[Senate Hearing 114-651]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 114-651

   ACHIEVING THE PROMISE OF HEALTH INFORMATION TECHNOLOGY: WHAT CAN 
 PROVIDERS AND THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES DO TO 
         IMPROVE THE ELECTRONIC HEALTH RECORD USER EXPERIENCE?

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             FIRST SESSION

                                   ON

EXAMINING HEALTH INFORMATION TECHNOLOGY, FOCUSING ON WHAT PROVIDERS AND 
     THE DEPARTMENT OF HEALTH AND HUMAN SERVICES CAN DO TO IMPROVE 
               ELECTRONIC HEALTH RECORD USER EXPERIENCE?

                               __________

                             JUNE 16, 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, Republican Staff Director

                  Evan Schatz, Minority Staff Director

              John Righter, Minority Deputy Staff Director

                                  (ii)

  


















                            C O N T E N T S

                               __________

                               STATEMENTS

                         TUESDAY, JUNE 16, 2015

                                                                   Page

                           Committee Members

Cassidy, Hon. Bill, a U.S. Senator from the State of Louisiana, 
  opening statement..............................................     1
Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode 
  Island.........................................................     2
Alexander, Hon. Lamar, a U.S. Senator from the State of Tennessee    23
Murray, Hon. Patty, a U.S. Senator from the State of Washington..    25
Roberts, Hon. Pat, a U.S. Senator from the State of Kansas.......    27
Warren, Hon. Elizabeth, a U.S. Senator from the State of 
  Massachusetts..................................................    28
Collins, Hon. Susan M., a U.S. Senator from the State of Maine...    30
Franken, Hon. Al, a U.S. Senator from the State of Minnesota.....    32
Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin..    34
Casey, Hon. Robert P., Jr., a U.S. Senator from the State of 
  Pennsylvania...................................................    36
Murphy, Hon. Christopher, a U.S. Senator from the State of 
  Connecticut....................................................    38

                               Witnesses

Washington, Boyd Vindell, M.D., MHCM, President, Franciscan 
  Medical Group, Chief Medical Information Officer, Franciscan 
  Missionaries of Our Lady Health System, Baton Rouge, LA........     4
    Prepared statement...........................................     6
Pletcher, Timothy A., DHA, Executive Director, Michigan Health 
  Information Network Shared Services, Adjunct Faculty, 
  Department of Learning Health Sciences, University of Michigan 
  Medical School, East Lansing, MI...............................     7
    Prepared statement...........................................     8
Moss, Meryl, MPA, EMHL, Chief Operating Officer, Coastal Medical, 
  Providence, RI.................................................    15
    Prepared statement...........................................    16

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Response by Boyd Vindell Washington, M.D., MHCM to questions 
      of:
        Senator Alexander........................................    43
        Senator Bennet...........................................    43
    Response by Timothy A. Fletcher, DHA to questions of:
        Senator Alexander........................................    45
        Senator Bennet...........................................    46
    Response by Meryl Moss, MPA, EMHL to questions of:
        Senator Alexander........................................    46
        Senator Bennet...........................................    47

                                 (iii)

  

 
   ACHIEVING THE PROMISE OF HEALTH INFORMATION TECHNOLOGY: WHAT CAN 
 PROVIDERS AND THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES DO TO 
         IMPROVE THE ELECTRONIC HEALTH RECORD USER EXPERIENCE?

                              ----------                              


                         TUESDAY, JUNE 16, 2015

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:04 a.m., in 
room SD-430, Dirksen Senate Office Building, Hon. Bill Cassidy 
presiding.
    Present: Senators Cassidy, Alexander, Isakson, Collins, 
Roberts, Whitehouse, Murray, Casey, Franken, Baldwin, Murphy, 
and Warren.

                  Opening Statement of Senator Cassidy

    Senator Cassidy. The Senate Committee on Health, Education, 
Labor, and Pensions will please come to order. We're holding a 
hearing on how to improve electronic health record systems with 
a particular focus on the physician experience. Ranking Member 
Whitehouse and I will each have an opening statement, and then 
introduce our witnesses. After the witnesses' testimony, each 
Senator will have 5 minutes of questioning.
    First, I thank Chairman Alexander for calling this meeting 
and allowing me to chair this hearing on Achieving the Promise 
of Health Information Technology: What Can Providers and the 
U.S. Department of Health and Human Services Do To Improve the 
Electronic Health Record User Experience?
    You get on the internet, and oftentimes it's kind of crazy. 
On the other hand, every now and then, you come across 
something good. Jonathan Halamka, CIO of CareGroup Health 
Systems recently wrote,

          ``Providers are fed up with interface fees; how hard 
        it is to accomplish workflows required by the 
        accountable care business models, including care 
        management and population health; unsatisfied with the 
        kind of summaries exchanging, which are often lengthy, 
        missing clinical narrative, and hard to incorporate or 
        reconcile with existing records.''

    I will add on a personal note, as a physician, that time is 
better spent looking into a patient's eyes to make sure that 
she comprehends that even though she has cancer, there is hope, 
as opposed to clicking on a computer screen to document 
something unimportant to her but required by someone far 
removed from the exam room. This panel will discuss how to 
transform electronic medical records from that just described 
to something better.
    Over the past few months, this committee has identified 
specific areas where EHR implementation is falling short. One 
of these is the overly burdensome Meaningful Use requirement 
developed by HHS. It does not just affect older physicians--
kind of the curmudgeons who remember the old days, but young 
residents as well.
    Indeed, only 11 percent of eligible physicians have 
successfully tested for Stage 2 of the EHR Meaningful Use 
Program, even though penalties for noncompliance begin this 
year. This suggests that Meaningful Use requirements are so 
burdensome that many doctors will take a financial penalty 
because of an inability or unwillingness to comply with 
burdensome government standards.
    Another concern is the lack of interoperability between 
different EHR systems. We have heard that there are reasons why 
interoperability is difficult to obtain. There are coordination 
problems where vendors implement technical standards in 
inconsistent ways or adopt divergent privacy, security, or 
trust policies that govern how EHR information is exchanged.
    The committee has also heard, however, that some vendors 
and providers adopt business practices which block the flow of 
patient information. If this is true, it is inexcusable.
    To put it boldly, taxpayers put up $30 billion with a 
promise that there would be better coordination of care and, 
therefore, better healthcare, and it is alleged that what has 
been delivered are proprietary systems and information siloes 
serving business models. If true, this is wrong and breaks 
trust with those taxpayers and those patients.
    I look forward to hearing from the panel on these issues 
and what Congress and HHS can specifically do to reform the EHR 
program so that it empowers physicians and other providers to 
serve patients better and delivers upon the promise to those 
patients and to taxpayers that their information is being used 
for their benefit and not for the benefit of others.
    I now recognize Senator Whitehouse for his opening 
statement.

                Opening Statement of Senator Whitehouse

    Senator Whitehouse. Thank you, Chairman Cassidy. I want to 
particularly thank Chairman Alexander and Ranking Member Murray 
for the opportunity that they have given Senator Cassidy and I, 
to preside over today's hearing.
    Health information technology is key to enabling national 
priorities like the President's Precision Medicine Initiative 
and the transition to alternative payment models. It is 
critical national infrastructure and should be seen just like 
our highway system, and it will support a learning, improving 
healthcare system done right.
    While the HITECH Act spurred a tremendous leap in the 
adoption of electronic health record systems, I think we all 
agree that there remains room for improvement. EHR adoption is 
necessary but not sufficient, and it needs to be done well.
    That's why today's hearing, which highlights healthcare 
providers' experience using electronic health records, is so 
important. We have a lot to learn from providers' experience 
integrating EHRs into the practice of medicine.
    I very much respect my Republican colleague's concerns 
about the usability of EHRs and remaining barriers to the 
interoperation of different EHR systems. There is a lot of 
frustration to go around.
    But since we aren't going back to paper records, let's 
focus on what we can do moving forward. The HELP Committee is 
squarely positioned to put the building blocks of our health IT 
infrastructure firmly in place to improve transparency in the 
electronic health record marketplace, to empower providers to 
vote with their feet if they're not satisfied, and to identify 
best practices for deploying electronic health records as a 
care management tool.
    If we make progress on these issues, I think we'll see 
improvements in the usability of electronic health records, 
gains on electronic health record interoperability, better care 
for patients both in treatment and in prevention, and a new 
wave of IT innovation which is really the hidden promise behind 
all of this. I look forward to hearing the witnesses' testimony 
and to working with the HELP Committee to achieve these goals.
    If I could make an introduction, I'll let you make the 
others. While I have the microphone, may I proceed?
    It's my pleasure, last but not least in my comments, to 
introduce our witness from Rhode Island, Meryl Moss. Meryl is 
chief operating officer of Coastal Medical, a primary care-
driven medical practice that cares for 120,000 patients at 20 
offices across Rhode Island. Coastal Medical has also taken on 
the responsibility of becoming an accountable care organization 
and is a leader as a provider organization in that area 
already, earning wonderful results.
    As Coastal's chief operating officer, Meryl Moss explores 
new ways to deliver high-quality, patient-centered care while 
building business lines and the Coastal Medical brand. She 
studied economics at Boston University, received her master's 
in administration at the Carroll School of Management at Boston 
College, and is a graduate of the Brown University Executive 
Master of Healthcare Leadership Program.
    I'm delighted that she could come down here, and I thank 
the chairman for allowing me to make her introduction.
    Senator Cassidy. The next witness is Vindell Washington. 
Dr. Washington currently serves as the president of the 
Franciscan Missionaries of Our Lady Health System Medical Group 
and chief medical officer where he provides strategic 
leadership to the five medical groups across the health system, 
overseeing the services that directly support these practices 
and leading physician adoption of technology within the health 
system.
    This is the hospital where I continue to see patients, and 
when I'm cussing and fussing at the computer system, I think of 
Dr. Washington.
    [Laughter.]
    Dr. Washington is board certified in emergency medicine and 
still sees patients at Our Lady of the Lake Regional Medical 
Center in Baton Rouge. In addition, he oversees 500 physicians 
and advanced practitioners in more than 70 care locations, 
working to fulfill the regulatory requirements for EHRs, 
providing recommendations on how to translate the regulatory 
requirements into useful tools for clinicians to improve care.
    Our third and final witness is Dr. Tim Pletcher from East 
Lansing, MI. Dr. Pletcher is the executive director of the 
Michigan Health Information Network Shared Services, a public 
and private nonprofit collaboration to facilitate the exchange 
of health information in Michigan to improve the healthcare 
experience, increase quality, decrease cost.
    Dr. Pletcher is also an adjunct research investigator of 
learning health sciences at the University of Michigan Medical 
School and presents nationally on the topics of health 
informatics and data science.
    Dr. Washington, will you go first, please?

 STATEMENT OF BOYD VINDELL WASHINGTON, M.D., MHCM, PRESIDENT, 
 FRANCISCAN MEDICAL GROUP, CHIEF MEDICAL INFORMATION OFFICER, 
FRANCISCAN MISSIONARIES OF OUR LADY HEALTH SYSTEM, BATON ROUGE, 
                               LA

    Dr. Washington. Good morning, Chairman Cassidy, Chairman 
Alexander, Ranking Members Whitehouse and Murray, and other 
distinguished members of the committee. Thanks for that 
introduction.
    I'll just add a little bit more about our health system. We 
do take care of about 40 percent of the residents of Louisiana. 
That's about 70,000 annual discharges across the health system, 
220,000 emergency department visits across the State.
    The physician group I lead is a multispecialty group. One 
other bit of background information. Our health system uses a 
couple of--actually many--but a couple of major electronic 
health record systems: Cerner, predominately on the inpatient 
side, headquartered in Kansas City, MO; and Epic on the 
outpatient side. We do have some of those challenges with a 
couple of electronic medical records.
    I do practice predominately at Our Lady of the Lake 
Regional Medical Center. The location is in Livingston, where I 
do most of my clinical emergency medicine work. We were joking 
just before the start. I will be documenting in Cerner on 
Thursday when I see patients again, so I do have some firsthand 
experience on the topic that we're going to talk about today.
    It's an honor to appear before you today alongside this 
accomplished panel. My comments really will focus on the 
challenge of improving the user experience of electronic 
medical records. I certainly get a lot from my colleagues in 
the health system about how I can make their lives better. 
Senator Cassidy is not the only one who is cursing occasionally 
when we have to implement new care activities.
    Really, if you talk about the Federal activity around the 
American Reinvestment and Recovery Act, it's been a great 
change in healthcare and healthcare delivery. In particular, 
the major tenets within the act, the high-tech portion of the 
act, the activity around improving quality, reducing errors, 
engaging patients and families, and making information 
available across all care venues--they're really universally 
applauded. Most folks are excited about that possibility and 
that potential.
    However, those complaints that were mentioned earlier about 
increased burdens on the practitioner, loss of some of that 
interaction between providers and patients, and frustration 
with the new requirements that are put upon folks as workflows 
change have come to dominate some of the discussions among 
providers within our health system. Even as the capability of 
electronic health records to reduce errors and to improve 
communication has gone forward, there's really been a lot of 
stress as providers try to meet this adoption and take 
advantage of this new technology.
    I really just want to share a couple of ideas that I think 
could improve the overall user experience. I think one of the 
main drivers and one of the main activities would be to adjust 
the required documentation for billing and quality, to adjust 
that documentation to more accurately align with the new care 
models that are developing with electronic health records.
    As an anecdote, we spend a lot of time in the health system 
redesigning workflow based on those new capabilities in 
electronic health records. If you look at what we are required 
to document and how we are required to gather data and put it 
into the EMR, it's the exact same set of activities that were 
required before we used electronic medical records. In my mind, 
it has driven some of the technology and deployment.
    In my opinion, too much effort is spent recreating the 
attestation and documentation checkboxes that existed in the 
paper world, which are just no longer relevant as we switch to 
electronic medical records. As the industry switches from 
volume to value, this attention to rewarding and policing the 
individual work effort should be replaced by efforts to really 
reward outcomes of the activities with patients. Right now, 
that's not the case.
    Documentation really should be just that effort of 
gathering the necessary elements for providing care and 
continuity of care. That information then is used as a reminder 
to providers of the care, as opposed to documentation being 
about this policing activity.
    The electronic health records are really becoming capable 
of constructing these care documents as this care is being 
delivered. Sometimes, in my opinion, this effort is stymied by 
some documentation requirements both in the quality area and in 
the billing area.
    The second point that I'd like to make is really this idea 
of setting tighter standards for interoperability and 
standardizing some of the terminology. One of the things I 
think most physicians were prepared to expect as we went to 
electronic medical records is there would be a tradeoff. There 
would be more effort placed on actually documenting those 
encounters electronically, but the tradeoff would be that after 
that information was input, it would be easily exchanged and 
easily available across all of the areas that healthcare has 
provided. That really has not turned out to be the case.
    We have a lot of work that's been done. The Office of the 
National Coordinator of Healthcare Information Technology has 
been working on this for about a decade so far. It's certainly 
being ably led now by Dr. Karen DeSalvo, also a fellow 
Louisianan, and I think the 10-year interoperability plan that 
they produced is the right direction. My push would be to 
accelerate the activities in that plan.
    The idea of being able to exchange that information easily 
across those care venues is the goal. Currently, what happens, 
though, is that even if you take something like the clinical 
continuity of care document, which is the standard document to 
exchange, and you try to plug that from one EMR system to 
another or to one HIE, even though they meet the standards, 
there's a lot of work and a lot of re-engineering that has to 
be done for those documents to be available, much less 
individual data elements between those.
    I would say there's also some problem that rests with the 
fact that in medicine, we really never got to the area of 
standardizing terminology in the discussion points among 
providers. One example is around labs. There has been for about 
21 years now a lab documentation standard called LOINC, but 
even though that's a standard format that's been around, it has 
not been universally accepted that that's how we're going to 
refer to labs.
    So in one system, a complete blood cell count or a CBC or a 
red cell count--all those terminologies exist. Even when the 
communication is improved, the actual documentation of data and 
where those data elements go is not always that 
straightforward.
    Senator Cassidy. Dr. Washington, can you summarize the rest 
of your remarks, and we can move to questions?
    Dr. Washington. Yes, sir. That is the end of that portion, 
which was really about the terminology. I would say those two 
actions would foster more innovation, reduce unnecessary work, 
and provide more value to providers.
    Thank you.
    [The prepared statement of Dr. Washington follows:]
       Prepared Statement of Boyd Vindell Washington, M.D., MHCM
    Increased user adoption of electronic health records (EHR's) in 
clinical practice has not led to universally improved provider 
experience. Complaints of increased time burdens on the practitioner, 
loss of provider interactions with patients, and frustration with new 
requirements and changed workflows dominate discussions among providers 
even as the capability of EHR's to reduce errors and improve 
communication has grown. Federal action in the American Reinvestment 
and Recovery Act has pushed the adoption of technology in medicine in a 
way only wistfully contemplated in the past. The major tenets of 
improving quality, reducing errors, engaging patients and families, and 
making important information available appropriately, are almost 
universally applauded. Most would agree that despite the promise of the 
effort, there is much room for improvement in the provider user 
experience.
    Three Federal actions could improve the overall user experience by 
changing the environment in which these activities take place.
    Recommendations:

