[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
IMPLEMENTATION OF THE HEALTH INFORMATION TECHNOLOGY FOR ECONOMIC AND
CLINICAL HEALTH (HITECH) ACT
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
JULY 27, 2010
__________
Serial No. 111-149
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
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COMMITTEE ON ENERGY AND COMMERCE
HENRY A. WAXMAN, California, Chairman
JOHN D. DINGELL, Michigan JOE BARTON, Texas
Chairman Emeritus Ranking Member
EDWARD J. MARKEY, Massachusetts RALPH M. HALL, Texas
RICK BOUCHER, Virginia FRED UPTON, Michigan
FRANK PALLONE, Jr., New Jersey CLIFF STEARNS, Florida
BART GORDON, Tennessee NATHAN DEAL, Georgia
BOBBY L. RUSH, Illinois ED WHITFIELD, Kentucky
ANNA G. ESHOO, California JOHN SHIMKUS, Illinois
BART STUPAK, Michigan JOHN B. SHADEGG, Arizona
ELIOT L. ENGEL, New York ROY BLUNT, Missouri
GENE GREEN, Texas STEVE BUYER, Indiana
DIANA DeGETTE, Colorado GEORGE RADANOVICH, California
Vice Chairman JOSEPH R. PITTS, Pennsylvania
LOIS CAPPS, California MARY BONO MACK, California
MICHAEL F. DOYLE, Pennsylvania GREG WALDEN, Oregon
JANE HARMAN, California LEE TERRY, Nebraska
TOM ALLEN, Maine MIKE ROGERS, Michigan
JANICE D. SCHAKOWSKY, Illinois SUE WILKINS MYRICK, North Carolina
CHARLES A. GONZALEZ, Texas JOHN SULLIVAN, Oklahoma
JAY INSLEE, Washington TIM MURPHY, Pennsylvania
TAMMY BALDWIN, Wisconsin MICHAEL C. BURGESS, Texas
MIKE ROSS, Arkansas MARSHA BLACKBURN, Tennessee
ANTHONY D. WEINER, New York PHIL GINGREY, Georgia
JIM MATHESON, Utah STEVE SCALISE, Louisiana
G.K. BUTTERFIELD, North Carolina
CHARLIE MELANCON, Louisiana
JOHN BARROW, Georgia
BARON P. HILL, Indiana
DORIS O. MATSUI, California
DONNA M. CHRISTENSEN, Virgin
Islands
KATHY CASTOR, Florida
JOHN P. SARBANES, Maryland
CHRISTOPHER S. MURPHY, Connecticut
ZACHARY T. SPACE, Ohio
JERRY McNERNEY, California
BETTY SUTTON, Ohio
BRUCE L. BRALEY, Iowa
PETER WELCH, Vermont
Subcommittee on Health
FRANK PALLONE, Jr., New Jersey, Chairman
JOHN D. DINGELL, Michigan NATHAN DEAL, Georgia,
BART GORDON, Tennessee Ranking Member
ANNA G. ESHOO, California RALPH M. HALL, Texas
ELIOT L. ENGEL, New York BARBARA CUBIN, Wyoming
GENE GREEN, Texas JOHN B. SHADEGG, Arizona
DIANA DeGETTE, Colorado STEVE BUYER, Indiana
LOIS CAPPS, California JOSEPH R. PITTS, Pennsylvania
JANICE D. SCHAKOWSKY, Illinois MARY BONO MACK, California
TAMMY BALDWIN, Wisconsin MIKE FERGUSON, New Jersey
MIKE ROSS, Arkansas MIKE ROGERS, Michigan
ANTHONY D. WEINER, New York SUE WILKINS MYRICK, North Carolina
JIM MATHESON, Utah JOHN SULLIVAN, Oklahoma
JANE HARMAN, California TIM MURPHY, Pennsylvania
CHARLES A. GONZALEZ, Texas MICHAEL C. BURGESS, Texas
JOHN BARROW, Georgia
DONNA M. CHRISTENSEN, Virgin
Islands
KATHY CASTOR, Florida
JOHN P. SARBANES, Maryland
CHRISTOPHER S. MURPHY, Connecticut
ZACHARY T. SPACE, Ohio
BETTY SUTTON, Ohio
BRUCE L. BRALEY, Iowa
C O N T E N T S
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Page
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 1
Prepared statement........................................... 4
Hon. John Shimkus, a Representative in Congress from the State of
Illinois, opening statement.................................... 8
Hon. Lois Capps, a Representative in Congress from the State of
California, opening statement.................................. 9
Hon. Phil Gingrey, a Representative in Congress from the State of
Georgia, opening statement..................................... 10
Hon. Janice D. Schakowsky, a Representative in Congress from the
State of Illinois, opening statement........................... 11
Hon. Joseph R. Pitts, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 12
Hon. Anna G. Eshoo, a Representative in Congress from the State
of California, opening statement............................... 13
Hon. Joe Barton, a Representative in Congress from the State of
Texas, opening statement....................................... 14
Prepared statement........................................... 16
Hon. Donna M. Christensen, a Representative in Congress from the
Virgin Islands, opening statement.............................. 22
Hon. Michael C. Burgess, a Representative in Congress from the
State of Texas, opening statement.............................. 22
Hon. John P. Sarbanes, a Representative in Congress from the
State of Maryland, opening statement........................... 23
Hon. Marsha Blackburn, a Representative in Congress from the
State of Tennessee, opening statement.......................... 24
Hon. John D. Dingell, a Representative in Congress from the State
of Michigan, opening statement................................. 25
Hon. Kathy Castor, a Representative in Congress from the State of
Florida, opening statement..................................... 26
Hon. Gene Green, a Representative in Congress from the State of
Texas, opening statement....................................... 27
Hon. Tim Murphy, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 28
Hon. Zachary T. Space, a Representative in Congress from the
State of Ohio, opening statement............................... 29
Hon. John Barrow, a Representative in Congress from the State of
Georgia, opening statement..................................... 30
Hon. Jane Harman, a Representative in Congress from the State of
California, opening statement.................................. 31
Hon. Henry A. Waxman, a Representative in Congress from the State
of California, prepared statement.............................. 155
Witnesses
David Blumenthal, M.D., National Coordinator, Health Information
Technology, U.S. Department of Health and Human Services....... 32
Prepared statement........................................... 35
Answers to submitted questions............................... 165
Anthony Trenkle, Director, Office of E-Health Standard and
Services, Centers for Medicare and Medicaid.................... 48
Prepared statement........................................... 51
Answers to submitted questions............................... 167
Frank J. Vozos, M.D., FACS, Executive Director, Monmouth Medical
Center, on Behalf of New Jersey Hospital Association........... 82
Prepared statement........................................... 86
Gregory D. Starnes, CEO, Fayette County Hospital................. 93
Prepared statement........................................... 96
Christine Bechtel, Vice President, National Partnership for Women
and Families................................................... 100
Prepared statement........................................... 102
Roland A. Goertz, M.D., M.B.A., President-Elect, American Academy
of Family Physicians, CEO and Executive Director, Heart of
Texas Community Health Center.................................. 107
Prepared statement........................................... 109
Matthew Winkleman, M.D., Physician, Primary Care Group,
Harrisburg, Illinois........................................... 116
Prepared statement........................................... 118
Glen E. Tullman, Chief Executive Officer, Allscripts............. 121
Prepared statement........................................... 124
Peggy C. Evans, Ph.D., CPHIT, Director, Washington and Idaho
Regional Extension Center, Qualis Health....................... 128
Prepared statement........................................... 131
Submitted material
Statement of The Academy Advisors, submitted by Mr. Shimkus...... 160
Statement of The Premier healthcare alliance, submitted by Mr.
Shimkus........................................................ 162
IMPLEMENTATION OF THE HEALTH INFORMATION TECHNOLOGY FOR ECONOMIC AND
CLINICAL HEALTH (HITECH) ACT
----------
TUESDAY, JULY 27, 2010
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 1:05 p.m., in
Room 2322 of the Rayburn House Office Building, Hon. Frank
Pallone, Jr. [Chairman of the Subcommittee] presiding.
Members present: Representatives Pallone, Dingell, Eshoo,
Green, Capps, Schakowsky, Harman, Gonzalez, Barrow,
Christensen, Castor, Sarbanes, Murphy of Connecticut, Space,
Waxman (ex officio), Shimkus, Pitts, Murphy of Pennsylvania,
Burgess, Blackburn, Gingrey and Barton.
Staff present: Ruth Katz, Chief Public Health Counsel;
Purvee Kempf, Counsel; Katie Campbell, Professional Staff
Member; Emily Gibbons, Professional Staff Member; Tim
Gronniger, Professional Staff Member; Virgil Miler,
Professional Staff Member; Alvin Banks, Special Assistant; Ryan
Long, Minority Counsel; Clay Alspach, Minority Counsel; Sean
Hayes, Minority Counsel; Brandon Clark, Minority Professional
Staff; and Garrett Golding, Minority Legislative Analyst.
OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. I call the meeting of the Health Subcommittee
to order.
Today we are having a hearing on implementation of the
Health Information Technology for Economic and Clinical Health
Act of 2000, or the HITECH Act. Now, I should mention, and Mr.
Shimkus reminded me, that this is actually in the Recovery Act,
so we are actually talking about the implementation of the HIT
part, if you will, of the Recovery Act. And I will recognize
myself initially for an opening statement.
The HITECH Act contained unprecedented funding to promote
the adoption of health information technology among hospitals,
doctors and health care providers through initiatives by the
Office of the National Coordinator of HHS and through Medicare
and Medicaid incentives. This historic investment will serve to
modernize our Nation's use of technology to truly ensure a
high-performing 21st century system.
The Energy and Commerce Committee has worked on a
bipartisan, collaborative basis for many years on health
information technology. This hearing will examine the progress
made so far and opportunities that will be realized in the
future through the implementation of the HITECH Act.
While the United States is a leader in medical technology
and innovation, we have a curiously antiquated system today
related to health IT. Only 20 percent of doctors and only 10
percent of hospitals use even basic electronic health records,
making coordination between health care providers challenging
and leaving the burden on patients to ensure that each provider
knows what tests have been done and what medications have been
prescribed. Too often, this information falls through the
cracks, resulting in wasteful, duplicative tests and preventing
providers from having the full snapshot of a patient's medical
profile.
The successful adoption of health information technology
will have a transformative effective on the quality of health
care in the United States. The provisions of the HITECH will
ensure that Americans nationwide have access to a truly
patient-centered health care system with better quality, more
affordable health care delivered in an efficient and
coordinated manner. It also will promote the advanced use of
electronic health records to facilitate the ordering of tests
and medication, aid in clinical decision-making and allow for
secure data-sharing and privacy protection among providers,
insurers and patients.
Now, it is timely that we have this hearing today, in my
opinion, since CMS just announced on July 13th the final rule
for the minimum requirements that eligible Medicare and
Medicaid providers must meet through their use of a certified
electronic health record technology to quality for the
incentive payments included in the HITECH Act. This rule was
dually released with companion final regulations on the
standards and certification criteria needed for EHR technology
to be successfully used by eligible professionals and
hospitals.
There are over 2,000 health care providers, patients and
other stakeholders who weighed in on the proposed rule when it
was released in January. Many changes were incorporated into
the final rule, which preserved the goals of the HITECH Act
while also making the requirements attainable. I look forward
to hearing an update on these rules from our witnesses today as
well as on other aspects of the HITECH Act.
I will note we have two great panels of government and
private witnesses here with us today. I am particularly pleased
that Dr. Frank Vozos, the Executive Director of my hometown
hospital, Monmouth Medical Center, can be with us today. I had
the opportunity to tour Monmouth Medical Center, which is a
community teaching hospital, over the, I guess it was the July
4th recess or work period, and I was very pleased to see the
work they are doing already to implement HIT adoption and to
learn how they plan to use HITECH funds and guidelines to
further advance their medical care, so I want to thank Frank
Vozos, another Frank, for being with us here today.
I have mentioned in the past sort of a personal story with
regard to the HIT issue. My mom passed away from pancreatic
cancer about 18 months ago now, and for the 7 months or so from
when she was diagnosed until she finally passed, we went to
various institutions including Monmouth Medical and Johns
Hopkins, and it would also drive me crazy because we would
have, I guess it was the CAT scan put on a disc--Robert Wood
was another one that we visited--and at each place I would try
to carry the CAT scan with me and say OK, here it is on a disc,
you know, these are the tests she had, and without reference to
any particular institution, I always had to have it redone,
because they couldn't use, either there was no interoperability
or whatever. And it drove me crazy but it just seemed to make
no sense, and of course, I was worried because she was in a bad
situation, that this wasn't a good thing for her to have to be
restested all the time. So that is just my own personal
experience that hopefully that type of thing we can guard
against in the future.
[The prepared statement of Mr. Pallone follows:]
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[GRAPHIC] [TIFF OMITTED] 78126A.002
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Mr. Pallone. With that, I will ask Mr. Shimkus to give us
an opening statement.
OPENING STATEMENT OF HON. JOHN SHIMKUS, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF ILLINOIS
Mr. Shimkus. Thank you, Mr. Chairman, for holding this
hearing to update us on the progress of implementing the HITECH
Act. This issue has shared bipartisan support as we seek to
modernize and create efficiencies in our health care delivery
system.
Despite the enthusiasm and promises of HIT, concerns have
been voiced from the provider community as we move forward.
Some issues have already been addressed such as loosening the
number of requirements in the first year to comply with
meaningful use and allowing critical-access hospitals
eligibility for certain payments under Medicaid. However, other
roadblocks remain and we must ensure providers across the
country are able to meet the requirements in the timeline set
out.
The hearing today is a chance for us to review where we
stand and ask ourselves if we are trying to make providers run
before they can walk when it comes to HIT. I particularly want
to thank a few of our witnesses for being here today from my
district back in Illinois. First, Mr. Gregory Starnes is here
from Fayette County Hospital, which is a critical-access
hospital. Mr. Starnes lends a voice to rural hospitals and the
unique challenges they face in trying to implement their
systems without the budget and attention of some larger urban
hospitals. I also want to thank Dr. Matt Winkleman from
Harrisburg, Illinois, for making the trip here today, and of
course everyone knows Harrisburg, Illinois--and that is
supposed to be a joke. My staffer is fired. That is a good
joke. It is all in the delivery, he says.
I look forward to hearing from Dr. Winkleman on his
practice was able to rise to the challenge of implementing HIT
while working off the small margins that come from serving a
rural working-class community.
Despite the promising future the HITECH Act holds, it is
difficult to look past the failures of the so-called stimulus
bill it was part of. The American people paid the tab on what
they were told would create jobs, keeping unemployment at below
8 percent and to stimulate the economy. The country has lost
over 3 million jobs since the stimulus passed and unemployment
hovers at 9.5 percent, even higher in my district in Illinois,
all this at a cost of $1.2 trillion to the American taxpayer,
an enormous failed policy continued with the health reform law.
We have been in session 15 weeks since the health care bill was
signed into law by the President in March, 15 weeks and 15
hearings on health, not on the law. In what is likely our last
hearing before recess, the majority has never responded to
numerous requests to hold hearings on implementation of the new
law. On several occasions we have asked for the Administration
to come before the committee, to no avail. Yet with ease we
were able to have representatives of both HHS and CMS to
discuss the HITECH Act today, and we appreciate them coming.
It has been over four months and the majority won't even
acknowledge problems exist with the new law and they aren't
going away. According to CBO, premiums in the individual market
are going to increase 10 to 13 percent as a direct result of
this law. Nearly all small businesses will see no relief from
the tax credit in the law. Many small businesses will opt to
pay fines rather than buy health insurance because they can't
afford the cost. Instead, they will raise prices to customers
and stop hiring new employees. High-risk pools that were
supposed to provide immediate coverage uninsurable are going to
have to have waiting lines and use preexisting conditions to
limit those who enter the new pools. We were told the
President's Executive Order would prevent federal dollars from
being spent on abortion services yet we already know in
Pennsylvania and New Mexico, millions of new federal dollars
will go toward coverage of abortion services through their
high-risk pools. The President promised the pro-life community
and pro-life Democrats in the House his executive order would
prevent this from happening. Will the President now make good
on the promise or is this evidence of what many of us feared
all along, that the health reform law lacks critical
protections to prevent taxpayer-subsidized abortions.
Millions of Americans will be forced into a Medicaid
program that is going broke. At the same time, half of all
seniors with Medicare Advantage will lose their coverage. Those
lucky enough to keep them will see increases in cost while
losing dental coverage and other benefits they rely on. For
those in traditional Medicaid, the billions of dollars in cuts
are unsustainable and will cause problems and reduce quality of
care for seniors. Leading the charge will be Dr. Donald
Berwick, CMS Administrator without any Congressional approval,
and we need to talk to the new CMS Administrator. He is a big
supporter of the British health system which has just reported
that it has failed and they were moving to a decentralized
process in system. The list continues to go on.
We have a responsibility to hold hearings on the
implementation of the new health care law just as we are doing
here today when it comes to the HITECH Act. Madam Chairman,
with the law that will touch every American life, I hope we
will at least have an explanation for the majority to the
American people on why this request is being ignored, and I
yield back the balance of my time.
Mrs. Capps [presiding]. The Chair recognizes herself for an
opening statement.
OPENING STATEMENT OF HON. LOIS CAPPS, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
Mrs. Capps. I am so pleased that today we are exploring the
beginning stages of the HITECH Act and our Nation's considered
effort to move toward a more efficient and effective system of
health care. Like many of my colleagues, I was here for some of
the earliest conversations we had in this committee about HIT
and I am really proud of what we have accomplished. This
includes Chairman Dingell's bill last Congress, the Protecting
Records, Optimizing Treatment and Easing Communications through
Health Care Technology Act of 2008, and that bill is actually
the one that laid the groundwork for many pieces of the HITECH
Act.
I hope that today we will be able to explore the
implementation of the HITECH Act to date including both the
successes as well as the challenges that have been encountered,
but I also hope to discuss the future implementation steps of
this bill as our Nation's health care system moves from paper-
based recordkeeping to a dynamic electronic system. The promise
of health information technology for both patients and
providers is, I believe, remarkable, and as the public
understands how it is so beneficial, it is going to make a
difference in the way we accept the changes in health care that
will come about as we see that they are very cost-effective.
I am a nurse by background and I am also a mother and a
grandmother, and I know firsthand the logistical challenge that
paper-based systems pose. That is one I have been familiar with
as a nurse most of my professional life. Every parent knows how
you struggle to find the proper records of their child's
vaccinations when they start back to school in the fall.
Medical specialists unsure of a senior's medical regimen from
their primary care provider, the senior maybe can't remember
all of the things that have happened since. Moving to a new
town, trying to fill out one's medical history at the doctor
for the very first time, or even when you go back and you are
asked to re-fill the form and you can't remember all the things
that have happened. Electronic health records can follow the
patient and can flag potential issues while at the same time
enhancing the medical provider's practice by reducing
inefficiencies in recordkeeping and frustration in collecting
an accurate medical history. And while HIT is not a silver
bullet to all of our health care problems, it is a key step in
modernizing our health system.
So I look forward to the testimony of our witnesses and I
yield back.
At this time I will recognize Mr. Gingrey for an opening
statement.
OPENING STATEMENT OF HON. PHIL GINGREY, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF GEORGIA
Mr. Gingrey. Madam Chair, thank you so much.
Health information technology has the potential to improve
the quality and reduce the cost of health care in this country.
In fact, according to the Rand Corporation, the potential
savings for both inpatient and outpatient care could average
$77 billion annually if most hospitals and doctors actually
adopted HIT, health information technology. The study found
that the largest savings would come from reduced hospital stays
and administrative time as well as more-efficient drug
utilization and not having doctors order the same test two
weeks apart, expensive scanning and that sort of thing.
Therefore, Madam Chair, I am interested to hear the
witnesses, Mr. Blumenthal's and Mr. Trenkle's thoughts on how
providers will achieve the broader information exchange
requirements specified under stage 2 in light of the relaxed
requirements that the final rule has under stage 1. In
addition, I look forward to hearing from our second panel of
witnesses and their thoughts on how we move forward.
Madam Chair, if there were silver bullet solutions for our
health care system, information technology would surely be one
of them, maybe the main one. This technology has the potential
to improve the quality and the efficiency of our health care
system while ensuring that tax dollars are spent wisely. With
it, we can better identify and we can cut waste, fraud and
abuse out of the system. Once implemented, we will be better
able to protect patients' privacy and eliminate the
inefficiency of a system based on paper charts. I know of what
I speak. I practiced medicine for 31 years.
Therefore, a series of targeted bills based on silver
bullets, medical liability reform, increased transparency,
electronic medical records, health insurance reform for sick
and low-income Americans could have passed in a transparent and
bipartisan manner. Instead, what did we do? We passed a 2,400
page omnibus bill that few members could read and understand.
Madam Chair, I have repeatedly used my opening statement in
this committee over the past few months to support my ranking
member, John Shimkus's call for a hearing on Obamacare, Patient
Protection and Affordable Care Act of 2010. Why? Well, because
on March 9th, Speaker Pelosi said that the bill is, and I am
going to quote her now, ``going to be very, very exciting but
we have to pass the bill so you can find out what is in it away
from the fog of controversy.'' Now, that is a direct quote.
