diff --git "a/data/CHRG-110/CHRG-110hhrg33807.txt" "b/data/CHRG-110/CHRG-110hhrg33807.txt" new file mode 100644--- /dev/null +++ "b/data/CHRG-110/CHRG-110hhrg33807.txt" @@ -0,0 +1,2079 @@ + + - SUBCOMMITTEE HEARING ON THE VALUE OF HEALTH IT TO SOLO AND SMALL MEDICAL PRACTICES +
+[House Hearing, 110 Congress]
+[From the U.S. Government Publishing Office]
+
+
+
+
+ 
+                  SUBCOMMITTEE HEARING ON THE VALUE OF
+                  HEALTH IT TO SOLO AND SMALL MEDICAL
+                               PRACTICES
+
+=======================================================================
+
+            SUBCOMMITTEE ON REGULATIONS, HEALTH CARE & TRADE
+                      COMMITTEE ON SMALL BUSINESS
+                 UNITED STATES HOUSE OF REPRESENTATIVES
+
+                       ONE HUNDRED TENTH CONGRESS
+
+                             FIRST SESSION
+
+                               __________
+
+                             MARCH 28, 2007
+
+                               __________
+
+                          Serial Number 110-11
+
+                               __________
+
+         Printed for the use of the Committee on Small Business
+
+
+ Available via the World Wide Web: http://www.access.gpo.gov/congress/
+                                 house
+
+
+                                 ______
+
+                    U.S. GOVERNMENT PRINTING OFFICE
+33-807                      WASHINGTON : 2007
+_____________________________________________________________________________
+For Sale by the Superintendent of Documents, U.S. Government Printing Office
+Internet: bookstore.gpo.gov  Phone: toll free (866) 512-1800; (202) 512�091800  
+Fax: (202) 512�092104 Mail: Stop IDCC, Washington, DC 20402�090001
+
+
+                   HOUSE COMMITTEE ON SMALL BUSINESS
+
+                NYDIA M. VELAZQUEZ, New York, Chairwoman
+
+
+JUANITA MILLENDER-McDONALD,          STEVE CHABOT, Ohio, Ranking Member
+California                           ROSCOE BARTLETT, Maryland
+WILLIAM JEFFERSON, Louisiana         SAM GRAVES, Missouri
+HEATH SHULER, North Carolina         TODD AKIN, Missouri
+CHARLIE GONZALEZ, Texas              BILL SHUSTER, Pennsylvania
+RICK LARSEN, Washington              MARILYN MUSGRAVE, Colorado
+RAUL GRIJALVA, Arizona               STEVE KING, Iowa
+MICHAEL MICHAUD, Maine               JEFF FORTENBERRY, Nebraska
+MELISSA BEAN, Illinois               LYNN WESTMORELAND, Georgia
+HENRY CUELLAR, Texas                 LOUIE GOHMERT, Texas
+DAN LIPINSKI, Illinois               DEAN HELLER, Nevada
+GWEN MOORE, Wisconsin                DAVID DAVIS, Tennessee
+JASON ALTMIRE, Pennsylvania          MARY FALLIN, Oklahoma
+BRUCE BRALEY, Iowa                   VERN BUCHANAN, Florida
+YVETTE CLARKE, New York              JIM JORDAN, Ohio
+BRAD ELLSWORTH, Indiana
+HANK JOHNSON, Georgia
+JOE SESTAK, Pennsylvania
+
+                  Michael Day, Majority Staff Director
+
+                 Adam Minehardt, Deputy Staff Director
+
+                      Tim Slattery, Chief Counsel
+
+               Kevin Fitzpatrick, Minority Staff Director
+
+            SUBCOMMITTEE ON REGULATIONS, HEALTH CARE & TRADE
+
+                   CHARLES GONZALEZ, Texas, Chairman
+
+
+WILLIAM JEFFERSON, Louisiana         LYNN WESTMORELAND, Georgia, 
+RICK LARSEN, Washington              Ranking
+DAN LIPINSKI, Illinois               BILL SHUSTER, Pennsylvania
+MELISSA BEAN, Illinois               STEVE KING, Iowa
+GWEN MOORE, Wisconsin                MARILYN MUSGRAVE, Colorado
+JASON ALTMIRE, Pennsylvania          MARY FALLIN, Oklahoma
+JOE SESTAK, Pennsylvania             VERN BUCHANAN, Florida
+                                     JIM JORDAN, Ohio
+
+        .........................................................
+
+
+                                  (ii)
+
+  
+?
+
+                            C O N T E N T S
+
+                              ----------                              
+
+                           OPENING STATEMENTS
+
+                                                                   Page
+
+Gonzalez, Hon. Charles...........................................     1
+Westmoreland, Hon. Lynn..........................................     3
+
+                               WITNESSES
+
+Kirk, Dr. Lynne M., MD, FACP, American College of Physicians 
+  (ACP)..........................................................     6
+Leavitt, Dr. Mark, MD, PhD, Certification Commission for Health 
+  Information Technology (CCHIT).................................     7
+Kelley, Dr. Margaret, MD, American College of Obstetricians and 
+  Gynecologists (ACOG)...........................................     9
+Shober, Dr. David R., D.O., Health Information Management System 
+  Society (HIMSS)................................................    11
+Napier, Dr. Kevin, Internal Medicine of Griffin..................    13
+
+                                APPENDIX
+
+
+Prepared Statements:
+Gonzalez, Hon. Charles...........................................    33
+Westmoreland, Hon. Lynn..........................................    35
+Kirk, Dr. Lynne M., MD, FACP, American College of Physicians 
+  (ACP)..........................................................    37
+Leavitt, Dr. Mark, MD, PhD, Certification Commission for Health 
+  Information Technology (CCHIT).................................    46
+Kelley, Dr. Margaret, MD, American College of Obstetricians and 
+  Gynecologists (ACOG)...........................................    53
+Shober, Dr. David R., D.O., Health Information Management System 
+  Society (HIMSS)................................................    58
+Napier, Dr. Kevin, Internal Medicine of Griffin..................    73
+
+Statements for the Record:
+Gingrey, Hon. Phil...............................................    76
+American Medical Association (AMA)...............................    80
+The Computing Technology Industry Association (CompTIA)..........    85
+National Association of Chain Drugstores.........................    92
+SureScripts LLC..................................................    98
+
+                                 (iii)
+
+  
+
+
+                   SUBCOMMITTEE HEARING ON THE VALUE
+                     OF HEALTH IT TO SOLO AND SMALL
+                           MEDICAL PRACTICES
+
+                              ----------                              
+
+
+                       WEDNESDAY, MARCH 28, 2007
+
+                     U.S. House of Representatives,
+                               Committee on Small Business,
+           Subcommittee on Regulations, Health Care & Trade
+                                                    Washington, DC.
+    The subcommittee met, pursuant to call, at 10:00 a.m., in 
+Room 2360 Rayburn House Office Building, Hon. Charles Gonzalez 
+[Chairman of the Subcommittee] presiding.
+    Present: Representatives Gonzalez, Jefferson, Altmire, 
+Sestak, Westmoreland, and Buchanan.
+    Also Present: Representative Gingrey.
+
+             OPENING STATEMENT OF CHAIRMAN GONZALEZ
+
+    ChairmanGonzalez. It is five after, and by D.C. standards 
+we are starting early. So it is my--and I am hoping that other 
+members will be joining us, and we may even have a Member of 
+Congress who has a great interest in HIT who is not a member of 
+this particular Committee, but we are going to welcome him if, 
+as, and when he gets here.
+    I call this Subcommittee to order now, and, of course, this 
+is the Subcommittee on Regulation, Health Care, and Trade, of 
+the House Committee on Small Business. And the hearing today is 
+entitled ``Value of Health Information Technology to Solo and 
+Small Medical Practices.''
+    I will be following the rules established by the chair of 
+the full Committee, Chairwoman Nydia Velazquez, meaning that 
+the chair--myself--and the ranking member, Congressman 
+Westmoreland, will be making opening statements. However, all 
+other members of the Subcommittee are welcome to submit written 
+statements that will be made part of the record at a later 
+date. And I appreciate your participation today.
+    Today's hearing will offer an opportunity to examine ways 
+we can expand and improve the implementation of health 
+information technology. Health information technology has the 
+potential to advance health care quality, but right now many 
+small health care providers simply cannot afford to offer it.
+    It is well known that HIT benefits are vast and wide-
+reaching. Practices which we are fortunate enough to have 
+access to this technology know that it reduces health care 
+costs, improves administrative efficiency, and reduces 
+paperwork. This leads to improved safety and quality and 
+ultimately increased access to affordable health care.
+    However, right now there are inadequate incentives for 
+health care providers to adopt many of these technologies. The 
+costs are too high in light of the benefits. As a result, a 
+significant gap exists in health IT adoption between large and 
+small practices.
+    A study conducted by the Commonwealth Fund revealed that 57 
+percent of physicians in practices with more than 50 physicians 
+used health information technology, compared with only 13 
+percent of solo practitioners. More importantly, 80 percent of 
+all outpatient visits take place in medical practices with 10 
+or fewer doctors, and solo practitioners comprise about two-
+thirds of all medical practices which provide these services.
+    Without changes in the way we promote health IT, small 
+physician practices will be left behind the technological 
+curve, and, as a result, patients will fail to benefit from the 
+quality of care electronic health records provide.
+    Congress needs to do more to help these smaller practices, 
+where the majority of patient care is actually received. This 
+is why I am introducing legislation that will provide financial 
+incentives and other resources to increase the pace of health 
+information technology adoption by smaller practices. These 
+resources will include tax incentives, grants, and subsidized 
+loans, all of which are instrumental to address this particular 
+problem.
+    I am pleased that the Small Business Committee also 
+recently passed the Small Business Lending Improvements Act of 
+2007, which will allow small medical providers in underserved 
+areas to access small business administration loans for health 
+IT. One of the most effective ways to do so is to provide 
+financial incentives for such practices to adopt and implement 
+health information technology. This will ensure that smaller 
+practices are encouraged to purchase and implement health 
+information technology while simultaneously protecting them 
+from the financial burden of government regulations and 
+mandates.
+    It has been estimated that purchasing and installing an 
+electronic health records system can cost more than $32,000 per 
+physician, and maintenance can exceed $1,200 per month. My 
+legislation would help defray some of these high upfront costs. 
+Modern technologies benefits are felt across our country in our 
+daily lives. We have seen and felt its benefits in education 
+and the sciences. Now it is time for our health care system to 
+catch up.
+    This hearing will focus on the importance of health 
+information technology to small practices, examine the barriers 
+to its implementation, and identify the steps Congress should 
+take to encourage greater adoption by small practices. Small 
+health care providers are struggling and desperately need our 
+help.
+    Some of the witnesses before us today are pioneers in that 
+they have taken the step and started implementing these 
+technologies. But unless we increase the pace of adoption by 
+smaller practices, there is little possibility that America's 
+health care system will be transformed.
+    I would like to thank each of our witnesses for taking time 
+out of their busy schedules to discuss this important issue, 
+and, of course, to share their own personal experiences 
+regarding this very important issue that is coming before 
+Congress and hopefully will be acted upon in the 110th 
+Congress, which we failed to do last Congress.
