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+[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.] + + [GRAPHIC] [TIFF OMITTED] T3807.001 + + [GRAPHIC] [TIFF OMITTED] T3807.002 + + [GRAPHIC] [TIFF OMITTED] T3807.003 + + [GRAPHIC] [TIFF OMITTED] T3807.004 + + [GRAPHIC] [TIFF OMITTED] T3807.005 + + [GRAPHIC] [TIFF OMITTED] T3807.006 + + [GRAPHIC] [TIFF OMITTED] T3807.007 + + [GRAPHIC] [TIFF OMITTED] T3807.008 + + [GRAPHIC] [TIFF OMITTED] T3807.009 + + [GRAPHIC] [TIFF OMITTED] T3807.010 + + [GRAPHIC] [TIFF OMITTED] T3807.011 + + [GRAPHIC] [TIFF OMITTED] T3807.012 + + [GRAPHIC] [TIFF OMITTED] T3807.013 + + [GRAPHIC] [TIFF OMITTED] T3807.014 + + [GRAPHIC] [TIFF OMITTED] T3807.015 + + [GRAPHIC] [TIFF OMITTED] T3807.016 + + [GRAPHIC] [TIFF OMITTED] T3807.017 + + [GRAPHIC] [TIFF OMITTED] T3807.018 + + [GRAPHIC] [TIFF OMITTED] T3807.019 + + [GRAPHIC] [TIFF OMITTED] T3807.020 + + [GRAPHIC] [TIFF OMITTED] T3807.021 + + [GRAPHIC] [TIFF OMITTED] T3807.022 + + [GRAPHIC] [TIFF OMITTED] T3807.023 + + [GRAPHIC] [TIFF OMITTED] T3807.024 + + [GRAPHIC] [TIFF OMITTED] T3807.025 + + [GRAPHIC] [TIFF OMITTED] T3807.026 + + [GRAPHIC] [TIFF OMITTED] T3807.027 + + [GRAPHIC] [TIFF OMITTED] T3807.028 + + [GRAPHIC] [TIFF OMITTED] T3807.029 + + [GRAPHIC] [TIFF OMITTED] T3807.030 + + [GRAPHIC] [TIFF OMITTED] T3807.031 + + [GRAPHIC] [TIFF OMITTED] T3807.032 + + [GRAPHIC] [TIFF OMITTED] T3807.033 + + [GRAPHIC] [TIFF OMITTED] T3807.034 + + [GRAPHIC] [TIFF OMITTED] T3807.035 + + [GRAPHIC] [TIFF OMITTED] T3807.036 + + [GRAPHIC] [TIFF OMITTED] T3807.037 + + [GRAPHIC] [TIFF OMITTED] T3807.038 + + [GRAPHIC] [TIFF OMITTED] T3807.039 + + [GRAPHIC] [TIFF OMITTED] T3807.040 + + [GRAPHIC] [TIFF OMITTED] T3807.041 + + [GRAPHIC] [TIFF OMITTED] T3807.042 + + [GRAPHIC] [TIFF OMITTED] T3807.043 + + [GRAPHIC] [TIFF OMITTED] T3807.044 + + [GRAPHIC] [TIFF OMITTED] T3807.045 + + [GRAPHIC] [TIFF OMITTED] T3807.046 + + [GRAPHIC] [TIFF OMITTED] T3807.047 + + [GRAPHIC] [TIFF OMITTED] T3807.048 + + [GRAPHIC] [TIFF OMITTED] T3807.049 + + [GRAPHIC] [TIFF OMITTED] T3807.050 + + [GRAPHIC] [TIFF OMITTED] T3807.051 + + [GRAPHIC] [TIFF OMITTED] T3807.052 + + [GRAPHIC] [TIFF OMITTED] T3807.053 + + [GRAPHIC] [TIFF OMITTED] T3807.054 + + [GRAPHIC] [TIFF OMITTED] T3807.055 + + [GRAPHIC] [TIFF OMITTED] T3807.056 + + [GRAPHIC] [TIFF OMITTED] T3807.057 + + [GRAPHIC] [TIFF OMITTED] T3807.058 + + [GRAPHIC] [TIFF OMITTED] T3807.059 + + [GRAPHIC] [TIFF OMITTED] T3807.060 + + [GRAPHIC] [TIFF OMITTED] T3807.061 + + [GRAPHIC] [TIFF OMITTED] T3807.062 + + [GRAPHIC] [TIFF OMITTED] T3807.063 + + [GRAPHIC] [TIFF OMITTED] T3807.064 + + [GRAPHIC] [TIFF OMITTED] T3807.065 + + [GRAPHIC] [TIFF OMITTED] T3807.066 + + [GRAPHIC] [TIFF OMITTED] T3807.067 + + [GRAPHIC] [TIFF OMITTED] T3807.068 + + [GRAPHIC] [TIFF OMITTED] T3807.069 + + [GRAPHIC] [TIFF OMITTED] T3807.070 + + [GRAPHIC] [TIFF OMITTED] T3807.071 + + [GRAPHIC] [TIFF OMITTED] T3807.072 + + [GRAPHIC] [TIFF OMITTED] T3807.073 + + [GRAPHIC] [TIFF OMITTED] T3807.074 + ++ +