Speaker Pelosi was successful and this Democratic majority did
pass Obamacare, but the fog of controversy still exists in
spite of her promise. It turns out that a large majority of
workers won't be able to keep the health care they like today
and they may even lose their jobs because of the law. The cost
projections for patients, employers and our government continue
to rise. Health insurance will not be available or affordable
to hundreds of thousands of sick Americans. These problems all
represent broken promises made by the President to the American
people. Where the President's rhetoric has not lived up to his
product, Congress indeed needs to investigate. The American
people deserve to know what is in this law, and I fear that
unless we hold hearings immediately to investigate the new law,
our constituents will find out the hard way.
Madam Speaker, I have gone a little bit over. Thank you for
your patience. I would like to submit three things for the
record as I yield back. One is a statement in regard to
electronic medical records by the American Medical Association,
another by the United Health Group, and finally, by Electronic
Health Records Association.
Mrs. Capps. Without objection, so ordered.
[The information was unavailable at the time of printing.]
Mr. Gingrey. And I yield back. Thank you so much, Madam
Speaker.
Mrs. Capps. The Chair now recognizes Ms. Schakowsky for 5
minutes--for 3 minutes.
OPENING STATEMENT OF HON. JANICE D. SCHAKOWSKY, A
REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS
Ms. Schakowsky. Thank you, Madam Speaker.
I just want to respond briefly to the ranking member, who
rather than addressing the potential for reducing costs and
improving care of health IT decided as usual to restate the
talking points of the insurance industry including saying that
this historic and important piece of legislation is the cause
of higher costs. Instead, what we have seen is excessive
premium increases--see Well Point--and higher profits--see
United Health Care, who at the same time as their profits went
up the amount of health care they actually provide for each
dollar has gone down. And a part of this bill is talking about
the advantages that we can reap from taking advantage of health
IT, which is vital for this country.
The development of a nationwide interoperable health
information technology system is a critical component of
improving health care quality, promoting care coordination and
reducing medical errors. I have been in the record rooms of
clinics and hospitals, rooms overflowing with files taking up
space that could be put to significantly better use. These
clinics need health IT, and the $2 billion provided in the
American Recovery and Reinvestment Act will go a long way to
upgrade and improve this Nation's health care system. As
someone who recognizes the substantial rewards of moving our
health care system toward health IT functions, I also know that
we must ensure complete security and privacy for consumers.
Through the chairman's leadership, the HITECH Act
strengthened federal privacy and security laws to protect
personal identifying information from misuse. Without critical
privacy and security guarantees, consumers will simply not be
willing to utilize electronic records. As we move forward with
greater utilization of electronic records, this is an area
where we have to remain diligent.
I would also like to thank the witnesses today for their
testimony, in particular, those from the Administration.
Congress tasked HHS with a large job when we passed the HITECH
Act, and they have worked quickly to implement this program.
They have also been responsive, addressing concerns with
implementation. I was one of several members that urged HHS to
reevaluate their first consideration of meaningful use, and
they have subsequently taken many of those concerns into
account during rulemaking. I look forward to working in the
months and years ahead as we implement the full promise of
health IT.
So I thank you, Madam Chairman, and I yield back the
balance of my time.
Mrs. Capps. The Chair now recognizes Mr. Pitts for his
opening statement.
OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA
Mr. Pitts. Thank you, Madam Chairman.
On February 17, 2009, the President signed the American
Recovery and Reinvestment Act, also known as the stimulus bill,
into law, promising that the $787 billion bill would create or
save 3\1/2\ million jobs over the next 2 years. We were also
told that the stimulus would hold unemployment under 8 percent.
At this point in the recovery, unemployment would be at 7.5
percent. No one, not the White House, not Congressional
leadership, can tell us with any degree of accuracy how many
jobs have been saved or created. In fact, it is impossible to
calculate how many jobs were not lost due to the passage of the
stimulus or any other bill, for that matter. As for jobs
created, we have an ever-expanding federal workforce, not a
thriving private sector, and as we all know, unemployment is
currently at 9.5 percent after peaking at 9.9 percent earlier
this year.
One of the provisions included in the stimulus was the
Health Information Technology for Economic and Clinical Health,
or HITECH Act. While I would question how the HITECH Act is
stimulative or how many jobs it has saved or created, we all
see the promise of health information technology from reduced
errors, greater efficiencies to being able to share information
across the country with the click of a mouse, and I support the
goals of the HITECH Act. Many of us have been contacted,
however, by providers from back home who panicked when the
proposed rule came out earlier this year, and it seemed that
few hospitals and doctors' offices could meet such an
aggressive implementation timetable or stringent criteria.
I hope that our Administration witnesses will discuss how
the final rule has been changed to address some of these
concerns, and I look forward to hearing from our witnesses.
Thank you, Madam Chairman. I yield back.
Mrs. Capps. The Chair now recognizes Ms. Eshoo for her
opening statement.
OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
Ms. Eshoo. Thank you, Madam Chairwoman. It is nice to see
you in the chair, and thank you for holding this important
hearing on the implementation of the HITECH Act.
The legislation we included in the American Recovery and
Reinvestment Act to promote health information technology was
adopted to revolutionize the health care delivery system in our
country. I have been so often struck by this: we live in the
Information Age and yet our health care system has really been
mired in the pen-and-paper past, and so the money that is
directed toward a comprehensive, interoperable and nationwide
HIT system is one that really meets what the 21st century is
all about, and I don't think that there is a doubt that this
will have a salutary outcome in terms of enhancing patient
safety, reducing medical errors, improving the overall quality
of care, and of course, having a system that protects the
privacy of patients as well.
I have been concerned for a long time about this issue. I
introduced comprehensive legislation, HIT legislation, in 2007.
We spent months meeting with doctors, with hospitals, with
technology companies, which I think everyone knows, many of
them make their home in my Congressional district, as well as
HIT vendors, and I am proud to say that the work that my staff
and myself did on that legislation really became the basis of
the legislation that Mr. Dingell introduced and now we are
going to be reviewing it.
So I am really pleased that Dr. Blumenthal, the National
Coordinator for HIT, and Anthony Trenkle from the Office of E-
Health at CMS are going to share with us their experiences in
implementing the legislation. I know that there are bumps in
the road. There always are. When constituents ask me about
legislation, I always say well, understand that legislation is
shaped by human beings and that legislation bears the mark of
humanity. It is less than perfect. But what is exciting to me
is that we have launched the effort. We have placed significant
resources next to it, $2 billion, and so today is a good chance
to hear about how we are doing on this very important journey.
So I look forward to hearing from our friends that are here to
be witnesses and also to the second panel that will instruct us
as well.
So I thank the chairwoman, I thank the chairman of the
subcommittee for scheduling this and I thank the witnesses and
look forward to hearing from you.
Mrs. Capps. I thank my colleague.
Now we turn to the ranking member of the full committee,
Mr. Barton, for his opening statement.
OPENING STATEMENT OF HON. JOE BARTON, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TEXAS
Mr. Barton. Thank you, Madam Chairwoman. I thank you and
Ranking Member Shimkus and Subcommittee Chairman Mr. Pallone
for holding this hearing. We thank our witnesses on this panel,
and I know we have several on the second panel. We thank them
for participating, especially the witness from the Heart of
Texas Community Health Center down in Texas. We are glad that
he is here.
Obviously the Republicans are not against health
information technology. Last year we worked on a bipartisan
basis to pass a bipartisan health IT bill. Unfortunately, that
bill did not become law. Instead, at the start of this
Congress, our friends in the majority passed their version of
health IT as part of the so-called stimulus bill. I would like
to hear from the witnesses later this afternoon just how
stimulative that has been. The unemployment rate is about 9\1/
2\ percent around the country. This bill that we are looking at
today didn't do much in the private sector. It focused more on
spending federal dollars while ignoring the less-expensive
avenues for health IT deployment. I think it would have been
better to allow hospitals and physicians to donate health IT
systems to each other, for example. It has been over a year
since this bill became law, the stimulus bill, that is. That
package is going to cost about $1\1/2\ trillion. Numbers that I
have been given indicate that according to the Bureau of Labor
Statistics, we have lost over 3 million jobs in that time, so I
think it is a fair question: where are these jobs and how has
this particular bill helped create jobs.
While it is not the focus of the hearing, last week myself
and several other Republicans asked for a hearing on the recess
appointment of Dr. Berwick to head the new CMS. Dr. Berwick was
appointed without being approved by the Senate, which I think
is a bad precedent, although not unprecedented. Obviously other
Presidents have done recess appointments. As we try to
implement the new health care law, the bigger law, I think
people have a right to know how Dr. Berwick plans to implement
that law and make all those cuts in Medicare in the
neighborhood of $145 billion.
So in any event, Madam Chairman, again, we are not opposed
to health IT, we are not opposed to the federal government
being involved, but we didn't have much say in this particular
bill, so it is going to be an interesting dialog as we go
forward.
With that, I will put the rest of my statement in the
record. And again, we do thank our witnesses and we look
forward to their testimony. Thank you.
[The prepared statement of Mr. Barton follows:]
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Mrs. Capps. Thank you, Mr. Barton.
And now we turn to Mrs. Christensen for her opening
statement.
OPENING STATEMENT OF HON. DONNA M. CHRISTENSEN, A
REPRESENTATIVE IN CONGRESS FROM THE VIRGIN ISLANDS
Mrs. Christensen. Thank you, Madam Chair, and I want to
thank you and Chairman Pallone and the ranking member for
holding this hearing on implementing of HIT, an issue that has
been of particular importance for me. Of course, it is
important to all providers, but providers of color, those in
minority and poor and rural neighborhoods in my district have a
particular interest in how it is going to be implemented.
The Health Information Technology for Economic and Clinical
Health Act holds out great promise for improving medical care,
and although a few would disagree, reducing health care costs
in the future. But I also want to make sure that it eliminates
disparities, not exacerbate them. I appreciate the response of
the public comments on what constitutes meaningful use, but if
some of the big guys like Partners in Health Care, Kaiser
Permanente and others have concerns about being able to meet
the standards, certainly the smaller, poorer, understaffed,
overworked providers will definitely have problems. I can
imagine that OMC has in balancing the need to get this
implemented, ensuring privacy and bringing all providers in. On
the other hand, I know the challenge of providers like I was
would have getting this implemented while trying to take care
of patients. We will be looking to the regional extension
centers like the one at the University of Ponce in Puerto Rico
with the Virgin Islands Medical Institute for their help in
getting this done. Dr. Blumenthal, in your testimony you say
that we should look at this not as investments in technology
per se but as efforts to improve the health of Americans and
the performance of their health care system, and of course key
to improving the health of all Americans is to ensure that
those who are disproportionately affected by health inequities
are able to access and take full advantage of the provisions of
the HITECH Act.
So I look forward to the testimony and thank and welcome
our witnesses for being here today.
Mrs. Capps. The Chair now recognizes Mr. Burgess for an
opening statement.
OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS
Mr. Burgess. I thank the Chair for the recognition. Welcome
to our witnesses. We are grateful that you are here. I am
grateful that our committee is exercising proper oversight to
see if the HITECH provisions of the stimulus bill are being
implemented as intended. After all, the United States Congress
put $20 billion on the table with the goal of increasing and
ultimately achieving universal electronic medical record
adoption.
For the record, I did not support the stimulus bill and I
continue to believe that some of the provisions relating to
health information technology contained within that bill have
actually been inhibitory toward their adoption. I am still
uncertain whether providing financial incentives such as grants
will be effective. I continue to believe that claims-based
incentives ultimately make more business sense.
In addition, our lack of addressing safe-harbor issues is a
flaw, and early in an early iteration of a health IT bill, H.R.
1031, I introduced such a concept but unfortunately it was not
part of the language that was adopted by the majority when the
stimulus bill was passed. I would also like to be certain that
new federal guidelines are working in coordination with the
quality improvement initiatives that many in the industry are
already undertaking and certainly not work at cross purposes to
those efforts.
We need to focus on implementation. Even if I didn't agree
on how, I am committed to ensuring that the taxpayer dollars
are now used responsibly to establish the goal that was set
forth. Even if $1 doesn't go out the door, penalties for
providers are coming no matter what, and guess what? They are
coming pretty darn fast. They will be here in just a couple of
years. I have been committed to see that the rules set up by
the federal government encourage adoption and allow providers
to avoid the proverbial sword of Damocles hanging over the head
of every doctor and every hospital in the country in just a few
short years. I have certainly been fearful that federal
regulations might bog down the normal and routine medical
treatment by requirements that are unnecessary and that I
imagine both patients and doctors will have some difficulty
with complying. Unfortunately, the draft regulations put out in
February were, in a word, unworkable. I authorized with
representatives Space, Stearns and Engel a letter pointing out
several issues with the proposed rule. These were so
intuitively obvious that 250 Members of Congress agreed to sign
on to the letter. Dr. Blumenthal, to his credit, has always
taken my calls, always listened to my concerns and did address
many of the issues that were raised. I do remain concerned
about the multi-campus issue which has been mentioned and on
certification of existing systems as qualified to receive
incentive payments, and Madam Chairwoman, I would like to
insert into the record a statement by the Premier Health Care
Alliance addressing that issue.
So we will continue to work in Congress on legislation to
address these issues as they come up. We hope we can achieve a
bipartisan consensus with our members in this committee on both
sides of the dais and with committee members of Ways and Means.
I certainly look forward to hearing the testimony today and I
will yield back the balance of my time.
Mrs. Capps. Hearing no objection, the Chair will insert the
letter that is recommended by the gentleman.
[The information appears at the conclusion of the hearing.]
Mrs. Capps. And now turning to Mr. Sarbanes for an opening
statement.
OPENING STATEMENT OF HON. JOHN P. SARBANES, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF MARYLAND
Mr. Sarbanes. Thank you, Madam Chair. I look forward to the
testimony from the witnesses today.
The search for the tipping point on health information
technology has sort of been for some like the search for the
Holy Grail. I don't think when we get there that is what it
will turn out to be but I do think it is going to make a huge
difference, first for patients and then for the costs of the
system in terms of reducing cost, promoting more efficiency and
so forth.
I always have every head in the room nod when I talk to an
audience about how frustrating it is when a patient goes to a
provider and has to have the baseline medical record recreated
for them because it is so difficult for the provider to put
their hands on tests and other records that have been done and
are available out there somewhere but they somehow can't get
hold of those, the result being that the patient is then
subjected to more tests, more pushing and prodding when that
information that we give the provider a baseline picture of the
person's health and condition is available, it is just not at
their fingertips. And HIT has the potential to solve that
problem. When it does so, it is going to make a tremendous
advance forward for patient care and obviously, as I said,
improve efficiency and reduce cost.
So I think the investment in this both in the stimulus bill
and in the health reform law was a smart investment. I am
looking forward to hearing from you today as to how we are
making progress on that investment, and I yield back my time.
Thank you.
Mrs. Capps. The Chair now recognizes Mrs. Blackburn.
OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TENNESSEE
Mrs. Blackburn. Thank you, Madam Chairman, and we do
welcome our guests and we thank you for being here.
We do want to keep tabs on what is happening with the
HITECH Act, with health IT as it moves forward. We are
concerned about the funds that were provided in the stimulus
bill, what was included there and we are also concerned with
the rules. I am glad that CMS has finally published the final
rules for the electronic health records and we know that our
doctors and our hospitals are working diligently to try to
comply with these rules because we are hearing from them, and
while we know that the EHRs are going to hold tremendous
promise, we also know that we have got some hurdles out there
if we are going to reach the goal of everyone having an
electronic health record by 2015.
I think that everyone is concerned with this deadline of
January 1, 2011. We will have some questions about that because
that is the time for provides to have in place a certified EHR
to qualify for those Medicare health IT incentive programs, and
between now and then our providers and vendors are going to
have to ramp up very quickly. I will say, Madam Chairman, I
think that when Congress does not engage in putting some of
these items in statute and leaves it to agencies to put in
place, we see unworkability and having to do some revisits. It
also appears that CMS had lowered the bar in some areas in the
recent rule while remaining overly prescriptive in others. An
example, Tennessee hospitals are extremely concerned about the
financial implications on multi-campus hospitals that share a
single Medicare provider number. That is another area we will
want to discuss with you today.
What we must keep in mind that government excels at
regulation, not innovation, and we are going to need to listen
to the private sector on this and we will look forward to some
questions there for our second panel, and as this rush is
taking place to build this nationwide network very quickly, I
am concerned that CMS could end up building a national but
suboptimal system, and I hope that we are going to continue to
see working through these problems together.
Tennessee is a leader in the health IT innovation and
implementation and we are hopeful that this can be put on the
right direction and some of these concerns and stumbling blocks
addressed as we move along the way.
I thank you for the time. I yield back.
Mrs. Capps. The Chair is now pleased to recognize the
chairman emeritus of the full committee, Mr. Dingell, for his
opening remarks.
OPENING STATEMENT OF HON. JOHN D. DINGELL, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF MICHIGAN
Mr. Dingell. Madam Chairman, thank you, and thank you for
holding this important hearing.
Health information technology has the ability to modernize
and improve our entire health care system by allowing for more
informed decision-making, by reducing duplicative and
unnecessary paperwork, by speeding up diagnoses and by reducing
medical errors. The Health Information Technology for Economic
and Clinical Health Act, HITECH, that was passed as a part of
the American Recovery and Reinvestment Act of 2009, created an
unprecedented investment in health information technology. In
fact, the Congressional Budget Office noted the adoption of
health IT would reduce Medicare spending by $4.4 billion over
the 2011-2019 period and create federal savings in Medicaid
over $7 billion in the same timeframe. Given this potential, we
must ensure that we get a good return on that investment and
vigorously move forward on the implementation of the statute.
These resources will put us on the path to a more
coordinated health care system, which is why the topic of
health information technology has long been a focus of this
committee. I would like to note that not only has this
committee spent many years studying and legislating on the
matter but that we have done so in a bipartisan fashion. For
example, in the last Congress, this committee passed the
bipartisan health information technology bill, H.R. 6357, the
Protecting Records, Optimizing Treatment and Easing
Communication through Health Care Technology Act of 2008. This
bill included language to codify the Office of National
Coordinator for Health IT and to provide grants designed to
stimulate the spread of HIT. It also included strong privacy
protections. This bill became the basis for the HITECH Act.
The Administration recently issued rules, final in
character, to support meaningful use of electronic health
records. I am delighted that the Office of National
Coordination for Health IT and Centers for Medicare and
Medicaid Service have worked with all interested parties to
develop standards that are attainable but also propel our
health technology systems forward. They have had to thread a
very fine needle, and overall they have done a commendable job.
However, we all understand that a few concerns remain. I am
confident the Administration will continue to hear and respond
to the legitimate concerns. I am also aware that the work of
the Congress may not be totally done on this issue.
I want to thank both of the panels of our witnesses today
for joining us and look forward to their updates on the
implementation process. We will find that the testimony today
will be in front of a group of people that has a real interest
in ensuring that HITECH Act moves forward in a way that
fulfills the intent of the legislation.
Again, Madam Chairman, I thank you and I yield back the
balance of my time.
Mrs. Capps. The Chair is pleased to recognize for an
opening statement Ms. Castor.
OPENING STATEMENT OF HON. KATHY CASTOR, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF FLORIDA
Ms. Castor. Thank you, Madam Chair, for calling this
hearing on how we improve health care through modern
technology. You know, the health care investments that have
been made through the Recovery Act have really been a godsend
to communities all across the country and created thousands and
thousands of jobs including in my hometown of Tampa and the
Tampa Bay area.
One of the initiatives that I am most proud of was made
possible by the HITECH Act included in the Recovery Act and it
is the Paper-Free Florida Collaborative Regional Extension
Center. In April, Paper-Free Florida was awarded nearly $6
million for its initiative developed by the University of South
Florida in my district. It is one of more than 70 regional
extension centers authorized by the Office of National
Coordinator. I notice that Glen Tullman from Allscripts is
here. He gave us great advice and encouragement from the get-
go, so I am glad you are here, Glen. Paper-Free Florida will
effectively implement electronic health records in more than
1,000 priority clinical practices, and I heard from the other
side of the aisle where are the jobs. Well, I am grateful that
a number of the jobs are right in my hometown in Tampa because
what we are going to be able to do is recruit and train and
employ over 100 e-health ambassadors as HIT extension agents in
20 countries. We are going to avoid costly medical errors for
patients, and you should have seen the young doctors when we
made the announcement. They are already there. They know this
technology and they just can't wait to get started, and it is
exactly what we intended by the Recovery Act, creating these
high-wage jobs that communities like mine need in this economic
downturn. So thank you.
While I am proud that one of the many success stories made
possible by the HITECH Act comes from my community, there are a
few roadblocks that we need to address to ensure that more
health care providers are able to coordinate care, and one area
of improvement I think I am hearing consensus across the board
here is the meaningful-use rules, and I think you for granting
additional flexibility as you took comments from folks and
providers all across the country, but we have more work to do
here. Dr. Blumenthal, you have worked hard to make sure that
certain entities that are eligible for HIT incentive payments
are going to be eligible, but as many of the members today
mentioned, the hospital systems with multiple campuses remain
in a tough spot under these new rules. And I was with a chief
medical officer in Florida for a big hospital system yesterday,
they were singing your praises, but this is giving them real
heartburn. The decision to allow only one payment per provider
number, even if that provider number is used for more than one
facility, puts multi-campus hospitals at a real disadvantage.
Meanwhile, they have great potential to deliver results, the
results that we need.
Nevertheless, the overall benefit of the HITECH Act is
among the most exciting components of the Recovery Act and
alongside the Affordable Care Act, we will continue to make
great strides to improve the health for American families.
So thank you, Madam Chairman, and I look forward to hearing
from our witnesses today. I yield back.
Mrs. Capps. The next opening statement will be by Mr.
Green.
