[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
__________
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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]