+    At this time, it is my pleasure to recognize my colleague 
+and ranking member, Congressman Lynn Westmoreland, for his 
+opening remarks.
+
+             OPENING STATEMENT OF MR. WESTMORELAND
+
+    Mr.Westmoreland. Thank you, Mr. Chairman, and thank you for 
+holding this hearing today, and it is a pleasure to work with 
+you on this Committee. I would also like to thank all of the 
+witnesses that are here today. I know you are solo 
+practitioners maybe, and it is costing you money to be here, so 
+thank you for your participation.
+    Mr. Chairman, I am glad this Subcommittee's first hearing 
+topic is one of such great importance. I look forward to 
+working with you on strengthening America's small businesses 
+during our time together on this Committee. Today we live in 
+the age of information. We have all become increasingly 
+dependent on having things at our fingertips at a moment's 
+notice.
+    It is now difficult to remember a time without Internet 
+search engines, e-mail devices fastened to our hips, or GPS 
+navigation systems in our cars. However, this wave of 
+technology has not yet been fully implemented in one of the 
+world's most important industries, and that is the health care 
+industry.
+    While the science of medicine makes dramatic advancements 
+almost daily, the method of managing patients' medical records 
+has lagged far behind. And this is why I am so glad to be here 
+today to discuss this issue. I think everyone involved 
+recognizes the tremendous value health information technology 
+provides. Collecting patients' information in a more efficient, 
+productive manner helps prevent medical error and reduces 
+paperwork.
+    Minimizing these two factors improves the overall health 
+care system while also lowering cost. I applaud President Bush 
+for his recognition of these benefits and for his call for the 
+widespread adoption of the electronic medical records, the 
+EMRs, within the next 10 years.
+    Unfortunately, while these values are understood by all, 
+the financial costs of implementing health IT are felt by most, 
+and for some it can be the barrier against establishing IT in 
+their own practices. This is especially the case for smaller 
+health care practices like the ones throughout my district in 
+Georgia. And even after addressing the financial burden, in 
+most cases a small practice must still confront the complex 
+state and federal laws that entangle all businesses.
+    There are many proposals focused on addressing these 
+problems, most of which use a mixture of financial incentives 
+and policy changes. Although there is no quick fix for a 
+national implementation of health IT, there is a considerable 
+desire for it. And I am glad that the Chairman has introduced a 
+bill, and also Congressman Gingrey has one, both that address 
+this issue.
+    For that reason, I believe that it is important that we 
+take as many ideas into consideration as possible in order to 
+make the best decision for our health care providers and our 
+health care system. This Congress faces a great challenge as it 
+tries to lower the overall cost of health care, and I am 
+hopeful that the work of this Subcommittee will do its part in 
+answering this challenge.
+    I welcome this distinguished panel, and thank you all for 
+your willingness to testify in front of us today. And, Mr. 
+Chairman, I would like to request that all members have five 
+days to revise and--legislative days to revise and extend their 
+remarks.
+    ChairmanGonzalez. Without objection.
+    Mr.Westmoreland. Thank you.
+    ChairmanGonzalez. I had indicated earlier that the 
+remaining members of the Committee will be able to--or the 
+Subcommittee will be able to submit their written statements 
+for the record.
+    To the witnesses, let me explain the little mechanism there 
+on the lights. Obviously, green means go. When it is yellow, 
+that means you have one minute left. When it is red, time has 
+expired. As you have already been instructed, you have 
+submitted written statements that obviously would exceed five 
+minutes, but we are asking you to please summarize your written 
+testimony in those particular five minutes, and then we will 
+proceed with questions.
+    At this time, though, I believe there may be an occasion 
+for Congressman Phil Gingrey from the great State of Georgia to 
+be joining us at a later time, and I would be asking at this 
+time for unanimous consent to allow a non-member of the 
+Subcommittee and the larger full Committee to sit here at the 
+dais and participate with members of the Committee.
+    So without any objection, it is so ruled. And when he gets 
+here, if you will just direct him to have a seat up here. Thank 
+you very much.
+    It is my pleasure to be introducing the witnesses at this 
+time. I will be deferring the introduction of two of the 
+witnesses to my colleagues, but I will start off with Dr. Lynne 
+M. Kirk is President of the American College of Physicians, the 
+nation's largest medical specialty society. The American 
+College of Physicians represents more than 120,000 physicians 
+in general and internal medicine and related subspecialties.
+    Dr. Kirk is also the Associate Dean of Graduate Medical 
+Education and Associate Chief of the Division of General and 
+Internal Medicine at the University of Texas Southwestern 
+Medical Center. Welcome, Dr. Kirk.
+    Dr. Mark Leavitt is Chair of the Certification Commission 
+for Health Care Information Technology, and we will learn more 
+about that particular commission during the testimony. The 
+mission is to accelerate the adoption of a robust inter-
+operable health information technology. The organization now 
+actively certifies electronic health record systems and 
+recently received official recognition from HHS as a 
+certification authority.
+    Dr. Leavitt is a Clinical Assistant Professor at the Oregon 
+Health and Science University and is a fellow of the Health 
+Care Information and Management System Society.
+    Dr. Margaret Kelley--and welcome Dr. Kelley because she is 
+a constituent--is a partner in Southeast OB-GYN Associates, 
+located in San Antonio, Texas, and serves as the Chief of 
+Surgery and Chief of Staff for Southeast Baptist Hospital. Dr. 
+Kelley will be testifying on behalf of the American College of 
+Obstetricians and Gynecologists, which has over 49,000 members 
+and is the nation's leading group of professionals providing 
+health care for women.
+    At this time, I am going to recognize Congressman Jason 
+Altmire for the introduction of Dr. David Shober.
+    Mr.Altmire. Thank you, Mr. Chairman.
+    Dr. Shober is from my district. He is a partner in Lawrence 
+County Family Medicine Practice, located in New Castle, 
+Pennsylvania. He and his partner own and manage their business. 
+They installed an electronic health record in 2004. Their 
+practice consists of two physicians, one physician assistant, 
+and a nurse practitioner. They have two offices that operate 
+simultaneously, a small one in a township and the other one in 
+a rural setting.
+    They provide in-patient medical care at one hospital and 
+four nursing homes. In addition, Dr. Shober serves as President 
+of the medical staff at Jameson Memorial Hospital. Previously, 
+he served as Vice President and Chairman of the Department of 
+Medicine. This is a 200-bed community hospital serving a 
+population of 90,000 people.
+    Dr. Shober is testifying on behalf of the Health 
+Information and Management System Society, HIMSS. That is a 
+membership organization focused on health care information 
+technology representing more than 20,000 individual members and 
+300 corporate members.
+    ChairmanGonzalez. Thank you very much. And I would like to 
+point out, in looking over the bios of members--and we don't do 
+that until actually we have hearings and such--it is my 
+understanding that Congressman Altmire has a master's in health 
+administration. Is that correct?
+    Mr.Altmire. That is right.
+    ChairmanGonzalez. So we are looking for a little bit of 
+leadership here.
+    [Laughter.]
+    At this time, I would like to recognize the ranking member, 
+Congressman Westmoreland, for the introduction of our next 
+witness.
+    Mr.Westmoreland. Thank you, Mr. Chairman. It is my pleasure 
+to introduce my constituent, Kevin Napier, M.D., who is an 
+Internist with Internal Medicine of Griffin, in Griffin, 
+Georgia. Dr. Napier has honorably served his community and his 
+nation since graduating from the Medical College of Georgia. He 
+spent five years practicing at numerous U.S. Navy medical 
+clinics before entering civilian medicine.
+    Dr. Napier has been a general partner with Internal 
+Medicine of Griffin since 2001, where they made the transition 
+to health IT in 2005. Former Chief of Staff of the Spalding 
+Regional Medical Center, currently Dr. Napier serves on the 
+Board of Directors of the Spalding Regional Medical Center.
+    I want to thank Dr. Napier for being here to share his 
+perspective as a small medical practitioner, and I look forward 
+to hearing the testimony he has.
+    ChairmanGonzalez. Thank you very much, and we will proceed 
+with the testimony and the first witness, Dr. Kirk.
+
+  STATEMENT OF LYNNE M. KIRK, M.D., FACP, PRESIDENT, AMERICAN 
+                     COLLEGE OF PHYSICIANS
+
+    Dr.Kirk. Thank you, Chairman Gonzalez and Ranking Member 
+Westmoreland. As a general internist at the University of Texas 
+Southwestern Medical Center in Dallas for the past 26 years, I 
+have had the privilege of providing health care to thousands of 
+Texans while training the next generation of American 
+physicians.
+    The American College of Physicians is the largest specialty 
+society in the U.S., representing 120,000 internal medicine 
+physicians and medical students. More Medicare patients count 
+on internists for their medical care than any other physician 
+specialty. Of our members involved in patient care after 
+training, approximately 20 percent are in solo practice, and 50 
+percent are in practices of five or fewer physicians. This is 
+the group of physicians that is least likely to have the 
+necessary capital on hand to invest in technology.
+    We greatly appreciate your attention to the barriers small 
+health care practices face in adopting HIT. ACP strongly 
+believes the goal of widespread adoption and use of HIT to 
+improve quality of care will only be successful if we first 
+recognize the complex issues of financing, redesign of practice 
+workflow, and the need for ongoing technical support and 
+training.
+    We believe it is absolutely essential for Congress to begin 
+to offer targeted financial assistance programs to fund HIT in 
+small medical practices. These practices need financial 
+assistance for the initial startup costs of acquiring the 
+technology, but also recognition of the ongoing costs as well.
+    Numerous studies and policy experts have confirmed that 
+full adoption and utilization of HIT can revolutionize health 
+care delivery by improving quality and reducing health care 
+costs. Despite these positive claims about HIT, few physician 
+practices are able to afford the substantial initial capital or 
+afford the costs associated with training for and maintaining 
+the technology. This obstacle is especially acute for 
+physicians practicing in small office settings where three-
+fourths of all Medicare recipients receive their outpatient 
+care.
+    Acquisition costs can average as much as $44,000 per 
+physician. The average annual ongoing costs can be about $8,500 
+per physician. The business case does not exist to make this 
+kind of capital investment. Another related barrier is that 
+savings from HIT will largely go unrecognized for the 
+physicians making these investments. Public and private payers, 
+not the physicians, will realize the savings from physician 
+investment in acquiring the necessary HIT.
+    Therefore, ACP strongly believes that physicians' 
+contributions must be recognized through implementation of 
+reimbursement policies that allow sharing of the system-wide 
+savings of HIT. First, the college recommends Congress build 
+into the Medicare physician payment system an add-on code for 
+office visits and other services provided with support of HIT. 
+The amount of the add-on should relate to the complexity of the 
+HIT adopted by the practice.
+    Secondly, Congress should allocate the necessary funding 
+for small practices to make the initial HIT investment. We 
+believe that grants, loans, tax credits, or a combination of 
+the three, coupled with the Medicare add-on, are sufficient to 
+put the necessary HIT systems into the hands of small 
+practices. That is why we are particularly supportive of the 
+bipartisan bill H.R. 747, the National Health Information 
+Incentive Act, sponsored by Subcommittee Chairman Charles 
+Gonzalez, because it specifically targeted those small 
+practices--the practices that are in need of the most financial 
+assistance.