Mr. Green. Thank you, Madam Chairman. Before I begin I
would like to ask unanimous consent to include a written
statement for the record. This is written testimony of Dan
Hawkins of the National Association of Community Health
Centers.
Mrs. Capps. Hearing no objection, so ordered.
[The information was unavailable at the time of printing.]
OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF TEXAS
Mr. Green. Like my colleagues, I thank you for holding this
hearing to check on the implementation and progress of the
Health Information Technology for Economic and Clinical Health
Act of 2009. For many years, this committee and Congress has
the goal of encouraging large-scale implementation of
electronic health records. The passage of the Health
Information Technology for Economic and Clinical Health Act of
2009, HITECH, in the American Recovery and Reinvestment Act of
2009 demonstrated Congress's commitment to improving and
coordinating patient care as well as streamlining and updating
our medical records system. In a high-tech world, the days of
paper records should be well behind us.
With integrated information technology, patients can manage
their own electronic records and avoid having to haul multiple
records to various physicians. The lack of coordinated care in
the country is startling, but if we can coordinate our care
systems through health IT, we have a potential to change our
health care system.
We are all aware of the benefits improved IT will bring the
health care sector and the patients it serves. If implemented
correctly, health IT will improve patient safety and garner
cost savings. That is why I am glad we are having the hearing
today to discuss the status and the implementation of the
HITECH Act. As we know, no legislation is perfect and Congress
has a history of revisiting legislation many years after its
passage. The HITECH Act is no exception. I am particularly
interested in discussing potential changes that need to be made
to assist community health centers and mental health providers
adopt health IT.
The implementation of health IT has dramatically improved
the community health center coordination of care in our
district and we are excited about the potential this has to
improve quality of health care for medically underserved in the
district. I do want to discuss how payments to health care IT
are made to individual providers at the community health
centers rather than the actual health center, which is a more
common practice in allowing recurrent funding for health
centers.
With regard to mental health providers, I sponsored the
Community Mental Health Services Improvement Act for many
years. This legislation contains funding for the establishment
of grant programs to improve health IT for mental health
providers. I recently began working with Representative Patrick
Kennedy and Representative Tim Murphy on H.R. 5040, the Health
Information Technology Extension for Behavioral Health Services
Act, which would amend HITECH to give mental health providers,
substance-abuse providers and psychiatric hospitals in parity
with other health care providers for medical use of health
information technology and electronic health. This legislation
clarifies the definition of health care provider to include
mental health professionals, substance-abuse professionals,
psychiatric hospitals, behavioral mental health clinic and
substance-abuse treatment facilities. The legislation requires
HHS through the National Coordination of Health Insurance
Technology to award grants for mental health treatment
facilities not eligible for meaningful-use incentives through
the HITECH Act. The grants would allow for purchase of
certified electronic records training of medical staff and the
use of electronic records and improve the exchange of health
information between mental health providers and other health
care providers. I am hopeful these issues can be discussed in
the future the community health centers and mental health
providers are an integral part of our health care system.
Again, I want to thank the witnesses for appearing. I want
to welcome Dr. Roland Goertz, CEO and Executive Director of
Heart of Texas Community Health Center in Waco on the second
panel, and I yield back my time.
Mrs. Capps. Thank you.
Mr. Murphy is now recognized for his opening statement.
OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA
Mr. Murphy of Pennsylvania. Thank you, Madam Chairman.
We all know that electronic medical records hold enormous
potential for the practice of medicine but tools like IT with
health are only valuable if we know how to use them and if we
have them, and that process began with more than $20 billion in
federal resources allocated. Today, only 6 percent of hospitals
and 2 percent of physicians rely on these health records.
These incentives no doubt are going to increase
participation but as I have heard from many doctors and
hospitals in my district, that initial requirement for
incentive payments seems to be too complex and unobtainable.
Now with CMS cutting back on the scope of HIT mandates, it has
given providers more time to adopt records that will collect
essential patient data, and I look forward to hearing what
providers can do before being financially penalized for
noncompliance.
HIT will be an essential component of medicine, or as Dr.
David Blumenthal has put it aptly, as accepted in the daily
lives of health professionals as the stethoscope and the exam
table. Well said. Health IT is most valuable when it is
available to providers across all disciplines, and as it
advances, we want to make sure government is not a barrier but
a team member to work better, effectively, efficiently and
economically.
I also believe that health IT needs to be integrated,
interactive, interoperable and intelligent in order to provide
great patient outcomes, and that is where I am afraid sometimes
we may fall short in terms of integrating care, and let me give
two quick examples. Patients in skilled nursing homes are
extremely ill on average and take eight different kinds of
medication. Eighty percent of this population comes from a
hospital, but there is little exchange of patient data
electronically, so a hospital may discharge a patient to a
skilled nursing facility on Friday, the paper records are sent
to the skilled nursing facility via fax a day or two later. If
it was electronic, that facility could do a better assessment
upon admittance and know the patient's medications immediately.
Second, we need to be thinking about the overall health of
an individual. Unfortunately, the incentives exclude mental
health providers. As my colleague, Mr. Green, said, Congressman
Patrick Kennedy and I have put in a bill, the HITECH Extension
for Behavioral Health Services, H.R. 5040, to make mental
health providers eligible for the federal incentive payments.
This is a critical bill, and it would extend Medicare and
Medicaid reimbursements for meaningful use of electronic health
records to mental health professionals across a spectrum.
So as Congress continues to support advances in technology,
I look forward to working with this committee to secure passage
of this bill and others. Keep in mind that those with chronic
illness run the risk twice that of the population for having
depression and other mental illnesses. We have to make sure
that all these records are integrated together so that whatever
medical problem they have, whatever complications people with
chronic illness have, the key feature of electronic medical
records is to make sure we can use them and provide the
incentives and provide the facilities for us to be able to make
better medical decisions.
With that, I yield back.
Mrs. Capps. Thank you, Mr. Murphy.
Mr. Space, you are now recognized for your opening
statement.
OPENING STATEMENT OF HON. ZACHARY T. SPACE, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF OHIO
Mr. Space. Thank you, Madam Chairman.
Thank you for holding the hearing on an issue that of
considerable important to all of us. When it comes to health
IT, there does seam to be a great deal of agreement on both
sides of the aisle with very good cause. Both Democrats and
Republicans, providers and consumer groups by and large seem to
agree that improving the adoption of health information
technology around the country will be beneficial to the
practice of medicine, reduce redundancies, save money, provide
a safer environment for patients and I certainly include myself
in this support. How we achieve the adequate adoption of health
IT is what has brought us here today. Ensuring that every
hospital, doctor and clinic in this country have high-quality
record systems that ensure patient safety is not an easy task
and there is no simple answer to how we reach that destination.
The HITECH Act included as part of H.R. 1 earlier this year
offers a promising framework for accomplishing this goal,
establishing an Office of the National Coordinator and
developing a structure for incentive payments has created a
framework for pushing the adoption of health IT in a strategic
and meaningful way. However, the meaningful-use rule provided
by CMS 2 weeks ago holds some troubling provisions that I fear
may steer us away from adoption, and I would like to touch on
two of those issues today. First, the multi-campus issue that
was brought up earlier I think during Mr. Burgess's statement.
I believe firmly that it was the intent of this body in passing
the HITECH Act to ensure that each hospital would be entitled
to its own incentive payments. The rule offered by CMS denies
those payments to hospitals that have chosen to structure
themselves with multiple campuses under a single provider
number, and I am disappointed in this decision, particularly
after we worked with Representatives Burgess, Engel and Stearns
to send a letter to CMS that was signed by 240 members of this
body. My staff will continue to work with those members and
their staffs along with the staff of this committee and the
Ways and Means Committee so that this issue can be resolved.
And the second concern we have is what this rule will mean
for smaller rural hospitals, like the 13 that we have in Ohio's
18th Congressional district. Most of those hospitals, indeed,
all of those hospitals, see an exceptionally high caseload of
Medicare and Medicaid recipients with an ever-growing number of
self-pay cases. That is a euphemistic term for charitable
cases. We see these cases increasing with the economy. For
these hospitals, investing in the needed capital to purchase
health IT systems that meet the criteria spelled out today is
especially challenging. Even with the promise of incentive
payments, these investments are costly and difficult. I still
have concerns about what these requirements will mean for our
hospitals and I certainly hope to learn more about how HHS and
CMS intend to help small rural hospitals in accessing this
vital technology.
Thank you, Madam Chair.
Mrs. Capps. Thank you.
The Chair recognizes Mr. Barrow for an opening statement.
OPENING STATEMENT OF HON. JOHN BARROW, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF GEORGIA
Mr. Barrow. I thank the Chair for the opportunity to
explore this topic.
In getting ready for this hearing, I reached out to some of
the folks on the ground back in my district and some of the
folks who represent them up here, and there still seem to be a
lot of unknowns and unanswered questions out there. We spent a
lot of time poring over legislative language and debating the
definitions of legislative terminology. I would like to bring
to the attention of the committee some of the more fundamental
challenges that I am talking about.
I represent areas that don't even have access to reliable
broadband services. I represent counties that are at least an
hour's drive away from the nearest IT professional. I am
concerned that even if we do everything right up here, we make
grant funding available, we offer technical guidance, we
provide reasonable rewards for proper implementation, many
providers out there are still going to be left behind because
we still don't have the proper technological infrastructure in
place to take full advantage of this. So my concern is that we
make great leaps forward in all other kinds of places with
information technology that we don't forget those folks who are
still struggling to get on board the IT bandwagon in the first
place, and I hope that can be addressed in the course of the
hearing.
Thank you, Madam Chair, and I yield back the balance of my
time.
Mrs. Capps. Ms. Harman, the Chair recognizes you for an
opening statement.
Ms. Harman. Thank you, Madam Chair. It is nice to have a
school nurse in the chair, and the quality of school nursing
care matters to this committee, and I think electronic IT will
be helpful even at that level, and I am sure you agree with me.
Mrs. Capps. Absolutely.
OPENING STATEMENT OF HON. JANE HARMAN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
Ms. Harman. Most of our colleagues have described what is
in this legislation, which is absolutely essential. I just
wanted to add a couple of things that haven't been said. One is
that a firm in my district makes dog tags, electronic health
dog tags for soldiers, and has had some success in selling
these to the Pentagon. I have no idea, and probably others
would know better than I, whether these could have a civilian
application, but the notion that a soldier hit on the
battlefield would have all of his health records in this tiny
little chip that he wears around his neck is an exciting idea
and it might really be useful to people who for any number of
reasons could get into problems and urgently need one health
provider to be able to download their history. There would
obviously be some notion of choice here. I don't assume
everyone would be compelled to wear these things, but I just
put it out there as something that I think may have promise.
The other thing I would want to mention that has been said,
I am sure, before but not while I have been sitting here is the
issue of both privacy and accuracy of records. I mean, once we
consolidate and integrate health data, and boy, do I think
``integration'' is a critical word, it has to be accurate. The
goal here is obviously to reduce errors and duplication, but
what is on those records really matters and so while our
legislation goes a long way in that direction, I just mention
to our witnesses that this is something that will need renewed
focus.
And I congratulate this committee for legislating on a
bipartisan basis in an area that is absolutely critical to the
quality and cost of health care for Americans including school
kids who go to excellent school nurses like our friend Lois.
Thank you very much. I yield back, Madam Chair.
Mrs. Capps. And on that note, we conclude our opening
statements by members of the subcommittee and we turn now to
our witnesses. I want to welcome you both and thank you for
your patience in listening to all of us. We have on our first
panel Dr. David Blumenthal, National Coordinator of Health
Information Technology for the U.S. Department of Health and
Services, also joined by Mr. Anthony Trenkle, Director of the
Office of E-Health Standards and Services, Centers for Medicare
and Medicaid Services. Welcome to you both.
Dr. Blumenthal, you may begin your testimony.
STATEMENTS OF DAVID BLUMENTHAL, M.D., NATIONAL COORDINATOR,
HEALTH INFORMATION TECHNOLOGY, U.S. DEPARTMENT OF HEALTH AND
HUMAN SERVICES; AND ANTHONY TRENKLE, DIRECTOR, OFFICE OF E-
HEALTH STANDARD AND SERVICES, CENTERS FOR MEDICARE AND MEDICAID
STATEMENT OF DAVID BLUMENTHAL
Dr. Blumenthal. Chairwoman Capps, Ranking Member Shimkus,
distinguished subcommittee members, thank you for the
opportunity to submit testimony on behalf of the Department of
Health and Human Services regarding the implementation of the
Health Information Technology for Economic and Clinical Health
Act.
The provisions of the HITECH Act are best understood not as
investments in technology per se but as efforts to improve the
health of Americans and the performance of their health care
system. Three interdependent rulemakings were required to
implement the provisions of the HITECH Act generally and the
Medicare and Medicaid EHR incentive programs in particular. The
first rulemaking establishes the requirements that eligible
health care providers will need to satisfy in order to qualify
for incentive payments. The second specifies the technical
capabilities and standards that certified EHR technology will
need to include to support these health care providers, and the
third creates the processes for EHR technology to be tested and
certified, thus providing confidence and assurance to eligible
health care providers that certify the EHR technology they
adopt will perform as expected.
On July 13th, with the issuance of the Medicare and
Medicaid EHR incentive programs' final rule and the initial set
of standards, implementation specifications and certification
criteria final rule, a 17-month effort was capped to publish
the three rulemakings necessary to implement meaningful use,
stage 1. These rules cumulatively reflect over 2,000 public
comments from stakeholders across the health care system and
illuminate the initial pathway to achieving an integrated and
electronically connected health care system. Our health
information technology policy committee and health information
technology standards committee played vital roles in advising
me and the Secretary on these rules and many other matters.
With the adoption of these three rules, attention now turns
to their implementation. The ONC, the Office of the National
Coordinator, is now ramping up the development of other
processes that will need to be in place to enhance
interoperability. Many of these processes will be components of
a comprehensive standards and interoperability framework
developed by the Office of the National Coordinate to expedite
standards harmonization as well as their adoption and use.
I am also pleased to report that in the approximately 4
weeks since the temporary certification program rule was
finalized, ONC has already distributed 32 applications to
organizations seeking to become authorized testing and
certification bodies to test and certify EHR technology. I am
highly encouraged by the strong interest shown thus far and I
am optimistic that multiple organizations will be granted ONC-
authorized technology and certification body status and thus be
authorized to test and certify complete electronic health
records and EHR modules under the temporary certification
program. Such a result should create a competitive market and
would provide EHR technology developers with multiple options
and could lower the costs to EHR technology developers that are
associated with testing and certification.
ONC has engaged in a number of cross-cutting activities
related to administering the provisions of the HITECH Act. The
major program investment established to date with the $2
billion appropriated to ONC under ARRA include the Health
Technology Extension program, the State Health Information
Exchange Cooperative Agreement program, the Beacon Community
Cooperative Agreement program, the Health IT Workforce program,
and the Strategic Health IT Advanced Research Projects program.
The Health Information Technology Extension program
includes the establishment of a national health IT research
center and a nationwide network of regional extension centers.
Regional extension centers will be dedicated to ensuring that
providers have all the necessary resources to meet the
challenges ahead to adopting and becoming meaningful users of
certified electronic health record technology. They will place
a special emphasis on providing technical assistance to
clinicians furnishing primary care services from individual and
small group practices.
The State Health Information Exchange Cooperative Agreement
program has the overall aim to advance appropriate, secure and
sustainable health information exchange within and across
States and other jurisdictions. Over $500 million has been
obligated to 56 States, eligible territories and qualified
State-designated entities to support health care providers,
demonstrate the meaningful use of certified electronic health
record technology and to leverage the additional efficiencies
and quality improvements gained from health information
exchange.
The Beacon Community Cooperative Agreement program provides
certain communities with funding to build and strengthen their
health IT infrastructure and health information exchange
capabilities. These communities will demonstrate the vision of
a future where hospitals, clinicians and patients are
meaningful users of health information technology and together
the community achieves measurable improvements in health care
quality, safety, efficiency and population health.
The HITECH Act provides for an unprecedented level of
funding to improve the quality and efficiency of health care
through HIT and its historic investment will undoubtedly help
transition our current antiquated paper-dominated health care
system into a high-performing 21st century health care system.
It is my privilege to testify before you today and I look
forward to continuing to work together in answering any
questions you might have.
[The prepared statement of Dr. Blumenthal follows:]
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Mrs. Capps. Thank you very much, Dr. Blumenthal.
Now Mr. Trenkle for your testimony.
STATEMENT OF ANTHONY TRENKLE
Mr. Trenkle. Thank you, Chairwoman. Chairwoman Capps,
Ranking Member Shimkus and other members of the subcommittee,
thank you for the invitation to discuss the CMS incentive
program for electronic health records, which is part of the
American Recovery and Reinvestment Act of 2009. Certified EHR
technology use in a meaningful way is one piece of a broader
health information technology infrastructure needed to reform
our Nation's health care system and improve the quality and
safety of care for both Medicare and Medicaid beneficiaries.
On January 13, 2010, we published a proposed regulation
that defined meaningful use and described the eligibility and
payment methodologies for the EHR incentive programs. This NPRM
was developed through close cooperation between CMS and the
Office of National Coordinator and also allowed for extensive
stakeholder input and recommendations from several federal
advisory committees, in particular the HIT policy committee.
The NPRM laid out three stages of meaningful use with stage 1
covering the first 2 years of the program. We received more
than 2,000 comments on the proposed rule from interested
stakeholders including health care providers, associations and
patients. Most of the commenters felt that the proposed set of
objectives was too difficult for stage 1 and asked for some
flexibility in meeting them. The agency carefully reviewed and
considered all submitted comments and took them into account in
making policy decisions for the final rule. Our goal was to be
as inclusive and flexible as possible within the bounds of the
statute. We continued to work closely with ONC and received
additional recommendations from the HIT policy committee. It is
important that this program provides payment incentives for
both Medicaid and Medicare. The programs have different
statutory requirements but we tried to harmonize the
meaningful-use requirements as closely as possible for stage 1.
Both the CMS rule and the ONC certification standard rule,
which sets out the functionality requirements for EHR, were
displayed the Federal Register on July 13, 2010, and will be
published in the Federal Register tomorrow, July 28, 2010.
I will now discuss some of the key areas of the final rule.
Eligible professionals, the major change in that was to expand
the definition of ``eligibility'' to hospital-based physicians
who work primarily in outpatient departments. This is made
possible by a change to the original statutory language made in
the Continuing Education Extension Act of 2010. Most Medicare
Advantage-affiliated eligible professionals will also quality
for this incentive if they are able to show meaningful use, and
on the Medicaid side we provide additional flexibility for
determining patient volume in order to quality more EPs.
Eligible hospitals--we have received, as was noted by a
number of the committee members, much comment and request that
CMS recognize each campus of a multi-campus hospital for the
incentive payments. We understand that this issue of importance
to Members of Congress, the hospitals and the public. However,
from the agency's perspective, we believe it is important to
treat hospitals consistently, and the decision to deviate from
longstanding policy in this particular instance without clear
statutory direction to do so would have made CMS vulnerable to
legal challenges asserting our policies are being implemented
in an arbitrary manner. We intend to remain consistent with
other payment policies and make incentive payments based upon
how hospitals have organized themselves under provider numbers.
There is a more detailed discussion of this issue in my written
testimony and I am happy to respond to questions on this. We
will continue to work with all interested stakeholders in
future rulemaking related to the implementation.
The other major hospital issue was with the Medicaid
program, and in response to public comments on the proposed
rule, we added critical-access hospitals to the definition of a
Medicaid acute hospital in order to allow CAHs to quality for
both programs. The major changes we made in the rule were with
the meaningful-use definitions. As we mentioned in the NPRM, we
received a number of comments that asked for more flexibility,
and we decided to make some changes based on these comments
that I will address in the next few moments.
Some of the major changes were modifying the all-or-nothing
approach to objectives that must be met for meaningful use and
reducing this requirement to a required set or a core and a
menu set or optional set. Eligible hospitals and professionals
have the flexibility to defer up to five of the menu set
objectives. Where appropriate thresholds to meet meaningful-use
requirements were reduced in the final rule in response to
comments. We also removed the administrative transaction
requirements in the final rule in response to comments these
transactions are often done through practice management
software as opposed to EHRs. We also modified the States'
ability to impose more-robust requirements that would have made
it more difficult for Medicaid providers to achieve elevated
targets. We believe it is important for States to have some
flexibility so we preserved the flexibility. However, in
response to the concerns raised, it was limited to four public
health measures. We also added additional objectives for
patient-specific education resources and advanced directives
for hospitals were added in response to numerous requests in
the comments and the HIT policy committee recommendations.
It is important to note that Medicaid providers are not
required to meet meaningful-use criteria in their first
participating year. Instead, they may qualify for an incentive
payment if they adopt, implement or upgrade certified EHR
technology. In subsequent years, Medicaid providers must
demonstrate meaningful use in order to receive the EHR
incentive payments. The meaningful-use definition described for
Medicare will also be the minimum requirement for the Medicaid
EHR incentive program. Unlike the Medicare program, however,
there are no Medicaid penalties for EPs and hospitals that will
unable to demonstrate meaningful use.
Finally, I want to mention that Congress recognized the
critical importance of reporting quality measures through EHRs
in the HITECH legislation. We support this requirement but
recognize that the infrastructure to support the reporting of
quality measures through EHRs is not yet available. In response
to comments, CMS limited CQMs to only those which have
electronic specifications. Eligible providers will now be
required to report on three core measures from a set of 41
measures. Hospitals will be required to report on 15 measures
as applicable to their population.
