Thursday, November 15, 2012

Fundamental Questions about Certified Electronic Health Records

The Technology and Innovation subcommittee of the House Committee on Science, Space, and Technology held a hearing on Meaningful Use.

The hearing charter observed, based on a CRS report on the HITECH Act, "The ONC drafted a framework that outlined four goals for HIT (Health Information Technology):
  1. informing clinical practice by accelerating the use of EHRs (Electronic Health Records);
  2. connecting clinicians allowing them to exchange information in a secure environment;
  3. personalizing health care by enabling consumers to participate in their care; and
  4. improving population health through public health surveillance and through the acceleration and application of health research in clinical care."
Opening statements were given by Chairman Ben Quayle (R-AZ), Dr. Farzad Mostashari (ONC), Dr. Charles H. Romine (NIST), Mr. Marc Probst (Intermountain Healthcare), Ms. Rebecca Little (Medicity), and Dr. Willa Fields (HIMSS).

Brian Ahier, Dan Bowman, and Joseph Goedert covered the hearing. Scant mention was made of the last 14 minutes of the Q&A time which were the most revealing. (Hearing Video)

A transcript of those exchanges follows.

Chairman Ben Quayle: We now recognize the gentleman from California, Mr. Rohrabacher, for five minutes.

Rep. Dana Rohrabacher: Thank you very much, Chairman Quayle, and to our witnesses as well.

I'm the first one to admit that I have limited knowledge into the area that we are talking about, so I guess I have to ask some fundamental questions.

This-- We seem to be talking about interoperability, and privacy is some of the issues, but as the discussion's gone on, it seems that we are talking about more than electronic health records. It seems to me that we're morphing into a discussion at some point into setting up a system of medical cooperation that will ensure that any hospital has the best technology available to it.

That's different than medical records.

So far, I take it the original goal was to have a national system where we could easily exchange information. That seemed to be a goal that people could actually accomplish within a certain budget. I mean I know people have apps right now. My wife actually invented an app over the Internet, and it's relatively simple. A lot of people are utilizing the Internet in a relatively inexpensive way.

But we've already spent two billion dollars on this information sharing which does mirror some of things that I think I've seen on the Internet, but are we now morphing this something into something that's far beyond just medical records that's going to cost more money that we may not ever have?

Dr. Farzad Mostashari: The payments authorized under the CMS Medicare and Medicaid Health IT incentive program are specifically for the meaningful use of certified electronic health records.

Rep. Dana Rohrabacher: OK, just for the records, not for...

Dr. Farzad Mostashari: Certified

Rep. Dana Rohrabacher: Because, listen, I'm not saying that we can't do a lot of other things in the healthcare arena that are--that will be to the benefit of our people, but I do know that when people try to do everything, they generally don't get anything done. So, we're just focused on the records, we're still-- This program is still focused on just setting up a system so that if someone goes into a hospital, his medical records can immediately be available.

Dr. Farzad Mostashari: The Medicare and Medicaid incentive pro-- payments are specifically for the meaningful use of electronic health records that are certified to meet interoperability and functional standards.

Rep. Dana Rohrabacher: And how much has been spent for that already? You say it was two billion dollars?

Dr. Farzad Mostashari: There was two billion dollars in appropriated funds for the grant programs and to establish the infrastructure like the Regional Extension Centers is the example I gave, and then there are mandatory payments as Chairman Quayle described in the beginning for eligible professionals and hospitals in approximately seven, a little bit over seven billion dollars has been spent to date out of an estimated twenty billion dollars.

Rep. Dana Rohrabacher: And that's to come up-- That money was spent to come up with a basic set of standards, or to set up a system?

Dr. Farzad Mostashari: Those payments are for individual eligible professionals and eligible hospitals who earn those mandatory payments if they adopt an certified electronic health record and they use them in these certain ways--check for drug-drug allergies, collect the information needed, and exchange it.

Rep. Dana Rohrabacher: So what we have spent the two billion dollars on is to encourage people to participate in a system that is a standard system for the country, is that right?

Dr. Farzad Mostashari: The incentive payments, which is the 44,000--up to 44,000 dollars over five years for eligible professionals and the two million plus for hospitals is payment to them for whatever system they choose, but the systems have to meet the national standards.

Rep. Dana Rohrabacher: And so-- But the point is, just to establish the national standard.

Dr. Farzad Mostashari: The goal is to get widespread adoption and meaningful use of the electronic health records which include the standards.

Rep. Dana Rohrabacher: Yeah, let me just suggest that twenty billion dollars to set up a standard is a big price tag.

Dr. Willa Fields: May I jump in here?

Rep. Dana Rohrabacher: Oh, absolutely ...

(Mr. Rohrabacher's five minutes had expired.)

Rep. Dana Rohrabacher: Chairman Quayle ...

Dr. Willa Fields: May I speak?

Rep. Dana Rohrabacher: Go right ahead.

Dr. Willa Fields: ...further. The point I want to make is that the goal is to have tools to help clinicians provide care. The ultimate outcome is improved patient care and health outcomes--a healthy American population.

