answer 3. Certification requirements as they exist today are 
adequate. Increasing these requirements will not result in better EHRs; 
the market will reward better functionality over time but only if it is 
not artificially distorted by burdensome regulation. As we discuss in 
previous answers, simplifying the Meaningful Use program will encourage 
broader adoption which will lead to higher levels of interoperability. 
We recommend that any EHR requirements mandated be specified at a high 
level while the design of EHR functionality be performed by the 
software developers and their clinical customers.
                            senator roberts
    Question 1. In your testimony, one of the reasons you cited for 
Epic not joining the CommonWell Alliance was the requirement during 
early stages of CommonWell's formation for members to sign a Non-
Disclosure Agreement. At the time of the hearing, were you aware that 
CommonWell does not currently require members to sign a Non-Disclosure 
Agreement?
    Answer 1. We were asked to sign an NDA with CommonWell after it was 
created and announced publicly. To the best of my knowledge, an NDA was 
still required at the time of my testimony. According to a Politico 
article published after my testimony, CommonWell changed that 
requirement.

    Question 2. Does Epic require any of its clients, business 
partners, or participants in the Care Elsewhere network to sign Non-
Disclosure Agreements? If yes, please explain why Epic believes those 
Non-Disclosure Agreements are necessary.
    Answer 2. No. We do not now and have not ever required a non-
disclosure agreement for the use of Care Everywhere, our patient record 
exchange platform.

    Question 3. Another reason you gave for Epic not joining the 
CommonWell Alliance was a concern about whether CommonWell data could 
be sold. Has Epic ever voiced that concern to CommonWell or its 
representatives? Did Epic receive any assurances that data could not be 
sold, and if yes, why did Epic nonetheless voice those concerns to the 
committee?
    Answer 3. In my testimony, I expressed concerns about the 
transparency of CommonWell's business practices.
    Information relating to CommonWell has been reported in the media. 
This includes their launch \21\ when they were presented as a 
repository-based model, their legal designation change and their 
changing membership requirements.\22\ CommonWell has released 
statements about not selling ``personal health data.'' CommonWell 
doesn't actually have patient data to sell. However, RelayHealth, the 
sole contractor for the transport of patient data in the CommonWell 
network, which was recently ordered to stop selling the VA's data,\23\ 
has historically monetized the information transported through its 
infrastructure. Other CommonWell members, like Cerner also have a 
history of selling de-identified data or data products. Epic does not.
---------------------------------------------------------------------------
    \21\ http://www.healthcare-informatics.com/news-item/report-epic-
wasn-t-invited-alliance-six.
    \22\ http://www.politico.com/morningehealth/0415/
morningehealth17818.html.
    \23\ http://www.amsus.org/wp-content/uploads/2014/05/June-2014-
Minutes.pdf.
---------------------------------------------------------------------------
    CommonWell's monetization strategy is still unclear although the 
CEO of McKesson, the parent company of RelayHealth, expressed 
enthusiasm for betting on CommonWell and RelayHealth to ``pay off '' 
during an earnings call \24\ (``So there's a bunch of interesting 
places that we're placing bets, including CommonWell Health, that we 
think will pay off.'')
---------------------------------------------------------------------------
    \24\ http://seekingalpha.com/article/2891376-mckesson-mck-q3-2015-
results-earnings-call-transcript?page=8&p=qanda&l=last.
---------------------------------------------------------------------------
    We believe that competition in the industry to provide low cost and 
successful exchange is important and we feel we can offer more to our 
customers and their patients through open standards and connected 
networks.
    One network will not solve all interoperability problems for all 
healthcare's stakeholders just as one bank can't solve all financial 
problems or one cellular networks can't connect the world. Networks 
(e.g., CommonWell, Epic's Care Everywhere, eHealth exchange, State and 
Federal HIEs) require a cell phone or ATM-like framework, a ``network 
of networks'' to get data moving smoothly through the systems.
    Epic's Care Everywhere exchanges with all CommonWell founders today 
(e.g., Cerner, McKesson, Allscripts, Athena, Greenway, etc). CommonWell 
is also participating with Epic in the Heathway's Carequality 
initiative that has just released an interoperability framework--the 
ATM-like framework for healthcare. Epic is one of the first 11 
organizations to pilot the rollout which will exponentially change the 
number of records exchanged in the United States.
    We fully expect patient records to flow across a wide variety of 
open, standards-based networks including CommonWell and Care 
Everywhere.