In conclusion, the CMS and ONC final rules lay the
groundwork for establishing a robust national health care
infrastructure that supports the adoption of EHR technology
that can help providers practice safer, more effective
medicine. CMS understands the scope of these programs is vast
and the doctors and facilities across the country have varying
awareness of EHRs and of the program. We are working closely
with ONC to conduct wide-scale outreach to educate those
eligible for the program as well as working with the States and
provider stakeholders. We look forward to working with Congress
and our many stakeholder partners as we implement this rule and
future rules and advance the use of HIT in our health care
system.
Thank you very much for allowing me to testify.
[The prepared statement of Mr. Trenkle follows:]
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Mrs. Capps. Thank you, Mr. Trenkle. And the statements of
both of our witnesses in the first panel will be made a part of
the hearing record. Each witness may also submit additional
pertinent statements in writing and at the discretion of
committee be included in the record, and now I recognize myself
for 5 minutes of questioning.
My first question is for you, Dr. Blumenthal. Dr.
Blumenthal, I believe that health information technology will
benefit all of us but it can also be particularly important in
improving the health of individuals with complicated
comorbidities such as people with severe mental illness. I am
aware that mental health providers are not authorized to
participate in Medicaid and Medicare reimbursement under the
HITECH Act. Because of that omission, I am a cosponsor of a
bill I want to acknowledge by our colleague here, Mr. Murphy,
and our colleague in Congress, Mr. Kennedy, H.R. 5040, to
correct that situation. I do worry that without health
information technology it will becoming increasingly difficult
for behavioral health providers to provide the necessary
coordinated care for people with serious mental disorders. They
cannot receive reimbursement for adopting HIT. Can behavioral
health providers participate in any part of the HITECH Act
technical assistance regional extension center program and will
you describe that for us?
Dr. Blumenthal. Sure. Thank you, Madam Chair. Well, as a
long-term primary-care physician, I well understand the value
of behavioral health information. I treated many patients with
dual diagnoses, that is behavioral health and problems or
substance-abuse problems as well as so-called physical
problems. So it is absolutely vital that that information be
available for accurate and careful management of patients.
There is no question that the regional extension centers can
serve any physician who is using electronic health record and
intends to become a meaningful user of that electronic health
record. There are certain priority providers that we have
outlined in order to achieve the intent of the law and we have
focused on primary-care physicians, critical-access hospitals,
physicians in small groups and in underserved areas but there
is no restriction that prevents a regional extension center in
addition from serving mental health providers.
Mrs. Capps. And you are reaching out to these communities?
Dr. Blumenthal. Yes, we are.
Mrs. Capps. OK. So that they know about what services they
can be eligible for?
Dr. Blumenthal. We certainly are making every effort to
make those services known.
Mrs. Capps. May I also mention another topic? The HITECH
Act provided $2 billion to the Office of the National
Coordinator for Health Information Technology, partly to build
an infrastructure that promote the electronic exchange and use
of health information. Can you describe how the health
information network and the health information exchanges are
critical to this effort?
Dr. Blumenthal. Well, exchange is absolutely essential to
good health-care management. Knowing what your patients'
experiences have been in other locations is a great benefit,
potential benefit of health information technology. At the same
time, we need to make it possible for exchange to occur. It is
not something that is under the control of individual
providers. Exchange is in many ways a team sport. You need to
have someone out there to get your pass when you throw the pass
and you need to be able to take the pass when it comes back to
you. So the health information exchange cooperative agreement
programs that provide funds to the States are meant to empower
the States and encourage the States to lead in the development
of health information exchange capabilities within state
jurisdictions and across state jurisdictions. Similarly, the
Office of the National Coordinator has undertaken an aggressive
program for the development of new standards and technologies
that can provide a tool kit for exchange that the States can
use and that local service providers can use.
Mrs. Capps. One final question to you. Your office, I know,
has been in touch with the providers that are required to start
exchanging health information electronically but once they have
begun that, is there the national infrastructure to allow it to
continue to work forward? In other words, are you building a
network? I have just a half a minute left for you to respond.
Dr. Blumenthal. We want very much for this to be an ongoing
feature of the health-care system and of health information
technology so we are working hard with our health information
exchange groups at the State level to make them sustainable
over time.
Mrs. Capps. So there is a network that is building within
the State and then will that filter----
Dr. Blumenthal. Absolutely. That network has to be created
or else exchange will not continue.
Mrs. Capps. Thank you very much.
Mr. Shimkus.
Mr. Shimkus. Thank you, Madam Chair.
First, I want to segue into and follow on the line of
questioning that Mrs. Capps talked about. Also, there is a
provision on the absence of physical therapy as part of being
not eligible to receive and I just want to throw that out
there. I think your answer would be very similar in the
response. But I think it is worth noting that there are some
gaps there and there will be a debate on who is eligible and
who is not eligible.
Dr. Blumenthal, what happens to eligible professionals and
hospitals that fail to meet the meaningful-use requirements?
Are they penalized? Will they be penalized?
Dr. Blumenthal. Well, Congressman, the law specifies what
will happen for failure to meet meaningful use.
Mr. Shimkus. And since you are implementing that law, what
would that be?
Dr. Blumenthal. Well, as of 2015, eligible providers that
have not implemented, not become meaningful users would be
potentially penalized in their Medicare and Medicaid----
Mr. Shimkus. When? When will that start? When will the
penalties start?
Dr. Blumenthal. Twenty fifteen.
Mr. Trenkle. Yes, 2015 is specified in the legislation.
Mr. Shimkus. We don't have any idea based upon where people
are in a survey of projection of how many providers may be
penalized?
Dr. Blumenthal. I think it would be premature to speculate
about that.
Mr. Trenkle. We put some estimates in the impact analysis
as part of the regulation, but----
Mr. Shimkus. And what would those analyses show?
Mr. Trenkle. We had both a high- and a low-end projection
for that.
Mr. Shimkus. I will give you a chance to look for that.
Mr. Trenkle. No, I have got them right here, actually. The
projection we had on the low end was by 2015, 21 percent of EPs
would be meaningful users, and on the high end, 53 percent
would be meaningful users, but keep in mind that that
represents numbers based on previous studies that our actuaries
used to come up with these numbers. They don't take into
account what the effects of outreach and other activities that
will be done under this Act will do.
Mr. Shimkus. You know, and I think from colleagues on both
sides of the aisle, especially those of us who represent rural
communities, I think, you know, our one of many concerns would
be major institutions have the capital or the foundations to
move in the aggressively upfront cost. Poor, rural hospitals do
not, and our concern is the timeline and our concern would be
then when they are servicing in poor areas that they will then
have a penalty when they are still trying to comply. So that is
part of the question.
Mr. Trenkle. Excuse me just a second, but the numbers I
gave you were for the professionals, not for the hospitals.
Mr. Shimkus. Well, it is true for them too.
Mr. Trenkle. Right. I understand.
Mr. Shimkus. What about the other issue that we have heard
of is interoperability between the family practitioner and
maybe the hospital, and the question would be, and it deals
with the incentive payment issues. Who would pay if you have
two systems that are not compatible and then you have to
develop a compatibility software system? The family
practitioner may balk and say well, that is our deal. The
hospital may say well, that is not our deal. How are you going
to take into consideration those issues?
Dr. Blumenthal. Well, one of the reasons why we put back to
stage 2 some of the more complete exchange capabilities was to
give the local providers a chance to work those things out,
come to agreements locally on who is going to do what to create
exchange. I think the two key factors at work here are the
incentives which will be available if exchange occurs, and
perhaps for some the avoidance of penalties. And the second,
the availability of good tools for exchange including open
source free software, which we are developing.
Mr. Shimkus. And my time is real short, but I want to just
ask, in your testimony, Mr. Trenkle, you have a range of
estimates between $9.7 billion and $27.4 billion over the next
10 years, and that is a pretty large range. Can you explain why
that is the case and that can't be narrowed down a little bit
more?
Mr. Trenkle. For the purpose of the impact analysis, we did
both a high- and a low-end scenario. As I mentioned a few
moments ago, those are based on studies and actuarial
projections. We also changed some of the numbers based on input
we received from a number of organizations including the
American Hospital Association, which allowed us to actually we
had to lower the lower end because some of the cost projections
and projections of getting up to speed had to be lowered
because of the longer implementation lead time they projected.
Mr. Shimkus. Thank you, Madam Chair.
Mrs. Capps. Mr. Waxman, the chairman of the full committee,
is recognized for his questions.
The Chairman. Thank you, Madam Chair.
The gathering of health IT should not be a goal in itself.
It is a worthy goal, but that is not the only reason we want
it. The lack of timely clinical information is a contributor to
our Nation's well-documented problems with uncoordinated care.
Health IT is a tool that can help deal with that problem right
at the time of the patient's visit. The health reform
legislation contains numerous policies to improve the delivery
system such as establishing accountable care organizations,
reducing hospital readmissions and moving towards greater
bundling of services.
Dr. Blumenthal and Mr. Trenkle, what role will health IT
play in making sure these kinds of delivery system reforms are
successful?
Dr. Blumenthal. Well, Mr. Chairman, you can't have
accountable care organizations without knowing how to make them
accountable, and to be accountable you need to know what you
are doing, and health IT is the best possible source of good
information about performance in real time quickly. Once you
have a system up and going, the system should generate
information about quality and efficiency and cost in real time
as a product of the work, not post-retrospectively through
chart review, which is costly, lengthy, and by the time it is
available often no longer relevant to the performance of the
organization. So it is really I think enormously empowering for
enabling providers to take responsibility for their
performance.
Mr. Trenkle. I would follow up on what Dr. Blumenthal with
the fact that we are actually building infrastructure over the
next several years that will support much of the health reform
from the electronic specifications for the quality measures to
the health information exchanges and the other work we are
doing will allow us to have the infrastructure, that will allow
the flow of data and support many of the objectives of health
reform, so we feel this is a critical first step in moving
towards some of the goals set out in the legislation.
The Chairman. Is it fair to say that without health IT we
wouldn't be able to have the reforms be as successful as we
hope them to be?
Dr. Blumenthal. Well, I would certainly agree with that,
Mr. Chair.
The Chairman. Now, there is another value in electronic
health records. The availability of information in these
records has the potential to support population research to
better understand disease and treatment patterns. What plans
are underway with other agencies to make use of the information
for public health planning and what role do you think this can
play in improving the quality and efficiency of health care
delivery?
Dr. Blumenthal. That is an excellent question. We are
working with our sister agencies to try to define how records
can privately and securely capture and make available
information that is relevant to the missions of other agencies
like the Food and Drug Administration or the National
Institutes of Health or the Agency for Health Research and
Quality or the Centers for Disease Control and Prevention, how
we can, for example, in real time learn about the occurrence of
influenza-like illness so that we can keep track of influenza
epidemics and know where vaccine needs to be administered or
keep track of foodborne illness outbreaks though real-time
availability of information on related types of illness. So
there is an enormous public health benefit and there is
enormous value with patient consent and agreement recruiting
patients into clinical trials for relevant new experiments
whether it is in cancer or heart disease or diabetes, patients
who want to be part of these experiments but who might
otherwise be located without the benefit of the information
that is available in electronic form.
Mr. Trenkle. Let me also mention that under the meaningful-
use objectives, one of the major goal areas was to improve
population in public health and we included a number of
objectives that provide for the capability to exchange public
health data, and as I mentioned in my testimony earlier, we are
also allowing States to have the flexibility to make some of
these objectives core measures and core objectives for the
purposes of meeting the meaningful-use criteria for the
incentive program.
The Chairman. Thank you. I yield back my time.
Mrs. Capps. Thank you, Mr. Chairman.
The Chair recognizes Mr. Gingrey for 5 minutes of
questioning.
Mr. Gingrey. Madam Chair, thank you very much.
I don't know who to ask this so I will ask both of you. The
HIT policy committee adoption certification work group recently
recommended that ONC work with the FDA and representatives of
patient clinician vendor and health care organizations to
determine the role that the FDA would play to improve the safe
use of certified electronic health record technology. Recently
the FDA has suggested that direct-to-consumer genetic tests--we
had a hearing on that just last week--that those should be
classified as medical devices for the purpose of oversight. Do
either of you believe that the FDA should consider electronic
medical records as medical devices for the purposes of
regulating these records?
Dr. Blumenthal. Congressman, our concern and the concern of
the policy committee that you cited was to take maximum
advantage of health information technology and electronic
health records to improve the safety of concern, and what
actually the committee focused on in addition to the FDA was
other alternatives for collecting information about the
implementation of electronic health records to make sure that
those implementations are as safe as they could possibly be. So
we also discussed using patient safety organizations and using
our new certification to collect post-market, post
surveillance, post-certification surveillance information. So I
think that the mandate to us, the recommendation to us, not a
mandate, was to develop and look at all the ways we could
collect information to make sure that our work was doing
everything it possibly could to enhance patient safety.
Now, whether or not the Food and Drug Administration takes
any action beyond what it already has I think is premature to
speculate about. They have no plans right now that I am aware
of to do anything further than what they have already done. So
we are right now at the Department looking at these information
collection opportunities that we already have and have created
and not looking at anything else beyond that.
Mr. Gingrey. Mr. Trenkle, do you have any further comments
on that?
Mr. Trenkle. No, I agree with what Dr. Blumenthal said.
Mr. Gingrey. I thank you. I hope that I understood
correctly your response, Dr. Blumenthal, that you really don't
think that the FDA should treat electronic medical records as a
medical device.
Dr. Blumenthal. Well, there are issues, there are legal
issues which I am not qualified to speculate about as to what a
device is or isn't. From the standpoint of policy, I would say
there is no plan right now for the FDA to do anything of that
sort.
Mr. Gingrey. Thanks. I have got about 2 minutes left.
Technology companies have told me, and we have a very good
one in my district, the 11th of Georgia, in Carrollton,
Georgia, I won't mention the name of the company but they are
very good and they have been out there doing this for a while,
that is, providing electronic medical record hardware and
software to specialty-specific groups, general surgery, OB/GYN,
et cetera, and they have told me how critically important it
will be to have 12 to 18 months of lead time in order to align
their products with the stage 2 criteria. Understanding how
critically important quality products are to the viability of
our future nationwide network, can you give these companies
like the one in my district some public reassurance today that
the development of stage 2 criteria will allow these companies
a 12- to 18-month window in order to bring their products into
compliance?
Dr. Blumenthal. We are going to do everything we can to
give companies as much warning as we can about what the
criteria will be, and we want to have time to learn from stage
1 about what the experience has been of providers and vendors
and others, patients, with the new rules and implementation
efforts. So we want to wait a while before we get that
experience. Then we also want to get the rules done as early as
possible.
Mr. Gingrey. Well, I don't want to interrupt you, but I
definitely want to ask Mr. Trenkle a question before my time
runs out. I have 10 seconds.
You said to one of my colleagues that the issue of the
final rule on the hospitals that have multiple campuses, that
they would just be eligible for one meaningful-user incentive
payment for Medicare and Medicaid. How about physician groups,
let us say a family practice group of five individual
physicians, they are affiliated in some way, how would you deal
with them? Would that group only be eligible for one payment,
$44,000 or $77,000, whatever it is, or multiple payments for
each individual doctor?
Mr. Trenkle. I just want to add one thing to the previous
question on the meaningful use stage 2. We have, in addition to
what David mentioned, we have also signaled in the preamble for
this particular rule that we were going to move the menu items
to the core objectives for stage 2 and also signaled our intent
to add administrative transactions in stage 2 as well as
increasing the percentage measurement for computerized
physician order entries. So we have given some signals.
But to answer your second question, we have--for this
particular rule, we have payments are made to individual
eligible professionals so they are not made by group, they are
made by professionals, and we made that decision very much
after listening to some of the comments, reading some of the
comments that came in and listening to some of the concerns
that people had on both sides where they felt the way the
legislation was written and the ability to track the dollars
spent in the performance to meet the criteria, we have
determined that we would go with the individual eligible
professionals. So if there are five members of a group
practice, each one of them would have to show meaningful use to
meet the requirements to get an incentive.
Mr. Gingrey. But they would each be eligible if they did
for the bonus payment?
Mr. Trenkle. That's correct.
Mr. Gingrey. Mr. Chairman, thank you. I thought that was
very important. I am glad you let him answer.
Mr. Pallone. Thank you.
Our chairman emeritus, Mr. Dingell, is recognized.
Mr. Dingell. Thank you, Mr. Chairman.
Dr. Blumenthal, would you agree that lack of certified EHR
technology has the potential to hinder our progress and
discourage physicians from participating in the EHR incentive,
yes or no?
Dr. Blumenthal. I don't think that is going to be a
problem, Mr. Dingell.
Mr. Dingell. It does have the potential, though, does it
not?
Dr. Blumenthal. If certified technology were not available,
yes, it would have that.
Mr. Dingell. Now, if eligible providers don't know which
technology will eventually pass the test, they will be slow to
go out and buy it. Isn't that correct?
Dr. Blumenthal. I don't think that is going to happen, but
yes, that is correct.
Mr. Dingell. It is a possibility. So it is critical that we
have a strong certification program in place as soon as
possible to provide some level of certainty for providers. Do
you agree with that?
Dr. Blumenthal. I agree with that.
Mr. Dingell. And I don't want you to be defensive about
this. I just want you to understand, I have the apprehension if
we don't make these things flow, there is going to be trouble.
Now, while the Medicare/Medicaid incentive programs begins
next year, the permanent certification program is not expected
to be fully operational until early 2012. Is that correct?
Dr. Blumenthal. That is correct.
Mr. Dingell. Now, what has the Administration done to
remove the potential uncertainty surrounding certification to
ensure that we have as much as early participation for
providers as possible?
Dr. Blumenthal. Well, we have already published in mid-June
a final rule creating a temporary certification process which
will be in existence until the final permanent process is
available. That process can certify records, will certify
records, will certify them by the fall, so that we believe
there will be ample time for eligible providers to have not
only installed a record but have some time to look them over,
think about what they want to install, and then some time to
install them, and still qualify for the full payments available
under the incentive plan.
Mr. Trenkle. Congressman Dingell, can I make a comment
also? One of the things we took into account when establishing
the criteria for meaningful use is to have a 90-day reporting
period in year one in recognition of the fact it will take some
time to set up the certification program and also to allow the
providers and hospitals additional time to sign up for the
program and demonstrate meaningful use.
Mr. Dingell. Thank you. I think you are both telling me
then that the temporary program is necessary but that it is not
going to be sufficient over the long haul. Is that correct?
Dr. Blumenthal. The temporary program will be, we hope, a
high-quality program but it won't meet all the criteria that
certification bodies should meet in order to meet international
standards.
Mr. Dingell. Now, will the technology certified through the
temporary program be subjected to additional certification
under the permanent program?
Dr. Blumenthal. It will continue to be certified for stage
1 until additional criteria come into play.
Mr. Dingell. Now, Dr. Blumenthal, I note that HITECH has
made substantial program investments including funding for
support of the Beacon Community Cooperative Agreement program.
The first round of awards were announced, and I understand that
there were strong applications from Michigan, but I also
understand that none of the Michigan applications were
selected. Am I correct that you plan to announce two additional
awards?
Dr. Blumenthal. You are correct, sir.
Mr. Dingell. And am I to assume that Michigan will be most
sympathetically considered?
Dr. Blumenthal. We will give it every sympathetic
consideration, sir.
Mr. Dingell. I will be looking forward to that. What will
be the timeline for this announcement?
Dr. Blumenthal. Middle of August, I believe.
Mr. Dingell. Beg your pardon?
Dr. Blumenthal. Mid-August, I believe.
Mr. Dingell. Now, I would like to get your assessment of
the current EHR marketplace. HITECH included a provision that
would require your office to make certified EHR technology
available if the marketplace fails to do so. Is that correct?
Dr. Blumenthal. That is correct.
Mr. Dingell. Now, what is your current assessment of the
marketplace? Do you feel that there is adequate innovation
currently going on so that I don't need to be apprehensive
about the prior point?
Dr. Blumenthal. I do believe so.
Mr. Dingell. Mr. Chairman, I note my time has expired and I
thank you for your courtesy.
Mr. Pallone. The gentleman from Texas, Mr. Burgess.
Mr. Burgess. I thank the chairman.
Dr. Blumenthal, the American Medical Association in the
brief that was submitted by Dr. Gingrey for the record makes
note about the need for small physician practice representation
on your policy committee. How are you addressing that?
Dr. Blumenthal. I think that is a fair point. We certainly
want to make sure that we have heard from the full spectrum of
physician practices and perspectives so we would be, I think,
open to that suggestion.
Mr. Burgess. Another thing that I have encountered, I don't
know if it has come up----
Dr. Blumenthal. Congressman, if I could just make one
amendment to that?
Mr. Burgess. Yes.
Dr. Blumenthal. The membership of that committee is
actually determined by the GAO and the Congress and then
specified by law as to who else the Secretary can appoint. The
only way we could appoint small physician practice
representatives would be as a member of a working group, not as
a member of the policy committee per se. That is just a matter
of the way the law is written.
Mr. Burgess. How many of those working groups do you have?
Dr. Blumenthal. We have several, so it would be quite
possible to include them.
Mr. Burgess. I would also then ask you to consider, I know
I have heard from a number of physicians who practice
orthopedics that they face a particular challenge in
instituting this technology from their offices and that the
packages that are available to them, the products that are
available to them that also include digital imaging, the
broadband requirements are so high, the storage requirements so
high that they are sometimes looking at systems that cost in
excess of several hundreds of thousands of dollars which
obviously is a barrier to entry. So I would encourage you to
hear voices from across the spectrum of the real world in
practice because ultimately these are the individuals you are
going to count on to make this work, and if it is not workable
for them, clearly we will have a problem.