    1. Encourage development consistent with new clinical work flows by 
adjusting the required documentation for quality and billing. The 
current information workflow and documentation requirements are largely 
based on paper documentation efforts. For example, having providers 
place their initials on outside laboratory documents was a way of 
ensuring that providers did the work of intellectually engaging in the 
review and interpretation of important patient data. This type of 
activity was critical for ensuring that work was appropriately 
performed and a version has found its way into much of electronic 
documentation. Checking boxes to show that data was reviewed, or that 
tests were performed, or attestations of agreement with documentation 
performed by others on the healthcare team place unnecessary burdens on 
providers and do not substantially improve the care. It also lessens 
the value of providers practicing at the top of license. As the 
industry switches from volume to value the importance of documentation 
as a check and balance should lessen and providers should be rewarded 
more for expected outcomes. Documentation should consist of gathering 
the necessary elements for continuity of care--as a reminder to 
providers of the care provided on a certain date and time. 
Documentation in the new workflow should be a product of the care 
delivery. EHR's are becoming capable of constructing care documents as 
a product of information gathering, but this effort will be stymied by 
burdensome documentation requirements.
    2. Set tight standards for interoperability and standardize 
terminology. One of the important value propositions for providers in 
the digital age is the free flow of information. Having key clinical 
data from all points of care has been a challenge for decades and the 
speed of future clinical improvements will depend on our ability to 
aggregate data from disparate clinical systems. The Office of the 
National Coordinator of Health Care Information Technology, currently 
under the direction of Karen DeSalvo, has been a champion in this 
space. They have recently published a 10-year interoperability plan 
that outlines a way forward. Adopting and accelerating the standard 
will help meet this challenge. ONC should not unilaterally set the 
standard, but could both convene the appropriate stakeholders where 
necessary and most importantly, select the specific standards. For 
example, clinical continuity of care document (CCD) standards have been 
developed, but they are not necessarily compatible. A vendor may 
produce a certified CCD, but this does not mean that another vendor can 
translate it into an understandable format. A more specific standard 
would help in this regard.
    Some of the problems rest in the fact that there are many areas of 
medicine that don't use truly standard terminology; therefore, setting 
a technical standard will not fix all issues in this space. For 
example, in laboratory, Logical Observation Identifiers Names and Codes 
(LOINC) give a standard format, but variance still exists in whether 
all laboratory values in all clinical systems maps to this format or 
any single format. The lack of full standardization leaves providers to 
input discrete data into their system, without getting the benefit of 
cross communication between systems.
    3. Match patient engagement goals to markets; the effort should be 
about making choices available. Much effort across the country has been 
spent on moving the adoption needle on patient engagement technology. 
Making medical records digitally available to patients, improving on-
line access to providers and information, and sending information 
digitally to other care givers has been the focus. This effort has most 
recently been measured not by availability but also by adoption. The 
question on this effort is not the inherent value of adoption, but the 
relative costs. As the information provided becomes more valuable 
patients will use the tools provided.

    Senator Cassidy. Thank you.
    Mr. Pletcher.

  STATEMENT OF TIMOTHY A. PLETCHER, DHA, EXECUTIVE DIRECTOR, 
 MICHIGAN HEALTH INFORMATION NETWORK SHARED SERVICES, ADJUNCT 
FACULTY, DEPARTMENT OF LEARNING HEALTH SCIENCES, UNIVERSITY OF 
           MICHIGAN MEDICAL SCHOOL, EAST LANSING, MI

    Mr. Pletcher. Thank you, Chairman Cassidy and Ranking 
Member Whitehouse and distinguished members of the committee. 
My name is Tim Pletcher. I'm the executive director for 
Michigan Health Information Network, MiHIN. It is the State 
designated entity or the focal point for health information 
sharing across the State of Michigan.
    It's referred to as a network of networks. What that means 
is we basically manage the ecosystem for data sharing. We've 
actually enjoyed quite a lot of success over the last couple of 
years, getting roughly 6 million messages to sort of flow a 
week. This is a pretty major success.
    The key to that success is largely that we've been able to 
get everybody to work together. When I say everybody, I mean 
the government, the health plans, even the commercial health 
plans, and obviously the providers, to pull together.
    One of the keys to that success has essentially been 
something we call the Use Case Factory, which I'll talk about a 
little bit more. It's important to understand that a use case--
and I apologize for techno speak here--but a use case is a 
common approach used by technology folks to extract 
requirements from individuals so they know what to build and 
deliver of value.
    What we've done is we've kind of industrialized this use 
case approach into kind of being able to mass produce data 
sharing. The way we've done that is to identify what we want to 
do. For example, a use case is: We need to send data to the 
State registry, or we need to notify a doctor when her patient 
has been discharged from the hospital. Or a behavioral health 
specialist needs to communicate that they've made a potentially 
dangerous change to a care plan and has to reach out to a 
primary care physician that they mutually share.
    Those would be functional, high-level, non-techy things to 
do that, under the hood, are pretty sophisticated. What we've 
done in Michigan with this Use Case Factory is we've begun to 
basically itemize--well, what are the top things we need to do?
    Once we kind of rank order them--and we rank ordered in the 
State of Michigan something called Admit, Discharge, and 
Transfer notification, telling people when someone has been in 
the hospital. Then we formalize what's the value proposition 
around it--who wins, who loses, who needs to have this 
information--and then we take it to the next step, and we write 
something called a Use Case Legal Agreement that says, ``These 
are the rules of engagement. These are the expectations. These 
are the limitations around use.''
    Once we get that done, we then move on to something called 
an implementation guide. The implementation guide packages up 
the context for how we are going to solve this, and it 
identifies which standards we're going to use to make things 
interoperable.
    What we do next in that implementation guide is we say, 
``There's lots of choices in these standards. Here is exactly 
what you need to do to conform to how this is going to work.'' 
What that does is it drives a very rigid standard that we can 
actually ensure when we send things out that it will happen.
    It turns out not everybody is wildly excited about sharing 
their data. What we then do, once all that is working, once all 
that is packaged, once all of the pieces are dealt with, we 
then align incentives to that use case to motivate its 
adoption.
    I believe there's an opportunity for us to bump up the 
interoperability dialog nationally and begin to itemize the top 
use cases of priority, rank them, and say, ``What do we need to 
do functionally,'' and then to go to the next step underneath 
and build out exactly what it is going to take in which order. 
I think this will buildupon the really wonderful foundation 
that's been put forward. It'll help us accelerate the rate that 
we get to the vision that's basically outlined in the ONC 10-
year plan.
    [The prepared statement of Mr. Pletcher follows:]
             Prepared Statement of Timothy A. Pletcher, DHA
                                summary
    Michigan Health Information Network Shared Services (MiHIN) is 
commonly referred to as a network-of-networks and has enjoyed success 
in Michigan with a unique approach known as The Use Case 
FactoryTM allowing health care organizations to routinely 
share more than 6 million messages each week (See www.mihin
.org).
    MiHIN formally endorses the work by the Office of the National 
Coordinator on the draft interoperability roadmap, especially the 
Learning Health System core values highlighted. The States and multi-
stakeholder organizations such as Carequality, Commonwell Health 
Alliance, Direct Trust, the National Association for Trusted Exchange, 
and the emerging Learning Health Community are expected to play a 
critical role in advancing the progress and governance necessary to 
achieve the roadmap's vision.
    Michigan uses a process called The Use Case Factory based on health 
information sharing scenarios, or ``Use Cases''. Each ``Use Case'' is a 
valuable ``package'' of health information sharing: such as a pharmacy 
updating a State registry with a child's Immunization status, a 
hospital notifying a primary care doctor that her patient was 
discharged from the hospital, or a behavioral health specialist 
informing a primary care provider of a change to a mutual patient's 
care plan. This approach to data sharing governance combines a Henry 
Ford style assembly line mass production technique with the modularity 
of container shipping, all linked to a lean manufacturing process for 
continuous improvement. Building a Use Case Factory reduces complexity 
by breaking data sharing activities into manageable chunks so that 
technical, legal, competitive, financial, or confidentiality concerns 
can be addressed without ``boiling the ocean''. Incentives, regulations 
or policies can target specific Use Cases to foster or accelerate 
adoption and data sharing, and also allow more meaningful measurement 
to occur. For example instead of asking if a doctor or hospital is 
``connected to an HIE'', a more valuable question can be asked, is the 
hospital able to notify an unaffiliated doctor when her patients are 
discharged? When notified can the doctor's office followup with the 
patient within 48 hours? In Michigan targeted incentives related to the 
statewide Admission, Discharge, or Transfer (ADT) Use Case has 
resulted, in less than 2 years, in 93 percent of all admissions being 
made available to help providers coordinate the care of patients to 
reduce unnecessary re-admissions or Emergency Department visits. A 
recent adopter clinic saw their ability to support transition of care 
management rise from 3 to 5 patients per month, to 40 patients a month.
    Summary of Recommendations:

    1. Encourage HHS to establish the top 100 prioritized Use Cases, 
including both infrastructure Use Cases (e.g., provider directory, 
patient matching, identity, consent, secure transport, etc.) as well as 
more functional population health, clinical, consumer, and 
administrative Use Cases.
    2. Promote the establishment of a Use Case Factory in each State or 
jurisdiction and at a national level by beginning with the HHS Use 
Cases and leveraging State government and national multi-stakeholder 
groups accordingly.
    3. Encourage health plans to use Direct Secure Messaging (DSM) or 
connectivity to health information exchanges for some percent of their 
interactions with providers so those providers can use the same 
infrastructure for both clinical and administrative purposes without 
having to go backward to a fax machine. Similarly, encourage judicial 
systems & public health to align.
    4. Encourage health plans to use query capabilities such as the 
eHealth exchange and pay for HIT (like the Social Security 
Administration established through the MEGAHIT program) to obtain 
electronic medical documentation using Meaningful Use aligned 
approaches such as HL7 Consolidated Clinical Document Architecture (C-
CDAs) to support claims audits.
    5. Encourage HHS to work with Medicaid and Medicare health plans 
and also commercial plans to seek greater alignment and consistency on 
quality measures and to develop a ``report once'' process for quality 
measures.

    The Learning Health Community movement and perhaps a number of the 
other multi-stakeholder organizations implicitly envision as one of 
their key goals--interoperation (as opposed to interoperability, which 
is a capability versus an outcome)--as a driver of better human health.
                                 ______
                                 
    Chairman Dr Cassidy, Ranking Member Whitehouse and distinguished 
members of the committee, thank you for the opportunity to share my 
thoughts on the physician experience relative to health information 
technology and to offer some near-term and long-term suggestions to 
help improve upon the current State. My name is Tim Pletcher and I 
serve as the executive director for the Michigan Health Information 
Network Shared Services (MiHIN). MiHIN is Michigan's State designated 
entity for health information exchange and is commonly referred to as a 
network-of-networks enabling healthcare organizations to share 
information. MiHIN has enjoyed success in Michigan with a unique 
approach known as The Use Case FactoryTM allowing health 
care organizations to routinely share more than 6 million messages each 
week (See www.mihin.org).


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    To begin, I would like to formally endorse the work by the Office 
of the National Coordinator on developing the draft interoperability 
roadmap and call attention to the learning health system core values 
highlighted in the roadmap document. The ultimate goal of the roadmap 
is to establish

        ``a nationwide learning health system--an environment that 
        links the care delivery system with communities and societal 
        supports in `closed loops' of electronic health information 
        flow, at many different levels, to enable continuous learning 
        and improved health. This kind of system allows individuals to 
        select platforms and apps to share and use their own electronic 
        health information to meet their needs without undue 
        constraints.''

    To achieve this objective it will be important to recognize and 
support the work of a number of organizations in addition to each State 
that I believe will play a critical role in advancing the progress and 
governance necessary to achieve the roadmap's vision. These are 
Carequality, Commonwell Health Alliance, Direct Trust, the National 
Association for Trusted Exchange, and the emerging Learning Health 
Community.
    Even before Electronic Health Records (EHRs) and Meaningful Use 
entered the scene, providers were drowning from administrative or 
defensive medicine workloads. It is my observation over the years that 
providers routinely share as much information with those who pay for or 
regulate care as they do with other providers. Yet the health plan or 
payer community, especially the commercial health plans, have been 
remarkably absent from the meaningful use dialog and the associated 
data sharing. Providers have been encouraged to send a certain 
percentage of their transitions of care to other providers using 
specific technology like Direct Secure Messaging (DSM), yet all of 
their interactions with health plans are done either by a payer-
specific portal that requires the provider to remember another login ID 
and password or to use a fax machine. Likewise, increasing Medicare or 
Medicaid audit requirements has resulted in a significant increase in 
new requests by health plans for supporting clinical documentation from 
providers. A major opportunity exists to have the health plans begin to 
adopt the same data sharing approaches as providers. This will help 
ensure that providers do not bear the whole cost associated with 
establishing these Use Cases and will help guarantee that providers 
have increased value and incentive to adopt the Use Cases for clinical 
purposes.
    If we are to achieve the vision of a Learning Health System we need 
to prepare for ultra-large scale data sharing. While there has been 
considerable success in motivating hospitals and providers to adopt 
individual Electronic Health Record systems (EHRs), connectivity 
between those disparate EHR systems and networks, and standards for how 
data is captured, stored and communicated, involves complex and 
burdensome problems that cause considerable frustration in the lives of 
providers and their patients.
    To help illustrate the complexity of scale and the associated 
benefit of standardization versus an unsustainable point-to-point 
approach let me share a network math formula of N*(N-1)/2, where `N' is 
the number of health organizations being connected. At small numbers 
the quantity of connections and data sharing is very manageable: two 
organizations equals one connection, 5 organizations equals 10, and 25 
organizations equals 300 connections. Extrapolating to about 5,700 U.S. 
hospitals and 230,000 practices, however, and applying this formula, 
results in 26.5 billion point-to-point connections. This does not 
include dentists, pharmacies, public health offices, schools, food 
banks, the judicial and corrections system, and the multitude of other 
organizations that increasingly play an important role in the social 
determinants of health. This simple math helps illustrate why a design 
for interoperability is necessary and also shows that, as more 
organizations attempt to share data independently with point-point 
connections this becomes overwhelming, an increased waste of resources, 
and ultimately unsustainable.


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    To help simplify this interconnectivity problem in Michigan we have 
created a network-of-networks where we share services that are focused 
on unique health information sharing scenarios, which we call `Use 
Cases,' and which we manage through a process we call The Use Case 
Factory. Each ``Use Case'' is a valuable ``package'' of health 
information sharing: examples of Use Cases include a pharmacy updating 
a State registry with a person's recent immunization, a hospital 
notifying a primary care doctor that her patient was discharged from 
the hospital, or a behavioral health specialist informing a primary 
care provider of a change to a mutual patient's care plan. One may 
think of this approach to data sharing governance as a Henry Ford-style 
mass production assembly line combined with the modularity of container 
shipping, all linked to lean continuous process improvement.
    Building a Use Case Factory reduces complexity by breaking data 
sharing activities into manageable chunks so that technical, 
competitive, financial, or confidentiality concerns can be addressed 
without ``boiling the ocean.'' Incentives, regulations or policies can 
target specific Use Cases to foster or accelerate adoption and data 
sharing and also allow more meaningful measurement to occur. For 
example instead of asking if a doctor or hospital is ``connected to an 
HIE,'' a more valuable question can be asked, is the hospital able to 
notify an unaffiliated doctor when her patients are discharged? When 
notified can the doctor's office followup with the patient within 48 
hours?
    Each Use Case has its own value proposition, its own legal 
agreement transparently outlining rules of engagement or conditions of 
use including any costs. Equally important, each Use Case includes a 
distinct implementation guide removing all ambiguity about how to 
implement the data exchange standards so that interoperability is 
achievable.