+    We also believe that the offering of SBA loans, which is 
+what this Committee has jurisdiction over, is an appropriate 
+mechanism to accomplish this goal. HIT alone will not lead 
+toward full recognition of the potential benefits that include 
+improved quality and better outcomes.
+    We believe that the use of HIT should be directly linked to 
+the concept of organizing care around primary and principal 
+care in a model called the patient-centered medical home. This 
+model is based on the premise that the best quality of care is 
+provided not in episodic illness-oriented care, but through 
+patient-centered care that emphasizes prevention and 
+coordination.
+    In summary, the college strongly believes Congress should 
+provide the necessary funding to offset the initial costs in 
+obtaining HIT and should recognize the ongoing costs in 
+utilizing this technology. It is the combination of one-time 
+and ongoing financial incentives put forward by Chairman 
+Gonzalez that we believe will substantially speak HIT adoption 
+and the use of technology to foster improvements in quality of 
+care.
+    Only when Congress begins to recognize the contributions of 
+physicians will we begin to achieve savings through the 
+adoption of HIT. Therefore, we believe funding initiatives 
+should allow for individual physicians to share in the system-
+wide savings attributable to HIT.
+    The college commends Chairman Gonzalez and the members of 
+the Subcommittee for holding this important hearing. We are 
+pleased that the Committee is examining the barriers small 
+practices face adopting HIT. The benefits of full-scale 
+adoption of interoperable HIT will be significant, leading to a 
+higher standard of quality in the U.S. health care system.
+    Unfortunately, without adequate financial incentives, small 
+practices and their patients will be left behind this 
+technological curve.
+    Thank you.
+    [The prepared statement of Dr. Kirk may be found in the 
+Appendix on page 37.]
+    ChairmanGonzalez. Thank you very much, Dr. Kirk.
+    Dr. Leavitt?
+
+STATEMENT OF MARK LEAVITT, M.D., Ph.D., CHAIRMAN, CERTIFICATION 
+          COMMISSION FOR HEALTH INFORMATION TECHNOLOGY
+
+    Dr.Leavitt. Thank you. Chairman Gonzalez, Ranking Member 
+Westmoreland, and distinguished members of the Subcommittee, 
+thank you for inviting me today. My name is Mark Leavitt, and I 
+am Chair of CCHIT, an independent non-profit organization with 
+the mission of accelerating the adoption of health IT.
+    The topic of health IT in small practices is near and dear 
+to me. I started solo practice 25 years ago, and I realized 
+that paper-based record-keeping would be not only inefficient 
+for me but dangerous for my patients. So I created one of the 
+first electronic medical records for myself 25 years ago.
+    A quarter of a century later my colleagues--fewer than 1 in 
+10--have the benefit of this technology today. I assume that is 
+why I am here, and that is why we are talking about it.
+    I think that others will speak to the issue of the benefits 
+of health IT as well as the costs, but there are really two 
+major barriers that I think we need to focus on. One is clearly 
+cost, and the other is risk. And we are going to hear about the 
+cost of health IT, the figure of $15- to $50,000 per physician 
+is a good one, or $32,000 per physician.
+    And, by the way, it is highest per physician the smaller 
+the practice, because they cannot amortize the fixed costs. The 
+ROI, the return on investment, is slow or absent. There is no 
+additional reimbursement when a provider adopts electronic 
+health record technology.
+    Now, besides the costs, physicians face significant risks 
+when they move to electronic records. Many have made mistakes 
+selecting and implementing these systems. Sometimes it can even 
+threaten the financial viability of their practices, and also 
+we are all familiar with the risks to patient privacy when 
+computer systems are not adequately secured.
+    Finally, the question: how can the government help 
+accelerate the adoption of health IT in these small practices? 
+Well, starting with the President's appointment of a national 
+coordinator for health IT in 2004, and followed by the 
+establishment of strategic advisory panels by the Secretary of 
+HHS, a number of federal initiatives have already been 
+launched.
+    Now, the organization which I chair represents one of those 
+initiatives. CCHIT was awarded a three-year contract with the 
+first year devoted to accelerating the adoption of health IT in 
+physician office practices. We think that certifying these 
+electronic health record products can help practices in four 
+ways.
+    First, reducing the risk when they select and purchase an 
+electronic health record. Second, making sure that these 
+systems will be interoperable. In plain English, it means they 
+will plug in and connect and exchange information--receiving 
+data from a lab, sending a prescription electronically, or 
+forwarding a record when they refer a patient.
+    Third, we hope that certification can enhance the 
+availability of financial incentives or regulatory relief. And 
+finally, and very critical, by making sure that when we move 
+from a paper to a digital health care information world, 
+privacy is enhanced rather than reduced. And I believe that is 
+possible.
+    Our efforts are showing signs of success. In just nine 
+months, we have certified 57 products targeted to ambulatory 
+care to physician practices, so they have a wide selection of 
+products to choose from. By the way, over 70 percent of these 
+products come from companies that are themselves small 
+businesses, and the majority of them serve small practices--
+one, two, three, up to five doctors.
+    Also, we are seeing payers now keying some financial 
+incentives. In Hawaii, Blue Cross Blue Shield of Hawaii is 
+offering $50 million in incentives for physicians who buy 
+certified electronic health records. We are also seeing health 
+information networks relying on certification. In New York, a 
+Medicaid project to share prescription history with doctors is 
+relying on certification to ensure that the systems are 
+sufficiently secure.
+    For this success to continue, it is critically important 
+that adequate funding be continued for the Office of the 
+National Coordinator and for these key enabling projects. Your 
+legislation should build on this momentum. I believe the most 
+effective policy stimulus involves physician payment 
+incentives, first for IT adoption and later for using the IT to 
+measure and improve quality.
+    The Medicare Physician Voluntary Reporting Program, PVRP, 
+offers a 1.5 percent bonus for reporting certain quality 
+measures. It is a step in the right direction, but it is too 
+small in magnitude by a factor of five to ten to have a 
+financial impact on these practices considering electronic 
+records.
+    Summing up, health IT promises all of us enormous quality 
+and cost-saving benefits, but small offices are struggling to 
+adopt it. The strategic federal initiative launched in 2004, 
+including certification of health IT products, is showing 
+positive results. I encourage you to offer legislation that 
+builds on this momentum, and help us achieve electronic medical 
+records by 2014.
+    Thank you for inviting me today, and I look forward to your 
+questions.
+    [The prepared statement of Dr. Leavitt follows:]
+    [The prepared statement of Dr. Leavitt may be found in the 
+Appendix on page 46.]
+    ChairmanGonzalez. Thank you, Dr. Leavitt.
+    Dr. Kelley?
+
+     STATEMENT OF MARGARET KELLEY, M.D., SOUTHEAST OB-GYN 
+ASSOCIATES, ON BEHALF OF THE AMERICAN COLLEGE OF OBSTETRICIANS 
+                       AND GYNECOLOGISTS
+
+    Dr.Kelley. Chairman Gonzalez, Ranking Member Westmoreland, 
+and all of the members of the Subcommittee, thank you for 
+inviting me to share my experiences in adopting information 
+technology in my OB-GYN practice. I am speaking today from my 
+experiences as well as on behalf of the American College of 
+Obstetricians and Gynecologists.
+    My father, Dr. Harmon Kelley, and I operate a two-physician 
+practice, Southeast OG-GYN Associates, in San Antonio, Texas. 
+We have about 14,000 patient visits a year and deliver about 
+300 babies annually. In 2004, we made the decision to convert 
+our antiquated records system to an electronic medical record 
+or an EMR. We wanted a more efficient and productive office.
+    Also, given the litigious environment in obstetrics and 
+gynecology, my father and I wanted to make sure we were able to 
+document everything that we do in our practice. An EMR would 
+allow us to keep a much more comprehensive and legible record 
+than our paper-based system did.
+    The initial cost of upgrading to an EMR was approximately 
+$100,000, $50,000 per physician. My father and I had to 
+carefully weigh the pros and cons of purchasing such an 
+expensive system, and ultimately decided that it was an 
+investment that we had to make, so that we could better meet 
+the needs of our patients.
+    Our staff of 10 took two full weeks away from patient care 
+to train on the new system with trainers provided by the EMR 
+vendor, but the formal training was just the beginning. 
+Virtually every aspect of our practice had to be modified. 
+Where we used to simply just jot down a note on a patient 
+chart, we now had to learn to navigate the new system and type 
+our notes into an electronic form.
+    Because of our learning curve, each patient visit took 
+longer, reducing the number of patients we could see in a given 
+day. This caused patients to wait longer to schedule 
+appointments, and because we were seeing fewer patients, our 
+practice revenue dropped as well. Ours was a frustrating 
+transition for staff, physicians, and patients alike.
+    In fact, it took our practice approximately two years to be 
+able to accommodate as many patients as we did before we 
+invested in our EMR. The investment of $100,000 up front, and a 
+diminished number of patients that we could see, made the 
+initial months of implementation very lean indeed.
+    Three years later our staff and our patients are finally 
+able to appreciate the full potential of health information 
+technology in our practice. Our old way of doing things seems 
+completely archaic in retrospect, and I could never go back.
+    One of the biggest benefits is 24-hour access to all 
+patients' charts. If I am at the hospital in the middle of the 
+night laboring a patient, and I need her prenatal record, I can 
+view it and print it through any computer that has Internet 
+access. I can view the patient's record, including her plan of 
+treatment, medications, when I am at home on call. And I also 
+can catch up on reviewing lab results and telephone calls 
+without coming into the office on the weekend.
+    There are also obvious patient benefits. Our EMR allows us 
+to view a patient record's drug allergies, check for drug 
+interactions, and so medications are prescribed more safely. It 
+links to the ACOG guidelines to facilitate the practice of 
+evidence-based medicine. We also add the patient's picture to 
+our medical record. It helps us remember the patients, but it 
+also reduces medical errors.
+    We received a positive response from our patients. They 
+like seeing doctors using modern technology, and it gives them 
+peace of mind because they know our commitment to their health 
+and safety is behind the change. The most obvious barrier in 
+the adoption of information technology in small practice is the 
+initial cost, usually about $50,000 per physician. This 
+investment is somewhat of a gamble.
+    The technology changes rapidly, and systems often do not 
+communicate with each other well. Many physicians are fearful 
+that this year's investment will be outdated or obsolete in a 
+few short years.
+    Some people mistakenly believe physicians will easily 
+recoup their investment, because the technology will make them 
+more efficient and able to see more patients. The irony is that 
+health information technology makes many offices significantly 
+less efficient for months, or even years after upgrading to an 
+EMR. And even when the practice adjusts to the new system, it 
+doesn't necessarily translate into more patients or more 
+revenues.
+    We want to use the technology to make our office visit 
+minutes more meaningful, not to strip additional minutes off of 
+an office visit that is already too short. Medicare and private 
+sector health insurers are complicit in keeping us in a paper-
+based system. Private insurances and Medicare constantly expect 
+us to deliver more care for less money.
+    For one of my insurers, global fee for prenatal care is 
+only $1,200, which includes the delivery, the care, and 60 
+days' postpartum care. Medicare is slated to cut physician 
+payment by 10 percent in 2008, and 40 percent over the next 
+eight years. As the rates continue to be cut from all angles, 
+it can be difficult for many practices to justify an investment 
+in health information technology.