What happens to professionals who fail to meet the
meaningful-use requirements?
Dr. Blumenthal. Well, in the period between 2011 and 2015,
they fail to accumulate the incentive payments that are
available. In 2015 and beyond, they are subject to the
penalties that were placed in the law with respect to Medicare
reimbursement.
Mr. Burgess. So if a practice elects to do nothing, it is
not that they will just ultimately be left alone, they
ultimately would be penalized by the provisions of HITECH and
ARRA?
Mr. Trenkle. Yes, if they are under the Medicare program if
they qualify.
Mr. Burgess. And what----
Mr. Trenkle. And that was legislatively mandated. That was
part of----
Mr. Burgess. But what are the penalties that they are
looking at?
Dr. Blumenthal. I will let Mr. Trenkle answer that.
Mr. Trenkle. The penalties are as they were put into the
legislation. It is 1 percent in 2015 and then it goes upward
beyond that, but we implement them as they were put into the
legislation.
Mr. Burgess. And just for the record, I argued strenuously
against that type of punitive approach to this because I don't
know if we have allowed ourselves enough time to ramp this up.
Dr. Blumenthal, you have worked a Herculean effort this past
year to get where you are right now. Imagine putting that
effort on top of a small physician practice working 16 hours a
day just to take care of their patients and pay their bills and
keep their doors open with all of the other stipulations we
have put up them. This one does seem onerous. For either of
you, how many providers are going to be penalized? Do you have
some notion as to how extensive this is going to be?
Dr. Blumenthal. There are estimates that were made by the
Office of the Actuary which I will let Mr. Trenkle summarize,
but I will add a prior comment to say that all those estimates
were based on experience prior to the availability of
incentives and prior to the availability of the regional
extension center program, the Beacon community program, our
workforce training program and all the other efforts we are
making to assist providers in becoming meaningful users.
Mr. Trenkle. As I had mentioned earlier in a similar
question, we had scenarios both high and low in the impact
analysis that were compiled by our actuaries using data from
studies and other information that they had.
Mr. Burgess. Maybe you could get back to me with that in
writing because I am going to run out of time and I would be
interested in your response to that.
Mr. Trenkle. OK.
Mr. Burgess. But I guess one of the other follow-up
questions I have is, obviously there are going to be people who
have these systems for sale. Now, the people who have the
systems for sale, the vendors, are they under any sort of
punitive aspects under this law or do they just simply present
their wares for sale and that is that?
Mr. Trenkle. No, they are not under any penalties. The only
issue with the payment adjustments was what was in the
legislation.
Mr. Burgess. Let me just see if I have this right. The
doctors are under penalty, under threat of penalty if their
practices are not compliant, but the doctors technically don't
really make any money off of having an electronic medical
records system. It may be good practice and it may be important
for patient safety but they don't actually benefit on the
bottom line from these systems and yet the vendors are going to
significantly benefit from the forced sale to practices of
these systems. Are you doing anything to mitigate that
discrepancy?
Dr. Blumenthal. Well, the provisions of the law are the
provisions of the law, Mr. Congressman, as you well know, so we
have limited--what we are doing is working very hard to make
sure that every well-intended provider who wants to be a
meaningful user has the opportunity to become a meaningful user
and that--but they won't fail through any lack of effort on our
part. So that is I think our commitment at the Office of the
National Coordinator and from the federal government.
Mr. Burgess. But with all due respect----
Mr. Pallone. The gentleman's time is a minute and a half
over.
Mr. Burgess. I will follow up with this in writing because
this is an important point, and we have already seen how your
rulemaking has progressed since the beginning of the year, and
it is going to affect practices all over the country.
Mr. Pallone. Thank you. Let me mention that you will get
additional questions from us in writing, and any member is
entitled to do that.
The gentlewoman from the Virgin Islands, Mrs. Christensen.
Mrs. Christensen. Thank you, Mr. Chairman, and thank you
both, Dr. Blumenthal and Mr. Trenkle.
My first question is to you, Mr. Trenkle. The territories
are not included in the EHR program under Medicare and
Medicaid. It is just the 50 States and the District of
Columbia. Is the reason because we don't use a prospective
payment program? I don't see why that should make a difference
but you can explain if it does. And Medicaid is different in
the territories, and while I don't agree with that either,
Medicare is not. And in the territories, Medicaid can only be
used in public hospitals and public clinics. So why are we
excluded?
Mr. Trenkle. In determining eligible professionals and
hospitals, we followed what was in the statute.
Mrs. Christensen. OK. So we did it?
Mr. Trenkle. Right, so you did it.
Mrs. Christensen. We will try to see what we can do about
that because it really shouldn't--in the territories, Medicare
beneficiaries and Medicaid beneficiaries should benefit from
the same benefits of HIT as everyone else. Don't you agree?
Mr. Trenkle. Yes, I agree. As I said, we followed what was
in the statute, so----
Mrs. Christensen. Thank you.
Dr. Blumenthal, on the Beacon Community Cooperative
Agreement program, and we heard that the first round has been
awarded, certain communities are provided with funding to build
and strengthen the HIT infrastructure and HIT capabilities.
Could you describe briefly the criteria for other communities
that are chosen? I am trying to get at--and if you know this,
if you would help me to understand, what proportion of racial
and ethnic minorities and low-income communities were served in
the first round?
Dr. Blumenthal. Well, I would like to get back to you with
specific numbers. I can tell you that my memory is that the
communities' populations are representative of the underserved
populations in the country as a whole. The beacon community
program was awarded, vendors were chosen through an objective
review competitive process. As a matter of fact, it took place
in the record-breaking snowstorm in February, and we funded
those programs in the order in which they were picked by the
external reviewers, just as an NIH grant would be awarded. The
criteria took into account of course the quality of the
application. It did take into account diversity. Seven of the
15 are rural communities. And it took into account the
commitment of the communities, the quality of the health IT
infrastructure, the governance arrangements and the
believability, the credibility of their goals which were very
precisely laid out in the applications.
Mrs. Christensen. Did you identify or have to respond to
any unique challenges in the implementation process or through
the comment process from poor, rural or communities of color?
Dr. Blumenthal. We certain tried to. There is a beacon
community in the Mississippi delta. There is one in the
Piedmont area of North Carolina. There is one in Tulsa,
Oklahoma. So they really go from Hawaii to upper New York and I
think are quite representative of the country as a whole.
Mrs. Christensen. And I guess to both of you, and you may
have answered this already but I didn't see it in reading your
testimony specifically. How have the providers been
incorporated into the setting of the standards, not just in the
comment period but as you were developing the standards? Were
doctors, hospitals, other providers included?
Dr. Blumenthal. We have two advisory committees that you
all provided us under the statute, the policy committee and
standards committee. They meet in public. Their work groups
meet in public. We have had over 180 public meetings of those
groups. We have had testimony from a wide range of advisors.
Mrs. Christensen. One other question. I am sorry. I am
hearing your answer. But there is room, because many older
doctors are used to dictating. Is there room in EHR for
including the dictation transcription process in the
implementation since that might provide an easier transition? I
needed to get that question and I have to leave, so I am sorry
for cutting you off but I hear where you were going with your
answer.
Dr. Blumenthal. Well, progress notes are not part of the
requirement for meaningful use in stage 1, so yes, there would
be an opportunity to dictate into the record in stage 1.
Mrs. Christensen. Thank you, Mr. Chairman.
Mr. Pallone. Thank you.
Next is the gentleman from Ohio, Mr. Space.
Mr. Space. Thank you, Mr. Chairman.
Mr. Trenkle, like many of my colleagues, the hospitals, as
I mentioned in my opening, in my Congressional district are
going to be impacted, at least some of them, by your decision
on multiple-campus hospitals, and in fact, Genesis, which is
one of the largest hospitals in my district in Zanesville,
Ohio, the largest city in my district, stands to lose about $2
million in incentive payments based on your rule and, as you
might understand, they are little frustrated by that rule.
Won't decisions like this ultimately make it more difficult for
hospitals like Genesis Hospital to adopt the very technology
that this law is designed to promote?
Mr. Trenkle. As I mentioned in my written and in my oral
testimony that we base this on existing policy and the provider
number is based on how the hospitals choose to organize
themselves for payments under other Medicare programs, so what
we did here without clear statute intent was to be consistent
with the payment policies that we have adopted for other
programs, many of which, as I said, were due to hospitals
themselves wanting to be organized in this manner to be paid in
a certain way.
Mr. Space. So absent clear statutory intent, at this point
you don't envision reconsideration of that rule?
Mr. Trenkle. That is correct, although we are happy to be
working with committee staff and others to look at potential
ways to work with us. We recognize that there has been a lot of
public comment as well as comment from yourself, your staff and
other staffs here that express concerns about them. We have
heard, of course, from many hospital groups as well.
Mr. Space. I appreciate your working with us on it because
it is a real problem for us and for our health care providers
which already are at so many disadvantages, given the rural
nature of our district, and the class of patients, the
Medicare, Medicaid, self-pay percentages are so high. In fact,
we have got one hospital now that is desperately attempting to
avoid bankruptcy and if these hospitals can't survive, it will
have a direct and profound impact on the folks that live in
places like Ohio's 18th district, and broadband and health IT
represents an opportunity to bridge many of the divides that
exist between rural America and urban and suburban area. So I
am grateful that you have expressed a willingness to work with
us.
Dr. Blumenthal, I understand last week you testified before
Ways and Means and you mentioned that Secretary Sebelius had
convened a working group on rural providers. Can you talk a
little more about how this working group will help hospitals
like the ones that I represent meet the health IT standards?
Dr. Blumenthal. Secretary Sebelius, as you know well,
Congressman, was the governor of a rural State so she has been
very interested in the issues that pertain to HIT access in
rural areas. She is convening the secretaries of commerce,
Agriculture, the Veterans Administration and the chairman of
the Federal Communication Commission actually next week for a
first meeting to discuss ways in which we can work together
using the resources of these different departments to bring to
rural communities the resources they need to be meaningful
users of health information technology. I don't want to presume
what is going to come of that meeting, it hasn't been held yet,
but there are broadband resources available at Commerce and
USDA. There are tele-health resources. The VA does a lot of
outreach in its communities. The FCC spends $400 million a year
on broadband and communications so we are trying to make sure
that between the Department of Health and Human Services and
these other agencies that we are dedicating all the resources
we can to making up for the differences, the special burdens
that rural communities have.
Mr. Space. Thank you, Dr. Blumenthal and Mr. Trenkle.
I yield back my time, my one second.
Mr. Pallone. I thank the gentleman and recognize the
gentleman from Connecticut, Mr. Murphy.
Mr. Murphy of Connecticut. Thank you very much, Mr.
Chairman. Thank you both for your all your work and for being
here today.
I wanted to build on a question that Chairman Waxman
raised, and let me first pose it to you, Dr. Blumenthal. I
think one of the most exciting pieces of the health care reform
bill is the path forward we have set on the change in delivery
system and the change in which we pay for medicine to really
move from a system in which we today value volume to a day in
which we can place the appropriate value on outcomes and
quality. I am obviously very happy to hear your emphasis on the
connection between health care IT and the day in which that can
happen. I think your response to him was in regard to
accountable care organizations, which I think will be
transformative.
I wanted to ask you about some other potential payment
changes and new models of delivery. One of the pilot programs
that I and others worked very hard on was looking at new ways
to bundle payments in particular with respect to post-acute
care, and in that setting, you are dealing with complex
patients that are coming in and out of hospital and physician
settings, often having some of their most expensive care in,
for instance, skilled nursing facilities. I know we can't cover
everybody with the payments in this law but I wanted to get
your thoughts on how we continue to broaden out the number of
providers that are eligible for these payments, or in the
absence of doing that, how we find a way to get comprehensive
health care information technology to places like skilled
nursing centers so that we can really implement these payment
delivery system changes that we know have the potential to do
some great things.
Dr. Blumenthal. Well, in my role as a provider, as a
practitioner, a primary-care practitioner, I am extremely
sympathetic to the need to bring long-term care, home care,
rehab in coordination and get the information from those sites
into the acute care part of the system. As you pointed out, the
law as currently structured does not make incentives available
to those provider settings, and that is a limitation. It
doesn't prevent, though, those institutions from finding
electronic heard record technology themselves, especially if
bundled payment arrangements were to make available some
savings that they could get access to and if having that
technology enabled those savings as I am certain it would.
So I don't think we should forget that the rest of the
health care world continues to march along and that this
technology is really inevitable. It is the way to collect and
use information and it will take over other sectors as well.
Mr. Murphy of Connecticut. I don't know exactly what the
number is but the statistic always given about the very small
number of patients who comprise a very large number of costs,
these are patients that are obviously in and out of hospital
settings and so whether it is through bundled payments or
another way, I do think we have to find a way to get some help,
especially skilled nursing.
Maybe I will ask the question, a little different version
to you, Mr. Trenkle. As HHS is looking at and CMS is looking at
how to implement these new payment methodologies or these new
pilot programs for delivery system change, are you looking at
implementing them on a time schedule that is consistent with
the rollout of health care information technology and
specifically on this change, post-acute-care bundle payments,
are you worried that there will be a lag in development of good
IT systems in skilled nursing facilities that might present a
barrier to that particular pilot program?
Mr. Trenkle. I don't have all the implementation dates here
but I will tell you, we are working closely with other parts of
the agency to ensure that we are coordinating with the rollout
of the health care reform implementation and the HITECH
provisions.
Mr. Murphy of Connecticut. One last question, back to you,
Dr. Blumenthal. Talking about certification, the temporary
system that we have set up today, obviously one of the things
you hear a lot about is providers and hospitals who have been
early adopters and who fear that they are going to be forced to
make some expensive and onerous changes going forward. Do we
expect that the certification process will be only for new
technology or do you think we will have existing technology
that might be out there today, it might have been out there for
a period of time certified as well?
Dr. Blumenthal. The requirements for certification are new
because the meaningful-use requirements are new, and we know
that frequently technology that is in place, though it may be
beneficial, doesn't meet the standards or the certification
requirements that meaningful use has created. So we can't
assume that technology in place right now is capable of
supporting meaningful and therefore we can't assume that it is
certified. So yes, if you have technology right now that hasn't
been certified under the new certification process, you will
have to get it certified. It may be quite easy to do that. It
may be that you have technology that is very capable. But we
can't assume that, and we don't want to create the impression
for providers that something they are using now will be capable
of meaningful when it is not.
Mr. Murphy of Connecticut. Nothing preventing an existing
system from being stamped as certified as long as it meets that
requirement?
Dr. Blumenthal. Absolutely not.
Mr. Murphy of Connecticut. Thank you. Again, thank you for
all your work. This is incredibly important. I appreciate your
being here.
Mr. Pallone. Thank you, Mr. Murphy. I am going to recognize
myself since I wasn't here earlier.
I assume, and I missed the beginning, that there was some
discussion about meaningful but it is the most or one of the
most controversial aspects of this round of rulemaking, and
demonstrating meaningful use is the key to attaining
eligibility for incentives for Medicare and Medicaid so there
is a lot of interest from provider communities about how those
rules are structured. So I wanted to ask each of you, first,
Mr. Trenkle, you have been criticized for setting the bar too
high for providers to demonstrate meaningful use. Others have
said the agency isn't demanding enough from providers. I
actually haven't heard that one. Please, if you would explain
to the committee how you define the balance between high
standards and reasonable expectations and how the final rule
reflects that balance.---
Mr. Trenkle. Yes, I would be happy to do that. I think it
is important to point out that the final regulation reflects a
17-month process. The Recovery Act was passed in February of
2009. The final rule came out in July of 2010. And during that
time we convened several committees that as Dr. Blumenthal
mentioned received input from a number of stakeholders. We had
a public comment period of 60 days. We came out with a notice
of proposed rulemaking. We heard back from the community that a
lot of the objectives were too high so we adjusted in response
to the comments. So I think a combination of all these efforts
have led us to what we believe is a balance between a strategic
framework for promoting future adoption and meaningful use and
recognizing the realities of the infrastructure and the
adoption rates today.
Mr. Pallone. I mean, I guess the concern that I hear is
that a lot of providers simply won't meet the bar and then our
efforts are in vain, but at this point you don't feel that is
the case?
Mr. Trenkle. Well, I think we heard loudly from the
community that the bar was too high so we have added
flexibility in terms of the objectives. They have a core and
they have a menu set. We lowered some of the thresholds. We
eliminated the administrative transactions and we did a number
of other changes to the meaningful-use requirements that
reflected a need to lower but also maintain a framework that
will propel us towards future stages.
Mr. Pallone. All right. Let me ask I guess essentially the
same question of Dr. Blumenthal. from your experience, do you
believe that providers will be able to meet the meaningful-use
criteria laid out in the final rule?
Dr. Blumenthal. I believe they will. I believe there are
tens and even hundreds of thousands of physicians who are
already effectively using electronic health records and are
close to meeting meaningful-use criteria. By the way, that is
true of many small hospitals as well, critical-access
hospitals. I have met with them and seen them with my own eyes.
So I think it is quite possible to do this, and the question
will be whether the physicians and hospitals feel that it is
possible and will devote themselves and make the effort. We
have to make sure that the taxpayer was rewarded with getting
real value from these records for the tens of billions that
were in the legislation, but at the same time we have to make
sure that it was achievable, and that is a balance that we have
been trying to find constantly over this 17-month period. We
will closely at what the experience is, try to learn from that
experience and see whether we have set the bar at the right
level. So we have done our due diligence. We have made our best
analyses and we are moving forward from there.
Mr. Pallone. I heard some of the members say that they were
concerned about the penalty if someone doesn't move forward at
a certain point with the HIT, but there is also an exemption.
Do you want to address that, Mr. Trenkle, in case we run into a
situation where they are facing the penalty but----
Mr. Trenkle. Yes, I should have mentioned that earlier,
that there is a legislative exemption in case of hardship on a
case-by-case basis, and we will need to define the criteria for
that hardship in future rulemaking.
Mr. Pallone. But that is not something you are doing in
this first round, in other words?
Mr. Trenkle. No, because the adjustments aren't scheduled
to come in until 2015 so we will be addressing that in future
rulemaking.
Mr. Pallone. All right. I know I have got a couple minutes
here. I just wanted to ask, you know, I always get the
questions, Dr. Blumenthal, about the small practices. The
majority of physician practices continue to be small practices
of one or a few physicians and of course, you know, given the
economics today, a lot of them are struggling, and it is an
investment obviously to move towards health IT and they say it
is going to decrease productivity when it is initially
implemented, a lot of things of that nature. What would you say
about that? I mean, the HITECH Act provides $2 billion to your
office but there is also the regional extension centers and
beacon community programs. Is this going to be some way to help
these single practitioners, or how do you envision that?
Dr. Blumenthal. Well, the small practice if the target of
the Regional Extension Center program. That is where we are
focusing our effort because we realize that those are the
practitioners who are going to have the hardest time and are
going to be the least attractive and have the fewest resources
to attract a commercial vendor, a commercial consulting company
or a so-called integrator to help them. So we are intending to
enroll 100,000 small practices through the Regional Extension
Center program in programs to assist them becoming meaningful
users, and I think that is going to be a big opportunity for
small practices, and over time I think we will learn how to do
that better and better and we will continue to provide that.
That is over the first couple of years. Later on I think we
will be able to do more as time goes on. So they are very much
aware of this group and the practice is changing and younger
physicians are much more adept at adopting these technologies
than physicians my age, and so I think over time this problem
is going to largely take care of itself.
Mr. Pallone. All right. Thank you.
The gentleman from Texas, have you been recognized? I
wasn't here earlier. The gentleman is recognized.
Mr. Gonzalez. Thank you very much, Mr. Chairman. I
apologize. I have been absent for much of the hearing, but I do
thank the witnesses.
I have a couple of questions. One is going to be more
parochial. I will start with the more general one, and that is
going to be--and first of all, the sources of the questions
come from the medical community, hospitals and such in my area
because my staff is very sensitive to getting their input, and
they say why don't you ask these particular questions, and they
are much better questions than I would come up with on my own,
so I want to make sure that I get some of the, I guess the
verbiage here, the quality improvement organizations and the
proposed rules, and back home they are saying because of
preexisting relationships with these quality improvement
organizations with the regional extension centers, what do you
see prospectively as those particular right now it may be prime
or subcontractors with individuals in San Antonio--I am from
San Antonio--as we go forward? Will you have some of these same
individuals, organizations playing a role? It seems like it
would be a good idea just because of preexisting relationships
and of course the expertise that they would bring to the table.
Dr. Blumenthal. Our regional extension centers, which is
what you are referring to, I think, here were chosen on a
competitive basis. We had many more applications through the
regional extension centers than we were able to fund. I think
about a third, if I am not mistaken, of our regional extension
centers are quality improvement organizations so that that
coincidence, that overlap already exists. Where are there are
not quality improvement organizations, we are instructing the
regional extension centers to work with quality improvement
organizations and with all the other pertinent organizations in
their community.
Mr. Gonzalez. The other question, and I don't know how
unique it is to San Antonio but obviously we have a very large
military presence. At the present time we have two major
military hospitals. One actually just closed recently, Wilford
Hall, but BAMC is being plussed up, Wilford Hall will have a
state-of-the-art ambulatory center, and we have a major VA
hospital. The issue that comes up is of course can they still--
will they be able to communicate, the interoperability issue
that comes up, the different guidelines and requirements that
maybe a military hospital or a VA may be subjected to as
opposed to the other hospitals in San Antonio because there is
quite a bit of overlap, believe it or not, as far as patient
care. Your thoughts on that?