Rep. Dana Rohrabacher: OK, that's different than what he just said.

Dr. Willa Fields: No, it's the same.

Rep. Dana Rohrabacher: No, I'm afraid it's not. I mean, that's your opinion on that. He just said it was medical electronic records, not what you just--

Dr. Willa Fields: And what I am saying is...

Rep. Dana Rohrabacher: Alright

Dr. Willa Fields: ...the medical electronic record is imperative for us in the United States to be able to give high quality care which ultimately will be healthy people. Without these tools-- So we can go through research study after research study that those organizations that have standards-based electronic health records, and they're using it in a meaningful way--like Intermountain Healthcare, and many other organizations--because of the data that is available to them to give care to individual patients, and then to their population, it's because of that information that we able to have healthier populations which I believe is something that everyone in this room wants.

Rep. Dana Rohrabacher: No one has any argument with the fact that we need to have the ultimate amount of information available to anyone who's a health provider for the person that comes in for treatment. There's no doubt about that.

It seems to me, however, Mr. Chairman, that billions of dollars in order to set a standard that would permit that type of availability-- As I say, I see people setting up businesses every day on the Internet that provide information on a global scale to various businesses and various enterprises, and it just doesn't seem to take that. much. money.

At a time when we're trying to bring down the level of deficit-spending so we can actually provide the medicine--provide the X-ray--that it seems like to me to--  The twenty billion-dollar expenditures is an awfully high price tag for something that the private sector seems to be doing and offering at a much lower rate.

Thank you very much.

Chairman Ben Quayle: Thank you.

Chairman Ben Quayle: Now I recognize the gentleman from Michigan, Mr. Benishek, for five minutes.

Rep. Dan Benishek: Thank you, Mr. Chairman.

Rep. Dan Benishek: I have a question. I'm a physician as well, and I've been familiar with several different electronic medical records, and some of them work better than others. I worked at the VA system, and that's a pretty good system as far as they go as far as I'm concerned.

My biggest concern really is this mandating implementation of electronic medical record that doesn't work as well as the VA system because many of the systems I've seen in the private sector are expensive, they are costly to maintain, and they don't do what we want them to do which is provide sort of a universal access to information, and I know in my practice we had electronic medical records, but we're still sending--trying to get a fax of an X-ray report because it's not available on this electronic medical record that I have. There's a lot of people in private practice that simple can't afford to spend 65,000 or 150,000 dollars on electronic medical records system for their practice, plus the 5,000-a-month maintenance fee for a system that doesn't produce.

So, I have a real problem with mandating implementation of a system that doesn't do what is--what--result that we want. And I think that frankly this interop-implementation or interoperability or--when you can't get a lab test because it was done in another hospital that your system is not--talk with, it wasn't worth that 150,000 dollars to me to have to tell my girl to have to get the get this test.

So, explain to me, why are we implementing it before it's universally interoperable?

Dr. Farzad Mostashari: So, I think your raising the issue of the up front costs and not just the cost for purchasing the system but also implementing it and changing the workflows and the challenges that are there--and you mentioned for a practice with a few physicians it can cost tens of thousands of dollars--that has been what has held back the adoption of electronic health records in the U.S.--and Congressman Rohrabacher's question about "What are we paying for?"--what we're paying for is providers, like yourself, to be able to be receiving the payment over a period of several years if they choose to adopt and meaningfully use the technologies. So--

Rep. Dan Benishek: But those payments-- That doesn't cover those costs.

OK, I've talked to-- Since I've been here in Congress, I've been talking to many small hospital administrators, they say, "Well, we got this one-time payment to implement this electronic medical record, but it's not going to cover what it's going to cost us, so I don't know what we're going to have to cut in order to comply with this rule, but our budget is not getting bigger with reimbursement. It's getting smaller, and this is a one-time payment we got for it, and now we have an ongoing cost associated with it that we're not being paid for.

So, it's very frustrating to me to hear a small critical-access hospital tell me this.

Dr. Farzad Mostashari: Sure.

Rep. Dan Benishek: Because they don't have any extra places to find money.

Dr. Farzad Mostashari: That-- There are-- One of the approaches that Congress took in HITECH was not to have the federal government procure the software, but to really leave it up to--  It's a market-based approach to let the hospitals and providers be the ones to choose what system works best for them, and there are a greatly expanded range, now, of software products, each with their own usability and the cost-structures, lease models, Web-based models and so forth that providers now can choose from.

And what we're seeing in practice is that the amount of the incentive payments has been sufficient to produce this great acceleration in the adoption of electronic health records.

Rep. Dan Benishek: Well, the people have implemented them because they're sort of terrified of the federal government cutting their reimbursement at that time to follow the rule. But as-- The people that I've talked to said they had to do it because the rule came in, but they're finding that their costs exceed what they're getting reimbursed.

To me, that's a problematic issue. I didn't hear any answers in any of your testimony to this part of the problem. