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Senate Hearing Transcript


before the

One Hundred Eleventh Congress


January 15, 2009

Hearing on Investing in Health IT: A Stimulus for a Healthier America

Edward Kennedy (MA)
Christopher Dodd (CT)
Tom Harkin (IA)
Barbara A. Mikulski (MD)
Jeff Bingaman (NM)
Patty Murray (WA)
Jack Reed (RI)
Hillary Rodham Clinton(NY)
Barack Obama (IL)
Bernard Sanders (I) (VT)
Sherrod Brown (OH)

Michael B. Enzi (WY)
Judd Gregg (NH)
Lamar Alexander (TN)
Richard Burr (NC)
Johnny Isakson (GA)
Lisa Murkowski (AK)
Orrin G. Hatch (UT)
Pat Roberts (KS)
Wayne Allard (CO)
Tom Coburn, M.D.


Jack Cochran, Executive Director (testimony)
The Permanente Federation, Oakland, CA

Janet Corrigan, President (testimony)
The National Quality Forum, Washington, DC

Valerie Melvin, Director of Information Technology (testimony)
The Government Accounting Office, Washington, DC

Peter Neupert, Vice President (testimony)
Microsoft Health Solutions, Redmond, WA

Mary Grealy, President (testimony)
Health Leadership Council, Washington, DC

Opening Statement:

Barbara A. Mikulski (D-MD): We want to reach out to our Republican colleagues that the working groups on this committee will continue the spirit of bi-partisanship.  We want to pass the bill in a robust way.  We want to have good manners.  We have an excellent model here with how we worked in higher education.  Today is my kick off for hearings on qualities.  I am fired up and ready to go.  In regards to health care, we have reached out and made sure we had bipartisan witnesses.  The purpose today is to talk about Health IT (HIT).  Everyone sees it as a silver bullet.  If it’s not going to function, we don’t want another technological boondoggle.  We cannot do health care reform without it.  We want to get the best views and thinking.  Under the Wire Act of the previous Congress, we will add to it.  We want it to be interoperable.  As someone who appropriates for the Commerce, Justice, Sciences Subcommittee, I am very familiar with this.  This will be user-friendly so it can be adopted soon especially in clinical practice and rural communities.  Every major group over the years has discussed why we need Health IT.  Every industrial nation has it.  Our surveys show that only 4% of physicians have health IT systems and only few have access to it.  What we do have is not interoperable in a primary care facility.  Surgery may have been completed for one procedure, but it may not be linked with other services or doctors for discussion.  We think there is tremendous potential for increasing quality, efficiency, and economic savings.  Efficiencies could mean cutting costs in delivering care.  Our challenge is to develop it, fund it, and promote it and keep it fresh and contemporary.  Sustainability is one of the issues we must extensively look at.  I want to introduce the panel to the committee.  We will start with Doctor Jack Cochran.

Dr. Jack Cochran: I am Dr. Jack Cochran, executive director of The Permanente Federation, the national umbrella of the eight Kaiser groups.  We employ more than 14,000 physicians.  KP Health connects computer health systems securely.  It helps connect 8.7 million people to their physicians and health care providers and gives them access to the latest medical knowledge.  We have experienced important breakthroughs.  You should not expect immediate cost savings, and you have to go slow at first to go fast eventually.  Physician leadership and patient understanding is crucial.  How do you collect data usefully into the system?  Physician input can help create tools that help the care givers more effectively provide care.  One of the greatest lessons we have learned is how much patients value using the internet for health reasons.  We have two million active users who securely email their doctors and access lab tests and prescriptions.  As we consider an economic stimulus package, we should consider these dollars tied to actual usage.  Having patients involved in their care in this way is helpful and effective.  Incentives should be focused not on implementation but on incorporation and interoperable with federally sanctioned standards.  Finally, done well we believe it can restore and help the healing mission.  It will optimize care for the patients.  The right system needs to focus on the patient’s needs.  It is needed to support our health care agenda nationwide.