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    For example in Michigan, targeted financial incentives from payers 
to providers related to the statewide Admission, Discharge, or Transfer 
(ADT) Use Case have resulted, in less than 2 years, in 93 percent of 
all admissions statewide being made available to help providers 
coordinate the care of patients to reduce unnecessary re-admissions or 
Emergency Department visits. Using Michigan's statewide ADT Use Case, 
recently one clinic saw their ability to support transition of care 
management rise from 3 to 5 patients per month, to 40 patients per 
month, a tenfold increase in care coordination.
    Finally, because specific incentives are directly linked to the 
statewide ADT Use Case, in addition to overcoming hospitals' initial 
reluctance to send ADTs, in order to continue the incentives hospitals 
have been asked to improve the quality and standardization of the data 
being sent as well as begin to support additional Use Cases such as 
Medication Reconciliation at Discharge, a Use Case that will help 
reduce the number of Adverse Drug Events (ADEs) and prescription 
errors. Adoption of a Use Case approach helps elevate the conversation 
so that it does not become mired in technology debates, but rather 
ensures that the clinical or business needs are driving the technology 
agenda and not the other way around.

    1. A first recommendation is to encourage HHS to establish a 
prioritization of the top 100 most valuable/important Use Cases.
    This would include the development of a formal value proposition 
for each Use Case Summary in the context of decreasing costs, improving 
the patient experience, increasing quality, or specifically reducing 
provider burdens. It would also require the development of focused 
legal agreements outlining for each Use Case the rules of engagement 
for sharing the data within that Use Case Agreement. Once these 
agreements are completed constituents can understand expected use of 
their data and follow a common chain of trust across organizations 
allowing them to consent to share their data for specific purposes and 
not be limited to either opt-in or opt-out at a high level. Finally, 
for each Use Case there should be an associated implementation guide 
describing exactly how to implement the underlying data standards to 
best support the function of the use case and insure interoperability. 
The implementation guides should include appropriate provisions for 
situations when multiple options for communication exist, such as when 
equivalent delivery standards may be acceptable viable alternatives.
    This initial list of 100 most important Use Cases should include 
both infrastructure Use Cases (e.g., provider directory, patient 
matching, identity management, consent management, etc.) as well as 
more functional Use Cases such as clinically relevant Use Cases 
(populating immunization registries, notifications of transitions of 
care, sharing lab results, care plan sharing, distributing death 
notices, etc.), Use Cases that enable research, and Use Cases 
associated with quality reporting and performance. Finally, some 
expectation for the required incentives needs to be identified to 
ensure that providers will have either the additional appropriate 
resources to adopt each Use Case or an anticipated penalty to motivate 
self-funded adoption.
    2. A second recommendation is to promote the establishment of a Use 
Case FactoryTM in each State or jurisdiction and at a 
national level by beginning with the HHS high-priority Use Cases and 
leveraging State government and national multi-stakeholder groups 
accordingly.
    This approach can accelerate the prioritization of data sharing 
efforts and help providers and their vendors prepare for more clearly 
defined functionality and understand why certain activities are desired 
versus compliance by simply checking off a requirement. It also offers 
a mechanism for health plans to align incentives to promote priority 
Use Cases at a local level.
    3. A third recommendation is to encourage health plans to use 
Direct Secure Messaging (DSM) or connectivity to health information 
exchanges for some percentage of their interactions with providers so 
those providers that have connected EHRs or DSM can use the same 
infrastructure for both clinical and administrative purposes without 
having to go backward to a fax machine once they have invested and 
overcome the onboarding process for using technology. Transactions 
related to priority Use Cases such as authorizations or care 
coordination are better than general communications.

        a.  Similarly, encourage legal staff and judicial systems to 
        use Direct Secure Messaging for some percentage of their 
        interactions with providers related to the release and exchange 
        of medical documentation and consent;
        b.  Encourage public health organizations to use Direct Secure 
        Messaging for at least some percentage of their interactions 
        with providers.

    4. A fourth recommendation is to encourage health plans to use 
query capabilities such as the eHealth exchange (like the Social 
Security Administration established through the MEGAHIT program) to 
obtain electronic medical documentation using approaches aligned with 
Meaningful Use such as HL7 Consolidated Clinical Document Architecture 
(C-CDAs) to support claims audits. Currently health plans send people 
out to clinics to conduct chart abstracting as the principle method for 
collecting of this type of information. Encouraging this dual use of 
query capabilities for both administrative and clinical purposes will 
help accelerate routine adoption on a broader scale and spread the 
costs across both the provider and payer community.
    Another major effort that will also help the physician experience 
is to align the commercial payer community better with Medicare and 
Medicaid activities. In Michigan we have begun a process to help reduce 
provider burdens related to better alignment of quality measures among 
commercial, Medicare, and Medicaid health plans and the physician 
community. The startling work of a MiHIN intern produced the Venn 
diagram below showing how few quality measures exist in common among 
the multitude of quality measures being collected. An examination of 
the measures available in the Physician Quality Reporting System 
(PQRS), the meaningful use stage two electronic clinical quality 
measures (eCQMs), the Healthcare Effectiveness Data and Information Set 
(HEDIS), and the Quality Rating System (QRS) resulted in only 14 
measures in common. Including the Medicaid core set in the comparison 
dropped the count from 14 to only five common measures. Further 
examination revealed that in Michigan and likely nationally each health 
plan has different data collection processes and different incentives 
linked to even those measures that are similar. One physician 
organization executive commented ``It's like the physicians are 
expected to work for multiple bosses at the same time''. Plan A wants 
one thing, Plan B wants another, and Plan C something different. A 
definite opportunity exists to allow providers to look at quality 
measures across their panel of patients without first having to be 
cognizant of which health plan the patient uses.


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    5. A fifth recommendation is to encourage HHS to work with Medicaid 
and Medicare health plans and also commercial plans to seek greater 
alignment and consistency on quality measures and to develop a ``report 
once'' process where providers are able to submit their quality and 
performance measures using one consistent means for their entire panel 
in a way that allows for important population segmentation, but does 
not require providers to experience unneeded duplication and extra cost 
to report the same quality measures to each individual health plan.

    In closing, the Learning Health Community movement and perhaps a 
number of the other multi-stakeholder organizations implicitly envision 
as one of their key goals interoperation (as opposed to 
interoperability, which is a capability versus an outcome) as a driver 
of better human health. These organizations are about working together 
to collaboratively realize an infrastructure built upon the fusion of 
technology, policy, people, and culture that leads to a national system 
for sharing health data to enable useful and rapid exchange that is 
governed, organized and operated by different levels of public and 
private multi-stakeholder collaborations.
    The Use Case Factory approach can help accelerate the creation of a 
secure information supply chain capable of evolving into a Learning 
Health System and prioritize the exchange of critical data, 
information, and knowledge aligned to improve health, reduce costs and 
enable an ever-growing list of Use Cases. Priority Use Cases will range 
from public health, surveillance, consumer engagement, new levels of 
clinical decisionmaking, empowering policymakers, to ultimately 
accelerating research to practice. Instead of interoperability being 
the end goal, there is an opportunity to enable the emergence of a 
culture of continuous and rapid learning in pursuit of protecting and 
advancing human health as the end goal, with achieving interoperation 
recognized as a driver, and interoperability being an essential enabler 
on the larger journey.
    Links of Significance:

    Michigan Health Information Network Shared Services: www.mihin.org.
    Carequality: http://healthewayinc.org/wp-content/uploads/2015/01/
Carequality
_Principles-of-Trust_Final_Carequality-template.pdf.
    Commonwell Health Alliance: http://www.commonwellalliance.org/.
    Direct Trust: http://www.directtrust.org/.
    Endorsers of the Learning Health System Core Values: http://
www.learning
health.org/s/LHS_Core_Values_Endorsements_80_06012015_V1.pdf; http://
www.learninghealth.org/endorsers/.
    National Association for Trusted Exchange: http://nate-trust.org/.
    Social Security Health Information Technology: http://
www.socialsecurity.gov/disabilityssi/hit/our-initiative.html.

    (Note: Due to high cost of printing attached examples of Use Case 
Factory artifacts are being retained in committee files.)

    Senator Cassidy. Ms. Moss.

 STATEMENT OF MERYL MOSS, MPA, EMHL, CHIEF OPERATING OFFICER, 
                COASTAL MEDICAL, PROVIDENCE, RI

    Ms. Moss. My name is Meryl Moss, as Senator Whitehouse 
said, and I'm the chief operating officer of Coastal Medical, a 
very large primary care group in Rhode Island. I can't tell you 
how excited I am to be here, and I thank Chairman Cassidy and 
Senator Whitehouse for inviting me. I want to give a nod to 
Senator Warren, who is my own Massachusetts Senator. I'm very 
honored to be here.
    Let me talk a little bit about Coastal. Coastal is a large 
physician group with 120,000 patients. We take care of about 20 
percent of Rhode Island, so kind of big fish in a little pond.
    We are so passionate about population health. We really 
feel like we can make a difference in the lives of our 
patients. We feel that with outstanding customer service, 
combined with improved quality, and reducing the cost curve, 
that we can actually do it. We can lead and move forward into 
this new healthcare environment.
    Just to give you a little bit of background, we were a 
Meaningful Use Vanguard practice. We are an NCQA Level III 
patient-
centered medical home. Every office is a patient-centered 
medical home and recognized. We adopted an E-ClinicalWorks 
electronic record in 2006, and in 2012, after lots of hard 
work, we won the National HIMSS Davies Award for most 
outstanding use of an ambulatory record in the country--so very 
excited.
    I wanted to talk a little bit about Meaningful Use for a 
moment. Let me go back and talk a little bit about our shared 
savings contracts. We are a Medicare ACO. We were very lucky 
that we were an advanced payment ACO and did well with that. We 
have met all the quality measures and are succeeding in that 
space.
    About 80 percent of our patients are now on shared savings 
contracts with some payer, whether it be Medicare or commercial 
payers. So we are sort of all in.
    One of our first recommendations is that programs like 
Meaningful Use continue. It made a big difference for us. What 
was so special about it is that it allowed us to get buy-in 
from our doctors. It combined what we thought was really good 
quality targets with financial rewards. The quality targets we 
never thought were jumping through hoops, and we felt that if 
we had to go to our doctors and say, ``You need to jump through 
hoops for this financial reward,'' they wouldn't have done it.
    Having those quality targets that we felt were real, 
combined with financial rewards that allowed us to hire 
infrastructure to support the record, in terms of clinical 
trainers and so on, and also have some money left over for the 
physicians, was really important to us for success.
    The other thing that Meaningful Use did was it gave 
standards to the electronic health vendors and said, ``You have 
to do these or people can't attest to Meaningful Use.'' It 
didn't leave it up to us to figure out who was able to attest 
or who wasn't. We knew that ECW had to meet certain standards--
at that time, it was CCHIT certification--and that if they did 
that, then we would be able to achieve Meaningful Use, and we 
have.
    Our second set of recommendations revolves around quality. 
Right now, Coastal is reporting on 129 quality measures. That's 
onerous. It's inefficient. It doesn't work well, although we're 
making them.
    What we did was said, ``We can't really live like this,'' 
and so we created what we call the Coastal Core. We took the 
highest standard, the highest measure of every measurement and 
brought them together, because CMS has different measure 
requirements than just Meaningful Use, which has different 
measure requirements than NCQA, which has different measure 
requirements than HQPAF and Five-Star and United and Blue 
Cross. By the way, those are always changing. We had to come up 
with something that was workable.
    We would recommend that the government consider having 
harmonized measures that we can all work with. We chose 30. It 
could be 20. It could be 40--whatever. It would be so much more 
helpful to practices like ours who are learning this new world 
and this new space to have something concrete to work with, and 
also to do something like they did in Meaningful Use and 
require the EHR vendors to support those quality measures and 
to support those workflows.
    My last recommendation is that we look at data analytics. 
We are now trying to bend the cost curve. We are in the 
population health space. You cannot do that without data. You 
cannot do that without data analytics.
    Right now, we get claims feeds from CMS, from United, from 
Tufts, and from Blue Cross, and we have a team of analysts who 
looks at the data, reviews it, analyzes it, and is looking for 
opportunities for us to intervene and provide better care at 
reduced cost. It is highly, highly inefficient.
    We think that data analytics should be embedded in the 
record. It should be combined with clinical data, and it should 
also be combined with quality data so that when we look at the 
patient, we're looking at cost, quality, and the clinical 
experience all together.
    That's my testimony, and I again thank you for allowing me 
to speak and sort of having a little bit of the front line. 
Thank you.
    [The prepared statement of Ms. Moss follows:]
              Prepared Statement of Meryl Moss, MPA, EMHL
                                summary
    Coastal Medical is a primary care-driven ACO that manages the 
quality, cost, and experience of care for 120,000 patients at 20 
community-based offices across Rhode Island. Providers work in a team-
based model of care, and a centralized infrastructure offers 
administrative and clinical services. All practices utilize the same 
electronic health record, and every office is NCQA Level III 
recognized. Coastal practices were amongst the first in the Nation to 
achieve Meaningful Use.
    In 2012, Coastal entered the Medicare Shared Savings Program (MSSP) 
and also implemented commercial and Medicare Advantage (MA) shared 
savings contracts. Coastal saved $7.2M and earned a shared savings 
payment in year one of the MSSP, and has since earned shared savings in 
other commercial and MA programs. The transition to population health 
management has driven the creation of a variety of innovative clinical 
programs, including a Medicare Annual Wellness Visit Center, a Diabetes 
Management Team, a Transitions of Care Team, and a ``Coastal 365'' 
clinic that provides urgent primary care visits every day of the year. 
These initiatives have improved quality, enhanced patient experience, 
and reduced costs.
    When Coastal first implemented an EHR in 2006, it was considered to 
be a tool for scheduling, billing, and documentation of care. Today, 
the EHR plays a crucial role in measuring and reporting quality of 
care, identifying cohorts of patients for specific interventions, 
closing ``gaps in care'', analyzing variation in performance amongst 
providers, enabling enhanced communication within office-based teams, 
and coordinating care with other providers.
    Federal incentive programs have supported evolution of the use of 
the EHR at Coastal. The Meaningful Use, Beacon Communities, Regional 
Extension Center, and other programs all promoted a higher level of EHR 
use by focusing on improving care for patients and providing revenue to 
build infrastructure and incent physicians. Given the current state of 
the industry, similar incentives appear to be needed for several more 
years.
    EHR certification standards have brought great value. Providers 
often do not have the expertise or bandwidth to ensure that required 
functionality truly exists in an EHR product. Coastal appreciated that 
CCHIT certification was necessary for Meaningful Use submission. 
Vendors rushed to comply and the physician community could be certain 
that certified EHR's would allow the practice to achieve Meaningful Use 
if used appropriately.
    The current complexity of multiple government and commercial 
incentive programs is daunting. Coastal now reports on 129 quality 
measures. ``Harmonization'' of quality metrics and other performance 
measures between government and private programs would greatly improve 
efficiency, and EHR certification standards could then be designed to 
support such standardized measure sets. Next generation EHR 
certification standards could also prescribe analytic capabilities to 
ensure that actionable financial and clinical data are analyzed and 
presented in an effective manner.
                                 ______
                                 