    Question 4. Your testimony focused a lot on Care Everywhere, Epic's 
interoperability tool for providers who use Epic. Your testimony 
indicated that for Care Elsewhere, the interoperability tool for Epic 
clients to share information outside of Epic systems, Epic charges on a 
per member per year basis. What is that cost? What is the median number 
of members for Epic clients who participate in Care Everywhere? What 
other fees might be involved to join and exchange information on Care 
Elsewhere, such as licensing fees, maintenance fees, consulting fees, 
or hourly labor fees, including instances when a client needs 
operational or technical expertise beyond what is included in Epic's 
standard contracts?
    Answer 4. At the time of my testimony, the charge was $2.35 for a 
record exchanged on the network. Since then, we have eliminated fees 
for Care Everywhere exchanges until at least 2020.
    Those costs were small and experts have told us we were one of the 
least expensive in the industry.
    Epic charges a standard hourly labor fee for building a Care 
Everywhere connection, whether that is the initial connection to the 
Care Everywhere network, a single connection to the eHealth Exchange or 
an HIE, or directly with another vendor's system at a different 
healthcare organization. The number of hours required to establish 
these connections varies widely based on the capabilities of our 
customer as well as the capabilities of the organization or vendor on 
the other side of the connection. Our goal is for such labor to be 
reduced as closely to zero as possible as the industry gains experience 
in building these connections.
    Care Everywhere is one of the largest exchange networks in the 
United States. Its participants include 320 healthcare organization 
comprising over 1,000 hospitals and 23,000 clinics. Every group that is 
live on our electronic health record system is live with Care 
Everywhere. Our customers rank us No. 1 for Health Information Exchange 
in KLAS surveys.