Dr. Blumenthal. We work very closely with the VA and DOD to
help them achieve seamless interoperability between their local
facilities. As a matter of fact, we prioritize some beacon
communities where there were VA and DOD facilities that were
trying to communicate because we wanted to support that
activity. So one of the ways we are doing that is by developing
software and standards that will work specifically to
facilitate their interoperability so very much on our radar
screen, Congressman, and we hope we can continue to help them
and make this a reality because I know it is also of great
concern to the President that our current servicemen and our
veterans get integrated care that benefits from all the
information that is available about them.
Mr. Gonzalez. Well, thank you very much, and I yield back,
Mr. Chairman.
Mr. Pallone. Thank you. I want to thank both of you for
your testimony and answering our questions. As I mentioned
before, obviously some members have said they are going to
follow up with written questions as well, but this is an issue
that is hugely important to our hospitals and our providers, so
thanks a lot really for----
Mr. Shimkus. Mr. Chairman, will you yield?
Mr. Pallone. Sure.
Mr. Shimkus. And I would hope that our first panel would
follow the hearing record. On the second panel, we have seven
folks on there. They are from small hospitals. They are from
family practitioners. A lot of these questions that we have
addressed come from them. I know you probably won't stay, but I
would encourage you to get the hearing record and see some of
the issues that have been raised in the second panel.
Dr. Blumenthal. Absolutely.
Mr. Pallone. I agree with Mr. Shimkus. Thank you very much.
Dr. Blumenthal. Thank you.
Mr. Trenkle. Thank you.
Mr. Pallone. And I will ask the second panel to come
forward. Now, we are expecting votes on the floor fairly
quickly so I doubt we will get through all seven people that
are on the panel but we are going to try to start and get as
far as we can because there are seven of you, I believe.
Well, first of all, let me welcome everyone. I know we have
a large panel here. I am going to introduce each of you.
Beginning on my left is Frank Vozos, Dr. Vozos, who is
Executive Director of Monmouth Medical Center speaking on
behalf of the New Jersey Hospital Association. Thank you for
being here, Frank. Monmouth Medical Center is in my hometown of
Long Branch, and I was actually born there. Next is Mr. Gregory
Starnes, who is CEO of Fayette County Hospital. That is Fayette
County, Georgia?
Mr. Starnes. Illinois.
Mr. Pallone. Fayette County, Illinois. OK. Sorry. And then
we have Ms. Christine Bechtel, who is Vice President of the
National Partnership for Women and Families; Dr. Roland Goertz,
who is President-elect of the American Academy of Family
Physicians and CEO and Executive Director of the Heart of Texas
Community Health Center; Dr. Matthew Winkleman, who is a
physician with the Primary Care Group in Harrisburg, Illinois;
Dr. Glen E. Tullman, who is Chief Executive Office of
Allscripts; and Dr. Peggy C. Evans, who is Director of the
Washington and Idaho Regional Extension Center with Qualis
Health.
We ask each of you to limit your testimony to 5 minutes.
You can certainly add additional testimony if you like and then
you will get more written questions from us later, and I will
start with Dr. Vozos.
STATEMENTS OF FRANK J. VOZOS, M.D., FACS, EXECUTIVE DIRECTOR,
MONMOUTH MEDICAL CENTER, ON BEHALF OF NEW JERSEY HOSPITAL
ASSOCIATION; GREGORY D. STARNES, CEO, FAYETTE COUNTY HOSPITAL;
CHRISTINE BECHTEL, VICE PRESIDENT, NATIONAL PARTNERSHIP FOR
WOMEN AND FAMILIES; ROLAND A. GOERTZ, M.D., M.B.A., PRESIDENT-
ELECT, AMERICAN ACADEMY OF FAMILY PHYSICIANS, CEO AND EXECUTIVE
DIRECTOR, HEART OF TEXAS COMMUNITY HEALTH CENTER; MATTHEW
WINKLEMAN, M.D., PHYSICIAN, PRIMARY CARE GROUP, HARRISBURG,
ILLINOIS; GLEN E. TULLMAN, CHIEF EXECUTIVE OFFICER, ALLSCRIPTS;
AND PEGGY C. EVANS, PH.D., CPHIT, DIRECTOR, WASHINGTON AND
IDAHO REGIONAL EXTENSION CENTER, QUALIS HEALTH
STATEMENT OF FRANK J. VOZOS
Dr. Vozos. Good afternoon, Mr. Chairman, Ranking Member
Shimkus and distinguished members of the committee. Thank you
for inviting me to testify today. I am Dr. Frank Vozos,
Executive Director of Monmouth Medical Center located in Long
Branch, New Jersey. Monmouth Medical Center is a member of the
San Barnabas Health Care System, the largest not-for-profit
integrated health care delivery system in New Jersey and one of
the largest in the Nation. I am also here on behalf of New
Jersey Hospital Association.
I am pleased to appear before you today to highlight how
the HITECH Act will support the transformation of Monmouth
Medical Center by helping us successfully fulfill our goals
related to the acquisition and implementation of health
information technology and to applaud the federal government
for establishing a program that will provide incentive payments
through Medicaid and Medicare to doctors and hospitals who
demonstrate meaningful use of the certified EHR system.
By way of background, Monmouth is a 527-bed community
teaching hospital that provides a full spectrum of services
from neonatology to geriatrics with more than 800 medical and
dental staff members. The medical center admits more than
22,000 adult and pediatric patients and cares for over 120,000
outpatients annually. We are one of the largest and oldest
teaching hospitals in New Jersey and we are the largest
academic affiliate of Drexel University College of Medicine and
that is a relationship that we have had for over 4 years. We
are further distinguished among the landscape of health care
providers in New Jersey by our relationship with the Long
Branch federally qualified health center, which opened in April
2004 and grew directly out of Monmouth Medical Center's
longtime motto of providing primary care to the community
through charity care clinics.
It is important to note that Monmouth is the leading health
care provider in the city of Long Branch, a multi-ethnic
enclave of residents who are disproportionately poor, young,
uninsured and members of minority groups. More than 35 percent
of the city's population lives at or below 200 percent of the
federal poverty level. There are four census tracks with the
city that have been federally designated as low-income,
medically underserved populations, and although there are 40
primary care health care providers located in the area, most do
not accept Medicaid or offer charity care. So as a result, the
medically indigent population of Long Branch and its
surrounding communities use the low-income clinics or our
emergency room at Monmouth as their only source of health care.
While Monmouth was moving fairly well down a path of HIT
adoption before the passage of the HITECH Act, the new law
certainly strengthens our ability to effectively transition to
more comprehensive adoption. I think we have pursued this goal
enthusiastically, embarking on a facility-wide effort to
upgrade our health information technology capabilities on
multiple fronts.
As an example, in our emergency department we have invested
significant resources to install many sophisticated information
technology components including directing the interface between
the emergency room clinical information system and hospital
charts using the EDIMS computer framework. All records and
tests are available of the care of the patient and it links to
our medical center health information record. Repeating testing
unnecessarily has declined and patient safety combined with
more timely care has been the core outcome of this initiative.
Monmouth Medical Center's clinical information system suite
of products, which is current the Cerner Millennium, is
currently CCHIT certified. These products adhere to
requirements dealing with functionality, security and
interoperability. On a regional level, we are one of the
leaders in developing protocols and an infrastructure to share
clinical data with four medical centers through Monmouth and
Ocean County, and that is regardless of our competitive
marketplace.
One aspect of the new system we are very focused on is
computerized physician order entry. We are dedicating
significant time and effort to changing behavior of physicians
to enter orders into the computer instead of handwriting them.
In a teaching hospital, it becomes important to leverage that
technology infrastructure such as CPOE as a teaching modality
as well as a recordkeeping modality as the large resident staff
interacts most frequently with the patients and completes
written orders.
Moving outward from our emergency department, the extent of
EMR use is varied throughout the rest of the hospital. In the
emergency department, EMR includes medication orders, lab
results, radiology readings, history and physicals, nurse and
physician notes as well as discharge instructions. On the
floors, the EMR has lab results, radiology readings and other
test results and other parts of the record are still
handwritten, although with easy access. So it is part of our
global IT initiative that all areas of the medical center will
be EMR active by 2011.
Further meaningful-use requirements with a compliance goal
of 2011 at Monmouth include provisions for a physician to take
advantage of EHR in their own private practice. Private
physician offices and their style of practice are being taken
into account as vendors are linked with these clinical partners
to create the EMR interface with Monmouth. By 2011, there will
be active physician connectivity with the hospital. Part of
this deliberate strategy includes the costs associated with
linking physicians and the medical center through EMR. What can
be subsidized and what is funded by the medical center or
physicians are important factors as we work through this
connectivity goal. The ability to eliminate potential errors
and medical errors including handwriting and timeliness of
order gives clear quality markers for both private physician
practice and care provided at Monmouth Medical Center.
In addition, we were recently selected and are currently
actively engaged as one of only two hospitals in New Jersey to
begin a CMS-funded 21-month pilot project to test and model
transitioning Medicaid patients who present to the emergency
department with non-emergent care needs to the appropriate
primary care setting through collaboration with our federally
qualified health center. This data-driven pilot has further
integrated electronic referral systems and electronic health
records through infrastructure enhancements and a
recommendation to the State and federal agencies administering
and coordinating the pilot in New Jersey and in 19 other
States. Currently, the FQHC clinicians can electronically
access the hospital record for a previous hospital history and
test results for their patient. By 2011, the new CPOE
functionality will be fully interoperable between the emergency
department and the Long Branch federally qualified health
center, allowing for truly comprehensive EMR for our patients
as well as CPOE for our physicians and other clinicians both in
the medical center and private offices.
Mr. Pallone. Frank, I am going to have to ask you to
summarize the rest.
Dr. Vozos. OK. I am done. I just want to let you know that
for the patients in this pilot study, we have seen a 70 percent
conversion rate from people that have been using the emergency
room as their medical home now to the federally qualified
health center as their primary care.
So again, thank you for inviting me. I appreciate this
opportunity to appear before you today and I will answer any
questions.
[The prepared statement of Dr. Vozos follows:]
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Mr. Pallone. Thanks so much, really.
Now, that was the bell. I think we can get at least two
more in, maybe three, before we go vote.
Mr. Starnes.
STATEMENT OF GREGORY E. STARNES
Mr. Starnes. Chairman Pallone, Ranking Member Shimkus and
other distinguished members of the committee, thank you for
this opportunity. My name is Greg Starnes and I am the Chief
Executive Officer of Fayette County Hospital and Long Term Care
in Vandalia, Illinois. I have been in health care
administration my entire career, and I consider it an honor to
be here today to talk with you about the HITECH Act.
First, please know that my colleagues and I support the
HITECH initiatives. Fayette County Hospital and Long Term I is
a critical-access hospital with 25 beds and 85 long-term care
beds. The facility serves a county of 21,000 people and resides
in the county seat of Vandalia with a population of 7,000. The
average household income is below the State average. The
percentage of elderly in the population is higher than the
State average. The unemployment rate is 10.8 percent. The
number of Medicaid eligible has increased in the last year and
the numbers of individuals who find themselves with no ability
to pay for health care services have also risen. They represent
the reality in today's rural health care environment and many
parts of Illinois.
The challenges I have faced during the last 18 months have
been the most difficult of my career. In early 2009, my
hospital began to feel the effects of the changing economy.
July of each year has typically been the month during which I
have been able to provide merit pay increases for my dedicated
employees. In May of 2009, I informed my employees they would
not be receiving any wage increases in July. The hospital
finances did not improve in the ensuing months as a local
employer with 140 employees relocated to another State. In
early October 2009, I conducted numerous meetings with all
employees to inform them that I was reducing the work hours by
5 hours per 2-week pay period, which represented a 5 percent
decrease in their wages. My managers and I accepted a 10
percent reduction in our salaries. I reduced vacation accruals
and temporarily halted the employees' 401(k) match and I
eliminated several positions. We saved a great deal of month in
the fourth quarter of 2009 yet we finished the year in the red
with a net income of a negative $74,000. On January 1, I
increased the managers' salaries 5 percent. Since that time
there have been no hour or wage increases for anyone. The
number of full-time-equivalent employees in September of 2009
was 225. The total now is 195. I represent only one example of
many hospitals that have faced those same challenges, hospitals
that are within the top three employers in the communities we
serve.
We are not just about health care in our communities, we
are also about jobs. We are about jobs for nurses, nurse aids,
physicians, lab and X-ray technicians, housekeepers, cooks,
maintenance workers, therapists and so on, and of course,
information technologists. In some of these jobs categories,
there are shortages of qualified personnel. In all of these
categories, these workers need the proper tools to do their
jobs to the best of their abilities. CT scanners, MRI units,
operating room equipment, ambulances, et cetera are hugely
expensive. Software, hardware and training are extremely cost.
To achieve the expectations of our patients along with those of
the governing authorities requires a great deal of money.
Awareness of this among our Congressmen and Congresswomen is
vital as we endeavor to improve health care in America.
There are 51 critical-access hospitals and another 15 rural
hospitals in Illinois out of 200 plus total hospitals. All are
taking steps toward meaningful-use criteria. At least 10 of the
critical-access hospitals have less than 20 days cash on hand
because of the impact of increased Medicaid and self-pay
patients. A reasonable estimate would suggest that roughly half
of the hospital have inpatient health information systems and
two-thirds of them have lab and radiology systems. However,
only 20 percent have physicians using computerized physician
order entry. The new meaningful-use rule with allow other
practitioners to enter orders into the system and that will
help but it will also place additional burdens on the hospital
staff.
Thank you for your support of the changes in the final
meaningful-use objectives. Some of them indeed lessen the
burdens for critical-access hospitals to achieve those
objectives. The loosening of the CPOE requirements as well as
inclusion of critical-access hospitals for Medicaid incentives
represent a very positive change from the original proposed
guidelines. That said, the challenges our hospitals still face
should not be underestimated. The capital necessary to
procedure the software and hardware is still less accessible in
today's economy than it was 12 to 18 months ago. In my case,
the estimated cost for software and hardware necessary to
achieve meaningful use will likely be close to $750,000. There
will also be substantial costs associated with establishing
interfaces to enable hospitals and providers systems to
connect. An additional $50,000 to $100,000 will be necessary
for training and process changes. So these numbers are large
for my hospital and for many others.
At this time my hospital needs a new CT scanner for a
minimum of $350,000 because the one we currently have is 8
years old and increasingly unreliable. We also need to buy a
digital mammography unit for approximately $350,000 so that
women in the community can take advantage of up-to-date
technology and so that unit can work with an electronic health
records system. There are numerous other needs that are very
expensive, and we all face challenges like that already, and I
know that we face the acquisition implementation of EHR as
well. I believe there may be rural hospitals that will not meet
the imposed timeline under HITECH.
Additionally, qualified health IT professionals are in high
demand and the supply is currently a problem. So increased need
for them in order for hospitals to achieve the IT requirements
for EHR systems may present real-time and cost concerns. It is
indeed fortunate that there are efforts underway to boost the
health IT workforce through funding for community colleges.
However, the boost might not materialize in time for hospitals
to realize the currently structured incentives for meaningful
use. Failure on the part of some hospitals to arrive at
meaningful-use capabilities could jeopardize patient safety.
It is my understanding that assistance to overcome these
challenges will be available through the RECs, and I applaud
that effort. However, I am concerned as we have seen through
other federal offices and programs there will not be a
sufficient focus on the challenges----
Mr. Pallone. Mr. Starnes, I am going to have to ask you to
summarize the rest, too.
Mr. Starnes. All right. Thank you.
My colleagues and I truly want to offer patients the
benefits of a fully functional electronic health record system.
We understand the advantages it can have in reducing overall
costs, duplication and errors while also improving
accountability and patient safety. However, I also want this
committee to understand that rural providers and patients face
unique challenges. A recent survey exemplifies that only about
30 percent of the critical-access hospitals nationwide would
quality for stage 1 incentives.
Thank you for this opportunity to offer my testimony. I
look forward to working with you to ensure that all hospitals,
providers, urban and rural, realize the benefits of electronic
health record systems. Thank you.
[The prepared statement of Mr. Starnes follows:]
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Mr. Pallone. Thank you.
We still have another 6\1/2\ minutes, so I am going to ask
Ms. Bechtel to go and then we will break.
STATEMENT OF CHRISTINE BECHTEL
Ms. Bechtel. Good afternoon, Mr. Chairman, Congressman
Shimkus, Congressman Gonzalez. Thank you for having me here
with you today. I am Christine Bechtel and I am the Vice
President of the National Partnership for Women and Families.
We are a nonprofit consumer advocacy organization here in D.C.,
and I was also appointed as a consumer representative to the
Federal Health IT Policy Committee.
So I am honored to be with you today to discuss the ways in
which meaningful use of information technology will benefit
patients and their families. That said, our discussion today
shouldn't actually be about technology. It should be about the
ways in which changes in health care payment and delivery can
create the kind of truly patient-centered system that we all
envision and that every consumer deserves. That means designing
systems around what patients say they want and need to improve
their own health outcomes, and what patients want is simple and
straightforward. They want their doctors to talk to each other.
They want information about their conditions. They want
providers to know them well enough to make treatment
recommendations that actually make sense for them and they want
their care team to have the information and support that they
need to do the best job they can. Technology plays a critical
role in delivering this kind of patient-centered care. It
cannot be done right, done well or done consistently without
interconnected health IT, and the regulations issued by the
Administration on meaningful-use lay the groundwork for doing
just that.
I would like to highlight some of the ways that the
meaningful-use program will result in tangible improvements for
patients and families by sharing with you the story of Susan
Crowson, who is a family caregiver from Maryland. Susan looks
after her father, Pop, who has Alzheimer's disease, heart
arrhythmia, prostate problems, low blood platelets and is
susceptible to other infections. He sees a primary care
physician, a cardiologist, a urologist, a hematologist and a
neurologist. Each monitors and treats a separate problem and
yet they don't talk to each other. So Susan had to build a
spreadsheet to keep track of it all. She leaves copies with
each doctor and asks that Pop's records be sent to his primary
care physician and his other specialists, but it is rarely
done. When she takes her dad for lab tests, she is the one who
makes sure that each doctor gets the results or it just doesn't
happen. Pop takes there prescription drugs, two over-the-
counter drugs and vitamins as well as occasional antibiotic.
These drugs are prescribed by different doctors. When his
doctors prescribe a drug, they actually tell Susan to make sure
that she checks with Pop's other doctors about potential drug
interactions.
Susan's situation is common. Millions of patients struggle
to gather and update hundreds of pages of medical records if
they can get them at all, toting them from doctor to doctor,
knowing that no provider is likely to have their full medical
history and test results.
Mr. Chairman, I am confident that we can help Susan and
other patients and families get better care by leveraging the
requirements that are now part of the meaningful-use program.
The new regulations are strong, sensible and patient-centered.
If the members of Pop's team were meaningful users of EHR
today, they would maintain up-to-date problem lists of his
conditions and medications. They would check those lists for
drug-drug interactions and allergies. They would provide Susan
with education resources, summaries of care after every office
visit, reminders about follow-up care and more, and his care
team would also start to develop the ability to communicate
with each other electronically.
Stage 1 of meaningful use also builds the foundation for
overall improvements in the quality, safety and efficiency of
care. For example, it requires the collection of race,
ethnicity, preferred language and gender data so that we can
identify and target health disparities. It asks physician
meaningful users regardless of specialty to focus on
hypertension, smoking and obesity so that we can better address
the public health challenges are driving the increase in
chronic conditions and causing costs to skyrocket, and it
advances an important set of criteria for protecting the
privacy and security of health information.
But our work on meaningful use is not done. Stage 2 should
enable the robust, secure exchange of clinical information
across all the providers in settings involved in the patient's
care in compliance with federal and State privacy laws.
Patients and families should have timely, ongoing access to
their health information in a way that is portable so that they
can assemble it in a secure place and quality measures should
assess outcomes, functional status and patient and caregiver
experiences.
Put simply, future criteria should be driven by the goal of
high-patient patient-centered care. It is what Susan deserves
and what all patients deserve. After all, health care
transformation is not about money and it is not about
technology, it is about people and it is about leadership, and
we thank you for yours.
[The prepared statement of Ms. Bechtel follows:]
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Mr. Pallone. Thank you.
We have three votes which normally takes about half an
hour, so we are going to recess and then we will come back and
hear from the rest of you and then take questions, so the
subcommittee now stands in recess.
[Recess.]
Mr. Pallone. The Subcommittee on Health will reconvene, and
we left off with Ms. Bechtel, so Dr. Goertz, you are next.
STATEMENT OF ROLAND A. GOERTZ
Dr. Goertz. Thank you, Chairman Pallone and Ranking Member
Shimkus and other members. As you said, I am Dr. Roland Goertz,
President-elect of the American Academy of Family Physicians
and I really am excited about the opportunity to give you our
testimony. As a user of EHR for nearly 14 years, the CEO of a
federally qualified health center that has won the HIMS award
for EHR use, and a representative of 94,700 members of the
AAFP, many in small- and medium-sized practices, I believe my
perspective and the AAFP's will be useful, particularly as to
how to implement HIT in small practices, how to serve diverse
populations with its use and how the HITECH subsidies will help
them.
Nearly one in four of all office visits is made to family
physicians. We provide more care to America's underserved and
rural populations than any other medical specialty. Our
commitment to improving patient care and clinical outcomes has
long made us supporters of HIT. We believe that the recent
meaningful-use regulations will support what the AAFP already
has been doing for many years. Our focus has been to ensure
that the meaningful-use rules are achievable by physicians in
small- and medium-sized practices and also improve patient
care. Our members want to accomplish what Congress intends.
Fifty-nine percent of our members currently have electronic
health records but their use of it varies greatly. We need to
help the rest purchase IT, encourage those who have it to
become more comprehensive users of it and have all begin to use
it more effectively. We ask that your committee ensure that the
first rounds of reporting and incentives from CMS be both
consistent and reliable.
Let me talk briefly about my FQHC's experience with HIT.
The mission of FQHCs is to provide health care to those under
200 percent of poverty, which includes Medicaid patients and
those who are dual eligible. Our center serves almost 50,000
people in the Waco-McClellan County area of Texas. That is
about 18 percent of the total population of the county. Our
center has 13 sites, two of which are in rural communities. I
am absolutely convinced that our use of EHR has led to improved
patient care and efficiencies.
Fourteen years ago, a number of our physicians were
uncomfortable with computers. Indeed, some even got cold,
clammy, sweaty hands when they came close to a keyboard. We
also are in a rural area, which is more challenging for
physicians using EHRs. Today, not one of our providers would
return to paper records.
Let me make two general observations about adoption of HIT.
One, physicians coming out of residency today expect to use HIT
and do so almost automatically. The issue of adoption is a
generational one and will resolve over time. However, we are in
the middle of a significant health care transition and must
assist all physicians by supporting the regional extension
programs, beacon communities, medical-home pilots and
dissemination of best practices.
Two, small, solo, rural practices in particular are short
of time and dollars. They are busy focusing on patient care and
operating on small margins. Assisting them is critical to
making HIT work in the United States. As an example, if your
office has a major computer problem, you have an outside
support team to analyze and fix the problem. I think of the
regional extension centers as a comprehensive support team for
small practices. These centers will provide not only technical
assistance but general information when these small practices
need help. Therefore, we ask you to closely monitor the
implementation and resources of the regional extension program
because they are essential to success of these practices. We
strongly support the HITECH Act incentives. These investments
are staged and crucial to improve quality and cost-
effectiveness of patient care. FQHCs also will need similar
support.
Let me conclude by restating three points. Number one, HIT
is critical to improving quality and effectiveness of patient
care; number two, physicians in small rural practices must
receive effective technical support during implementation and
use of HIT; and number three, the HITECH grants are crucial as
physicians make these transformative changes to their practice.
I thank you again, and I am personally excited about the
potential for improving patient care that the tools of HIT
offer us.
[The prepared statement of Dr. Goertz follows:]
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Ms. Schakowsky. [Presiding] Thank you, Goertz.
Dr. Winkleman.
STATEMENT OF MATTHEW WINKLEMAN
Dr. Winkleman. Chairman Pallone, Ranking Member Shimkus and
Congressman Gonzalez, let me begin by thanking you for the
opportunity to provide testimony today. My name is Matt
Winkleman. I am a family physician practicing in Harrisburg,
Illinois. Our community is in rural southern Illinois and has a
population of about 10,000. I practice full time and I am one
of the owners of Primary Care Group in Harrisburg where we
serve patients not only from Harrisburg but from several
surrounding communities and rural counties. Our practice is a
rural health clinic that includes eight primary care doctors,
five mid-level providers and a general surgeon. In total, the
clinic employs around 50 people. I am honored to share with you
today our experience with an electronic health record and a
little bit about it impacts our practice and the care we
provide to our patients.
One of the obstacles many physicians cite in the decision
to employ an electronic record is the initial upfront cost. Not
only is the software, hardware and necessary infrastructure
costly but the process of seeing patients at least in the
initial weeks of transitioning requires changes in work flow
that will likely decrease efficiency and the number of patients
seen. As you are all aware, under our current reimbursement
system, fewer patients means less added to the bottom line, and
as a result, many physicians calculate they cannot afford the
initial financial investment. This is especially true for
physicians like myself who practice in rural areas where the
average payer mix includes minimum commercial insurance and
where profit margins may already be thin.
Thankfully, the HITECH bill is going to help physicians
address many of the challenges and begin reaping the benefits
of electronic health records. The approach taken within the
legislation to reward utilization and not just purchase was
smart. The regional extension centers will be immensely useful
to small practices without the know-how to feel comfortable
moving to an EHR on their own and the funds going to develop
broadband networks and other infrastructure will be crucial in
eventually allowing us to exchange clinical information.
The benefits of EHR use, as I said, are significant. At a
time of great uncertainty within the general health care
industry, at least one thing seems clear to me: technology will
have a role in helping us provide the kind of high-quality,
safe, efficient care our patients deserve. On nearly a daily
basis, my EHR helps me avoid prescribing a medication to a
patient because they have an allergy to it, allows me to print
out materials for patients to help them understand their
diagnosis and reminds me to order a mammogram on a 55-year-old
patient who came in only for a sore throat.
It is not uncommon for me to see patients struggling to
manage six to eight medications, caring for three to four
chronic diseases. Medicine is complex, and the reality is that
even the most astute of clinicians can benefit from the safety
checks provided by an electronic health record. Furthermore,
while the individual patient benefits from the improved safety
that stems from use of an EHR, my practice has begun to see the
benefits to the population as a whole. With the use of our EHR,
we were recently able to generate a report of all the diabetic
patients from the practice's census who had not received
appropriate follow-up and proactively schedule an office visit
to get them back in, giving them a much greater chance of
avoiding the costly complications that can result from
diabetes. Additionally, after the recently controversy
surrounding the diabetes drug Avandia, we were able to generate
a list of all of our patients receiving this medication within
a matter of only minutes. These types of things would have been
nearly impossible with a paper system.
It is also important to keep in mind, however, that all of
these things I am describing would have been just as impossible
if the information in our EHR such as lab data and medication
history were not included as discrete structured elements in a
database. Had they been scanned copies of paper reports, the
information may as well have been in a paper chart. There must
be standards in place which foster the use of technology in
such a way that it truly benefits patients and provides the
most value to the physicians when they are making care
decisions. For this reason, while I am not generally an
advocate of large-scale government involvement and government
management of health care, I do think this is an area where
focused guidance steering the medical community is absolutely
needed.
In summary, as a rural family physician practicing with an
electronic health record, I have seen the benefit they can
provide by helping improve safety, increase compliance with
recommended preventative care and proactively manage chronic
diseases. My practice is located in a county ranked by a recent
Robert Wood Johnson Foundation study as 98th out of 101 in
Illinois with regard to the health of its population and many
of the neighboring counties were also near the bottom of that
list. I am optimized that the meaningful-use incentives and the
work of the regional extension centers can help providers in
rural areas like Harrisburg to begin not only to take advantage
of health information technology but recognize it as another
instrumental tool in the pocket of their white coats. I am
excited about what the future holds and look forward to the
next steps in the process as we move even further forward in
connecting providers to allow the exchange of health
information.
Thank you for the opportunity to provide testimony today.
[The prepared statement of Dr. Winkleman follows:]
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Mr. Pallone. Thank you, Dr. Winkleman.
Dr. Tullman.
STATEMENT OF GLEN E. TULLMAN
Mr. Tullman. Actually I am not a doctor.
Mr. Pallone. Mr. Tullman, CEO Tullman.
Mr. Tullman. Chairman Pallone, Ranking Member Shimkus and
other distinguished members of the committee, thank for the
opportunity to testify today. My name is Glen Tullman and I
serve as the Chief Executive Officer of Allscripts. Allscripts
is the largest provider of electronic health records,
electronic prescribing, practice management software and other
software that helps physicians manage their patients. More than
160,000 physicians, which is one-third of all practicing
physicians outside the four walls of the hospital, use
Allscripts software along with 800 hospitals and over 10,000
other health care providers in post-acute care facilities and
home care agencies to manage their patients. Allscripts
solutions automate daily activities and connect their clinical
and business operations.
It is now 17 months since the passage of the American
Recovery and Reinvestment Act and it is clear that health care
information technology as an industry is forever changed. It is
my belief that we are at the beginning of the single fastest
transformation of a major industry in the history of our
country. Congress and the Administration in a sign of true
leadership have provided an investment in technology that will
lead to the delivery of better care for all Americans, improve
patient safety and deliver significant savings due to
efficiency.
I speak to hundreds of health care professionals every
month across the entire spectrum of care and it is clear from
them that the meaningful-use incentives in the stimulus package
are an essential component of the sea change that health care
is undergoing and that will benefit all of us today. However,
understanding how the stimulus and meaningful use applies to
our clients and how to implement an electronic health record
can be challenging. This is especially true because our clients
span the entire continuum of care from single physician primary
care practices and rural geographies to federally qualified
health centers to the largest and most prestigious academic
medical centers in the country.
Allscripts have committed extensive resources over the past
17 months to educating all of these groups, not just our
clients, about meaningful-use incentives. We have hosted
hundreds of free educational sessions across the country and
webcasted many more, and in 2 weeks since the release of the
final rules on July 13th, we have already provided educational
content to thousands of webcast attendees. We expect our
educational efforts to continue as we work closely with
regional extension centers in the coming months and years.
The HITECH incentives had a measurable stimulative effort
on our business in three ways. First, inquiries about our
electronic health records have been at record levels since the
initial passage of ARRA. Second, we have increased our annual
R&D expenditures a full 25 percent from $72 million to $90
million, which will help drive innovation into the industry.
And third, we have hired more than 560 people since the passing
of ARRA with plans to hire several hundred more in the next
year. These are high-paying technology-centered jobs, just the
kind of jobs that the American workforce needs.
Even more importantly, our clients are also hiring directly
as they work to ensure success in their health care IT adoption
efforts. For example, Denver-based Catholic Health Care
Initiatives, in part spurred by the meaningful-use incentive
program, has announced that they will be hiring 200 health IT
professionals over the next year, and we have many other
clients with similar plans. So if you had any questions, the
health care incentive stimulus plan is working in our industry.
Now, the final rule is out and hospitals and health care
organizations among our client base are very pleased. The
uncertainty about meaningful use has been removed and many of
the changes that the provider community requested during the
comment period were in fact incorporated. This process was a
positive example of a productive public-private partnership.
Many physicians particularly appreciated the flexibility
related to what constitutes meaningful.
You have created real incentive and real momentum with
meaningful and with health care reform efforts. Now I would
encourage you to take three steps to build on that success.
First, push vendors like Allscripts and providers to achieve
even higher standards related to more-robust connectivity. All
systems should be able to connect and accept data from outside
systems as if it were their own by using common standards as
the banking industry does today. Second, it is time to mandate
electronic prescribing. This is a patient safety issue and one
we believe we can address. And finally, let us continue to
focus on performance metrics and use payment and delivery
system reforms to reward physicians who demonstrate positive
outcomes for their patients.
In summary, the final rule on meaningful use will result
not only in a higher number of providers participating in the
incentive program but more importantly higher quality and safer
care for patients. We expect most providers not only to meet
but to exceed the requirements of meaningful use, which we call
meaningful value, by doing more than the minimum. We have key
clients across the country who are doing just that. For
example, the University of South Florida and Wellspan in
Pennsylvania are both using electronic health records to
deliver better diabetes care and better inform patients. Sharp
Healthcare in San Diego is approaching 90 percent electronic
orders. Heritage Valley Health System in Pittsburgh is writing
100 percent of their prescriptions electronically and there are
a host of others who are leading the way. We also see leaders
like North Shore Long Island Jewish, Hartford Hospital and the
University of Massachusetts, who are leading the way by
connecting their communities for better care with the goal of
one patient record.
Your actions have served to both encourage and accelerate
all of these activities and to spur other organizations to take
similar actions. As the technology becomes part of the regular
work flow and electronic health records provide critical
information, we will see that meaningful use is essentially a
jumping-off point, ultimately resulting in the connected system
of health that we are all working towards.
Thank you for all of your efforts and the opportunity to
testify today, and I would be happy along with the panel to
answer your questions. Thank you.
[The prepared statement of Mr. Tullman follows:]
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Mr. Pallone. Thank you, Mr. Tullman.
Dr. Evans.
STATEMENT OF PEGGY C. EVANS
Ms. Evans. Thank you. Good afternoon, Mr. Chairman and
members of the subcommittee, thank you for inviting me here
today. I am Peggy Evans, Director of WIREC, the Washington and
Idaho Regional Extension Center for Health Information
Technology. I represent Qualis Health, a private not-for-profit
health care consulting firm and a Medicare quality improvement
organization for the States of Washington and Idaho. I am
honored to be here today to tell you about how WIREC will
provide vendor-neutral EHR adoption services to help health
care providers attain meaningful.
Providers often start their EHR adoption believing that
once the technology has been installed, they are at the end of
their EHR implementation journey. In fact, once implementation
has occurred, the journey has just begun. Technology is a great
tool when it works well, but no matter how well it works, it is
just a tool. Training people to utilize their technology is an
essential component of successful EHR adoption.
Our initial experience working with providers strongly
indicates that there is a need for EHR technical assistance
service through the REC program. For example, there is a
community health center in the readiness planning stage of EHR
adoption. They received a bid from a commercial, that is a non-
REC, consultant for services at $225 an hour for a total bill
of $45 million. The cost of a commercial consultant was
prohibitively expensive for a community health center and they
enrolled in WIREC, thus saving $45,000 for support of patient
care and other administrative needs.
Another story is that at our first site with another small
clinic, we learned that the practice had not considered
designating a project manager for their EHR implementation with
only six weeks until their go-live date. While EHR vendors help
providers with a bulk of their implementation and technology
needs, providers often need to understand that there are tasks
on their end that should be completed in order to help them
help themselves, which is where WIREC steps in.
WIREC's program strategy is threefold. First, we provide
on-the-ground health IT coaches that deliver one-on-one
customized technical assistance to providers. Second, we
establish and maintain network IT communities of practice to
share learning. For example, we have implemented an EHR
regional group purchase committee with an independent
consultant who is facilitating the process and committee
members supporting the work. Third, we plan to support peer-to-
peer networking activities that will allow participating
providers to learn from one another, a very powerful method of
communication. Our WIREC staff delivers a suite of services to
providers across the three stages of the EHR adoption
continuum: selection, go live and optimization. For providers
in all stages, we disseminate information about the CMS
incentive payments, help providers understand the meaningful-
use criteria within a framework for reaching that level of EHR
use and provide assistance in workflow evaluation and redesign.
The importance of workflow redesign cannot be stressed
enough. Many providers are under the assumption that they will
transition from paper to EHRs but continue to use the same
workflow processes that supported their paper-based records,
but if they do that, they are unlikely to succeed with their
EHR adoption. Health IT professionals and researchers have
shown time and time again that workflow redesign is critical
for successful EHR implementation and that it is not business
as usual.
Recognizing that providers in our region may have already
adopted a multitude of EHR systems as a starting point toward
meaningful use, WIREC offers vendor-neutral services and will
work with providers regardless of their choice in EHR systems.
Among the first several hundred providers who have enrolled
with WIREC, they are currently 14 different EHR products
already in use which hopefully you can see displayed on the
screen. There you go. I won't take the time to read them all
but you can see that there is a wide variety of EHRs that we
currently support.
Because one of WIREC's major objectives is to assist
providers in meaningfully using their EHR systems, our
consultants help identify the gaps between where the provider
is now and where he or she needs to be in order to reach
meaningful use. We then lay out a customized path for how to
achieve meaningful use. We have received feedback from many
providers that the meaningful-use criteria just seem like a
long list of unorganized requirements. WIREC staff provides a
framework for organizing the criteria in a way that is more
readily digestible by providers and their staff and then
suggest doable chunks that providers can tackle without being
overwhelmed. To date, we have successfully enrolled practices
that represent about 500 primary care providers as indicated on
the map. Among our initial enrollees, there is a distribution
of practice locations across the two-State region that includes
both urban and rural sites.
The REC program focuses on smaller provider offices,
community health centers, rural health clinics and other
ambulatory practices affiliated with the critical-access
hospitals and rural hospitals and providers that primarily
treat the underserved and uninsured. As you can see on the
display graph, a vast majority of our enrolled providers are
from smaller practices. Of the larger practices that we are
serving, mostly all are community health centers or rural
health clinics.
The WIREC consulting team has now begun providing
educational programs and direct assistance in the field to our
participating practices. Initial survey results suggest that
providers find REC services to be valuable. As you see on the
display screen, among our practice sites thus far, 100 percent
of the providers have reported satisfaction with WIREC
services. The number of practices surveyed thus far is small
but the results are encouraging.
Additionally, our educational webinar series for providers
has been well received with evaluation responses showing
consistent ratings around 90 percent of respondents agreeing
that each of the sessions has been a value as indicated again
on the display.
In conclusion, Qualis Health's startup experiences show
that providers across our region, both urban and rural, are
enrolling into the WIREC program and initial feedback from
providers shows that they are finding value in working with the
REC program as a supplement to the support that they may
receive from their EHR technology vendor. Implementing an EHR
system and moving toward meaningful use is a transformation far
beyond the technical aspects of implemented a computer system.
WIREC looks forward to helping providers embark on that
transformation through our vendor-neutral support.
Thank you again for the opportunity to share our
experiences.
[The prepared statement of Ms. Evans follows:]
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Mr. Pallone. Thank you, Dr. Evans.
We are going to take questions now, and if we don't have
votes, we will do two rounds. I just don't know when the votes
are coming to come. I will start with myself for 5 minutes.
I want to start with Dr. Vozos. One of the most important
functions of health IT is to connect a patient's doctor and
hospitals together across a patient's illness, and EHR could
follow a patient from an outpatient clinic to the hospital,
back home again, facilitating communications and care along the
way, and of course, I am following up on my visit to Monmouth
Medical Center where we discussed this. You describe how
Monmouth is integrating its health records across settings
including with your affiliated federally qualified health
clinics. Just tell us more about how that project is
progressing, and I of course witnessed part of it when I was
there a few weeks ago.
Dr. Vozos. Our health system, as you know, was developed
really back in 2004, April 2004, and the reason we put it
together was that though we had a lot of clinics, you know, we
saw that the long-term evolution of those clinics was going to
be a continuing loss of money and plus we had declining of
services to the community in our area there. So converting that
to a federally qualified health center and also with the
reimbursement that was available to a federally qualified
health center, you know, really kind of saved it, not only
saved it, actually grew it to where it is probably one of the
premier health providers in the area. In fact, it provides
pretty good competition to private practitioners.
Mr. Pallone. I used an example about one day when I visited
and there was a guy sitting there in a business suit, which I
thought was unusual, but may not anymore.
Dr. Vozos. Well, what is a little bit unique about this
particular FQHC is that it was necessary that we incorporate
our teaching programs into the FQHC because the clinics, as
everybody knows, are a major source of teaching for residency
programs so we did incorporate them in, so our faculty actually
are doctors in the clinic and the residents are also there. So
it is a little bit unique, maybe not quite as efficient as Dr.
Winkleman's FQHC or, I mean, Dr. Goertz's FQHC, but it is an
excellent source of care. So it has grown tremendously.
Mr. Pallone. How does the HIT fit in with----
Dr. Vozos. What we did was initially we connected them. It
is a one-way connection right now from the FQHC into our
hospital, meaning that they can access all the record of the
patients that are in our hospital that they see in the clinic,
and as you could imagine, most of the patients in that clinic
when they do need to come to the hospital, they use Monmouth
Medical Center or the Monmouth emergency room. So the
physicians of the FQHC have direct access through the Internet
into our----
Mr. Pallone. But wasn't there also something where if you
went to the emergency room and they thought that you could use
the services of the community health center, that they set up
an appointment or something for you, right?
Dr. Vozos. Well, that is our other pilot program where, you
know, under a grant we----
Mr. Pallone. This is the demonstration program?
Dr. Vozos. Right.
Mr. Pallone. That was my second question.
Dr. Vozos. Yes, and that program, what the pilot was to
take all the patients who really were using our emergency room
as their medical home, so to speak, identified those that
really needed to have a primary care provider and arranged for
them to be followed up in our federally qualified center. We
thought initially we could easily make that happen once but we
were kind of curious as to what the true conversion was going
to be where they were not going to use the FQHC as their
private, you know, physician office. There has been a 70
percent conversion. It has been really a tremendous success,
and what it has done is, it has decompressed the emergency
room, improved the throughput for the emergency room and really
unclogged our emergency room and created a whole--a much better
atmosphere even in our emergency room.
Mr. Pallone. But it also made it possible for the people
that have regular care so they didn't----
Dr. Vozos. Well, they now have----
Mr. Pallone [continuing]. End up just using the emergency
room.
Dr. Vozos [continuing]. A regular physician in the FQHC.
Mr. Pallone. Now, is there also a Medicare demonstration
program that looked at whether gain sharing between hospitals
and physicians can reduce cost?
Dr. Vozos. Right.
Mr. Pallone. And then there was an electronic health
records component of that too?
Dr. Vozos. Yes, there is. We are part of a Medicare
demonstration project, which is 12 hospitals in New Jersey,
where we put together a set of criteria with the coordination
of the New Jersey Hospital Association, a set of criteria to
measure quality care, and if in the performance of these
measures there was a savings of money, you know, the federal
government has kind of relaxed itself a little bit and allowed
us to share in those cost savings. So we have recently gone
through the first phase of that where there was not only the
signing up of physicians but we completed the first 6 months of
measuring data, and what we are looking at right now is length
of stay, complications, mortality rates and readmission rates,
and there was--we actually issued the first set of checks and
now we are going through the second phase of additional
enrollment because initially not everybody wanted to enroll.