                      coastal medical: a snapshot
    Coastal Medical is Rhode Island's largest physician-owned and 
governed primary care driven ACO (Accountable Care Organization). 
Coastal manages the quality, cost and experience of healthcare for 
120,000 patients at 20 community-based offices across Rhode Island. Our 
84 physicians and 27 advanced practitioners work closely with nurse 
care managers and clinical pharmacists in a team-based model of care. A 
centralized infrastructure offers a broad range of administrative, IT, 
and analytic support functions to the office practices, as well as 
clinical programs that serve every Coastal patient. Most Coastal 
physicians hold ownership in the organization, and many serve in 
significant leadership roles.
    All practices utilize the same eClinicalWorks electronic health 
record. New practices that join are converted immediately to use of 
this EHR. The majority of Coastal patients receive care under one of 
six shared savings contracts based on total cost of care.
        coastal's journey to meaningful use and accountable care
    Coastal first implemented the eClinicalWorks EHR in 2006, and began 
pay for performance contracting shortly thereafter. This was our first 
foray into ``value-based payment''. In 2009, Coastal decided to make 
the patient-centered medical home (PCMH) model of care a cornerstone of 
its plan for the future. By early 2011, every practice had achieved 
NCQA Level Ill recognition.Coastal practices were also amongst the 
``Meaningful Use Vanguard''--the first practices in the country to 
achieve Meaningful Use of an EHR. In 2012, Coastal received the HIMSS 
Davies Award, given to just one ambulatory care organization in the 
country each year in recognition of ``utilizing health information 
technology to substantially improve patient outcomes while achieving 
return on investment.''
    In January 2012, Coastal implemented its first commercial and 
Medicare Advantage shared savings contracts with Blue Cross Blue Shield 
of Rhode Island, and then in July 2012 Coastal went live with both the 
Medicare Shared Savings Program (MSSP) and the Advanced Payment Model.
  success in accountable care, and the requirement of a sufficient ehr
    Happily, in Performance Year 1 of the MSSP, Coastal was able to 
reduce the total cost of care for its population of 10,000 Medicare 
beneficiaries by 5.4 percent below benchmark, pay all advanced funds 
back to CMS, and earn an additional shared savings payment from the 
MSSP. For every $6 saved by the Coastal MSSP ACO in Performance Year 1, 
$3 went to CMS, and $2 went to repay CMS the advances that were used to 
cover the incremental costs of providing accountable care. There was $1 
left for Coastal to reinvest or distribute. A portion of Coastal's 
shared savings payment from CMS was reinvested to support new clinical 
programs, and the remainder was distributed to every Coastal employee--
not just the physician owners. The shared savings distribution checks 
were hand delivered by Coastal leadership with a message of thanks for 
supporting all of the change that was required to achieve success. That 
change is ongoing.
    The transition to population health management has driven the 
creation of a variety of new and innovative clinical programs at 
Coastal. These include an Annual Wellness Center for our Medicare and 
Medicare Advantage members; a pharmacist-led Diabetes Management Team 
for blood sugar regulation and insulin titration, a Transitions of Care 
Team to ensure that patients transition safely from the emergency room 
and hospital to home, and a ``Coastal 365'' clinic that provides urgent 
primary care visits every day of the year. Coastal is also in the 
process of opening a specialty clinic to serve our highest risk cardiac 
and pulmonary patients, and is expanding a pilot of embedding 
behavioral health specialists directly in primary care offices.
    Our work in population health management has improved performance 
on quality, enhanced the patient experience of care, and reduced the 
overall cost of care. None of this success would have been possible 
without our CCHIT certified EHR.
                      the evolving role of the ehr
    When Coastal implemented an electronic health record in 2006, we 
had no idea that the electronic record would play such an important 
role in changing the way that we actually deliver care. Our initial 
notion was that the EHR would function like a glorified word processor. 
In 2006, providers, office staff and leadership were thinking of the 
EHR only in terms of scheduling, billing, and documentation of care. 
Over time, Coastal recognized the power of the EHR as a tool for mining 
data to guide proactive outreach and provision of care to patients. It 
also became clear that the EHR is an essential tool for communication 
between the professionals working in our office-based teams, and for 
coordination of care with community-based specialists and hospital-
based providers. Today we view the electronic health record first and 
foremost as an essential tool for population health management.
    It is interesting to note that in the early days of our electronic 
health record implementation, we were really forced by circumstances to 
begin the work of standardizing documentation. That exercise was a 
harbinger of our work today to accomplish standardization in so many 
more domains of care delivery, such as clinical quality improvement, 
patient engagement, cost efficiency, and customer service. In 2006, we 
simply could not foresee the crucial role that the EMR would play in 
population health management. Today, the EMR plays a crucial role in 
functions such as:

     measuring and reporting quality of care,
     identifying cohorts of patients (such as patients with 
diabetes) for specific interventions (e.g., our Diabetes Management 
Program),
     identifying and closing ``gaps in care'' (e.g., scheduling 
a procedure for a patient who is overdue for a screening colonoscopy),
     analysis of variation in performance from provider to 
provider (e.g., comparing how well one provider does in treating high 
blood pressure vs. her peers).

   the importance of federal incentive programs and the value of ehr 
                        certification standards
    Coastal providers have embraced the EHR. Incentive programs helped 
make that possible. The Meaningful Use, Beacon Communities, and 
Regional Extension Center programs supported a higher level of EHR 
functionality and EHR use in four concrete ways:

    1. They focused on improving care for patients;
    2. They provided a clear road map and guidelines for achieving 
program goals;
    3. They supplied dollars for infrastructure development and 
support; and
    4. They created a financial incentive for physicians.

    We would recommend that incentive programs continue to reward EHR 
adoption, interoperability, improved patient access, and improvement of 
performance on quality measures. This is still new work for many in our 
industry, and we are learning how to better care for populations of 
patients every day. These programs help us to focus on what is most 
important, and provide revenue for infrastructure support that is in 
short supply in many physician groups.
    In addition to financial support, the Meaningful Use program 
organized providers and vendors around a single set of measures 
designed to positively impact patient care. This was most important. 
Individual physicians and physician groups often do not have the 
expertise, sophistication or bandwidth to differentiate between 
individual electronic health records and ensure that the required 
functionality truly exists in an EHR product. We greatly appreciated 
the fact that CCHIT certification was necessary for meaningful use 
submission. Vendors rushed to comply and the physician community could 
be certain that the record would allow the practice to achieve 
meaningful use if used appropriately.
    As organizations embrace population health management and 
successive iterations of payment reform, we can see that the cause of 
improving performance of our health care system will once again be 
well-served if certification standards can stay out ahead of where most 
providers are working.
            one solution to redundancy: the ``coastal core''
    We believe that tracking and reporting on quality truly makes a 
difference in the care of patients. However, the complexity of this 
work has been daunting at times. Coastal currently reports on 129 
different quality measures, many of which differ only slightly among 
payers. To help channel our providers' focus, we created the ``Coastal 
Core'': 30 streamlined measures with a single set of instructions. 
Coastal created processes in each practice that are focused just on 
these 30 measures, and we hired and trained quality staff to audit 
progress. We track our performance on these measures each month. Every 
day our offices use Coastal Core ``exception reports'' and ``alerts'' 
to close gaps in care.
                ehr certification: core quality measures
    We are coming to the realization, through our most recent 
experience, that there should be harmonized quality measures that all 
medical groups can use as a standard. The government uses one set of 
measures for CMS ACOs and a different set for Meaningful Use. Insurers 
require us to achieve different quality targets and these are ever-
changing. NCQA requires different measures as well. All are good, but 
many are overlapping. This just creates unnecessary complexity and 
confusion.
    If CMS and commercial payers were to establish an agreed upon 
``core'' group of quality measures, and if electronic health vendors 
were driven to support that ``core'' through certification standards, 
this could greatly improve the efficiency of quality measurement, 
quality reporting, and quality improvement across our industry. The 
physician community could be certain that whatever record that they 
purchased would have the basic functionality to manage the core 
measures that should be used by insurers, the government and 
accrediting bodies. It is worth noting that several State-based 
collaboratives have already attempted to ``harmonize'' quality measures 
in order to reduce the burden of measurement and reporting and allow 
aggregation of performance data relative to a standard set of 
performance metrics. An analogous process on a national level would 
likely yield significant benefit and produce substantial systemwide 
cost savings.
       ehr certification: analytics, both clinical and financial
    One of Coastal's biggest challenges has been in the area of data 
analytics. We are fortunate that we receive claims files from CMS, 
United, Tufts, and Blue Cross. However, extensive work needs to be done 
by our analysts to process those files in a way that helps us to 
understand how we can intervene with patients to impact the quality and 
cost of care. This work is currently very costly and inefficient. 
Smaller physician groups probably cannot afford to make the investment 
needed to do this work, and in which case the cost of investing in 
analytics becomes a barrier to their entry into population health 
management and new payment models.
    We believe that this is another area where the physician community 
could use help. We are moving to population health management and this 
work is virtually impossible without the right information. We would 
recommend that future iterations of EHR certification criteria include 
a requirement that data analytics capabilities be integrated into the 
electronic health record, so that both the financial and clinical data 
can be analyzed and presented in an efficient and effective manner. 
This would reduce the need for labor intensive and expensive ``manual'' 
report preparation by analysts.
    Some vendors have already developed this technology as an add-on. 
Coastal has worked very closely with eClinicalWorks, our EHR vendor, to 
design an integrated solution for some of the analytic functionalities 
that ACOs will require, and we are just now poised to go live with this 
new analytics platform. We will need such tools if we are to succeed in 
our mission to provide better care, better health, and lower cost of 
care for the populations we serve.

    Senator Cassidy. Thank you, Ms. Moss. Thank you all.
    Mr. Pletcher, before the meeting started, I was speaking to 
Dr. Washington. At the hospital where he serves, they have Epic 
as an outpatient, Cerner as an inpatient despite a lot of 
effort with a lot of money spent on the middle where the two do 
not communicate.
    When I read your testimony, you described yourself as a 
network of networks, and that one hospital could speak to your 
network and your network would speak to another hospital, 
limiting the number of interactions that would have to occur. 
We've heard how these programs don't talk to each other. Does 
Epic talk to your network, and, in turn, does your network then 
talk to Cerner?
    Mr. Pletcher. Yes, for certain use cases. The Epic 
hospitals and the Cerner hospitals all send out alerts or 
notifications that----
    Senator Cassidy. I got it. Your use case would be something 
essential regarding discharge planning, but it wouldn't be the 
entirety of the note.
    Mr. Pletcher. Exactly.
    Senator Cassidy. I think you also discussed the 
bidirectional.
    Dr. Washington, you mentioned the problems that we have--I 
guess it would be Epic for your outpatient, so the pediatrician 
does the immunization, but it does not feed into the 
immunization registry, and the registry does not speak back to 
the program. Is that a fair statement?
    Dr. Washington. Yes, sir.
    Senator Cassidy. Again, it sounds like your use case would 
give you that capability. Correct?
    Mr. Pletcher. Yes. We have a submit immunization use case 
that is working very well, and we've just opened up for 
business the query for immunization use case, which, again, 
happens technically under the hood a little bit differently.
    Senator Cassidy. Dr. Washington.
    Dr. Washington. Mr. Chairman, I was just going to expound 
upon that answer. We are able to submit information to the 
LINKS registry in Louisiana. We've done that for a couple of 
years now. There are two elements. One is just the amount of 
work and effort it takes to do that and the amount of tweaking 
and retooling as upgrades and those other things happen. It 
requires a lot of maintenance to keep that working.
    The State system is not an EMR system. There's another side 
of that equation for this two-way communication that you're 
speaking about.
    Senator Cassidy. The CBO originally scored the HITECH Act 
as saving money over the long run because they thought there 
would be more efficient transfer of records. It seems as if 
that promise probably has not been realized.
    Ms. Moss, I was intrigued by what you were saying. I was 
speaking to a specialist earlier, and he was saying how, 
ideally--say, ophthalmology, gastroenterology--there would be a 
bidirectional flow where the gastroenterologist could report if 
she reached the cecum--the furthest extent of the colon on a 
colonoscopy--it would automatically filter up into a registry, 
and then it would come back to a dashboard in which she could 
compare herself to colleagues. That sounds kind of like the 
data analytics which you're describing.
    Ms. Moss. Yes. I think that if we had those dashboards--and 
that's why we're saying if we could convince or regulate the 
EHR vendors to have certain workflows within the record. I 
think it's very important that we compare with each other.
    Senator Cassidy. I only have 2 minutes left, so I'm going 
to ask you quickly. 21st Century Cures mandates that there's 
going to be a government agency that's going to set these 
standards. I'm a little nervous when the government attempts to 
regulate anything as dynamic as software standards.
    There is another private organization, CommonWell. I'm told 
all participate except for Epic, and this would somehow come up 
with standards in which all could speak, one to the other.
    Real quickly, Dr. Washington, would you rather the Federal 
Government convene this or that we basically force everybody to 
go into a voluntary organization, where it's all voluntary but 
you'd better sign up?
    Dr. Washington. I guess my opinion on it is there needs to 
be some agency or group that says this is the standard that we 
will follow. I think it is a rapidly moving activity, and if I 
were able to outline what that would look like, it would more 
likely be a stakeholder group where that group comes up with 
standards.
    Some of that's been done. LOINC, for example, that I 
mentioned earlier, was done without a regulatory agency. After 
that's done, it has to be sort of singled out. The Federal 
Government may be the only group after that stakeholder group 
that----
    Senator Cassidy. Mr. Pletcher.
    I didn't mean to cut you off. I'm almost out of time.
    Dr. Washington. Yes, sir. Go ahead.
    Mr. Pletcher. I listed in my written testimony a number of 
multi-stakeholder organizations that are equivalent to 
CommonWell. I think there's a role for all of them. I actually 
think the conversation needs to bump up to a higher level.
    Senator Cassidy. Would that be the Federal Government?
    Mr. Pletcher. The use cases could come out from the Federal 
Government. The standards then could be partitioned among 
whoever is best to sort of deal with that particular domain 
area.
    Senator Cassidy. Ms. Moss.
    Ms. Moss. We're not policymakers. But I can tell you from a 
practical level we could really use these kinds of standards.
    Senator Cassidy. You're agnostic as to who establishes them 
as long as they're established?
    Ms. Moss. Yes.
    Senator Cassidy. Thank you.
    Senator Whitehouse.
    Senator Whitehouse. Thank you, Chairman. I think from 
reviewing everybody's testimony that there's quite a lot of 
agreement among the entire panel, and I'd like to just 
summarize a few points where I think we have agreement.
    We seem to have agreement that when you consider the amount 
of money that's been spent on electronic health records through 
the Meaningful Use Program compared to the amount that supports 
information exchange, we've been heavy on the former and light 
on the later. The exchange part, the networking part, is where 
we need to pay more attention now. Is that something that 
everyone would agree with?
    Mr. Pletcher. Yes.
    Senator Whitehouse. I think I'm summarizing everybody's 
testimony pretty fairly there. The second is that there are 
administrative and regulatory elements to what is required now 
through the H.R. process that could stand to be reduced or 
automated. I think Dr. Washington was most clear on that, but I 
assume everybody agrees with that.
    Mr. Pletcher. Aligned, I would say. I think there's a lot 
of opportunity to bring them--everybody's asking for roughly 
the same thing. It would be nice if they asked for exactly the 
same thing.
    Senator Whitehouse. Then there's some elements that I think 
everybody sees as the key to a successful electronic health 
record. One is that it creates a platform so the medical 
provider can engage in a better way with the patient. We may be 
great people, but we're terrible patients.
    To have support, where our personal data equipment can 
somehow support that doctor-patient relationship so that we 
become better about taking medicine, better about reporting 
results, better about doing the things we need to do, and maybe 
get a friendly prompt from a nurse at the practice if we're not 
getting it in, that would be an important goal for the 
electronic health record system to improve. Correct?
    Mr. Pletcher. Absolutely.
    Senator Whitehouse. We need to do a better job of figuring 
out what data needs to get where when, because flooding all of 
the data into systems creates data blizzard. That's an 
important goal as well that you all accept?
    Dr. Washington.
    Dr. Washington. There may be even a pretty high degree of 
consensus on the amount of that blizzard that you want to 
exchange. I think people settle on use cases because it's the 
thing that's achievable. I want an admit, discharge, and 
transfer document.
    I would like more than that if a patient has been seen and 
I'm seeing them in the emergency department. That's the thing 
that I can get at the easiest. That's how I would expound on 
that.
    Senator Whitehouse. The third sort of element of the 
electronic health record that seems to be very important to 
everybody is that we find a way to simplify and clarify the 
quality targets so that there isn't such a, again, data 
blizzard. Ms. Moss mentioned that she had 192 that she had to 
try to collapse down to 20.
    Dr. Washington, you said that your organization had 300, I 
believe.
    Dr. Washington. Yes, inpatient and outpatient. Yes, sir.
    Senator Whitehouse. My experience is that when you've got 
that much data, people are a lot less accountable about when 
they meet the standard because they can find some other 
standard where they did OK, and now it's a who struck John 
about which standard comports. It's not as effective a driver 
toward quality as if we simplified it.
    So there are two benefits I take from that. One is 
simplification, and you know what your target is, and it'll 
tend to be the better standard, and two is there'll be more 
accountability toward those standards. Is that something that 
you all agree on?
    Mr. Pletcher. Yes.
    Dr. Washington. Yes. I would also add the billing 
requirements as well. They are as much of a driver of 
additional documentation as is meeting the quality targets.
    Senator Whitehouse. That's a really terrific point and one 
that we should pay a lot of attention to, because the billing 
morass that doctors have to deal with--I went to the Cranston 
Health Center at Cranston, RI, the community health center, a 
couple of years ago. They told me they had more people fighting 
billing than they had providing medical care.
    That's a system that's gotten a little out of hand. When 
you have multiple providers and nobody's synchronizing what 
their billing requirements are, there you are, stuck again.
    The last thing I'd suggest is that on a lot of these 
issues, if we empower the local health information exchange, if 
we empower CurrentCare in Rhode Island, if we empower MiHIN--is 
that what you call it--in Michigan, they can be a forum for 
sorting through a lot of those issues without having to get the 
Federal Government engaged in doing a national thing.
    Obviously, you want some national standards that they 
comport with. In terms of the application, I'd love to see 
State by State, network by network, a lot of exciting work 
being done to try to coordinate in these areas. It's hard for 
us to do that when the support for, say, CurrentCare in Rhode 
Island is so intermittent and so weak compared to the river of 
money that flows into Meaningful Use.
    With that, I'll yield back my time, and I thank you.
    Senator Cassidy. Senator Alexander.