+    I am a firm believer in the enormous potential of health 
+information technology, but leadership from the Federal 
+Government spearheaded by this Subcommittee is necessary to 
+make it possible for small and rural physicians.
+    Thank you for holding this important hearing and striving 
+to help small practices provide the best care to their 
+patients.
+    [The prepared statement of Dr. Kelley may be found in the 
+Appendix on page 53.]
+    ChairmanGonzalez. Thank you very much, Dr. Kelley.
+    Dr. Shober?
+
+ STATEMENT OF DAVID R. SHOBER, D.O., PRESIDENT, MEDICAL STAFF, 
+   JAMESON HOSPITAL, LAWRENCE COUNTY FAMILY MEDICINE, PC, ON 
+   BEHALF OF THE HEALTH INFORMATION MANAGEMENT SYSTEM SOCIETY
+
+    Dr.Shober. Chairman Gonzalez, Congressmen, Congresswomen, 
+it is a pleasure to have this opportunity to meet with you 
+today.
+    We were motivated to purchase an electronic health record 
+for a number of reasons--we wanted the instantaneous 
+connectivity between both offices, we wanted access to our 
+files from outside locations, insurance and medical legal 
+requirements driving a need for more thorough documentation, 
+need a more efficient record-keeping system. We wanted to be 
+able to reduce documentation errors, standardize our record to 
+a level not possible with a handwritten chart. We wanted to be 
+able to electronically audit our performance.
+    Unfortunately, as you will see, the road to using the 
+electronic health record system is a difficult one. We 
+purchased our system three years ago. The cost was 
+considerable. Our initial investment was $200,000. Our annual 
+costs are $50- to $60,000. While we have been able to recoup 
+some savings, the record is still an expenditure for us.
+    We realized a number of benefits and challenges with our 
+implementation of the electronic record. The initial challenge 
+was deciding which system to purchase. Our next challenge was 
+to develop an electronic connection between our two offices. 
+With no Internet access to our rural office, we installed a 
+dedicated T1 line, which is a high-volume telephone data line, 
+at an additional cost of over $200 a month.
+    The implementation of our records system required 
+considerable staff and physician education and training. It has 
+created a financial challenge for a small business. We were 
+required to commit a considerable amount of time, both inside 
+and outside of the office, and this was quite difficult in a 
+busy practice.
+    While we have eliminated the cost of creating a paper 
+record, we still have the cost of scanning and shredding all of 
+the unnecessary paper that continues to arrive at our office. 
+We also found ourselves dependent upon a reliable electrical 
+system. We needed to install generators at the offices in order 
+to keep our system running with outages.
+    The system has allowed us to create a more complete note. 
+The development of templates for standard portions of exams 
+creates further efficiency. I am, however, concerned that the 
+use of templates has been scrutinized by the insurance chart 
+reviewers and attacked in the courtroom or deposition. I 
+believe that for us to move forward templates must be accepted 
+as an adequate method of record-keeping.
+    Another challenge is that we have not been able to 
+integrate some of the standard federal forms into the EHR, 
+examples being the FMLA, DOTCDL. Normally, companies create or 
+purchase their own versions of these forms, and hand signatures 
+are required. For the electronic record process to move 
+forward, legislation will need to standardize the forms and 
+permit electronic signature.
+    Medical record copying now being easier for us to 
+accomplish, we have found ourselves still limited by the fact 
+that other entities are not capable of accepting the electronic 
+transfer of information. At present, we are the only practice 
+within a 30-mile radius that has an electronic record. When it 
+comes time to move a record, we need to copy it on paper and 
+then mail it or give it to the patient, adding further 
+inefficiency.
+    Currently, we hand write, print, or fax prescriptions. We 
+are not able to e-prescribe to all pharmacies or the VA. This 
+inconsistency creates additional work and inefficiency. Some 
+insurance carriers and mail order pharmacies even demand that 
+we cut and paste on our old prescription pads.
+    I believe all pharmacies should be required to accept e-
+prescriptions. One of our major barriers is our ability to 
+communicate with other electronic health record media. In order 
+for us to communicate with these difference license programs, 
+an interface between systems must be built. As a small 
+business, I can't afford to pay for multiple interfaces.
+    Federal regulations should require that health IT software 
+have the capability to interface with other licensed programs, 
+to allow free market pricing and break down costly 
+communication barriers. In order for us to maintain and operate 
+our system, we have had to dedicate a full-time employee as a 
+computer specialist.
+    From a payer standpoint, electronic health records with 
+universal connectivity could eliminate the unnecessary 
+repetition of testing, which often occurs when test results are 
+not available in a timely manner. Not only will it save money, 
+but it will certainly improve the quality of patient care.
+    In small communities like mine, the physician and the 
+hospital are dependent upon each other to deliver quality care. 
+Jameson Hospital, our local facility, is struggling with the 
+acquisition on information technology, trying to perform a 
+balancing act as they provide necessary hospital services, try 
+to bring their staff along with information technology.
+    I see the only initial way to provide an incentive for 
+adoption of health information technology is to provide 
+financial assistance. As you can see, the burden for electronic 
+record acquisition is significant. The ongoing cost is fixed. I 
+believe the physicians and hospitals should be given financial 
+assistance to cover their acquisition costs, as well as 
+reimbursement to help cover the ongoing cost of this program.
+    In spite of the significant cost, time, and effort required 
+to implement a system, I am optimistic that with universal 
+adoption of electronic health record efficiencies for payers, 
+physicians, and health care providers will materialize. Most 
+importantly, my experience demonstrates that the EHR system 
+will help improve the quality of patient care.
+    Thank you.
+    [The prepared statement of Dr. Shober may be found in the 
+Appendix on page 58.]
+    ChairmanGonzalez. Thank you very much, Dr. Shober.
+    And before we proceed with the next testimony, I wanted to 
+welcome our colleague, Congressman Phil Gingrey, from the great 
+State of Georgia. Welcome, and thank you for your participation 
+today.
+    Mr.Gingrey. Thank you.
+    ChairmanGonzalez. And next witness, Dr. Napier.
+
+ STATEMENT OF KEVIN NAPIER, M.D., INTERNAL MEDICINE OF GRIFFIN
+
+    Dr.Napier. Chairman Gonzalez, Ranking Member Westmoreland, 
+and members of the Committee, thank you for the opportunity to 
+testify before you today regarding my experience in information 
+technology and health care.
+    My name is Kevin Napier, M.D., and I practice internal 
+medicine in Griffin, Georgia.
+    Information technology is a subject of great importance to 
+members of the medical community and government, as well as the 
+general public. Internal Medicine of Griffin has nine 
+physicians and admits patients to Spalding Regional Medical 
+Center, which is a facility with 180 beds.
+    We made the transition to electronic health records in 
+February 2005. Prior to that point, the health records were in 
+traditional folders where loose paper was placed in the order 
+in which it was generated, which generally included office 
+notes, laboratory reports, radiology reports, physician 
+correspondence, insurance correspondence, as well as Medicare 
+correspondence.
+    This led to frequent episodes of the inability to locate 
+items needed for care, and occasionally not being able to 
+locate the chart at all on the day of the visit. Internal 
+Medicine of Griffin evaluated systems for two years prior to 
+our selection of a vendor. After that decision was made, it was 
+nearly another year prior to implementation of that system due 
+to hardware installation and training needed for physicians and 
+staff.
+    It was recommended to us by our vendor that, due to the 
+complexities of the system, we should consider reducing our 
+schedules for a short period of time to allow the practice to 
+adjust. The final cost including training was nearly $400,000. 
+Six of the physicians in my group are primary care physicians, 
+and we quickly learned that we were going to be financially 
+impacted during this transition period.
+    We financed the cost of this IT implementation and began 
+paying $1,000 per month per doctor, and we will continue to do 
+that for the next three years. After considering the yearly 
+threat of payment reductions from the Centers of Medicare and 
+Medicaid Services, CMS, it is easy to see why more practices do 
+not quickly transition to EHR.
+    In the first year after implementation, we did see a 
+reduction in both the number of patients treated as well as a 
+reduction in our incomes. However, as we start our third year 
+on the system, I am pleased to report that we have become more 
+proficient, and we now see more patients than ever.
+    The benefits for our patients and physicians now include 
+immediately available and legible office notes, laboratory data 
+automatically entered into the system by the laboratory 
+company, digital EKGs, and remote access to the entire record. 
+We believe that this has improved the quality of our care, both 
+for hospital-based as well as hospitalized patients.
+    Recently, the hospital we utilize announced that its 
+emergency department was also implementing an electronic 
+record, and they selected the same vendor that we utilize. This 
+further promises to improve information flow and quality.
+    Our story is not unlike most practices that have made this 
+transition. I recently had the opportunity to meet with several 
+solo practitioners in southern Georgia, some of which also 
+utilized EHR. The number one barrier to full implementation 
+reported by these physicians was cost. Another area of concern 
+includes the lack of a uniform standard between EMR vendors.
+    If a solo practitioner were to join another group, he could 
+not integrate his old patient files into the new practice 
+without a costly conversion process. Physicians also worry that 
+the increased productivity offered by the system does not 
+balance the additional cost.
+    Due to the nature of health care, certain specialties feel 
+that EHR is not easily adaptable to their style of practice. 
+However, despite these reservations, I feel that the benefits 
+of IT in health care outweigh these risks. There are several 
+options for fostering implementation in IT and health care. 
+These include offering tax credits rather than deductions for 
+IT implementation, and offering technology bonuses for 
+practices treating Medicare beneficiaries that utilize IT.
+    The creation of a common standard for EHR companies would 
+further enhance the portability of the public's health records. 
+It is my belief that physicians want to adopt information 
+technology into their practices, but simply allowing market 
+forces to steer that change is not enough. Health care 
+providers are feeling pressure more than ever, and assistance 
+with this transition is greatly needed.
+    Thank you for the opportunity to testify.
+    [The prepared statement of Dr. Napier may be found in the 
+Appendix on page 73.]
+    ChairmanGonzalez. Thank you very much, Dr. Napier.
+    I have been informed that we were going to have a series of 
+votes, but they have been postponed. So we might have an 
+opportunity to go uninterrupted this morning, which would be 
+very nice.
+    One of the benefits of chair is I get to go first. That is 
+kind of--which I enjoy quite a bit.
+    [Laughter.]
+    Dr. Leavitt, we have some prepared questions. And, 
+generally, I go all over the place, but I am going to stick to 
+this particular script, because I think there is some important 
+information that we need to gather today. A critical step 
+toward a national health information technology network will be 
+some way to evaluate the systems themselves, and to ensure that 
+they will not quickly become obsolete.
+    You have already heard the concerns expressed by the 
+practitioners in different parts of our country. Small 
+practices often do not have the financial resources, expertise, 
+or time to perform extensive evaluations of the quality, the 
+price, the support, ease of use, and impact on productivity of 
+information technology systems.
+    Now, are you aware of any organizations, independent of 
+your own, that is engaged in the practical evaluation of health 
+information technology products sold by vendors today that 
+might assist the physicians as they go through that process 
+that has already been described by Drs. Kelley and Shober and 
+Napier?