They either didn't trust the project, they didn't want to have
their name in some file that the federal government could be
steering. There is all kind of reasons why doctors wouldn't
sign up. But after the first phase of this, not we have had
about three times the number of physicians signing up. So we
are going to be well over 200,000 physicians signed up for
this, and it has actually produced savings.
Mr. Pallone. All right. Thanks.
Mr. Shimkus.
Mr. Shimkus. Thank you, Mr. Chairman. I have been writing
and scratching notes all over the place, so this may get really
disjointed, which would be very similar to most of my questions
that I ask. But it has been very educational. I am a very
outspoken critic of the stimulus bill but obviously we can se
some future benefits down the line in this provision.
My first question is, all of the examples of health care
information technology that is being used now, how many have
been deployed based upon stimulus dollars? I mean, there are a
lot of examples of health information technology that have been
talked about. Mr. Tullman, you sell it. Dr. Winkleman, you are
using it. Dr. Vozos, you are using it. How much of that
deployment was based upon taxpayer dollars?
Dr. Vozos. I would say at Monmouth the upgrade to the
Cerner Millennium----
Mr. Shimkus. Let us talk about stimulus dollars.
Dr. Vozos. Right. I mean, we need to do that in order to be
able to qualify at any point for the stimulus dollars.
Mr. Shimkus. So your upgrade was, but your original
deployment was not?
Dr. Vozos. No, original deployment was Cerner.
Mr. Shimkus. And Dr. Winkleman, I know that none of yours
was done based upon--your practice made the decision on their
own and incurred the capital expense and assumed the risk.
Dr. Winkleman. Yes. I mean, our practice made the decision
to move forward with this several years ago before there was
discussion of money available.
Mr. Shimkus. OK. I just want to put that--I mean, it is an
important thing to be placed on the record. Again, no one is
argue that is not beneficial and that we shouldn't be all in
but I also want to point out that a lot of the examples being
used are people who have done it without government help and
government intervention.
I want to go to the--again, Mr. Tullman, we understand how
this really does benefit your business plan and your ability to
hire a lot of folks because there is a new market being
generated by this government push, which we hope will provide
savings and better recordkeeping and hopefully lower medical
liability costs based upon all those benefits. But Mr. Starnes
from my district, in your opening statement you made some
compelling arguments about the crisis in rural America of
operating a small rural hospital. Can you incur these costs and
provide the continued service?
Mr. Starnes. Well, the economic downturn did play a very
devastating role for us, so we have had to make lots of changes
in order to rebound from that. What we find and what I was
commenting about was we do have several capital needs, you
know, diagnostic equipment----
Mr. Shimkus. And you would put those above HIT?
Mr. Starnes. If I have a person come into the emergency
room and need a CAT scan, I need a reliable CAT scan machine in
order to provide that service, so I have got to put that just
ahead of EHR at this point.
Mr. Shimkus. Right, and that does segue into kind of Dr.
Evans' point because I think your testimony mentioned about how
you can be in essence a low-cost consultant for small rural
hospitals and practitioners but you are paid on the government
dole, you are not a private consultant that is for profit,
paying taxes, paying for the office space, paying properly
taxes and other issues because you are part of this government
payout that we are doing, but I am not going to argue with the
help but there is probably some computer consultants who now,
you are the lowest bidder on providing, you know, consulting
services and so they are probably going to Mr. Tullman trying
to find a job over in his sector.
Let me--my time is short. For the two hospitals here, the
CMS actuary stated that about 15 percent of Part A providers
would become unprofitable within 10 years based upon the new
health care law because of lower payments, and the new health
care law cuts $500 billion from Medicare. Dr. Vozos, are you
going to be one of those 15 percent?
Dr. Vozos. If that it all that occurs, yes.
Mr. Shimkus. You would be?
Dr. Vozos. Of course I would be.
Mr. Shimkus. You are a major----
Dr. Vozos. I am a major teaching hospital but I am going to
rely on those 32 million or the 1.3 million people in New
Jersey who now have insurance to cover that reduction in
Medicare reimbursement. I have to rely on that.
Mr. Shimkus. Well, we can talk about that later on. And Mr.
Starnes, kind of the same question. I am shocked. I thought you
would be saying I can survive it because we are big.
Now Mr. Starnes.
Mr. Starnes. Under the critical-access hospital
designation, then hopefully we will be fine, but it is not
going to be easy for sure. We will have to be lean from----
Mr. Shimkus. You are already lean. You already can't
provide needed capital equipment to your hospital.
Mr. Starnes. Right. Yes.
Mr. Shimkus. Mr. Chairman, my time is expired and I will
yield back.
Mr. Pallone. Mr. Gonzalez.
Mr. Gonzalez. Thank you very much, Mr. Chairman.
My first question, and it may have been covered in the
absence with the other witnesses and it would have been
appropriate for them, but it is a situation that in San Antonio
the hospitals have made me aware of, and I want to make sure
that I frame the question, that is that the Medicare incentives
to grantees would be based on a CMS provider number if you have
multiple campuses, so if there is anyone on the panel can
explain the consequences of having one Medicare number but
having more than one campus as far as the incentives and how
that would be paid. I don't know if Doctor, is it Vozos?
Dr. Vozos. Yes. I mean, it doesn't affect us because we
have our own Medicare provider number but I can explain to you
how it works. You know, there are hospital systems, let us say,
five hospitals within one system all operating under one
provider number so therefore they are going to get the stimulus
once, not for each of the five hospitals. So theoretically some
of the smaller or more rural hospitals in that system on a
standalone basis would never be able to probably go through all
this.
Mr. Gonzalez. Anyone else have an opinion on the problems
that that may present?
Mr. Starnes. We just have the one campus and so it really
doesn't apply for us, but I can imagine that it is going to be
devastating for hospitals with several campuses because each
facility is going to have its own separate staff to be trained
and all of those costs that they will incur.
Mr. Gonzalez. I understand a rural setting is totally
different from what I have described, and Mister--let us see.
Where is--well, it is Dr. Winkleman. I apologize. Mr. Shimkus
has touched on the cost and how we would go about assisting. We
know about the stimulus money but of course that is finite and
such, but prospectively, as a physician, how is someone's
practice going to afford the technology and the training? We
introduced a bill a couple of years ago and it was a bipartisan
bill. It was never passed, but we had everything in there. But
I want your opinion, anyone on this panel that could give me an
opinion as to the best way to assist the physicians to make
that transition. We could have grants, a combination of grants.
We could have low-interest loans, guaranteed, or tax credits or
tax incentives. Is there any way that we should rank those or
just have them all available? Anybody?
Dr. Winkleman. Well, I think that having money and grants
available to help physicians use electronic records is a
positive thing but ultimately I think even better than that is
that physicians begin to get paid for doing a good job and that
as we start to--that our practice gets transformed by things
like electronic health records, that industry will be motivated
to make a product that works well, they will be motivated to
make a product that produces better care, I am going to be
motivated to use that product to provide better care, not just
intuitively for my patients but because I am rewarded for it.
So I think creating an environment where we are encouraged to
use things like this to improve the quality helps make that
transition make financial sense to a doctor because when you
look at it on paper, sometimes it is a tough sell. There is a
lot of upfront capital cost. There is initial reductions in
productivity. On the long term, there are gains. I think a lot
of practices become more efficient. They certainly do a better
job of billing and coding to get paid for what they actually
do. So I think one of the ways to do it is to make them make
financial sense, and part of that would involve creating a
situation where our reimbursement is tied to us doing a good
job, not just seeing a volume of patients.
Mr. Gonzalez. I think that is built in as far as the
incentives and how we proceed with that and do it right. Of
course, any time you have some positive reinforcement or reward
or whatever you want to call it that encourages that behavior,
there is another way of doing that, and that is obviously you
are penalized for not adopting, for not being more efficient in
the use of the technology, so there is all sorts of different
angles. Of course, we would like to do it in a positive mode,
and I appreciate your testimony today and I yield back, Mr.
Chairman.
Mr. Pallone. Thank you. I am going to have a second round
for anyone who would like to participate, and I will start with
myself.
I am going to go back to Dr. Vozos, but I guess any of you
could answer it. When I was--I mean, we asked many of you to
come here today because we knew that you were being innovative
with HIT, you know, before we passed the Recovery Act and we
put in this legislation that we have been discussing. I mean,
the idea at least in my mind was to hear from those who have
sort of been the precursors and did this before there was any
money from the federal government through the Recovery Act. But
I would like to know, because I know when I went to Monmouth
Medical Center that even though we discussed all the things
that we are doing, you also discussed with me what you could do
if you were able to tap the funds under this legislation. So
maybe you should talk to me a little bit about where you would
go from here, assuming you participated in this program.
Dr. Vozos. I mean, we are on the road and we are making a
lot of moves but we are far from there, and it is going to be a
tough journey and an expensive one, so really funding for us it
going to be a big issue going forward. You know, for Monmouth
Medical Center the full-blown HIT system is going to be about
$19 million over some period of time, and when I listened to
Mr. Starnes talk, I said I want to go find out where you are
buying that one, that $750,000 one. So it is a $19 million
project for our system. It is just shy of $100 million. So as
you can imagine, there needs to be all type of incentives to be
able to spend that kind of money. Now, there is the return on
investment so I would say right now, you know, we are moving
forward on a regular basis. We still have to install more
modules into our system to be able to get to the level where we
are fully operable to even qualify for the stimulus money and
that is what we are doing right now. So it will change the
practice at the hospital for sure. I mean, it will change even
how testing is done and what the residents are learning and the
efficiency of the hospital but we have a road to go, but there
is a bit team working on it and continues to work on it. And
our big thing is linking the physicians and private practices
and private offices and having a two-way exchange of
information. We want to be able for them to populate the record
in the hospital from what they're doing in the office but at
the same time what is happening with their patients in the
office should be able to go the opposite direction back into
their office records too, so that is why we view as very
important to have very compatible EMRs in the physician office
and at the hospital with the appropriate interfaces set up, and
we are putting a lot of effort into doing that.
Mr. Pallone. Maybe I will go to Mr. Tullman because Dr.
Vozos gives me the analysis from the hospital, but what about
you in terms of your systems? I think I said in my opening
statement that currently less than 20 percent of hospitals and
10 percent of physicians are using electronic health records,
and CMS is saying that they are going to go to 95 to 100
percent of hospitals and 70 percent of physicians. How are you
going to get there? Are you prepared, and what are the
pitfalls?
Mr. Tullman. I think it is a good question. What we have
seen, and you recognized that this panel includes a number of
innovators who have taken those steps, and I commend Dr.
Winkleman and the other physicians and members of the panel for
taking those first steps, but in technology adoption generally
you get the first 20 percent are early adopters. The next 70
percent are where the real dollars and the benefits are and
they take longer, and so the incentive program that you have
put into place will help us get the next 70 percent and drive
that throughout the rest of the market. From our perspective,
we believe we are ready. We are investing heavily in making
sure that the systems are easier to use, more easily deployed,
and again produce the kind of measurable results that we need
in health care, and I think the RECs, the regional extension
centers, the other programs that have been designed are going
to help us move that along. There are tremendous employment
opportunities. There is tremendous work to do, and that is not
just from the vendors, that is from actually the medical
centers across the country.
You know, the one thing I would say in terms of a
recommendation that we were asked about before is, I think
there is an opportunity to open the program even further to
rural providers who in some cases are excluded because they are
not off the same revenue schedules and to certain other
programs like Medicare Advantage where some of our leading
clients like Sharp Healthcare in California in fact have
problems in terms of getting their physicians covered to use
that, and they cover a significant amount, but overall, we
think we are ready and we think the country is ready for better
health care.
Mr. Pallone. All right. Thank you, Mr. Tullman.
Mr. Shimkus.
Mr. Shimkus. Thank you, Mr. Chairman.
Mr. Starnes, do you know, what is your closest REC? do you
know it?
Mr. Starnes. It is Northern Illinois University.
Mr. Shimkus. And that is located where? DeKalb?
Mr. Starnes. Yes.
Mr. Shimkus. And how far is DeKalb from Vandalia?
Mr. Starnes. I couldn't tell you. Somebody else?
Mr. Shimkus. Four and a half, five hours.
Mr. Starnes. OK.
Mr. Shimkus. I know Idaho-Washington is a big area too, so,
I mean, it is just a point I wanted to raise.
If we follow up on the chairman's point, Mr. Tullman, about
trying to get those numbers of 75 percent to 90 percent, that
is really a rush for obviously a population that you and the
other 12, 15 providers--Dr. Evans, you had that list up, I
don't know how many there were, 12, 15 providers who provide
the same type of services as Mr. Tullman. Are we concerned that
they will go to the bigger institutions prior to the smaller
ones?
Mr. Tullman. We really--I will take the first shot at that.
We believe and what we are seeing is accelerated adoption
across the board, so we know that at least until the stimulus
package, the larger organizations were in fact advantages
because they had CIOs, they had a capital budget and the like.
What the stimulus program does it open it up so smaller
physician groups and offices and independent physicians can do
that. That is number one. Number two, a lot of the larger
organizations, for example, I mentioned North Shore Long Island
Jewish, what they have done is, they not only bought licenses
for their 1,200 employed physicians but they have actually
extended that offer to 7,000 affiliated physicians in the
community to help connect them up and bring those benefits. The
last point is that many of the vendors have come out with
innovative programs like a financing program with no payments
for 6 months to help bridge the gap until smaller providers
actually get the stimulus funding. So I think you are seeing a
lot of innovation.
Mr. Shimkus. And I appreciate that. My time is short and I
don't mean to be disrespectful but I think that is going to be
an interesting case study to follow to make sure that happens.
There are just in the broadband world, the other committee I
serve on is Telecommunications. There are still communities on
dial-up. There are still communities not--and one of our
attacks on the stimulus bill is they are overbuilding broadband
areas and not deploying to what we call unserved areas. Well,
Dr. Evans, you probably know that. Probably in Idaho and the
eastern part of Washington State, there are unserved areas. So
the stimulus on the other end has to get broadband out so
everyone can take advantage of this.
I got a chance to visit with Dr. Winkleman earlier today,
and he brought up this issue that even though he is--and I have
to do this before I do that. I am sorry. Two letters, I ask for
unanimous consent, and one is a compelling argument of a
community of 15,000--Mr. Starnes would know-- Washington County
Hospital, Nancy Newby, president and CEO, a population of
15,000. They are on HIT already and did the risk, did the same
thing. So there are folks who realize the importance of this
and did it previous to the government intervening.
In the HITECH Act, incentives are based on charges under
the Medicare fee schedule or a provider can qualify for more
than 30 percent of their volume is from Medicaid patients. As a
rural health clinic, will you meet either of these criteria?
Dr. Winkleman. We will have a very hard time achieving the
standard under the--well, let me back up. We will be very close
under the Medicaid, the arm of being 30 percent. Our problem
under the Medicare arm is that since our reimbursement comes
via the rural health clinic system and not directly from
Medicare. Our charges to the Medicare fee schedule are very
limited. The only thing we bill to Medicare fee schedule under
fee-for-service are some ancillary things. So we really don't
have a Medicare option despite the fact that we see a good
percentage of Medicare patients. You know, we really are
limited to the Medicaid option. And so for some of my
partners--it would be different for me, I do family medicine
where a see a good portion of children and a lot of them are
Medicaid, but some of my partners that do primarily internal
medicine, primary care and see mostly adults, a lot of those
patients are Medicare and then they could be sort of left out
in the cold. Seeing a large number of Medicare patients, having
adopted EHR, using them meaningfully, and yet we don't really
have the Medicare charges per se technically that qualifies
under the incentive.
Mr. Shimkus. Thank you, Mr. Chairman. My time is expired
but I want to note Dr. Evans was nodding yes, I think and I
guess she would agree with pretty much of that analysis.
Ms. Evans. Yes, and actually we have heard the same concern
from many of the rural health clinic providers that we have
been talking to that they are shut out because they may not--
they basically bill via a bundled mechanism rather than the
provider fee schedule so that leaves them out of Medicare, and
then they don't see the 30 percent patient panel required for
Medicaid or 20 percent of their pediatricians. So they are
really very much interested in how CMS is going to address the
fact that there may be no incentive payments coming to them.
Mr. Shimkus. Well, hopefully CMS is paying rapt attention
to this hearing and that is part of the record.
We haven't talked about HIPAA implications. We haven't
talked about the whole privacy debate. That is really critical
when data is flowing, and I am not smart enough to go into, Mr.
Chairman, so I yield back.
Mr. Pallone. Thank you. Mr. Shimkus has asked unanimous
consent to enter these two documents into the record. Without
objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Pallone. Mr. Gonzalez.
Mr. Gonzalez. Thank you, Mr. Chairman.
This question will go to Dr. Evans. Has it been your
experience--now, my understanding is, you are vendor neutral.
That means when you go on site, the hardware has been
purchased, the software. The system is in place, you just--I am
going to read something to you. I am almost embarrassed, Mr.
Chairman, and I am hoping Mr. Shimkus is not listening as to my
sources of information.
Mr. Shimkus. I usually don't.
Mr. Gonzalez. That is an understatement. But anyway, this
is Hilda Gorito of Kaiser Permanente: ``If you give a
lumberjack who has been using an ax his whole life a chainsaw
and he starts hacking at a tree with it, it is not going to
help him at all. It is what you do with the technology that
makes the difference.'' So you go there, and so now the
physician who used to be a lumberjack now has the chainsaw, and
you are going to teach him basically how to use that
effectively about the technology. When you go on site, are you
discovering that many times--I don't know how to put this--they
have overpurchased? One size doesn't fit all, and my experience
has been with my friends who are physicians and a couple of
friends who actually sell the systems that a lot of physicians
really are not--because you are coming after the fact, that
prior to the purchase of what is a very expensive investment
that it is not done many times with the knowledge. And Mr.
Tullman, I want you to chime in as soon as Ms. Evans finishes.
Where does a physician or a small practice get the direction
and the advice to purchase only that which they really need and
to make an investment and not realize the return that they
could?
Ms. Evans. Well, my experience in doing some of the
consulting out in the field is that many times providers
purchase something and then underutilize the system for a
variety of reasons. I can't really speak to whether they have
overpurchased, but what I have seen is that there are many
functions and features that are available to them, particularly
for reaching meaningful use, that they haven't even necessarily
looked at or they don't know exist. And so we go into the
practice to educate them about some of the availability of the
features and functionality as well as determine the workflow by
which they might be able to use the system is a more effective
manner.
Mr. Gonzalez. Your thoughts, Mr. Tullman?
Mr. Tullman. Yes, I think I would concur, and we think the
largest problem, most significant problem is underutilization,
and that would be true in most pieces of software that people
buy. They tend to use them not at the maximum but the minimum,
so we think the RECs are a good idea. We also are seeing more
and more physicians get counseling from a variety of ratings
services so as a vendor we are evaluated by a number of
different organizations and of course CCHIT, there are minimum
requirements, so there used to be about 300 different
electronic health record providers. Last year under CCHIT to
meet the minimum standards, that 300, only 70 qualified as
meeting the minimum requirements. Those requirements are now
even greater and will continue to get greater, and we think
that is a good thing. We think that it improves the value of
the products.
But your point I think is very important, and that is, and
we believe it is one reason this legislation made sense and
that was you weren't simply buying physicians electronic health
records, you were saying we will help pay for them if you use
them, and that is really the critical aspect of meaningful use,
which we are very supportive of.
Mr. Gonzalez. Last question. I have a minute. Ms. Bechtel,
you represent the consumer and such, and I am one of those that
just believe that a patient goes in there believing that the
doctor is up to date on the latest literature, continuing
education, has the best equipment and so on. Do you believe
that HIT should be part of that equation, that each patient
should expect that that particular physician have that
electronic medical records and the efficiency, effectiveness
and cost savings that it should bring?
Ms. Evans. I do, and I think it is interesting because
there are a number of consumers who see technology in every
other sector in this country and assume that their physicians
have it as well, but then they experience the acute challenge
of trying to communicate with the care team, trying to
coordinate their own health care, understanding that doctors
just aren't talking to each other fully and in the way they
could be without interoperable health IT and so we have done
actually a fair amount of research with consumers directly to
understand what do they think about information technology and
the reasons that it appeals to them are exactly those but they
get that it will begin to reduce the burden that they face,
particularly around care coordination. So we would be delighted
to start to see consumers asking their physicians are you a
meaningful user of information technology, do you have an
electronic health record. I know that when I chose my own
doctor recently, it took me several months to find out that has
an electronic health record, and I did, but to the point of
this hearing, the practice actually doesn't use it in a
meaningful way whatsoever. They really just actually automated
paper. So I think the conversation has to start with, do you
have an electronic health record, but it can't end there. It
has to be, how are you giving me access to my health
information, how are you sending me reminders, how are you
summarizing my care for me and other benefits of technology.
Mr. Gonzalez. Well, I thank all of you for your testimony.
I yield back, Mr. Chairman.
Mr. Pallone. Thank you. That concludes our questions, so we
want to thank all of you for spending all of your time here
today, and obviously this is very helpful and it is probably
just the beginning of what we are going to have to look at in
dealing with HIT.
The way the rules work, you will get some written questions
from members. We try to have them to you within 10 days, and
then of course we ask you to respond as quickly as you can, and
if you want to submit testimony, you can. But thank you very
much. I really appreciate it.
Without objection, this meeting of the subcommittee is
adjourned.
[Whereupon, at 5:30 p.m., the Subcommittee was adjourned.]
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