                     Statement of Senator Alexander

    The Chairman. Senator Murray and I asked Senator Cassidy 
and Senator Whitehouse to chair this hearing as one of the 
series that we have as a committee to try to make the 
electronic medical record system become something that realizes 
its promise, something that physicians look forward to rather 
than dread, and something that helps take better care of 
patients.
    We're seeking to identify five or six things that need 
fixing in the next 6 months to a year, working with the 
administration. If the administration can fix those things, 
great. That's better. If we need to include some of this in the 
law that we'll be passing the beginning of next year, we'll do 
that. So I thank them for that.
    Senator Collins will chair a hearing on who owns the 
medical records. We think we know who owns them, but who has 
the control of those. These are important, and these are 
something that--we have working groups, bipartisan working 
groups, that are already at work on several areas, and we 
intend to get a result.
    Let me ask this question of the witnesses. Electronic 
healthcare records became law in 2009. Money began to be 
delivered in incentives in 2011. About $28 billion to $30 
billion has been provided. We've gone through Meaningful Use 1 
and 2.
    We have two new rules that were promulgated in March, which 
would take us into what we call Meaningful Use 3. Those are 
supposed to become final this fall and to be implemented in 
2018, although everyone will have to start working on that 
implementation right away.
    I was visited yesterday by the CEO of the Mayo Clinic who 
said they have been trying to have a single medical record 
since 1907. Ten years ago, they had 10 different systems, but 
they weren't speaking to each other. Now they're down to four. 
They're headed toward one.
    They're starting the process of converting that. It will 
take 500 people 4 years at a cost of over a billion dollars to 
get their 4,700 physicians and 1.3 million face-to-face 
patients onto one vendor system and still maintain the single 
medical record. That's a big hospital organization, but that's 
just one. We have half a million doctors, and 5,000 hospitals 
that are affected.
    My question is this: I, for one--and I suspect most of us--
we don't want to slow down the promise of electronic medical 
records because we know it can save lives and help care for 
patients. Would it be wiser to slow down the finalization of 
this rule that's scheduled for this fall until we, working with 
the administration and physicians and doctors, have a chance to 
work on these suggestions about physician documentation, about 
who controls their own data, about data blocking, and make sure 
that the rule that you're required to implement is the right 
rule so that we can work toward a system that doctors and 
hospitals look forward to rather than dread?
    Or would it be better just to push on ahead? Or would it be 
better just to push on ahead with some parts of these two new 
rules in the fall and reserve judgment on the rest while we 
continue to work on it? What would your advice be about that?
    Dr. Washington. Well, I'd say that I've probably learned 
more about interim final and final rules from the Meaningful 
Use standards in the last 4 years than I ever have, and I think 
that sort of goes toward your last comment, which is to say is 
there a way that we can say this is a good metronome for us. It 
keeps us on track if we keep the spirit of the Meaningful Use 
activity live but pay close attention in this interim period 
that you're describing to make sure that the rules that come 
out for Stage 3 do advance us and not hinder us in our progress 
forward.
    I think that's kind of how I would view it. We have parts 
of that activity that have been very beneficial for us in 
setting standards from a health system perspective. We've also 
had changes in the hearings up to the final rules that have 
been adjustments that have been very common since--out of ONC.
    The Chairman. Mr. Pletcher and Ms. Moss, if Mayo Clinic is 
spending over a billion dollars in the next 4 years, everybody 
else is spending billions more. What's your advice?
    Ms. Moss.
    Ms. Moss. We can't do any of this work without the record, 
and we can't do it without really using it robustly. I think 
what Meaningful Use did was it forced people to use it 
robustly. We can't improve quality if we can't measure it, if 
we can't track it.
    I'll tell you we thought we were fantastic. You would ask 
any of our physicians, all Ivy League educated, and they would 
have said they hit it every time, and you know what? They 
weren't because we weren't measuring it. We were doing a good 
job, but now we're doing a better job.
    Some of our quality targets are so outstanding that we know 
we have to be improving the care of patients, and the record is 
helping us do it. We can't go back.
    The Chairman. Could I get an answer from Mr. Pletcher in my 
time left?
    Mr. Pletcher. I think we absolutely have to stay the 
course. I think we have to be more specific, but, absolutely, 
stay the course. We're getting better across the board. We're 
all learning, and it's been an incremental process, and that's 
been very good.
    Even the quality measures, which are such a challenge in 
Meaningful Use 3, start to bring that into alignment and look 
at electronic clinical quality measures. I say we're on the 
right track, but we do have opportunity to improve. But, yes, 
stay the course.
    The Chairman. Thanks, Mr. Chairman.
    Senator Cassidy. Senator Murray.

                      Statement of Senator Murray

    Senator Murray. Well, thank you very much, Senator Cassidy, 
for chairing this hearing and to you and Senator Whitehouse for 
contributing, and a lot of members of our committee 
contributing to a very important discussion. I really 
appreciate that.
    Health IT is absolutely essential to improving the quality 
and value of care for patients, and, as Senator Whitehouse 
referenced in his opening remarks, it's going to be invaluable 
in advancing precision medicine. Physicians are having a very 
hard time finding a user friendly electronic-healthcare record 
system that meets their needs.
    I was really concerned to hear recently that there's a 
study that found that many electronic health-record vendors 
don't even have a team dedicated to user-centered design. In 
fact, one vendor with over a billion dollars in annual revenue 
and over 6,000 employees has zero employees dedicated to user-
centered design.
    That's why we need to make sure providers are able actually 
to vote with their feet when a system isn't meeting their 
needs, and more pressure from providers will actually force EHR 
companies to compete based on the quality of their systems.
    Ms. Moss, I wanted to ask you what kinds of information 
would empower providers to be smart shoppers for EHRs and force 
vendors to compete on the quality of their product.
    Ms. Moss. I think it's really hard. This is really 
sophisticated stuff. Even in a group like ours, where we can 
spend a lot of time and we have infrastructure to be comparing 
one record against another and to go with one vendor against 
another, this is very hard. That's why we believe that 
standards would be incredibly helpful.
    We have other work to do. We have to change the care we 
deliver for our patients. We really don't want to spend time 
deciding what vendor we're going to use.
    Senator Murray. A lot of our providers are really concerned 
about the number of quality measures they're required to report 
on. You've all referenced that. Those reporting requirements 
aren't just from the HITECH Act, by the way. They're from other 
medical care quality programs and even from quality initiatives 
that run in the private sector by commercial insurers.
    That is actually one of the reasons why the Center for 
Medicare and Medicaid Innovation is experimenting with a multi-
pair demonstration that aligns not only the financial 
incentives, but also the quality reporting requirements. In 
Rhode Island--Ms. Moss, Rhode Island and Coastal Medical have 
been leaders in multi-pair demonstration programs. Can you talk 
a little bit about that and how you think that's helping?
    Ms. Moss. I think what you're talking about is CSI or CTC.
    Senator Murray. Correct.
    Ms. Moss. I don't think that we would be where we are right 
now if we hadn't started there. CTC--CSI at the time--was a 
multi-demonstration project, as you said, where all the payers 
got involved and they really invested in patient-centered 
medical home.
    It really started us on our journey, and we've been able to 
move away in some ways from patient-centered medical home and 
now move into population health. None of that would have been 
possible without that foundation.
    Senator Murray. All right. Focusing on quality improvement 
is no easy task for doctors, Dr. Washington. I'm sure you would 
assume that. It requires keeping a lot of details in mind, and, 
meanwhile, you're interacting with a patient who's sitting in 
front of you.
    Not only that, but the science of measuring quality is 
still developing, which means a lot of our providers have a 
limited set of quality measures to choose from. It's especially 
true for providers in very specific subspecialties.
    At our last committee hearing, Dr. Payne of the University 
of Washington testified that requiring that electronic health 
records work off of a set of standard data building blocks 
would make it easier to document quality measures and to 
develop new quality measures.
    Dr. Washington, do you agree that working off a standard 
set of data building blocks could streamline the way that 
providers document the quality of care?
    Dr. Washington. I think I understand what you're talking 
about in terms of building blocks. We do have considerations 
when we talk about how to put together numerators and 
denominators for certain quality metrics as they come forward. 
If that was put together in a more modular way, I think that 
would be helpful.
    We've struggled with that idea as well of having a 
multispecialty group and having subspecialists with very few 
defined quality standards. Even some of the agencies like the 
National Quality Foundation don't have a slew of choices for 
those providers.
    We've actually gone to talk about more patient-centered 
care and looking at some of those chronic diseases even with 
those subspecialty providers and, depending on their own 
clinical mastery and other drivers, to have them do the right 
things for their super subspecialized activity in the meantime. 
But, yes, I do believe some of that building block strategy 
would be helpful as we move forward.
    Senator Murray. Thank you very much.
    Thank you, Mr. Chairman.
    Senator Cassidy. Thank you, Senator Murray.
    Senator Roberts.

                      Statement of Senator Roberts

    Senator Roberts. Well, thank you, Mr. Chairman, and I'm 
happy to be here to witness the first peaceful coup I've seen 
in a committee in a long time. So I congratulate Senator----
    Senator Cassidy. I think I am a regent.
    [Laughter.]
    Senator Roberts. I appreciate the committee's commitment to 
oversight of our Federal investment in the electronic record 
system and continued work toward achieving the goal of 
interoperability. This is a $35 billion Federal investment in 
expanding the use of electronic health records, and it was sold 
on the promise of improving care and lowering cost. I think 
we've all said that and understand that.
    Many doctors have adopted it as technology, whether they 
wanted to or not, and are seeing benefits. The majority of docs 
that I hear from in Kansas tell me that the administrative 
burden on them is taking away from their time with their 
patients. A Wichita doctor told us,

          ``We're basically key-punching operators, 
        transcriptionists, having to input the data ourselves. 
        It has essentially tripled the time to complete a 
        medical record. How on earth do you accomplish that 
        when you're already working 12 to 14 hours a day?''

    Couple this individual, but common, plea for relief with a 
medical economic survey from last year that says nearly 70 
percent of physicians think their electronic health systems 
have not been worth it, and you can see the real problem that 
we're facing. Obviously, the system needs to work for our 
providers, and they need to see the benefits of improved care 
coordination to validate their financial time and investments.
    Dr. Washington, are you able to quantify or estimate how 
much of your doctor's time is spent on functions or, as you say 
in your testimony, checking boxes that, prior to our electronic 
system, nurses or assistant staff would otherwise perform?
    Dr. Washington. Senator, I'm not sure if I can actually 
quantify that. Certainly, in our studies--we've done studies on 
how long it takes to do transcribed medical orders in the 
hospital versus electronic orders, and, certainly, the overall 
time of the physician at the computer to do that has increased.
    I will say when I talk to physicians about adoption in that 
space, though, that the clinical decision support tools that 
are within those EMRs that are the safety tools really only 
work if you, as the provider, are inputting the data. You get 
those alerts. You get those directions from the computer to do 
those activities.
    Once you place an electronic order in the hospital, every 
division in the hospital that needs to act on that order gets 
it right away, as opposed to the old days in our practice where 
you would do rounds, and you would depend on the unit secretary 
to take your chart down, and you may be fourth or fifth in 
line, depending on what was going on before that order got sent 
to lab and some other places in the health system.
    Those are, in some ways, the tradeoffs that happen. There 
is certainly a burden that's been increased by the electronic 
health record. The balance in my mind is to try to make sure 
that there is some value around the clinical decision, 
important things that we didn't do as well on paper.
    Senator Roberts. Let me ask you the obvious question. Do 
you think there's some documentation that nurses and other 
physician extenders can do as part of the care team to reduce 
the time and burden on physicians?
    Dr. Washington. Yes. In fact, one of the things I was 
trying to reference in the testimony about billing is that 
there's a requirement now that we had literally trained on last 
week that, as a provider, I have to go behind a scribe or a 
technician and attest that a document that I'm already signing 
electronically--that I agree with what they've already 
documented.
    That is all in this sort of billing and regulatory 
perspective. A review of systems requires an attestation by 
them, an attestation by me, and a signature at the bottom of 
the record in order to pass the billing hoops. To me, that 
takes away the advantage of having those folks practice at the 
top of their license.
    Senator Roberts. I'm concerned----
    Ms. Moss. Senator Roberts, could I comment as well?
    Senator Roberts. Yes, ma'am.
    Ms. Moss. We did a survey on our physicians last year about 
their satisfaction with the record, and it was not good. They 
said that they were working until the evening. When we really 
investigated, what we found was that the record itself drove 
all the work to them. I don't know if it was because it was a 
documentation tool to begin with and like a glorified progress 
note.
    We spent the last year ripping that apart, and now our 
doctors do not do that. We've created workflows where nurse 
care managers and pharmacists and medical assistants do that 
kind of work. We're going to be surveying our doctors soon, and 
we're really hopeful that they have felt a tremendous 
difference.
    Senator Roberts. Let me ask you a followup question on 
that, Ms. Moss. From your experience in upgrading and 
implementing the EHR systems, what's the range in financial 
costs you are anticipating in transitioning from Stage 2 
Meaningful Use to Stage 3?
    Ms. Moss. I can't answer that. I don't know, sir.
    Senator Roberts. Well, there you go.
    I'm worried about the interoperability, Mr. Chairman, that 
is required to meet the financial investment that these medical 
groups and hospitals are making. It's like siloes in the 
intelligence community--not quite, but perhaps.
    My time has expired. I thank you, Mr. Chairman.
    Senator Cassidy. Thank you, Senator Roberts. Just to let 
everyone know, our next Senators to ask questions are Senator 
Warren, then Collins, Franken, Isakson, Baldwin, Scott, Casey, 
and Murphy in the order in which they came.
    Senator Warren.

                      Statement of Senator Warren

    Senator Warren. Thank you, Mr. Chairman. According to a 
2013 survey by the Massachusetts Medical Society, nearly every 
doctor in the commonwealth that works in a practice with 10 or 
more providers and 75 percent of doctors in smaller practices 
use electronic health records. Unfortunately, more than two-
thirds of the physicians in these small practices reported that 
implementation of an EHR either significantly or somewhat 
slowed down their practice.
    Here's the key. That same survey asked doctors what they 
would recommend to fix EHRs, and the No. 1 answer they gave is 
to make their system exchange medical information with other 
doctors.
    I'd like to start with you, Ms. Moss. How has Coastal 
Medical's EHR, which exchanges patient information with major 
hospitals in Rhode Island, helped improve patient care?
    Ms. Moss. I can't even tell you the difference. I've got 
some measures here and I'm looking at influenza for our folks 
over 65. Flu vaccines save lives. In 2012, we gave shots to 57 
percent of our patients over 65; last year, 93 percent. I think 
we could say we could have saved a life or two there.
    BMI--same thing, 64 percent 3 years ago; now 93 percent of 
our patients have BMI measures in followup. If we can share, as 
you say, with specialists--and we're really just starting that. 
We get direct feeds right now from CurrentCare in Rhode Island 
for all hospital admissions, ER. We have a transitions team 
that's just helping those patients transition back to the 
office and home.
    I think we're making a difference every day, and without 
that information, we wouldn't know what to do.
    Senator Warren. Well, that's very helpful, Ms. Moss. Thank 
you very much.
    Doctors have been willing to work hard. They've invested 
time and they've invested money to implement these systems 
because they were promised that EHRs would accomplish three 
things: they would improve efficiency, they would decrease 
cost, and they would help the doctors provide higher quality 
care, as Ms. Moss just spoke to.
    For those doctors who are part of practices that have the 
resources and the will to make their systems exchange data with 
other providers, it appears that that promise has been 
fulfilled or is certainly along the way. For most doctors 
around the country, especially doctors in small practices 
without the resources of a large healthcare system, there's 
still a long way to go.
    Clearly, the technology exists to make interoperable 
records that can exchange patient information. Doing so can be 
both costly and have administrative burdens.
    Mr. Pletcher, what barriers did you have to overcome to 
establish the Michigan Health Information Network Shared 
Services which promotes the regional exchange of health 
information?
    Mr. Pletcher. I'll tell you shortly about a statewide ADT 
use case that's letting doctors know when their patients have 
been in the hospital. Typically, doctors know that about 27 
percent of the time on their own, but the rest of the time, 
they don't.
    When we first asked all the hospitals to start sending this 
notification out, they were highly reluctant. When we packaged 
up the use case, and then we were able to get incentives behind 
the use case, essentially, part of their population health 
incentives paid them to say, ``You must send, or you don't get 
the incentive,'' and they all started sending in a very short 
order of time.
    Then incentives lined up with doctors being able to receive 
that same message. If I graph the utilization and the adoption, 
remarkably, it tracks to how the incentives were paid out or 
when the deadlines for them occurred.
    This results in real patient value. It shifts some of the 
workload sometimes away from the doctor to other folks. I just 
attended a presentation last week where a care coordinator, 
basically, who was doing maybe three to five transitions of 
care activities a month is now doing 40 a month. That's a 
tenfold increase.
    Some of those things are little things, where they notice a 
pattern that a patient has been going to the emergency 
department on a regular basis on the afternoon on Saturdays, 
because, theoretically, they're lonely. All they do is place a 
call on Friday, saying,

          ``By the way, Ms. Jones, we're open on Saturday until 
        noon if you want to come in, and you're scheduled for 
        an appointment in a couple of weeks,''

and they say, ``OK,'' and it's just enough to tip the balance.
    There's lots of little things that can fix this problem. 
It's sort of death by a thousand cuts. People are trying to 
swing for the fence when, really, it's lots and lots of little 
tiny things that add up to make a difference.
    That's why it's so important to not just think of this as 
all around the doctor, which is very important, but also the 
implications. Those extra minutes that a provider takes helps 
inform a much wider circle of people that can interact and take 
care of the patients, too, and ultimately help reduce the sort 
of demand in some cases for overworked and busy providers.
    Senator Warren. I want to thank you both, and I know I'm 
out of time here. I just want to say that you make it clear 
that we need to create interoperable healthcare record systems 
so that all the doctors and their patients and everyone who is 
trying to help the patients can realize the promised benefits 
of a health exchange system. Interoperability is a top concern 
for doctors in Massachusetts, and I hope this committee will 
take real steps to address this problem.
    Thank you, Mr. Chairman.
    Senator Cassidy. Thank you, Senator Warren.
    Senator Collins.

                      Statement of Senator Collins

    Senator Collins. Thank you, Mr. Chairman.
    Dr. Washington and Ms. Moss, I want to touch on four issues 
that I have heard about repeatedly from physicians. The first 
has to do with physician satisfaction. Senator Roberts 
mentioned the survey that showed that some 70 percent of 
physicians say that their electronic health record system has 
not been worth it. Another study done by Rand said that the 
EHRs are the leading cause of physician dissatisfaction.
    In Maine, I'm hearing from physicians telling me that it 
takes time away from the face-to-face interaction that they 
value with their patients, that they have to keep turning their 
back to the patient to enter data, to answer questions, that 
they really need scribes so that they can focus on the patient.
    The second issue is relevance. I've heard complaints that 
the questions that are being asked are not relevant in a lot of 
cases, that they're not, for example, adjusted for the 
patient's age, that the focus is on checking the boxes rather 
than on outcomes and the quality measures that you've 
mentioned, Ms. Moss.
    The third issue is cost. It's not only the penalties for 
doctors that are going to be imposed by CMS, but a physician in 
Maine, a gastroenterologist, who has a very small practice told 
me that he was looking at costs in excess of $200,000 in order 
to adopt the latest electronic health record for his small 
practice. That's no small amount if you're in a small practice.
    And fourth is the frustration over the lack of 
interoperability. I remember very well a few years ago visiting 
a federally qualified community health center in Maine that had 
adopted an electronic health record which it could share with 
other community health centers in Maine. I asked the question, 
``Well, can you share with the local hospital where your 
patients will go?'' The answer was no, much to my amazement. 
That may have been fixed now, but it was amazing to me that 
that wasn't built into the design.
    So I'd like your thoughts on the satisfaction issue for 
physicians, the relevance of the design of the electronic 
record, the cost, and interoperability.
    Dr. Washington. Thank you for the question. I think that 
the provider satisfaction and the interoperability and the 
relevance of the data that's asked or that's part of that 
process--they're all related. I think that if you're really 
talking about that physician experience, part of it is the tool 
that I'm using helping me get through my day.
    I think the capabilities are certainly there. I am 
certainly a champion of the electronic medical record from a 
use perspective. There have been lots of occasions where having 
some data at my fingertips has been helpful in making me either 
think about a diagnosis or a treatment pattern that I would not 
have otherwise or helped me not prescribe a medication that a 
patient had an allergic reaction to that I would have had to 
dig through the chart to find otherwise.
    But your point is well made in that the promise was that we 
could get that information about allergies or other treatments 
from all care venues, and it's just difficult. The technology 
does exist, but the actual implementation and the cost pieces 
are very difficult to overcome.
    Senator Collins. Ms. Moss.
    Ms. Moss. I'd like to take a step back. I represent a 
primary care group. Five years ago, they were miserable. We 
could not hire a resident out of training. Nobody wanted to go 
into primary care. I didn't even think we were going to have 
primary care providers for all of us baby boomers as we aged.
    Going into this new value-based medicine and population 
health and really focusing on quality and reducing fee for 
service, our physicians are much happier. Our staff are 
happier, and our patients are happier. Our physicians like 
happy patients, and they also like happy staff. We have staff 
doing things that they would never have thought of before. They 
were glorified tour guides moving people from room to room.
    I think the record is a tool, but I think the real 
important robust work that none of us should forget is the new 
way we're going to deliver care in the future. I'm just 
grateful that at the end of my career, I can participate in it.
    Senator Collins. Thank you.
    Senator Cassidy. Thank you, Senator Collins.
    Next is Senator Franken.

                      Statement of Senator Franken

    Senator Franken. Thank you, Mr. Chairman.
    I'm hearing a lot of the same things, but also some slight 
contradictions between--sometimes between the Senators who are 
asking the questions and you. For example, let's just talk for 
1 second about the experience of the doctors.
    Ms. Moss, you just said the doctors, the primary care 
physicians at your place, are much happier than they were 5 
years ago. You're also getting a lot of improvements in value 
of care--so that I'm hearing. I'm also hearing physician 
dissatisfaction. I'm sure they both do coexist, and that's what 
we're hearing.
    I'd just like to ask of anybody here: Is there a big 
difference between older, crotchety doctors, like Senator 
Cassidy----
    [Laughter.]
    Senator Franken [continuing]. And younger, tech-savvy 
physicians who aren't Luddites? I'm not saying you are. I know 
you're not.
    Ms. Moss. We didn't find that. We thought that. We thought 
we were going to have to spend a lot more time with our older 
physicians, and we found that if people are organized in a 
certain way, then they're organized within the record. I think 
younger doctors--they're coming in, they use it, they used it 
in their residency clinics. It's really very, very simple for 
them.
    But our older physicians are not retiring right now. Our 
primary care physicians are not retiring. I mean, that's a big 
deal. They're hanging on.
    Senator Franken. You're just getting a win-win from what 
I'm hearing.
    Ms. Moss. Yes, we're getting a win-win.
    Senator Franken. Dr. Washington.
    Dr. Washington. Our experience has been a little bit 
different than that. Generally speaking, our residents, who 
have all trained with EMRs, come out and they have very little 
transition, whether they're going to the inpatient setting or 
the outpatient setting. Where we've had more trouble is the 
mid-career or late-career physician, for whom this sort of 
change in practice has been quite different.
    I'm not sure it's just the medical record. This idea of 
switching from volume to value, where my worth was judged by 
whether or not I could see 50 patients a day rather than 
hitting certain quality measures--there are a lot of pressures 
on that group of physicians in terms of changing the entire way 
they think about medicine. We have had better adoption with 
younger physicians.
    Senator Franken. You said something interesting earlier, 
which was sort of about the use of a scribe and how you--I 
understand that for the older, crotchety doctor, a scribe might 
be good. You were sort of saying that not using the technology 
directly has a downside. Can you describe that?
    Dr. Washington. It does. A lot of the promise around 
clinical decision support, which I guess is the EMR technical 
term, is around the EMR's ability to gather and look at data 
across all different settings, all different time periods. I 
may be very well aware of that lab that I ordered today or last 
week. If the EMR can bring to my attention, say, for example, a 
blood clotting study from last month and ask me about 
prescribing a new medication----
    Senator Franken. Being hands-on with the technology is 
helpful.
    Dr. Washington. That is valuable at that point in time. I 
do believe, though, in terms of the use of a scribe, there are 
certainly areas of documentation where I should be able to 
accept the work that's been done by another team member. The 
old days of having me only be the captain of the ship, and I'm 
the only one who can document and make decisions--that's gone.
    In my mind, having people practice at the top of license--
and then areas around orders and areas where it's critical for 
me as a provider to engage with the EMR to get those alerts and 
directions--those are the critical areas.
    Mr. Pletcher. If I may comment?
    Senator Franken. Yes, but I want to get to use cases, so 
you've got to give me time to do that, because that would be in 
your best interest.
    [Laughter.]
    Mr. Pletcher. Yes. I just want to say that many of the 
younger doctors are incredibly technically savvy, meaning 
they're much more sophisticated about what they want. We're 
seeing a whole new crop of folks saying ``You give me this, 
this, and this'' differently than folks who it's new to.
    Senator Franken. OK. Well, I see you left a lot of time for 
use cases. This seems like a really good organizing principle, 
use cases, which is, as I understand it, you lay out a number 
of commonsense use cases--if a doctor's patient is admitted to 
the hospital, you can tell the doctor. I couldn't believe what 
I heard, that 27 percent before knew it, and now 93 percent 
know it, something like that.
    Mr. Pletcher. If the message gets to them and they're able 
to receive it. It's got to be sent, yes.
    Senator Franken. That is a statistic that just blows my 
mind in the sense of, boy, that's an improvement. It seems to 
me that what we're saying is that there's agreement that we're 
going in the right direction, and that this is good and we 
don't want to not do--we want to keep doing this, but we've got 
to either simplify or--and make it interoperable.
    How do you go there? I remember when there was VHS and 
Beta, and we went to VHS. I mean, at a certain point, that 
decision was made. It's criminal that these things aren't 
interoperable. I'm sorry I'm over. Best use--you guys think 
that's a way to go? Is there a way to go?
    Dr. Washington. I think there is a way to go. This sort of 
concept--I was referencing this clinical care document, because 
that was the element of exchange specified in Meaningful Use. 
There's a CCDA document. The fact that I cannot send that 
document unaltered and have it be received by another system 
without some tweaks, or to send it to a repository--we used 
Harris, Cerner, Epic, and some other vendors to exchange those 
documents. It was not sent out of the gate.
    In my mind, it's the Beta or the VHS. It's the rail 
standards that the trains run on. That's the part where I think 
the government could be most helpful in saying, ``This is the 
single standard.'' Even the fact that there were two bodies 
that certified EMRs for Meaningful Use meant that there was 
room for nuance in the interpretation of whether or not you met 
the standard or you met the standard, if you certified by CCHIT 
and you certified by another body.
    Mr. Pletcher. If I can comment, the rails is a necessary 
but not sufficient analogy, because you actually have to ask 
people to change their business process to get 
interoperability. You can say, ``Send a care summary upon 
discharge,'' but you have to actually step back a little 
further and say,

          ``Hey, I want you to do a med reconciliation. Check 
        what meds the patients are on when they come into the 
        hospital, check what meds the patients have when they 
        leave the hospital, take those two pieces of 
        information and put it in the same package.''

    Part of this use case process is to sort of articulate,

          ``We're going to need you to change your business 
        process and standardize on your business process so 
        that everybody downstream who receives this big brown 
        envelope with that data in it knows what to expect and 
        how to use it.''

    The envelope will get it there, but what you now need to do 
is interpret it when it lands, and that's why being very 
specific and concrete about what you're trying to use it for is 
essential.
    Senator Franken. Thank you.
    Senator Cassidy. Thank you, Senator Franken.
    Somehow I feel accused by the kettle, being called old and 
crotchety.
    [Laughter.]
    Senator Franken. I just meant crotchety.
    [Laughter.]
    Senator Cassidy. Senator Baldwin.

                      Statement of Senator Baldwin

    Senator Baldwin. Thank you, Mr. Chairman and Ranking 
Member. I'm really encouraged that this committee is having 
this important conversation about improving electronic health 
records for both patients and providers. I wanted to start by 
commenting on an issue that came up at both last week's hearing 
as well as today's hearing already where it was suggested that 
Congress could compel all vendors to join one of the existing 
vendor developed exchange networks.
    I have some strong concerns with that approach. I don't 
believe that it is Congress' role to pick winning or losing 
vendors. Last week, we heard from Cerner, which has developed a 
network, and at a previous meeting, we heard from Epic, which 
has also developed a network.
    But there are more than just those two data exchange 
networks that are operating today and that are advancing the 
work of sharing information. In my mind, instead of forcing all 
vendors into one, we should help put a national structure in 
place to connect all of the existing networks so they can 
seamlessly and securely share patient records with each other.
    Dr. Pletcher, I am encouraged to hear that the Michigan 
Health Information Network Shared Service is already doing a 
lot of this work. You're doing it at the State level by 
creating common rules of the road, including identifying 
standard, technical, and legal agreements.
    In your opinion, how can the Federal Government help build 
on this to create a national framework and to help facilitate 
the secure exchange of records between all of the existing 
networks and States?
    Mr. Pletcher. I think it starts with enumerating a list of 
things we want to do. These are the big tasks. It could be a 
growing list, but, say, the top 100, and they would be in two 
groups. They would be sort of infrastructure kinds of things 
and then very clinically facing kinds of things.
    A lot of times, doctors on the front line aren't terribly 
interested in infrastructure. It's necessary to get the value 
that they really want to see at the point of care. 
Infrastructure things are like ways to match patients, a common 
list of all the providers. Do you realize there isn't sort of a 
directory you can go to say where are all the doctors in the 
Nation? There's thousands.
    Those kinds of infrastructure functions can get sort of 
spelled out, and then the list of the more clinically facing 
things to do. As we make these lists and put them in order and 
basically build the incentives to fund people to actually do 
them, we can start pointing to the standards and say,

          ``Oh, you know, the care summary we've built will 
        work for this one and that one and this one. Oh, here's 
        a gap. We need to do something else.''

    We can get all of this aligned so that the clinical needs 
and the business needs are driving the technology. I think 
there are, like I said in my written testimony, multiple groups 
working on pieces of this problem, and I think you need to have 
a mechanism to bring them all together. I think there's some 
work being done in the learning health community that is 
potentially very powerful, because it's got that long-range 
vision.
    Senator Baldwin. I have a couple of questions for the 
entire panel. Should Congress establish a public database with 
pricing information and performance measurements for various 
vendors, networks, and other EHR technology platforms to 
increase transparency for providers and for health systems? Why 
don't we start with Ms. Moss and go across?
    Ms. Moss. I don't feel like I'm equipped to answer the 
specifics of that question. I can tell you that the provider 
community needs the support, and we do need it simplified, and 
we do need the data.
    Mr. Pletcher. I'm not sure there's a lot of precedent for 
where that's done elsewhere. I think if you make the data open 
and allow it to come out of all those different systems and 
other people to build services on top of it like we see on our 
iPhones and things, there'll be a lot of pressure to make 
things more transparent.
    Dr. Washington. I'm not sure if I am capable of answering 
that, either. I think one of the difficulties around selecting 
vendors is just that it's not most providers' day job. It's a 
choice that might last you 7 years or 10 years. These are long 
contracts. It takes a long time to put them in and pull them 
out.
    I think the idea of having at least the notion that if I 
pick Vendor A or Vendor B or Vendor C, and if they go out of 
business, I could exchange my data and get it into another 
vendor's system, that doesn't make the choice such a critical 
and heavy choice. I think that would be one of the things that 
could be helpful.
    Senator Baldwin. I've run out of time for my last question, 
but let me just put it on the record and we can ask for 
feedback afterwards.
    We've heard today from a number of stakeholders that many 
pieces of information that must be documented in the electronic 
health record under Meaningful Use are not necessary to quality 
patient care. I'm hoping that you can provide us with extra 
information on the types of data that are essential to direct 
patient care and what functions of EHR technology we should 
help accelerate.
    Thank you, Mr. Chairman.
    Senator Cassidy. Thank you, Senator Baldwin.
    Senator Casey.

                       Statement of Senator Casey

    Senator Casey. Thanks very much, Mr. Chairman.
    I want to thank our panel for your testimony and for being 
here today. This is a complicated subject so we need to listen 
to people who are in the trenches on this.
    I really have two questions. One is on discharge and the 
aspects of the difficulties that can be encountered if a 
discharge doesn't go well from a hospital, and, second, a 
question on safety.
    In the first case, discharge from a hospital in the context 
of so-called medical reconciliation--Mr. Pletcher, you were 
talking about your Use Case Factory, including health systems, 
pharmacies, and State labs. In particular, I guess I wanted to 
ask you about the question of pharmacists. Many pharmacists 
don't have access to patient records to verify patients' 
discharge medication list and other relevant information as to 
allergies or weight or some other circumstances they face.
    What can you tell us about how we need to work better with 
pharmacies and physicians on this problem where they may have 
some information but not enough in the context of a discharge?
    Mr. Pletcher. The president of the Michigan Pharmacist 
Association is actually chair of my board. Medication 
reconciliation, discharge--med discharge use case I described. 
Who can it go to? Are we allowed to take that discharge and 
send it to the pharmacist?
    It turns out your question is very timely, because on 
Thursday, we're convening the entire community of stakeholders 
to really work through the issues around where does pharmacy 
fit, where does monitoring prescription medications for safety, 
and what are the key use cases that we really need to focus and 
prioritize around that?
    Pharmacists have said for a long time, ``We need to get 
that information.'' What we really don't have are the rules of 
engagement packaged to sort of say,

          ``OK, everybody who sends the information is 
        protected under an appropriate chain of trust if we 
        deliver it to a pharmacist who's not connected to their 
        immediate organization.''

    We believe we've got a process to sort of walk through 
those hoops and make it a very deliberate, very transparent, 
very measurable way to do that. We know the need is there, but 
what we haven't got is sort of the alignment across the 
unaffiliated groups.
    Senator Casey. I'm thinking about particular circumstances 
where you might--an antibiotic prescribed for a child who--
depending on their weight and things like that. I'm glad that 
you're working through that.
    I wanted to ask a broader question, I guess, about safety 
and whether hospitals are safer. There's some conflicting 
information about it. It might be premature to make an overall 
determination.
    We know in a recent report by HHS, the inspector general 
said the department has failed to ensure that electronic health 
records data are secure and accurate. Concerns have also been 
raised by the Institute of Medicine.
    We're at the point where the Office of the National 
Coordinator has settled on a center that would--and this is for 
the whole panel. That center would have no investigatory power 
but would provide a safe environment in which real life 
problems could be analyzed and solutions developed. The only 
problem is Congress didn't fund it.
    I guess the question is: What can we do by way of either 
statutory change or pursuing a regulatory strategy to make sure 
that this center can provide the kind of information we hope it 
would? Anybody have an opinion on that?
    Doctor, do you have----
    Dr. Washington. I would say that I think it is--to the 
general thought about whether or not hospitals are safer as 
part of the effort, I would say that we have a lot of examples 
in our health system where that is, indeed, the case, and we've 
been able to leverage that over the course of time. I think it 
has taken a long time. We first deployed an EMR in 1998 in our 
health system, and so we've been on the journey a long period 
of time. I think that, that is the case. I think that resources 
to help us study and look at it more specifically over the 
course of time would be a helpful thing.
    I'll tell you one of the dynamics that became very clear to 
me after I got involved in healthcare informatics is when I 
made--or when errors are made in patient care when you're on 
paper, I mistake an O for a U, and they get whatever--the wrong 
dose, et cetera, and that happens for that one case and that 
one patient.
    If we have a programming error, and an architect builds an 
order incorrectly, all 100 patients who were to get that 
medication had an issue that had to be resolved for that case 
during the day. So they're on scale. Our errors are on scale 
these days.
    I think we've done--through lots of checks and balances to 
help us get better at that deployment and to improve the safety 
in that space. That's the kind of nuance difference that 
happens from a workflow perspective that does need more intense 
study, in my opinion.
    Senator Casey. Thanks very much. I'm out of time.
    Ms. Moss, do you have something?
    Ms. Moss. Yes. I wanted to go back to the issue of 
pharmacy, because for us, there's another flip side to it, 
which is we really don't know when our patients fill 
medication--they get refills. It's very hard for us, because we 
want to ensure that we have very compliant patients.
    But no files, no claims data can give us that, and patients 
go everywhere for their pharmacy. I think that this is another 
case where if we really shared data, it would go both ways.
    Senator Casey. Thanks very much.
    Thank you.
    Senator Cassidy. Thank you, Senator Casey.
    Senator Murphy--a good Irish lineup here.

                      Statement of Senator Murphy

    Senator Murphy. Thank you very much, Mr. Chairman.
    Thanks, everyone. This has been really helpful. The fee for 
service system is baked into the DNA of our healthcare system, 
and so--reorienting practice so that we're chasing outcomes and 
quality rather than volume. It's a difficult thing. It's 
turning around a battleship. I'm interested as to some of the 
ways in which you've used data to anchor this transition to 
quality.
    Maybe I'll ask a question of Ms. Moss. A couple of things 
struck me about your testimony. First, you've taken some of the 
shared savings and distributed it to all of your employees, not 
just to your physicians, I assume with the goal of getting 
everybody baked into this new strategy.
    And, second, you talk about with respect to this Coastal 
Core model, paying money to auditors, to folks that are just 
taking a look at the data and making sure that practice is 
aligning with your quality measurements.
    Can you talk a little bit about how those two things have 
helped to turn that battleship around so that you're focusing 
on outcomes anchored by the data instead of just simply volume?
    Ms. Moss. To have engaged patients, we really feel we have 
to have engaged staff, because to have patients become 
compliant, we have to have groups and teams of staff working 
with them--
patient-centered medical home care, nurse care managers and 
pharmacists and nurses and others, and even the person who 
answers the phone. They have to really do it the right way to 
capture that engagement.
    When we were successful in shared savings, we made the 
decision with the support of our physician board and 
shareholders that we would distribute it to every single 
employee at Coastal, and it was meaningful. It amounted to 
about a week's pay for every person. Not only was there 
complete buy-in from the staff--and they're still smiling 7 
months later--but it also said, ``Next time, and if we keep 
working on this, you'll also partake in this.'' This isn't just 
about the physicians.
    The physicians--it really meant something for them, because 
it made their staff so happy, and it made everybody feel like 
they were part of a team. I know that was your first question.
    Senator Murphy. Well, the second one is--and others can 
answer as well--which is the question of how you find the 
resources to manage the data and make it relevant to your 
frontline staff. That's what ACOs are supposed to do. ACOs are 
supposed to give you the money and the flexibility in order to 
put some money into auditors or case managers or whatever it 
may be.
    What are the challenges we need to be thinking about in 
terms of the resources necessary to actually make the data 
useful to physicians and practitioners?
    Mr. Pletcher. I'll take a quick first. There are activities 
that are paying people for information. One of the things in my 
written testimony was there's probably a real opportunity to 
sort of look at the payer community as a whole, and as these 
sort of flow down, audit requirements come to--right now, they 
send people out into clinics to audit and look at the medical 
record to sort of figure out what's going on. Well, the Social 
Security Administration has an electronic way to do that that 
could potentially be used to sort of help augment the sort of 
way that people are manually doing some of those things now.
    I think there's a real opportunity for dual use of some of 
that technology for the payer community to sort of get onboard 
with some of the things that we're actually trying to do with 
this sort of Meaningful Use EHR incentive. A lot of times, 
payers communicate back to those clinics and to those staff by 
fax while we've got doctors trying to do things electronically.
    One of those opportunities for staff to be more satisfied 
is to not have to go back and forth to the sort of old world 
and the new world.
    Senator Murphy. Dr. Washington, part of your testimony is 
about the patient facing side of this. I think we're going to 
have another hearing in which we talk about the relevance of 
this information to patients.
    Dr. Washington. Yes.
    Senator Murphy. Just talk a little bit--are there any 
concerns from the practice side about the information that 
should and shouldn't be available to patients? Are there pieces 
of the EMR that should be shared versus shouldn't be shared? 
We're going to have a separate conversation about how to make 
that relevant. Should there be any cautions that you'd provide 
to us?
    Dr. Washington. I think we've worked through that in our 
health system over the past 4 years or so as we've opened up 
patient portals. I think the only--what I would consider a 
persistent or valid concern is when releasing lab results, for 
example, requires some consultative interaction with the 
provider, some conversation.
    It's really been--the discussions that are relevant have 
been about the timeline. If the lab is available at 10 a.m., 
should I have an opportunity to call the patient that day? 
Should it be released in the next 24 hours?
    I think we're past--at least in our health system, we've 
passed this idea that there's some information that needs to 
stay in a box. There's certainly some privacy items that people 
work through. We've been able to manage those with our 
agreements for use and with parents and children that are close 
to maybe 13 or 14 years of age where those sort of nuances 
happen. We've worked through that. I think it's a very positive 
outcome.
    Senator Murphy. Thank you.
    Thank you, Mr. Chairman.
    Senator Cassidy. I have a couple of followup questions, and 
I think Senator Whitehouse has a closing statement.
    Dr. Washington, have you all done a time study--you 
mentioned younger physicians versus older physicians. When I 
instruct residents, I find if I ask if they've had an 
appendectomy, they don't look at the patient's abdomen to look 
for a scar. They look on the chart.
    You're chuckling. I think that your--have you done a time 
survey? Epic, I think, estimates that it takes an additional 13 
minutes per patient interaction to interact with the chart--13 
minutes more of clicking boxes. Have you all done a time survey 
of the amount spent on the computer versus actually speaking to 
the patient?
    Dr. Washington. We haven't done that in that particular 
way. We've certainly looked at the computerized physician order 
entry time and looked at those time stamps, and it does take a 
longer period of time to do that particular entry.
    I chuckled just because I have had that particular 
experience in working with some mid-levels and newer providers, 
where somehow or another, that art has gotten sort of lost in 
the shuffle.
    Senator Cassidy. Believe me, when we speak about the 
curmudgeon, it's only because the curmudgeon knows that you 
should look at the belly.
    Dr. Washington. Yes.
    Senator Cassidy. Senator Alexander asked the two of you 
about Meaningful Use 3, and both of you endorsed continued use 
of Meaningful Use 3. Here's a 74-page Federal Register of the 
new Meaningful Use 3. Have you all actually reviewed that 
Meaningful Use document? You all would endorse this 74-page 
kind of approach? Or is it just Meaningful Use in general that 
you endorse, not necessarily the way it's being outlined in 
Meaningful Use 3?
    Ms. Moss. Yes to the latter. I actually got the link 
yesterday, and we have not reviewed it. I did notice that some 
of the older stuff was being let go. They felt that it was 
redundant. No, we haven't gone through it with a fine tooth 
comb.
    Senator Cassidy. Believe me, if you can understand that, 
hats off to you.
    Let me go to you, Dr. Washington. I spoke to a specialist, 
and he was saying that science progresses so rapidly, the idea 
that the Federal Register will have something which is relevant 
to his practice in 2 years is--and you're nodding your head yes 
again. We understand that intuitively. In the SGR bill, we 
allowed interaction between CMS and specialty societies to come 
up with the registries--a way for quality improvement.
    We're looking for ways to improve this. Would it be 
reasonable for the Meaningful Use 3 to be defined by a 
specialty society in an iterative process, where if it's 
ophthalmology, they have something that they agree to and it 
feeds back to them, as opposed to how many flu shots have you 
given?
    Dr. Washington. In the physician adoption side, it is much 
easier to talk to clinicians about recommendations from their 
specialty society than it is to take any other reference, 
including some of the ones that we believe in strongly or that 
have been vetted, and the timeline is about what you've 
outlined. We know that if the ADA or the American College of 
Emergency Physicians or fill in the blank is going to come up 
with a recommendation, it's usually around 18 months, a couple 
of years or so, before those sort of get encapsulated in a 
formal Federal----
    Senator Cassidy. As we look at recommendations, indeed, 
that iterative process might be a better way than something 
which is written in stone.
    Would the two of you intuitively agree with that? Primary 
care may not be--Mr. Pletcher?
    Mr. Pletcher. Some aspects absolutely probably have to be 
iterative, but others where we know and we have alignment, I 
think we need to make sure they move forward and don't go 
backward. The last thing we want to do is send the wrong 
message that all was for naught, because we've made so much 
progress.
    Senator Cassidy. So, again, a Meaningful Use in concept, 
but the details could be worked out. Senator Murray--again, Dr. 
Washington--talked about people should have a chance to change 
vendors. We heard from Senator Alexander that Mayo Clinic is 
spending a billion dollars. It's hard for me to think that 
they're going to change their vendor after they've invested a 
billion dollars.
    In your contract, is there a lock-out provision, that if 
you do attempt to change vendors, that the vendor locks you out 
of the data?
    Dr. Washington. No, and I guess that's contract by 
contract, because I do remember with one of our last renewals, 
we had to negotiate clauses for how that transition may happen, 
including PACS data, the radiology data, which is the most 
difficult to transfer system to system. It's not a formal lock-
out. It's just the difficulty of changing a system that you've 
invested 7 years in.
    Senator Cassidy. Decertifying and changing vendors may not 
be practical.
    Thank you all. This has been very helpful for us, looking 
for solutions. Let me defer to Senator Whitehouse to close the 
hearing.
    Senator Whitehouse. I just wanted to thank you, Chairman 
Cassidy, and thank our committee chairman, Senator Alexander, 
for having held this hearing and for the very helpful, 
productive and substantive way that we've gone about it. I 
thought all of the witnesses were terrific, and I really 
appreciate that each of you took the trouble to come here.
    Of course, I thought Ms. Moss was more terrific than the 
other two of you.
    [Laughter.]
    She's from Rhode Island, so I have to be a little biased in 
that respect. I think you've helped us lay out a framework, a 
pretty clear agenda, some things that we really can bear down 
and focus on to make sure we encourage to happen. I think that 
while nobody wants a central command somewhere at CMS directing 
every iota of the development of this process and probably 
inhibiting it, we are responsible here in Congress for setting 
the terms under which industry will operate, providers will 
operate, people who are inventing the apps and the EHRs of 
tomorrow will operate.
    I hope that we're able to go forward in a bipartisan and 
productive way, as has been the hallmark so far of Senator 
Alexander and Chairman Murray and this committee.
    Thank you for this hearing, and thank you for the larger 
context in which it takes place.
    Senator Cassidy. Senator Alexander does have an additional 
question.
    The Chairman. Actually, it's Senator Baldwin's question I 
wanted to re-emphasize. First, I want to thank the witnesses 
for coming and for your very helpful testimony. I thank Senator 
Cassidy and Senator Whitehouse.
    Senator Baldwin's question was: Exactly what is it that 
doctors should not have to document? I would appreciate your 
writing that to us. What we have heard is that it would almost 
have to be--you talked about medication reconciliation orders, 
documentation, transition planning. It's almost as if someone 
would need to say in the government documents, ``But you do not 
have to do this one yourself. You may have an aid do this.''
    Is there some way, some simple way, to identify some 
functions in the doctor's office that the doctor does not have 
to do his or herself and at least clear that much up? If there 
is, we'd like to know it. Dr. Cassidy is a doctor. I'm not. I'd 
like to have it in language that a non-physician could 
understand.
    Senator Whitehouse. Let me second that emotion.
    Senator Cassidy. Thank you both. The hearing record will 
remain open for 10 days. Members may submit additional 
information for the record within that time if they would like.
    Again, thank you for being here. This committee stands 
adjourned.
    [Additional Material follows.]

                          ADDITIONAL MATERIAL

     Response by Boyd Vindell Washington, M.D., MHCM to Questions 
                of Senator Alexander and Senator Bennett
                           senator alexander
    Question 1a-c. We have heard that there are a number of things 
under current documentation requirements that could easily be handled 
by other members of the care team.
    a. In your opinion, what specifically should absolutely be recorded 
by a physician?
    b. What should be passed on to other members of the care team, and 
which members should they be?
    c. Is there a way to clarify that this sort of delegation is 
allowed so that doctors don't feel they need to do all of the data 
entry themselves?
    Answer 1a-c. In a team-based care environment, the physician should 
document in the electronic record specifically those items that either 
require his or her expertise in medical decisionmaking or where the 
direct interaction with the electronic medical record provides support 
for a clinical decision. The other areas of medical documentation 
should be reviewed by the physician, but direct entry by the physician 
does not inherently add to patient care. It likely only burdens the 
physician and does not allow the care team to operate at maximal 
efficiency.
    Following this rationale, the physician should document the 
patient's physical examination (objective clinical findings and 
observations), assessment and plan (the result of the provider's review 
of all pertinent data and the care plan that comes from that analysis) 
and all orders that come from these observations and analyses. There 
are a subset of orders that arise as a part of pre-determined protocols 
that others on the care team should be free to enter (either as a 
result of a presenting complaint or as a result of objective data 
point--such as an EKG order on a patient with chest pain or a 
antipyretic drug for a patient with fever) or orders that are in 
keeping with a care giver's level of training. These delineations are 
often already designated by CMS, State licensing requirements, or 
facility bylaws.
    Other members of the care can often collect the remainder of the 
necessary data--the history of the present illness, the review of 
systems, the medical history, the social history, allergies, and the 
medication list and its reconciliation. Of course upon review, the 
physician would be expected to gather and input additional information 
as necessary if the information is incomplete or the case particularly 
complex.
                             senator bennet
    Question 1. While the capability of electronic health records 
improves in functionality, error reduction and information exchange, we 
have heard that many physicians are still facing burdensome reporting 
requirements that take time away from focusing on patient outcomes. Dr. 
Vindell, you mentioned in your testimony complaints regarding increased 
time burden on practitioners. What steps can be taken to decrease the 
time burden on our physicians?
    There are many billing documentation requirements that are hold 
overs from the paper record. In that setting, initializing documents to 
demonstrate that a caregiver has carefully reviewed them has been 
unnecessarily translated into electronic form. Assessment of the 
clinical complexity of medical decisionmaking continues to be measured 
by the number of items documented and tests ordered and interpreted. A 
review of evaluation and management (E&M) coding in the new electronic 
documentation paradigm would likely eliminate several unnecessary 
steps. Focusing payment more on the presenting condition and diagnosis 
could simplify the activity and free provider and vendors to 
concentrate on streamlining the documentation experience.