+    Dr.Leavitt. This is a very good question. And as you know, 
+we focus on part of that, which is the compatibility of the 
+systems and the functionality. But we don't publish prices, and 
+we don't do surveys of end users.
+    To my knowledge, there is no organization doing that with a 
+public mission. It is being done commercially by consultants, 
+but, unfortunately, that generally just adds to the cost of 
+buying the system. In fact, sometimes part of the cost of 
+buying the system is retaining a consultant to help you pick 
+one.
+    So in terms of a way to efficiently help the physicians in 
+a way that doesn't increase their costs, I am not aware of any 
+initiative other than the certification initiative.
+    ChairmanGonzalez. So if I was a physician, and I was 
+looking for some guidance, there is no really recognized 
+organization that doesn't have a product or service to be 
+marketing that I would be able to turn to.
+    Dr.Leavitt. That is correct. Your professional 
+associations, most of them--the American College of Physicians, 
+the American College of Obstetricians and Gynecologists, the 
+Family Physician Organizations--they are actually helping. But 
+it is probably not appropriate for them to actually start 
+selecting vendors and saying this commercial company is one 
+that you should use, so I think they tend to steer away. They 
+simply help educate their members. So what you are asking for 
+doesn't exist as a--in the marketplace today that I know of.
+    ChairmanGonzalez. Thank you very much.
+    Questions for Dr. Kelley--small practices that are part of 
+an integrated care system are more likely to adopt health 
+information technology than those that are not, help networks 
+provide financial support, technical assistance, and legal 
+protection. In your opinion, why are more small practices not 
+part of an integrated care system? I know that you and your 
+dad--and you know other practitioners, and they may be part of 
+a greater group--if you understand my question, or I can try to 
+clarify it.
+    Dr.Kelley. Are you asking why--I guess if you could 
+clarify, you are asking why small practices, individual 
+practices, aren't in a larger network to help--
+    ChairmanGonzalez. Correct. Is it possible to--in other 
+words, it is just you and your father. But is it possible to 
+expand that with other of your colleagues to maybe minimize 
+that cost?
+    Dr.Kelley. I think that it really doesn't minimize the 
+cost. It actually expands the cost. And I think that also it is 
+just such--this is not widespread now, and there is such great 
+hesitancy that it is not a real driving force right now for 
+smaller practices to integrate, just for implementing 
+information technology in the practices.
+    ChairmanGonzalez. The biggest barriers that you pointed 
+out, first of all, was going to be the cost, just the cost to 
+your and your father exceeding--was it $100,000?
+    Dr.Kelley. $100,000.
+    ChairmanGonzalez. And yet you did that, and then you--I 
+think the testimony or your experience was actually the same 
+experience that the other physicians had, and that is that 
+there is the learning curve, which means you have less time to 
+tend to the physicians, you have a drop in the patient 
+caseload, and obviously that translates to less income and 
+such. That was your experience?
+    Dr.Kelley. Correct.
+    ChairmanGonzalez. And having experienced that, I think the 
+most telling sentence that you had was you still would not go 
+back to the old system.
+    Dr.Kelley. Correct.
+    ChairmanGonzalez. So it was worth the investment.
+    Dr.Kelley. Yes, sir. It was quite worth the system. The 
+practice three years later runs much more smoothly. You have 
+everything in one resource. You don't have missing--as other 
+physicians said, you don't have missing lab reports, you don't 
+have missing charts.
+    Another point that I really, really love about the system 
+is documentation of telephone calls with physicians and 
+patients. Typically, you just don't--on call at night, you 
+don't have documentation of that conversation with patients, 
+and it becomes a bigger problem in larger groups where a 
+physician is covering three or four other doctors. You just 
+have no documentation of a conversation between a physician and 
+patient, and all of those conversations can be documented 
+within the patient's chart.
+    And also, laboratory follow-up. You have the laboratory--
+you have the results, you have the plan of care, and you have a 
+checking point to make sure that the care was--the plan of care 
+was carried out. And so you have checks and balances that you 
+now have better control over and documentation of, and that 
+improves safety for patients.
+    ChairmanGonzalez. I appreciate it.
+    My time is up, and at this time I will recognize the 
+Ranking Member, Congressman Westmoreland.
+    Mr.Westmoreland. Thank you, Mr. Chairman.
+    Dr. Leavitt, you mentioned that your organization did not 
+certify how the end user I guess, how this affects the end 
+user. Don't you think that is an important part? And I guess 
+the other part of the question is: do you look at the 
+integration factor for all of these systems as how they would 
+integrate with each other, or if they had that capability?
+    Dr.Leavitt. Very good questions. So the first question is 
+the user experience. We definitely have physicians and other 
+users of these systems asking CCHIT if we could measure the 
+usability of the systems and rate them. And it is right now a 
+concept, but you have to be able to do this objectively. And 
+sometimes what works for one physician doesn't work for 
+another.
+    So usability of a system is not something that everyone 
+agrees on how to measure. But we hope to be able to move into 
+that. We do it in a crude way now, in that the systems are 
+inspected. There are actually expert jurors, and one has to be 
+a practicing physician. And they observe the system, and it has 
+to go through a scripted demonstration. If it runs over a 
+certain time limit, the system would not be certified. So that 
+is a rough measure of usability.
+    Now, your second question, what are we doing about making 
+sure that the systems integrate? That is actually one of our 
+major roles is making sure that the systems are interoperable, 
+and this year we are requiring that the systems can send 
+prescriptions and refill prescriptions electronically, so you 
+can't be certified if your system doesn't do that.
+    We also require that they can receive laboratory results. 
+And I was talking to Dr. Shober before the session, and the 
+laboratories are telling him, ``We can't hook up to your system 
+unless you pay us, because we have to customize it.`` That has 
+to stop. It needs to be plug and play.
+    You buy the system, it connects securely, just as if anyone 
+has used--so many systems on the web, whether those are 
+personal finance applications that connect to your bank or your 
+credit card and download the information securely, the 
+physician system should be able to download the labs securely, 
+transfer patient records securely, and we are pushing toward 
+that. It will take several years, but we raise our criteria 
+every year.
+    Mr.Westmoreland. Well, I think that is going to have to be 
+a goal, because I can see where some small practitioners, when 
+you start talking about investing $100- or $200,000, and it may 
+not even be compatible or be able to be upgraded or--you know, 
+that is a big investment to make, not having any security, 
+especially just for a short term.
+    Dr. Napier, in your testimony, you said you implemented 
+this information about two years ago. And just to give Mr. 
+Leavitt some help, is there anything you would have done 
+differently in looking at--in how you did it? Is there anything 
+that you might suggest to some other practices, if they were 
+going to do this today, different than what you did?
+    Dr.Napier. Well, as I testified, we spent about two years 
+evaluating systems before we finally moved forward with a 
+vendor, because of these issues that have already been listed 
+out by the other experts here today. We really felt like we 
+went with the best vendor that we had available to us, and in 
+looking back we would still choose the same vendor that we did.
+    However, I think that we would have spent more time--and as 
+I mentioned, we spent a year before full implementation of the 
+system after purchasing it. And two months of that was in 
+customization of templates. A lot has been talked about 
+templates here today, and we spent two months customizing 
+templates.
+    And in retrospect, we should have spent about four months 
+customizing templates, because once you go live with the system 
+it is very difficult to put the additional time into going back 
+and doing more customizing. And so we would have spent more 
+time on the front end with customization.
+    Having said that, I think part of the certification 
+process, it would be nice if we had specialty-specific 
+certifications for various programs that are available, because 
+many companies they are trying to sell as many products as they 
+can. And many of them do not fit for certain specialties, and 
+they are not going to tell you that up front. And it would be 
+nice if we had an independent way of knowing which ones are 
+appropriate for which type of practice and in which specialty.
+    Mr.Westmoreland. Just to follow up on that, you practice 
+internal medicine.
+    Dr.Napier. That is correct.
+    Mr.Westmoreland. Would you be able to share your template 
+with other internists that were going to get on an IT system? 
+Would you be able to share that with them, or is that now the 
+product of the vendor?
+    Dr.Napier. That is a product of the vendor, and what we end 
+up doing is we create what are called test patients, and we 
+build templates on these test patients, and we will often print 
+these out and share them with other people that use our system 
+to allow them to see how we did it.
+    But there is not a current way of simply sending that to a 
+practice, for example, in Atlanta for them to integrate into 
+their system.
+    Mr.Westmoreland. Thank you. I see my time is up. I will 
+yield it back.
+    ChairmanGonzalez. Thank you very much, and the chair will 
+recognize the gentleman from Pennsylvania, Mr. Altmire, for 
+five minutes.
+    Mr.Altmire. Thank you, Mr. Chairman.
+    Dr. Shober, as a rural practitioner, how has the health IT 
+better allowed you to serve your patients? You just said a 
+little bit, but if you could go into maybe some more detail on 
+that with your practice. And do you feel that there are unique 
+challenges for rural practitioners that health IT can help 
+address above and beyond what we have heard from the witnesses 
+today?
+    Dr.Shober. As far as the first question, our practice per 
+se, we have one office which is in a township-type setting, the 
+other is more rural. As I mentioned, we had a hard time 
+obtaining a connection. We had to get a dedicated line with the 
+telephone company, and there is no Internet access. It ended 
+half a mile down the road one way and a mile down the road 
+another direction.
+    So we bought the system, and then realized that, yes, we 
+had to go to the local information sources, whether that be the 
+telephone company, the cable network, and really negotiate with 
+them to see how best we could be connected. Satellite really 
+wasn't an option, security and all other measures being 
+considered. That was definitely a challenge for that office.
+    But the nice thing about having the information technology 
+available connecting these two offices live, patients often 
+roam between offices. I mean, they are 12 to 15 miles apart, 
+but they will show up at one on one day and go to another one 
+the next day. And if they are sick driving down the road, they 
+stop in.
+    And we are linked live right now, so we are able to pull up 
+their record at the front counter when they walk in, address 
+their issue, and know what happened at the other office 
+yesterday, or what happened on the phone call this morning, if 
+they called on a cell phone and spoke to a nurse at the other 
+office on the way in.
+    So it has really helped us provide much better care, much 
+better continuity of care. As far as the challenges for us in 
+the setting that we are in, we are in a small town. We have one 
+hospital. We have a number of outpatient labs that are national 
+vendors. We have a few outpatient X-ray centers.
+    The information technology that we have in the office is 
+nice, but, again, our problem is we need to be able to connect 
+to everyone else. There seems to be a lot of apprehension out 
+there in the community as far as the safety of connecting with 
+someone else's software. We hear excuses of, well, we don't 
+know if we could trust that vendor, or we don't know if it is 
+going to cause us a problem running our system.
+    So I share some of the concerns that some of the experts 
+here have brought forward. There has to be a standardization, 
+so it--we are not on the island. We don't have a beautiful 
+system in the office. We can't use it in the community, to be 
+able to run this out through the community, expand it to the 
+hospital, have a nice flow of information to help everyone.
+    Mr.Altmire. That actually leads into my next question, and 
+there does need to be widespread adoption of IT for it to be 
+fully--for us to fully realize the benefits. If it is not 
+widespread, then we are not going to see the implementation be 
+beneficial.
+    So even with financial assistance, many doctors might be 
+reluctant to change from traditional record-keeping. So do you 
+have any thoughts of what methods beyond financial incentives 
+that we would use to encourage doctors to adopt health IT?
+    Dr.Shober. From what I have seen in my experience, when we 
+move from an old X-ray system at the hospital to a PAX or an 
+integrated digital system, the only things that will move 
+physicians oftentimes are deadlines.
+    And we have to--just like happened with Medicare and 
+billing where you had to submit billing electronically, you 
+have to say to the practicing physicians, ``Listen, in X number 
+of years, you need to move forward with this. In order to help 
+you with this, we are going to incentivize you up front 
+financially to help pay for the system, provide financial 
+incentives as we move along.'' That would help pay for the 
+education, help pay for the extra time in the office, help pay 
+for that consultant to come in.
+    I think we have to move forward making all of the other 
+media electronic. Cardiology is a good example. That is moving 
+in the electronic direction; cardiology has moved forward in 
+that direction.
+    When it comes to prescribing, we see a lot of resistance. 
+We have a lot of small-town Mom and Pop pharmacies. They don't 
+want to do it. They actually gave us a very hard time when we 
+started to fax prescriptions to them electronically. We would 
+fill a prescription in the system, and it would be sent to 
+their fax machine, because that was the only mode of 
+communication.
+    Some of them now complain that it was costing them money on 
+the fax paper. In my mind, the benefit of handwriting 
+inaccuracy is tremendous. But if we help move these other 
+entities forward, then we are all going to move in that same 
+direction.
+    ChairmanGonzalez. The chair is going to be recognizing 
+members of the Subcommittee, and then Dr. Gingrey will be able 
+to ask questions. But, first, I will recognize for five minutes 
+of questioning my colleague and member of the Subcommittee, Mr. 
+Jefferson from Louisiana.
+    Mr.Jefferson. Thank you, Mr. Chairman.
+    I think this is a very important hearing, and I appreciate 
+the chance to participate. We, of course, in New Orleans were 
+made to be well aware of this problem when we lost tens of 
+thousands of medical records of citizens that were simply paper 
+records when the storms came, and for the hospital system and 
+private physicians' offices, all of it.
+    And had there been some way to electronically preserve 
+these, they would have been somewhere out there safely tucked 
+away in cyberspace in somebody's computer way outside of town. 
+It would have made life a lot more simpler for physicians, and, 
+of course, we would have had better outcomes for patients, 
+especially those that have special issues like young cancer 
+patients, and like people who had diabetic treatments, and all 
+of these things that required so many repeat treatments.
+    But in any event, we recognize the need for it in our area 
+I think more than most. I want to ask you this about--each of 
+you has talked about developing standards for IT, for the use 
+of IT, I guess for the standards with respect to systems and 
+equipment and all the rest.
+    Who should develop these industry standards? I mean, should 
+they come from us, should they come from the private--should we 
+just enable the private physicians associations to do it, or 
+should there be some other way that we come up with what we 
+call standard? Because it all depends on who is writing the 
+prescription for the things and who gets the business at the 
+end of it. But how do we end up with the public purpose coming 
+out of this that will just--so who should set these standards?
+    Dr.Leavitt. There actually is an effort--and that is a very 
+good question. Standards don't do much good if there is 100 
+different standards. There actually is already a very powerful 
+effort to--the word is ``harmonize'' standards, and that is one 
+of the initiatives that was launched in parallel with the 
+Certification Commission.
+    There is a health information technology standards panel 
+that is also under contract with HHS, and they basically 
+organize--the standards are developed by groups called 
+standards development organizations, and they actually have to 
+be accredited as such. But the problem is you have competing 
+and conflicting standards, so this harmonization is done by 
+this panel. And as I said, it is a parallel contract to our 
+certification.
+    So when we test the systems, we make sure they comply with 
+the accepted standard. They can't choose from 100 different 
+standards to comply with. It is the accepted standard for 
+transmitting prescriptions, or the accepted standard for 
+receiving a lab result.
+    Mr.Jefferson. Should the Congress give any guidance with 
+respect to how these standards ought to be arrived at?
+    Dr.Leavitt. Congress needs to make sure that it is being 
+done through a transparent and consensus-based process. I think 
+it would be a mistake to try to legislate the details of a 
+standard, because we need these standards to evolve and move 
+forward, so that they can keep up with technology and with the 
+needs of health care.
+    So I don't think you want to cast standards in law. You 
+actually want to create an office that supervises the 
+harmonization of standards, and you have that in Office of the 
+National Coordinator.
+    And there is also the question of funding. The funding of 
+these organizations is important. If you leave the funding to 
+chance, then there are issues, because then standards become 
+kind of a commercial football, and you really--they are a 
+public good. And so I think federal funding to help develop the 
+standards to fund the organizations is appropriate.
+    Mr.Jefferson. The other common grain that cuts through all 
+the testimony is the issue of cost that a physician must incur 
+to adapt to this new system. Someone has talked about credit, 
+various other incentives. And there are also--there has also 
+been some talk about credits for the industry representatives 
+as opposed to the physicians.
+    Who should get the credits in this? If we should authorize 
+credits, how deep should they be, if you have a suggestion 
+that? Who should get the credits? Should there be some for 
+industry? Should it be for the physicians? Or should it be for 
+somebody else up and down the line? And how do you see this 
+whole issue of incentives--having the credits apply not just to 
+what you buy but also to training for physicians and training 
+for staff?
+    Dr.Kelley. I personally think that the credits ought to 
+apply to who is expending the money to purchase it, so in 
+practices I believe that it should be--the practice was the one 
+that purchased the information technology. That practice should 
+be able to have a tax credit.
+    And, furthermore, you have to keep--think about that you 
+have the maintenance costs from here on out once you establish 
+that. That is a tremendous expense for practices, and any tax 
+relief from--that can be given for practices that make that 
+investment would be greatly appreciated.
+    Dr.Kirk. I think credits, things like credits, tax credits, 
+loans, and grants, for as we have heard the initial startup, 
+which is so expensive, but I think our reimbursement system 
+needs to take health information technology into account in an 
+ongoing fashion to maintain these costs that we all have as we 
+roll these out and continue on upgrading, training staff, 
+changing our systems to incorporate those.
+    And I think that needs to be accounted for in the 
+reimbursement system, that if you are using the technology--and 
+I think we are reaching a tipping point here, and it will 
+happen very quickly if some of these incentives can be built 
+in, that it will be much easier for physicians to incorporate 
+those into their practice.
+    Dr.Napier. Congressman Jefferson, if I may add also, if 
+those credits are passed to the vendors, they already, as costs 
+of some of the certifications that are presently there, those 
+costs are simply passed on to the physician practices anyway in 
+the form of the purchase price. And so whatever costs are going 
+to be extra, in order to ensure interoperability, as well as 
+whatever privacy concerns the government may have, those costs 
+will be passed on directly to the physician practices that are 
+implementing these.
+    And so it is my opinion, and I think most physicians' 
+opinion, that whatever credits are going to be given by the 
+government should be given to the ones who are actually 
+purchasing those systems.
+    Mr.Jefferson. Mr. Chairman, if I might just clarify--I know 
+that the time is up--I didn't mean--I understand what you're 
+saying in that regard, but I meant with respect to having those 
+in industry adopt standards and create the interoperability of 
+this equipment, so that it works, you know, across the board, 
+so that one doesn't necessarily have to exclude the other.
+    Dr.Shober. Can I address that real quickly? If, indeed we 
+create independent systems, in order for them to operate and 
+communicate with each other, I think if you set the standard, 
+they must communicate with each other at no cost to the 
+individual purchasing the system. That mandate alone will drive 
+that industry to sit down and talk to each other.
+    And if they are going to maintain their licensure, which 
+should be a mission for--we are assuming about paying a 
+physician practice more, you would have to enroll within a 
+licensed program. So you make that a mandate. If I want to buy 
+a program, make it a licensed program. If it is going to be 
+licensed, it has to communicate with everyone else. That way I 
+am going to look at it before I buy it, and the industry itself 
+will have to sit down and they will decide which language they 
+are going to use to communicate or set those--set up those 
+interfaces.
+    That doesn't fall to our laps. I don't have to understand 
+why one can't talk to the other. Let us let the industry fix 
+their own problem and set that as a condition.
+    Mr.Jefferson. That is what I am talking about. I appreciate 
+that very much.
+    ChairmanGonzalez. Thank you. And, Dr. Shober, we are real 
+sensitive to that particular concern, and Dr. Leavitt I know 
+could discuss it with you at length, but we are very, very 
+aware of that being a huge factor.
+    At this time, the chair is going to recognize our colleague 
+from Georgia, who may not be a member of this Committee, but we 
+welcome his input today, and that is Dr. Gingrey.
+    Dr.Gingrey. Mr. Chairman, let me first of all thank you, 
+because I know it is not traditional that a guest is allowed 
+the opportunity to ask a question from the dais, and I really 
+appreciate that courtesy. I am very happy to be here at the 
+Small Business Subcommittee hearing on health information 
+technology as a physician member.
+    I thank my colleague, Representative Westmoreland, as well 
+for submitting my written statement for the record and for 
+inviting Dr. Napier from his district in Griffin, Georgia.
+    I want to address my first question, though, to Dr. Leavitt 
+in regard to the line of questioning between Representative 
+Westmoreland and Dr. Napier in regard to the certification 
+process and that it is--I think Dr. Napier recommended that 
+maybe it should be specialty-specific. I think that is a very 
+good recommendation, but Representative Westmoreland was asking 
+you more specifically about what advantage was it, what 
+information could physician groups, subspecialty groups, get 
+from you in regard to the value of a particular vendor.
+    And you explained that very well, but can you tell us what 
+the value is of a vendor being certified versus one that is not 
+certified. I wanted to particularly ask that question.
+    And then maybe, Mr. Chairman, if you would indulge me, I 
+have a follow-up question in regard to how to deal with the 
+cost.
+    Dr.Leavitt. Certainly. Thank you. The value of 
+certification is that a physician office may not have to spend 
+the one or the two years evaluating 10, 20, or more systems to 
+determine which ones meet their needs. And when we certify a 
+system, we inspect it against some 250 criteria of 
+functionality, which is what it does and how it works; 
+interoperability, how well it connects to other systems; and 
+security, does it protect the information, does it require 
+passwords, does it track every access in an internal audit log.
+    That would be a lot of work for every physician office to 
+go through with all of these products. So we do it once, and 
+they can all benefit from it at no cost to the physician 
+office. That is really the value. At the end of our first year, 
+we heard from the physician community, ``We like this, but we 
+want you to make it more relevant to us, so we want you to 
+address our specialty or our setting, and we actually just 
+announced a launch of an expansion.''
+    So we are going to address professional specialties, which 
+might be obstetrics, it might be cardiology, we are going to 
+address settings--for example, the emergency department, it is 
+not a doctor's office and it is not quite like the rest of the 
+hospital, and we are even addressing populations.
+    And this is how we are addressing children, because 
+children are not just cared for by pediatricians, they are 
+cared for everywhere, so there are features in the products 
+that should be there for the safety of children, checking the 
+medication dose. It is very dangerous--
+    Dr.Gingrey. Dr. Leavitt, thank you. I don't mean to 
+interrupt you, but my time is limited. But basically, what you 
+might suggest, then, I guess to any of the three practicing 
+physicians--OB-GYN, family practice, internal medicine--that 
+are part of the witness panel is that maybe you ought to call 
+Dr. Leavitt's office and find out if the vendor--the particular 
+vendor who is in your office trying to sell you a product, are 
+they indeed certified? Would you agree with that?