Janet Corrigan: Thank you for inviting me here today.  I am CEO of The National Quality Forum, a private sector who wants to improve national standards and quality of health care by setting national goals and endorsing performance manners to improve the front line of health care.  Health IT is necessary for regulatory oversight.  I commend the committee for focusing the attention of Health IT on the economy and the interests of the patients.  I am going to focus on the linkage between Health IT and patient care.  First, it’s important to use federal funds from the stimulus for HIT to improve safety, quality, and affordability.  We must invest now.  These funds should be tied to the effective use of HIT, not just having it in place.    Second, we must use the quality of standards that translates into promoting the development of better care.  We encourage you to build off of work already existed and not reinvent the wheel.  Third, this will only bring improvements of care if the system helps the exchange of data and is interoperable.  It is important that the investments ties to care delivery that leads to real outcome.  We have developed standards that measure HIT.  Federal funding will only result in improvements in care including the exchange of data for prescriptions and lab tests.  Interoperability is important but investments should be focused on patient care and improvement.  In conclusion, NQF supports the adoption of HIT for the safety and advancement of medical care.  Thank you very much.

Senator Barbara A. Mikulski (D-MD): Excellent.  This complements with what Dr. Cochran says.  It has to be usable, and you have to have buy-in from physicians. We need to turn to the private sector guy to look further into this.

Peter Neupert:  We have a dynamic view of the future.  A totally connected network of the exchange and reuse of data is essential.  The Marshall Clinic and others can use this to improve health care.  We need to embrace technology as a means to improve outcomes and quality and reductions of cost.  First, we must drive the right health outcomes and payments in an innovated way.  We need to reward physicians who provide prevented care and deliver care in new ways.  Second, we must connect and share data between health organizations.  Having access to prescriptions and tests will allow health care advisors to reduce spending and improve care.  Third, we must empower consumers to be stewards of their own health data.  Just as health scores show past transactions, so should internet data.  We should begin today with the health data that already exists electronically.  We can do this with the existing data with five recommendations: first, encourage innovation by setting out objectives and goals and not mandating specific technologies, second, reward innovated doctors who make the internet the connection for data to patients, third, provide incentives for sharing data today, fourth, focus on making it interoperable today and not waiting.  Venders should make their programs interoperable with one another.  Finally, enable the private sector to develop an infrastructure that helps doctors and patients.  Stake holders in the ecosystem can find ways to reach these goals.  Microsoft looks forward to working with the public sector.

Senator Barbara A. Mikulski (D-MD):  That was excellent and needed.  This is exactly what we were looking for.  I want to welcome a new member to the help committee—
Senator Jeff Merkley, (D-OR).

Mary Grealy:  I want to thank you for this opportunity to testify on HIT for economic and health reform.  President-elect Obama discussed HIT recently, and he expressed commitment to invest in HIT.  We couldn’t be more supportive of his priorities.  One of our members, North Shore Health System has an electronic system that was implemented a few years ago.  Thousands of patients can log online and check their data.  They have reduced error by 80%.  They have reduced MRSA infections by 70%.  They estimate savings over 400 billion dollars if a national health information network is implemented.   What we should do now is to create funding mechanisms to assist heath care providers.  As you noted only a small portion have adopted this system because of cost.  Investing in HIT in a stimulus package or healthcare reform would be a catalyst for economic recovery.  We need to foster innovation.  We firmly believe that the private sector should work hard to develop a road map for effective change and interoperability.  Progress hinges on patient privacy and making sure medical providers have access to the necessary information to provide care.  All involved stake holders should be at a stake table.  Gathering trust will be extremely important to HIT.  Patients need access to their data.  The evidence is clear: HIT will pay substantial dividends in lowering costs.  We have seen the restoration of costs for patients.  We look forward to working with you in all issues of health care reform.

Senator Barbara A. Mikulski (D-MD):  Thank you.  Just the data you gave on saving money (along with lives) is demonstrative.  My background is that of a social worker.  I love case examples because that is where you can get the picture of the real impact.  What are the potholes?  You can develop technology to deal with potholes.

Valerie Melvin:  I am pleased to be here today.  Proper implementation of HIT can make data more readily available which can improve the efficiency of health care.  It is a complex endeavor and the best way to accomplish it has been subject to debate.  Clearly defined HIT standards need different systems to work together to provide the correct information to patients.  We previously recommend that HHS build technology to define such standards.  However, while progress has been made, continued standards on HIT need to be implemented.  Because it involves many stake holders, it is important that they be guided by performance measures that can be assessed and monitored.  We have seen repeated instances where planning measures have not been comprehensive.  Finally, a consistent approach to privacy protection is needed to help assistance.  Obtaining consent is an important principle and challenge.  This concludes my statement.

Senator Barbara A. Mikulski (D-MD):  I will turn to my questions for a few minutes.  I didn’t want this to become an appropriations hearing.  I have to ask questions on what will be before us in this stimulus package.  We cannot afford to waste time on a fools journey or waste money.  We don’t have either one.  I want to work with President-elect Obama to move HIT forward.  We know about interoperable challenges and privacy; what would you recommend in the health care stimulus when spending money that we are achieving goals?  There is no difference of opinion.  Should we put it in the stimulus?  What in addition to adequate funding should we do?  Please share your thoughts.  I want to get this right.  Should we wait on it?  If we don’t, how do we get it right?  I am going to go down the room in the way we testified on that.

Questions and Answers:

Jack Cochran:  I appreciate your recognition on being skeptical on things that in the past haven’t been taken seriously.  We can debate.  What I would say would be to understand the issues and not try to find quick fixes.  It could cost a lot of money and get few returns.  I came from a private surgical background, and the way we pay for health care can be really perverse, because we didn’t pay for prevention.  We have few codes for outcomes and cure.  When you plan this process, financing is not the only answer.  We need more social workers, nurses, and primary care physicians.  President Clinton’s plan was holistic but lost lots of support.  President-elect Obama is looking into this and being interactive with it.  The silver bullet is not IT or financing mechanism, but if you are going to make a difference you have to look at all of the issue.

Senator Barbara A. Mikulski (D-MD): Thank you

Janet Corrigan:  Good question.  Some investment in the stimulus is appropriate, but it needs to be viewed in a broader context.  I would encourage a multi-pronged approach.  The initial idea about Health It is that it has been used.  It is important to invest in HIT that has available information.  We should reward those who invested in HIT that was good and put it to effective use.

Peter Neupert:  I need to express agreement with our prior speakers.  Payment review is the first step.  I would say that one additional comment is that the data exists today.  We don’t need to invest in new data but rather leverage what already exists, such as large pharmacies and labs (like Quest).  I really would focus the near-term stimulus to access the data out there.  We need to look at important factors already out there and then eventually focus on reform.  We can go a long way to empower patients and physicians.

Senator Barbara A. Mikulski (D-MD):  You are saying that (and others have indicated) this will be a network of networks.  I have a primary care doctor who is a doctor with privileges at Mercy Hospital.  Any acute care needed would be done at Mercy, Johns Hopkins, or University of Maryland (and blood tests by Quest).  What you are saying is that we need to meet the networks that are already networking and then as we do the stimulus, get started with the networks that exist and already have networked.  Think of it as a network of networks, not like social security.  So do we work off of networks that already exist?

Peter Neupert: Yes, there is not going to be one network because data already exists.  The different hospitals need to have copies of your data, but you need to have the longevity of your data to use.  We have the knowledge and technological capabilities today to make this available and happen.  It is important to get the hospitals to open to each other and share.  It is not that hard to extract.  We have the knowledge to make it viable.  Right now, we have all closed systems.  We need to get them open and sharing—that’s most important.

Mary Grealy: Peter made a critical point.  You want to share among health care providers.  I use an example from the past of my 89 year-old father going to six different appointments.  Each time we had to turn over the latest blood work result.  We have the technology and data, and we can do this now.  Let’s think on parallel tracks.  We would like to see in the stimulus package loans and grants for those who have committed already.  We need others to come on board and do work on increasing standards.  We don’t want to duplicate what has already been done.  We need to take it and keep going.  We can share critical data.  We want to make sure data can be shared.  We can see very short term dramatic results.  We need to make sure to not be overly prescriptive.  Each system will want to tailor its system to its own needs, but we need to make sure the critical components are exchangeable.  We have had members that knew this was the right thing to do, they didn’t expect to save money on it, and they have been pleasantly surprised.