    Question 2. While it is crucial that we work to improve the 
functionality and interoperability between doctor's offices and health 
systems, we must also remember that patients themselves have a critical 
role to play. Their ability to both access and contribute to their 
health information will help in the overall mission of a successful 
electronic health system. We know that patients want access to their 
data, yet many either lack access or have to collect and combine 
records from different providers in order to see their comprehensive 
record. How do you see the evolution of patient involvement and are 
there steps the HELP Committee can take to help ensure access at a 
patient level?
    Answer 2. Patient involvement in the future is critical and we 
should continue to encourage participation. Engaged individuals are 
more likely to maintain their health and manage illness more 
effectively.
    We should encourage strict interoperability standards that would 
make it easier to combine data from different vendors and enhance 
portability. Accelerating the 10-year interoperability plan espoused by 
the office of the national coordinator for healthcare information 
technology (ONCHIT) would most facilitate this goal. Data flow between 
electronic medical records is a key principle.
    Second, recognizing that medical data is often highly specialized 
and the majority of patients cannot easily manage, we should help make 
it easier to obtain all care data from varied sources. If we facilitate 
standard nomenclature and taxonomy across the industry by adopting 
standards, data could be easily recognized across platforms. Last, 
accelerating the National Health Information Network (NHIN) Direct 
effort and granting access to Centers for Medicare and Medicaid 
Services (CMS) data repositories to patients could allow gathering of 
individual medical documents from different providers of care that 
Medicare patients could download without bearing the burden of primary 
data entry.
Response by Timothy A. Pletcher, DHA to Questions of Senator Alexander 
                           and Senator Bennet
    In response to Senator Lamar Alexander's questions:

          ``We have heard that there are a number of things under 
        current documentation requirements that could easily be handled 
        by other members of the care team.''

    Upon my return, I reached out to several of our leading physicians 
in our community to help formulate a response to the Senator's final 
question. Generally, there were two key areas of focused response: (1) 
encourage CMS to make the coding requirements more simple (it should 
not be harder than filling out taxes!); (2) facilitate ways for EHR's 
to become more reliable and improve the human computer interfaces to 
better reflect how doctors care for patients. I have done my best to 
capture and reframe their recommendations below.

    1. Simplify coding. CMS has made coding much, much more difficult 
with recent decisions that specify many more extraneous factors, such 
as the type of patient, type of provider, etc. According to one 
physician ``just looking at the CMS approved transition of care 
requirement makes one's head spin''. Attached is a care management 
example.\1\ The service code should have been limited to the first part 
that describes the service: 20 minutes of documented staff time 
performing coordination of care. CMS then added all sorts of attributes 
of the patient that makes documentation requirement so much more 
difficult. The description for the Transition of Care codes 99495 and 
99496 are even worse. Just google these codes to see the descriptions. 
These codes should describe the service and avoid describing the 
circumstances of the patient. The documentation burden is that the 
physician must describe all the elements of patient complexity, etc. 
Great idea to pay providers for transition of care, terrible new burden 
for documentation.
---------------------------------------------------------------------------
    \1\ The referenced example may be found at: www.cms.gov/Outreach-
and-Education/Medicare-LearningNetwork-MLN/MLNProducts/Downloads/
ChronicCaseManagement.pdf.
---------------------------------------------------------------------------
    2. Re-examine CMS requirements for documenting risk adjustment. 
Risk adjustment is an important area where CMS can stop the needless 
burden. The Medicare Advantage program is adding enormous, unjustified 
burdens to doctors and health plans. This all started with noble 
intentions. CMS didn't want health plans ``cherry picking healthy 
patients and lemon dropping sick ones.'' They wanted to pay more to the 
plans that had enrolled sicker populations. Unfortunately the risk 
adjustment approach that they used proved very, very easy to ``game.'' 
A huge industry of medical record reviewers, documentation specialists 
and the like now work for Medicare Advantage plans optimizing payments 
made by CMS for risk adjustment. Because CMS wanted to make sure that 
the patients truly had the conditions in their risk adjuster, a whole 
new dimension of documentation was created around Monitoring, 
Evaluating, Assessing/addressing or Treating the condition (nicknamed 
MEAT). Because it is so prone to manipulation, it now appears under 
this system that the Medicare recipients of California are sicker than 
those in Michigan. This is very unlikely. This means that the entire 
process is not only burdensome, but it is not achieving the CMS purpose 
of distinguishing the disease burden of the Medicare Advantage 
population.
                           senator alexander
    Question 1. In your opinion, what specifically should absolutely be 
recorded by a physician?
    Answer 1. Doctors should absolutely record the information 
necessary to inform themselves in the future when they need to review 
the patients history and it should be sufficient to explain the medical 
decisions they have made for when other providers who treat the patient 
after them need to know. Billing codes should be limited to describing 
the service provided and avoid describing the circumstances of the 
patient. The documentation burden comes when a physician is forced to 
describe all the elements of patient complexity purely for 
administrative purposes when it does not add any medical value.

    Question 2. What should be passed on to other members of the care 
team, and which members should they be?
    Answer 2. It's unclear that a focus on documentation for medical 
necessity by doctors will result in other individuals having to do 
more. My recommendation is to seek ways to remove documentation burdens 
under new health care transformation programs as a way to incentivize 
providers to embrace new healthcare reform objectives. One can envision 
that under value-based payment models traditional fee for service codes 
become less important and good documentation about medical decisions 
increasingly valuable. However, the evolving group of individuals 
focused on care coordination are better target for documentation of 
other factors associated with the patient.

    Question 3. Is there a way to clarify that this sort of delegation 
is allowed so that doctors don't feel they need to do all of the data 
entry themselves?
    Answer 3. Develop billing codes specifically for documentation by 
both physicians or non-physicians. One way to improve documentation is 
to pay for it. If CMS had to pay for additional documentation, then it 
would be less likely to request potentially unnecessary or limited 
value data attributes. Similar to the 1994 paperwork reduction act, a 
time calculation could be estimated so a definite provider ``cost'' or 
CMS value could be attributed to each documentation requirement.

    My overall personal assessment from the physician dialog in our 
community around improving EHR design and usability is that a major 
thing that can be done legislatively would be to authorize funding or 
encourage some place within HHS to fund activities that lead to 
creating better human-computer interfaces for clinicians to use. This 
could even be the evaluation of novel ways to use multi-media and to 
record patient-provider sessions automatically or to explore methods to 
create modern shared notes with attribution; use of Wiki's instead of 
separate notes. Below is the summary and attached is an article\2\ that 
many felt did an elegant job of capturing the main points. Here are 
some specific items that there was general agreement on.
---------------------------------------------------------------------------
    \2\ The article referred to may be found at: http://annals.org/aim/
article/2089368/Clinical-documentation-21st-century-executivesummary-
polcy-position-paper-from-the-the-american-college-of-physicians.

    1. Effective and ongoing EHR documentation training of clinical 
personnel should be an ongoing process.
    2. Highlighted Policy Recommendations that link to EHR Design:

    a. EHR developers need to optimize EHR systems to facilitate 
longitudinal care delivery as well as care that involves teams of 
clinicians and patients that are managed over time.
    b. Clinical documentation in EHR systems must support clinicians' 
cognitive processes during the documentation process.
    c. EHRs must support ``write once, reuse many times'' and embed 
tags to identify the original source of information when used 
subsequent to its first creation.
    d. Wherever possible, EHR systems should not require users to check 
a box or otherwise indicate that an observation has been made or an 
action has been taken if the data documented in the patient record 
already substantiate the action(s).
    e. EHR systems must facilitate the integration of patient-generated 
data and must maintain the identity of the source.

    Finally, included in these types of improvements must be the 
appropriate use of alerts related to clinical decision support or 
clinical reminders. Currently, these systems are harnessed in ways that 
often insult doctor's intelligence or at best cause alert fatigue so 
the really important things are ignored or missed.
                             senator bennet
    1. While it is crucial that we work to improve the functionality 
and interoperability between doctor's offices and health systems, we 
must also remember that patients themselves have a critical role to 
play. Their ability to both access and contribute to their health 
information will help in the overall mission of a successful electronic 
health system. We know that patients want access to their data, yet 
many either lack access or have to collect and combine records from 
different providers in order to see their comprehensive record. How do 
you see the evolution of patient involvement and are there steps the 
HELP Committee can take to help ensure access at a patient level?
    In my opinion one of the major omissions of the Meaningful Use (MU) 
certified EHR requirements was that the emphasis was placed on sending 
data out, but not accommodating for data to come in with equal 
emphasis. For example patients can easily view, download or transmit 
data from their patient portal, but they cannot have data from another 
provider's EHR incorporated into their preferred providers portal.
    Another related issue is that providers are incentivized to have 
patients use the provider's own portal versus another physician or 
health system portal. Technically, everyone should be excited about 
which ever solution works to get patients to utilize and engage around, 
however, the current model creates competition among providers for the 
patients to use the provider's own portal instead of the portal the 
patient feels most comfortable using. An opportunity exists to award 
all providers MU credit when patients being seen by multiple providers 
use any of the portals assuming the providers are exchanging data.
    One Use Case that we are pursuing in Michigan is called ``Patient 
Share'' and has been designed to remove the burden from both the doctor 
knowing where to send the data for each individual patient and also the 
burden from the patient from having to pull (download or transmit) 
manually their own data from each portal. Instead, the ``Patient 
Share'' Use Case functions like a general purpose ``carbon copy'' of 
the patient's data from the provider after every encounter and sent to 
the statewide service. Patients are expected to have configured a 
statewide consumer directory with their preferences for where this data 
should be rerouted to services entirely under the patient's control 
such as personal health records or other services like clinical trials 
and other consumer level support programs consumers might consent to 
share their data with. This process is being designed to be completely 
automated.
    One critical precursor to the ``patient share'' use case mentioned 
above and being able to share structured data with patients 
automatically in high volumes is the requirement to uniquely match each 
patient correctly. As the issues around patient matching and patient 
consent are resolved, combined with the improving capabilities for data 
to automatically come out of the EHRs the ability to provide data at 
the patient level will dramatically increase.

    Question 2. Are there steps the HELP Committee can take to help 
ensure access at a patient level?
    Answer 2. In addition the above, as mechanisms for consumer data 
access mature (e.g., HL7 FHIR resources, State level Use Cases like 
``patient share'', Direct messaging, etc.) the HELP Committee can 
advocate for funding and regulations that encourage providers to not 
just offer patients access to their own data via provider specific 
portals, but also allow for and encourage electronic data exchange from 
third party services that have been approved by the consumer.
Response by Meryl Moss, MPA, EMHL to Questions of Senator Alexander and 
                             Senator Bennet
                           senator alexander
    Question 1a-c. We have heard that there are a number of things 
under current documentation requirements that could easily be handled 
by other members of the care team.
    a. In your opinion, what specifically should absolutely be recorded 
by a physician?
    b. What should be passed on to other members of the care team, and 
which members should they be?
    c. Is there a way to clarify that this sort of delegation is 
allowed so that doctors don't feel they need to do all of the data 
entry themselves?
    Answer 1a-c. This question hits upon one of our greatest 
challenges: figuring out how to re-route work away from physicians when 
it can be done by other members of the clinical team.
    Prior to the emergence of electronic health records (EHR's), 
ancillary staff supported providers by facilitating prescription 
refills, processing orders for labs and diagnostic tests, arranging 
specialty referrals, and filing clinical reports and consult notes. 
Unfortunately, adoption of EHR's now appears in many cases to have had 
the unintended consequence of funneling tasks previously performed by 
others back to physicians and advanced practitioners. On top of this, 
documentation requirements associated with new pay for performance and 
quality incentive programs have added another layer of administrative 
work. At Coastal, we have been learning just how burdensome this 
problem has become, as providers extend their days into the evening, 
and their weeks into the weekend.
    We are all concerned about physician burnout and dissatisfaction. 
At Coastal, we are now re-examining our use of the EHR and re-
engineering our office workflows in order to improve the professional 
experience of providers. Physicians often cite the EHR as a primary 
cause for burnout, but we believe that the root cause in many cases may 
actually be poorly designed workflows and a lack of appropriate 
delegation of administrative tasks. Our goal is to have every staff 
member perform to the highest level of his or her license, while 
ensuring that providers have timely access to all the information they 
need to care for patients.
    At Coastal, we believe that physicians or advanced practitioners 
need to perform and document the physical exam, including the review of 
systems, current complaints, history of present illness, diagnosis, 
treatment plan including medications, and followup plan for each 
individual patient at each unique visit. Providers must also select the 
correct visit code for billing.
    Medical assistants, given appropriate training and oversight, can 
verify current medications, review medication allergies, review past 
medical/surgical history, verify family and social history and perform 
and document fall risk, depression and other screening. They may also 
document tobacco/alcohol use, obtain and document vital signs and 
provide and document immunizations.
    As we have begun to systematize preventive healthcare and improve 
communication across sites of care, review of correspondence and test 
results has become an increasingly time-consuming task. Many providers 
complain of ``information overload''. At Coastal, we are figuring out 
which reports a physician must see, and which reports can be reviewed 
by others. For example, which subset of normal test results that can be 
reviewed by a nurse and then simply filed electronically? Our providers 
are helping us develop standards to address such questions.
    The key is to re-engineer the flow of work in a physician office to 
ensure that the work is performed or handled by the right person. Staff 
must be well-trained, supervised, and have the appropriate 
competencies. Physicians must be confident that patient care will not 
be compromised in any way. With the correct delegation of duties, 
patient care should actually improve as an enhanced and expanded 
medical team surrounds the patient.
    For offices that are part of a larger organization, some 
administrative work can also be handed off to a centralized team that 
can serve many offices simultaneously. For example, at Coastal Medical, 
routine prescription refills are now accomplished by a team of pharmacy 
technicians using a detailed protocol and working under the supervision 
of a clinical pharmacist. Only a subset of refill requests--such as 
those for anticoagulants and controlled substances--are routed to 
physicians or advanced practitioners for review.
    At Coastal, re-engineering of office workflows is part of our plan 
to create the ``medical office of the future''. Developing new patient-
centered practices without overburdening the physician takes 
leadership, creativity, and good execution. Potential barriers for 
small practices are that they just don't have sufficient scale to 
support centralized programs, and may lack the operational expertise to 
make much-needed changes in workflow. Such practices may functionally 
hold themselves captive to whatever workflows seem to follow most 
naturally from the design of their particular EHR.
                             senator bennet
    Question. While it is crucial that we work to improve the 
functionality and interoperability between doctor's offices and health 
systems, we must also remember that patients themselves have a critical 
role to play. Their ability to both access and contribute to their 
health information will help in the overall mission of a successful 
electronic health system. We know that patients want access to their 
data, yet many either lack access or have to collect and combine 
records from different providers in order to see their comprehensive 
record. How do you see the evolution of patient involvement and are 
there steps the HELP Committee can take to help ensure access at a 
patient level?
    Answer. Coastal has had tremendous success with the implementation 
and use of the patient portal. Greater than 70 percent of our patient 
population is enrolled and we hear nothing but positives from patients, 
staff, and physicians. However, as your question points out, the 
information that we provide to our patients through the portal is 
limited to the data that exists within their primary care record.
    Rhode Island's State HIE Currentcare is developing a tool which 
will enable patients to access elements of their PHI stored within the 
HIE.
    We agree that both providers and patients should have access to 
complete, comprehensive and current PHI data. We recommend the 
following:

     Support and fund interoperability and HIE platforms.
     Mandate that EHR vendors share data and support HIE's.
     Mandate that EHR vendors support interfaces and data 
exchange between providers, and limit the fees that can be charged for 
such services.
     Require standard data formats for ease of communication 
and sharing.
     Encourage providers to invest in interfaces or HIE 
connectivity through incentive programs that would provide financial 
support for those investments.
     Support and incent easy patient access to their own data 
in HIE's.

    Patient education is also a crucial component in all of this. When 
confronted with a technical laboratory or diagnostic report, patients 
often need background information and context from a provider in order 
to fully appreciate the significance of a test result.

    [Whereupon, at 11:40 a.m., the hearing was adjourned.]

                                  [all]