+    Dr.Leavitt. Yes, we have published on the web a list of the 
+certified products, and we have a communication effort to reach 
+physicians everywhere and let them know that that's available.
+    Dr.Gingrey. Mr. Chairman, my last question before my time 
+expires. In regard to the doctors in private practice--and you 
+mentioned as an example it would be great if there were a tax 
+credit. Now, let me just suggest to you that part of that 
+problem is that we estimate that there are 400,000 physicians 
+in this country who actually do not have electronic medical 
+records systems, certainly not one that is fully integrated.
+    And if you gave a $1,000 credit, and Dr. Kelley was saying 
+it was going to cost her and her dad $100,000 for a system, if 
+you gave a $1,000 credit to each of those 400,000 physicians, 
+you are talking about--I believe that would be about, if my 
+math is correct, how many--would that be $40- or $4 billion? 
+But what--in any regard, it is a lot of money. And it is not 
+likely that we are going to be able to do that with all of the 
+priorities we have on the taxpayer's dollars.
+    But what I want to let you know in my time remaining is 
+that I have an idea, and I think it is a good idea, and it is 
+called the Adopt HIT Act, Adopt Health IT Act. And basically 
+what it would try to do would be to incentivize these 400,000 
+physicians. With the Tax Code, there is a Section 179, which 
+now would allow any small businessman or woman, not just 
+physicians, to write off $100,000, to take a tax deduction, not 
+a credit, in the first year of an expenditure for a capital 
+improvement like an electronic medical record.
+    And I think this is the way we need to go. We would expand 
+that for the purchase of electronic medical records to $250,000 
+for, say, doctors in a nine-member group, if that is how much 
+they spend. And then, they would also be able to rapidly 
+depreciate other assets, capital improvements for their 
+practice, also under Section 179.
+    So if there is any time permitted, Mr. Chairman, for them 
+to respond to that, I would love to know what their opinion is 
+on that.
+    ChairmanGonzalez. No. Go ahead. Please proceed. You all may 
+respond if you have your own thoughts regarding that particular 
+proposal. Dr. Shober?
+    Dr.Shober. My only thought with that would be, as with Dr. 
+Napier here, in a larger group, if you have one corporate 
+entity, if that tax credit is based on the single corporation, 
+there would need to be some mechanism in there to allow for 
+that greater cost. I know you mentioned the $250--
+    Dr.Gingrey. There is a mechanism in the bill to do that.
+    Dr.Shober. Okay. That way, if you have a larger group or 
+there are groups of 30, 40 doctors on a system where it is much 
+more expensive than mine, that credit would be able to roll 
+through.
+    Dr.Napier. And I would echo that an expansion of the 
+deductibility of the cost of these systems would certainly be a 
+dramatic improvement over what we have now.
+    ChairmanGonzalez. Anyone else?
+    [No response.]
+    Thank very much, Dr. Gingrey.
+    Dr.Gingrey. Thank you.
+    ChairmanGonzalez. We are going to go into a second round of 
+five-minute questioning, because we have that luxury, the few 
+members that are remaining. I do have a couple of questions.
+    I guess in addressing Dr. Gingrey's proposal, which I would 
+be supportive of, I think we just need to be creative and have 
+a combination, as already--as has been touched on by Dr. Kirk 
+in her presentation this morning, and in her written statement, 
+that it should be a combination of assistance in grants, loans, 
+taxes, and such.
+    The big thing, of course, is going to be Medicare, and the 
+proposal there of course is simply that government is going to 
+save a lot of money. It is a good investment for government, 
+and I am approaching it from that particular standpoint.
+    Dr. Kirk, there was a revolution in the legal field when I 
+was a lawyer when we went into--we replaced our libraries with 
+CD-ROM, we went crazy, the old guys anyway. But I know this, 
+that law students that were coming out of law schools and such, 
+they were totally proficient on it. I mean, we were the 
+dinosaurs.
+    But I did learn this, and that is Einstein once said that 
+information is not knowledge, so you had a lot of information, 
+not necessarily knowledge. But what are the medical schools 
+doing? Because this is really important. It is preparing the 
+doctors, introducing them into the technology, and advise 
+them--and I don't even know if you do that particular aspect in 
+the educative process.
+    Dr.Kirk. Right. I think we are very good at immersing them 
+in the technologies that we have available at our academic 
+health centers, which can be very variable. I think as the 
+other doctors here mentioned, you remember the day that you 
+switch to an EMR. Mine was October of 2004 in my health system 
+at the University of Texas Southwestern Medical Center, because 
+it is such a change in your life.
+    I also practice a significant amount of time at Parkland 
+Memorial Hospital, and I must say we are not there yet, because 
+Parkland is a public hospital. We are phasing it in, but we 
+still--I was just in clinic yesterday with charts ``this'' 
+thick. So what our students and residents get exposed to is 
+variable, depending on the practice they are in, but we have 
+all made a commitment to move in that direction as quickly as 
+we can given the resources of the health care systems in which 
+we practice.
+    It is an integral part or is becoming an integral part of 
+teaching how staff--looking at clinical decision-making and 
+health information technology. One of the core competencies 
+that is now required for all residents training in the United 
+States through the Accreditation Council for Graduate Medical 
+Education is what we call systems-based care and practice-based 
+learning, which seem real gobbledly-gooky.
+    But what that means is that we have information at our 
+fingertips from the patient, and information from our 
+fingertips--at our fingertips, like Dr. Kelley mentioned--
+clinical guidelines, evidence-based medicine, and how to 
+practice, and we bring those together to make the best 
+decisions for the patients.
+    So we are very facile at doing that, but we need to move 
+more quickly and some of these resources will be helpful there, 
+especially for reimbursement for a place like Parkland to be 
+able to make that investment.
+    ChairmanGonzalez. Thank you, Dr. Kirk.
+    And then, a question--Drs. Kelley, Shober, and Napier. You 
+all made the decision to go ahead and purchase health 
+information technology. I can't help but think that somewhere 
+along in that consideration there may have been a discussion 
+about maybe additional liability exposure as a result of this 
+type of information that you are maintaining.
+    First of all, it is a new method, a new manner, you have 
+guidelines, you have mandates, you have all sorts of 
+requirements on privacy, for instance, but now you have it in 
+an entirely different manner or form. That is one 
+consideration. The other is just civil liability. Should you 
+know a lot more, again, your exposure is out there. You have 
+the benefit of the latest technology that would have kept you 
+informed regarding the proper care for a patient.
+    All of that, the fact that you have a new method that you 
+are utilizing, and somehow you have to apply all of the 
+mandated governmental standards on privacy, and, in addition, 
+the potential, just the potential that there may be greater 
+exposure for you on the civil liability end, was there that 
+discussion? And, obviously, it wasn't something that kept you 
+from actually adopting HIT.
+    Dr. Kelley?
+    Dr.Kelley. Well, in regards to the privacy issues, we are 
+completely--at least in our practice we are dependent on the 
+vendor stating that at the time when we implemented it is when 
+the HIPAA laws were just coming into regulation, and so that 
+was very important, that the vendor was HIPAA-compliant with 
+those issues.
+    With the issue of patient privacy, one aspect of the system 
+that is available that we decided not to was the ability for 
+labor and delivery nurses to get into patient's prenatal 
+records. And in our practice, we decided not to do that, just 
+because--mainly because of patient privacy issues, that it just 
+didn't seem secure enough to have whatever nurse was there, 
+nurses change at the hospital, being able to get into a 
+patient's prenatal record just to print it out.
+    So if we need a prenatal record at the hospital, only my 
+father and I will print it out. The nurses--we do now allow the 
+nurses to have accessibility to the patient's record.
+    ChairmanGonzalez. Dr. Shober?
+    Dr.Shober. Similar lines. When we initially put our system 
+in--granted, we are wireless within the office, so we are 
+always worried about wireless connectivity. Drug reps would 
+come in, and they tell us they tried to break in and they 
+couldn't. They are all wireless. They are connected all over 
+the place.
+    So we had mainly the vendor, plus another consultant come 
+by to make sure this place was fireproof and nobody could get 
+in. As far as connectivity to the hospital, very similar to Dr. 
+Kelley here, the only people that could access our records are 
+myself and my partner. We are apprehensive about a free 
+exchange between the ER physician when patient X comes in, or 
+can they be given a code to get into my system.
+    Granted, we worry about them getting into that patient or 
+another patient or that code being lost. I am very much behind 
+the development of some type of system whereby that free flow 
+could take effect, where myself as the recordholder would not 
+be held liable in the sense that Dr. X or the emergency 
+department was given access to records on this patient, because 
+they are a mutually cared for patient.
+    As soon as that patient walks in the ER, he is the patient 
+of that doctor. We really need to give that doctor the 
+opportunity to get all the information he can, whether it be 
+from maybe my office, the X-ray department upstairs, or the lab 
+medical records, whatever it may be, or even the next health 
+system over where the patient was discharged from yesterday.
+    Again, this bears back to the free flow of information, but 
+you worry about liability. The hospital itself is apprehensive 
+about tying into other systems. Everybody sort of has their own 
+little system, whether it be a larger entity, teaching hospital 
+system, or a community hospital like the one I work in. You 
+have to sit down at your computer, log into one or log into the 
+other.
+    But, again, if you think about that ER concept, over the 
+care and management of the patient, you need to be able to give 
+that physician the capability to access the information.
+    ChairmanGonzalez. Thank you.
+    Dr. Napier?
+    Dr.Napier. You raise the question, Chairman Gonzalez, about 
+civil liability risk, and that is something that we were very 
+concerned about, because, unfortunately, in the earlier EHR 
+programs that were available, it looked very dry in terms of 
+the interaction that you had with the patient. And not only in 
+civil malpractice cases did they look at what you did, but, 
+more importantly, why you did that. And that is the thing that 
+is often lost in electronic records is the way, the discussion 
+of why decisions were made.
+    And as I mentioned to you, we should have taken longer in 
+our customization. That is exactly the thing that we are 
+working continually on is enhancing the ability to integrate 
+into our record the reasons behind the decisions that we are 
+making in order to justify those.
+    ChairmanGonzalez. Thank you very much.
+    The chair recognizes the Ranking Member.
+    Mr.Westmoreland. Thank you, Mr. Chairman.
+    Dr. Kelley, on coding--and I am assuming that when you--if 
+you are doing it electronically to get your reimbursements, 
+whether it is Medicaid, Medicare--do you do Medicaid and 
+Medicare?
+    Dr.Kelley. Yes, sir, we do.
+    Mr.Westmoreland. Or if it is from Blue Cross Blue Shield or 
+United Healthcare, or whoever it is from. Do you see your 
+system, or does it work with all of those insurance--with all 
+of the reimbursements?
+    Dr.Kelley. No, it does not.
+    Mr.Westmoreland. Okay.
+    Dr.Kelley. And this is an example of evolving technology. 
+When we purchased the system three years ago, it basically was 
+just an electronic medical record. It didn't integrate into the 
+billing system that we have in the office or what you are 
+asking to other insurance companies and things.