Valerie Melvin:  The most important aspect we see is a comprehensive approach to do this.  We think it is important to take from lessons learned and see how successes can be applied and see what has and hasn’t worked so far.  Also, trying to work at this in incremental approaches is necessary.  This cannot and shouldn’t be done very quickly—it has proven it can’t be done quickly.  We should build upon what has been done.  We should look at experiences that have already been tried and continue those.  The demonstrative uses I would advocate are oversight and goal-setting.  From that standpoint, having interim measures to work toward a final outcome would be in our view.

Senator Barbara A. Mikulski (D-MD): Don’t use skepticism to stop you, but rather use it in a prudent and productive way. Look at where we will be heading. We need agreement on testimony. We all know the ultimate end game with HIT and reform: improve patient care, chronic illness, and accidents so information will be necessary and also encourage consumer responsibility. You have to take responsibility for your own health care-keeping appointments and asking good questions.  These are excellent recommendations. I am going to ask for my staff to talk to you about what is essential. I am going to turn to Senator Merkley for questions he might have.

Senator Merkley (D-OR):  Thank you Senator. I want to clarify what this looks like to the average American. I have moved around and have many records in different places. The physician of the capitol-how would he access my records? Would one of you explain this from a consumer’s point of view?

Peter Neupert: At Microsoft we have a system called health vault so consumers can manage their own system. I don’t imagine connecting all electronic systems to each other. It is easy to connect all to one hub (some have competitors).  Google has one too. Just like you choose what bank you keep your assets in, you ought to be able to choose where you want to store your critical health data at. All you need to do is access important attributes stored (weight, what you eat…). When the acute incident happens, you will have an e-approach to that.

Senator Merkley (D-OR): If I am critically injured, how does the emergency room access this?

Peter Neupert: You give them a password for access.

Jack Cochran: If you are injured or sick you want people to have access to your data. You want that system to be secure.  In a great world, progressively, we want secure data online where people can access their data and where doctors can share that information. This could be done on a national level. This creates a safe system for people, especially for any idiosyncratic diseases.

Senator Merkley (D-OR): Thank you for clearing that up. My wife works for Providence. However, it is harder to get rural and smaller institutions involved in our country. How do you do this?  What kind of efforts do we need to make HIT solutions reach out to rural areas?

Mary Grealy: This is one of the great things about HIT.  It can share information across geographical areas. This is where financial support is crucial. It will create tremendous change for these people to get access to high quality health care. There is great hope for those hospitals to get informed.  They need national financing.

Janet Corrigan: We now have a two-class system for those who have access to HIT and those who don’t. Those who have this computer database and have sophisticated HIT systems will get higher quality and more affordable health care.  We need to encourage these relationships.  Baylor has reached out to doctors who are heavy admitters to Baylor’s system. It is when you move out to communities that are highly fragmented where there needs to be these systems for connectedness.  We need to breakdown barriers, even policy barriers. The anti-kick back legislation has been a barrier to rural hospitals in getting support and capital to be part of the HIT system.

Senator Merkley (D-OR): Thank you very much. My time has expired.

Senator Barbara A. Mikulski (D-MD): Thank you. Those were excellent questions and it shows that you will be excellent on this committee. I want to be sure we have unanimous consent for senators that want to be a part of this. I am going to ask one final question about interoperability, and then this committee will adjourn.  Mrs. Melvin, how can we work on the interoperability? How can we get it going now?

Valerie Melvin: I would emphasize prioritization.  If that works in a streamline process or the ultimate outcome, the key is to look at the significant needs and outcomes based on experiences that have been proven.  This should be used to drive what priority needs should be focused on.  The VA and DOD did this initially. They identified key data that can be shared. In terms of interoperability, there are different levels. It is important what needs to be done and establish priorities of what needs to be done. We should go for goals that we have set. They should be to improve health care.

Senator Barbara A. Mikulski (D-MD): We should do stuff now to keep this going.  I looked at the chart of HHS, and it is very extensive.  I will leave it to the secretary of HHS to streamline this.  We need to consult with you and privacy groups like the ACLU because they have good insight and raise questions we don’t always think about.  We really look forward to ongoing conversations with you and that which is represented in this room.  At the end of the day, we want to improve patient health care and have providers with tools of what they need to know from data and each other. I view this hearing as a down payment on discussions on HIT.  Any additional information can later be discussed.  I welcome all additional information.  This meeting is now adjourned.

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