    Question 5. In a March 5, 2015, ONC Health IT Policy Committee 
Interoperability and Health Information Exchange (HIE) Workgroup 
meeting, Epic's President, Carl Dvorak, advocated for CMS to create a 
nationwide record locator service. Why should CMS spend government 
funds to stand-up such a network, when CommonWell Alliance already has 
a record locator service? Do Care Elsewhere, e-Health Exchange, or any 
other HIEs have record locator services?
    Answer 5. Carl Dvorak made the observation that CMS has the 
knowledge of all of the places a patient has been seen for services 
covered by Medicare and Medicaid and that as a result of this, 
healthcare providers could easily locate such patients' records if that 
knowledge were made available. The standard way to make that knowledge 
available would be through a record locator service (RLS). Other payors 
could easily do the same for the patients they cover.
    CMS doesn't need to set up an RLS, but they should provide an open 
data set so that another group could create an RLS to inform networks 
of where patients have received care (e.g., Care Everywhere, eHealth 
Exchange, State HIEs, CommonWell) and regulate pricing of open record 
locator services so search costs do not inhibit exchange.
    The largest record locator service in the United States is 
Surescripts. They have a master patient index of over 230,000 patients, 
span 700 electronic health record providers, 93 percent of all 
pharmacies and over 900,000 health professionals. We recently announced 
our connection to their RLS services which can exponentially expand our 
network's effectiveness to close the information gaps in care 
transitions.
    CommonWell's RLS service is new and has been described by 
CommonWell staff as currently supporting a small number of initial 
organizations and their patients.
                            senator cassidy
    Question. As a physician, I have concerns that mandated 
``meaningful use'' of health information technology such as EHRs, while 
providing useful medical data, has complicated physician-patient 
encounters and distracted the physician from what they have been 
trained to do--provide patients with personalized care and give 
patients their undivided attention.
    In over 46 States and in a variety of settings--emergency rooms, 
hospitals, urgent care clinics, and practices including OB/GYN, 
cardiology, orthopedics, and oncology--medical scribes are used as a 
means of significantly reducing the healthcare practitioner's burden of 
entering data into the EHR. The scribe accompanies a provider into the 
exam room and documents the physician-patient encounter into the EHR in 
real-time and at the point of service. This relationship allows the 
physician to spend more time delivering care directly at the patient's 
bedside and less time in front of a computer screen navigating EHRs. 
The use of a scribe allows a physician to focus on the patient and 
think clinically, not clerically. One of the unintended consequences of 
the ACA is that ED volumes have risen, some argue this is due to access 
to care issues. Scribes could help provide greater access to 
appropriate levels of care.
    I'm curious about how your products are being used by medical 
professionals in the ``real world.'' Are EHR capabilities being fully 
maximized in the marketplace today? Or do the EHR products and 
platforms that you (and your competitors) offer have robust features 
enabled that users are not currently employing (such as coding, ICD-10 
modules, Population Health Management and Care coordination)? After 
all, there's a limit on the amount of attention a physician can give 
the EHR vs. the actual patient during an encounter. As professionals 
that have been expertly trained in EHR use, would you agree scribes 
could enhance the degree to which useful features that currently sit 
fallow due to a physician's capacity to do only so many things at once, 
are utilized?
    Answer. Our customers have found scribes to be beneficial in 
certain settings such as the Operating Room or when documenting certain 
procedures in real time such as placing a stent into an artery of the 
heart.
    In general however, the use of most of the EHR features by 
clinicians themselves is still very important.
                             senator murray
    Question. Providers are reporting difficulty achieving meaningful 
exchange of electronic health information across electronic health 
records produced by different vendors. In other cases, providers report 
that creating interfaces between electronic health records produced by 
different vendors involves paying substantial fees to vendors. Why does 
it cost so much to connect electronic health records that have been 
produced by different vendors? Why is it more complicated to share 
clinical information than billing information?
    Answer. A typical billing transaction includes about 60 well 
defined fields, as exemplified in the CMS medical claim form.\25\ 
Fields include time, date, SSN, provider, charge code, diagnosis code, 
quantity, fee, etc. These are generally consistent across all clinical 
specialties and rarely change through time.
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    \25\ http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/
CMS1500805.pdf.
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    By comparison, clinical data is magnitudes higher in complexity 
than billing data. A typical ophthalmology exam might include over one 
hundred measurements and observations. An EHR that focuses on Bone 
Marrow Transplant might collect hundreds of data element specific to 
that specialty. There are more than 120 specialties and subspecialties 
recognized by the Association of American Medical Colleges. Each of 
these specialties has many data items unique to its practice and 
routinely identifies new measurements and data elements to collect. 
Consider genomics alone adding thousands of new data points and 
changing frequently with new discoveries. In addition, each specialty 
shares hundreds more data elements with other specialties.
    Flexibility is essential to allow growth and changes in data 
elements and definitions as our knowledge in medicine grows. The 
evolution of medicine will require that we continually modify and 
enhance our ability to share more and more clinical information through 
time.
    Cooperation in the industry is working to standardize more of these 
elements and to share them fluidly across multiple networks at a 
reduced cost. ONC is wise to focus on the Core Clinical Data Set, 
useful to all specialties, as defined in the interoperability road map.
                             senator warren
    Question. As you know, our electronic health record systems often 
have trouble matching a particular scan or a test result to the right 
patient, and those mismatches endanger patients. As more providers move 
to electronic health records and data bases contain records for more 
patients, the risk of mismatching information to patients only goes up. 
A 2008 RAND Corporation study estimated that even with database 
management software and personnel dedicated to preventing these 
mistakes, hospitals mismatch patient information about 8 percent of the 
time. A 2012 survey conducted by The Council of Health Information 
Management Executives found that one in five physicians encountered 
mismatched information that that put a patient at risk at least once 
over the previous year. Accurately matching health information to the 
correct patient record is critical to creating an electronic health 
information exchange that works. How can we reduce these errors?
    Answer. There are two kinds of patient matching errors that can 
occur: false negatives and false positives. A false positive means that 
you believe you've matched a patient's record but it is in fact the 
wrong one. The false negative means you believe there is no match when 
there actually is a matching record. The false positive is typically a 
much more severe problem. In our experience, false positives have been 
greatly diminished while false negatives have been significantly 
reduced over the years by using a few reproducible techniques. These 
techniques include:

     Using more durable identifiers. An example is a person's 
mobile phone number. While a patient may change her address many times 
and even her name, she usually retains her mobile number.
     Searching intelligently for record locations. Most 
healthcare is local--searching for a record near a patient's home or 
work address will usually yield the best results. This does require a 
searchable phonebook that is indexed by address. This is a cornerstone 
of Epic's national Care Everywhere platform and could be easily 
reproduced in other networks.

    In our experience these errors have been significantly reduced 
since the time of the studies you cited.

    [Whereupon, at 11:30 a.m., the hearing was adjourned.]

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