+    So right now, as it stands, it is now--the other aspect of 
+it, to be able to even implement the electronic medical record 
+we had to change the--purchase a new operating system that we 
+use for patient scheduling and billing and all of that, to be 
+able to integrate basically the appointments from the 
+electronic medical record into the operating system for the 
+office.
+    But still, that automatic billing process, if you see a 
+patient that is coded and you file it with insurance, still, it 
+is in place.
+    Mr.Westmoreland. Okay. And, Dr. Shober, did you find it 
+similar? I mean--
+    Dr.Shober. What we had done--our system allowed us to start 
+with the scheduling. We actually bought a system, a scheduling/
+billing EHR, with open ends to other possibilities. When we 
+started to build that, we really have to add patient names. You 
+can't work with it until everybody is in it. You have to build 
+and add the names, and we started actually, before we used EHR, 
+to build patient names and demographics.
+    This is a process of an active office where you have to add 
+your existing patients to that roster. So from our sense it was 
+a process, but it was internal within one system.
+    Mr.Westmoreland. Dr. Napier?
+    Dr.Napier. Yes, we purchased a system that includes both 
+the practice management, which is in scheduling and billing, in 
+addition to an EHR, and they are fully integrated with one 
+another. Furthermore, old practice management software, we 
+purchased an interface that allowed us to simply electronically 
+transfer all of the demographics for our patients, so that our 
+process was a little easier than it sounds like Dr. Shober's 
+was, but that came at additional cost, though, to the practice.
+    Mr.Westmoreland. So can you bill Medicaid and Medicare, 
+United Healthcare, Blue Cross Blue Shield, TRICARE, you are 
+hooked up with them right now and can you get your 
+reimbursements?
+    Dr.Napier. Every practice utilizes a clearinghouse to 
+manage the claims, and so your claims are submitted at the end 
+of each business day to a clearinghouse, and those 
+clearinghouses then have independent contacts with all of our 
+carriers. And so the answer to the question is, yes, it is 
+fully connected, so at the end of each business day we simply 
+enter in the charges and that goes to the clearinghouse, and it 
+is done. and it has dramatically improved our turnaround time 
+for reimbursement, I must add that.
+    Mr.Westmoreland. Well, that is good. A follow-up to what 
+the Chairman asked about the privacy. You know, the HIPAA 
+regulations that you have now, I would assume there has got to 
+be some concern about these records getting out into cyberspace 
+out there and somebody getting hold of all of them.
+    But has it affected your practice insurance? Do you get a 
+break on it, or is it costing more because you have an IT 
+program?
+    Dr.Kelley. Actually, our medical malpractice insurer is 
+Texas Medical Liability Trust. And when we implemented--after 
+implementing the EMR, the malpractice insurance carrier came 
+and did a site visit to make sure they had certain standards 
+that they wanted in place, and after passing that inspection 
+then we did get a discount on our medical malpractice.
+    Mr.Westmoreland. Ten percent? Five percent? One percent?
+    Dr.Kelley. Oh, probably more like two, maybe two, three 
+percent. Less than--anything helps, but it was--
+    Mr.Westmoreland. No, I understand.
+    Similar situation with you, too?
+    Dr.Napier. We did not get any break on our malpractice 
+rates, and they are certainly higher now than they were when we 
+implemented the system.
+    Dr.Shober. Likewise. We had no change. They continue to go 
+up by the year.
+    Dr.Leavitt. I think there are three or four malpractice 
+insurers that are offering discounts of two to five percent. I 
+had never heard of a 10 percent discount.
+    I have not heard, though, of any that increased their rates 
+because of an electronic record. In general, they are 
+associated with higher quality care, and less likelihood to 
+forget something or lose track of a lab result. So they are 
+generally associated with a decrease in liability, but the 
+issue of privacy is still really an open question.
+    ChairmanGonzalez. I am happy to welcome my colleague again 
+from the great State of Pennsylvania, and that is going to be 
+Congressman Joe Sestak. And at this time, Congressman, you are 
+recognized for five minutes for questioning.
+    Mr.Sestak. Thanks, Mr. Chairman. I apologize I wasn't here. 
+And if my questions are redundant, please, I will move on to 
+the next.
+    I had been curious, have there been any cost-benefit 
+studies done that are accessible to kind of try to see the 
+tradeoffs between large medical providers versus small medical 
+providers in terms of going into the IT and electronic health 
+records?
+    I mean, the reason I am fairly interested in this is I have 
+watched what the VA has done and been quite taken with it, 
+sitting over there in the hospital and somebody calls in all of 
+a sudden and I am sitting there and they are doing some 
+checkup, and the doctor goes boom, boom, boom, yes, give her 
+this, and then in seconds it is all done. I was quite taken 
+with the efficiency.
+    But are there cost-benefit analysis studies on this, if 
+that hasn't been asked already? Please.
+    Dr.Leavitt. I don't know of formal studies, but it is 
+generally accepted that the cost-benefit ratio, the return on 
+investment is most favorable for the largest organizations.
+    Mr.Sestak. Right.
+    Dr.Leavitt. And least favorable for the smallest, and I 
+will mention a few reasons why. This is why the VA, once it 
+computerized, recognized an enormous benefit. The larger the 
+organization, the more different places a paper chart can be. 
+So there is an overhead cost. You know, one doctor office, 
+generally you know where the chart is, generally, although 
+there are still five or six places it can be.
+    In the VA, the chart could be in thousands of places, so 
+you realize a savings on just managing and finding the paper. 
+You also realize a savings on things such as transcription. 
+Some doctors are able to stop dictating and start clicking or 
+typing in a few notes, and that can be quite a savings. Again, 
+if it is a small office and it is the front office clerk who 
+does the typing, you are not going to fire your front office 
+clerk if you are not able to realize that benefit.
+    And, of course, the big system amortizes the fixed costs, 
+like the server and the technical expert. So it is--the bigger 
+the system, the more likely the return. That is why in the 
+largest clinics, over 100, more than a third of them now have 
+EHR, whereas in the solo offices probably fewer than 10 percent 
+have EHR.
+    Mr.Sestak. What would one think about, then, as the proper 
+incentive to be able to move smaller ones towards this type of 
+system which bodes so much I think? What are the right 
+incentives to get them? I mean, if you don't have a cost-
+benefit analysis study done for the break-even point, so to 
+speak--and I gather we don't for smaller ones--I understand the 
+general concept, but what is the right incentive, then, to try 
+to move--which I think our whole national health care has to 
+move. But what is the right incentive financially to move them, 
+do you have any ideas on that?
+    Dr.Leavitt. Well, of course, that has been the topic of 
+discussion here, and I think most of the witnesses have agreed 
+multiple mechanisms, whether those be grants, loans, tax 
+credits, tax deductions, and incentives, I would personally 
+suggest that one of the most powerful is an actual incentive 
+payment from Medicare, because anything Medicare does is 
+instantly recognized and often flows out to the private sector.
+    So even though federal dollars are about half of health 
+care, the other half tends to follow the federal lead. So if 
+there were a bonus payment in Medicare for seeing a patient and 
+using this technology, and eventually there might be a 
+decrement for using paper, so that you're revenue neutral, it 
+not only is a financial incentive, it sends a signal.
+    Mr.Sestak. And one last--I am sorry. Please, Doctor.
+    Dr.Kirk. Just to add--and I think you alluded to this--in 
+terms of the efficiencies, I think both for large and small 
+practices, most of them aren't actually realized by the 
+practice or by the physician. For example, if because you have 
+access to the information you don't order something that has 
+already been done, then that is--the payer saves for that, for 
+not paying for that additional blood test.
+    And it is very hard for those savings to come back to the 
+physician, because that is in a different bucket of money. So I 
+think multiple mechanisms, depending on the size of the 
+practice and depending on the way that technology is financed, 
+is going to be most helpful to move the most people in that 
+direction.
+    Mr.Sestak. And I gather part of the--for the smaller 
+practitioners--last question--is that part of the challenge, 
+then, is not just the changeover, but I gather the 
+administrative staff and the continuing cost of that?
+    Dr.Kelley. Correct. One aspect--one additional cost that we 
+now have is having service with a computer technology company. 
+I personally don't--I mean, I never was a computer guru, so 
+when the computers go down I don't have the knowledge to know 
+how to fix it. So you have to have the company that comes in, 
+since the--we call him the ``computer dude''--to come in to 
+figure out what is going on.
+    But it is now an additional expense that we have to have, 
+because we have this technology that we didn't have before, and 
+we don't really have a way to increase revenue to compensate 
+for this cost.
+    Mr.Sestak. Thank you. I am sorry to repeat the questions 
+that you already had gone over. I just was so--I spent 31 years 
+in the military, and then I went to the VA system, and I was 
+just so taken by watching the efficiency, and then watching 
+what happened with Katrina, that this bodes well for us. And I 
+am sorry I wasn't here for the rest of it.
+    Thanks, Mr. Chairman.
+    ChairmanGonzalez. Well, thank you for your participation.
+    And I see that Congressman Altmire is back. We went through 
+a second round of questioning, Jason. Is there anything that 
+you want to ask at this point?
+    Mr.Altmire. No.
+    ChairmanGonzalez. All right. The chair is going to 
+recognize the Ranking Member.
+    Mr.Westmoreland. Thank you, Mr. Chairman, and I just want 
+to close with this. Remember that when government gets involved 
+in stuff, it tends to screw it up. And so what I would like to 
+ask each one of you to do, and especially the doctors, go to 
+your organizations, whether it is internal medicine or the OB-
+GYN, whatever it is, come up with some solutions and some ways 
+that we can help you.
+    And I ask Dr. Leavitt the same thing, and Dr. Kirk, with 
+your organizations to come up with what we can do to help you. 
+When we think we are helping you, sometimes we are not. And so 
+you will be better telling us what we can do to help you than--
+trust me, than us trying to help you on our own.
+    And that is all I had. Thank you.
+    ChairmanGonzalez. Thank you very much.
+    And, of course, here we go into the philosophical 
+differences.
+    [Laughter.]
+    I think government can be an agent of change for good, and 
+if we do it right and if we do it smart. And that is the whole 
+purpose of this hearing. But I think that we recognize that 
+government is going to have to get involved to some extent, 
+whether it is the Tax Code or more aggressively and creatively, 
+and just that we do it right.
+    But there is no doubt of the advantages that are there to 
+be had by the adoption of health information technology. I 
+applaud and commend the doctors that are here today, that 
+before we had all the incentives in place, because it is going 
+to get better, that you took the bold step. I think it makes 
+you a better practitioner. I think your patients are the true 
+beneficiaries.
+    And, again, this is going--unless we have anything further, 
+this is going to conclude this hearing. The record will remain 
+open for five days. I want to thank all of you for taking the 
+time to be here. Continue to give us your suggestions.
+    I do believe we have to move forward. Government, in 1965, 
+decided it was going to take a huge step in covering the 
+medical needs of its population, and we are there today, and we 
+are not going to be retreating from that. That is the reality. 
+Now, let us just figure out how we are going to do it, and do 
+it where the best interests of all citizens are served.
+    Again, thank you, and this Committee stands adjourned.
+    [Whereupon, at 11:36 a.m., the Subcommittee was adjourned.]
+
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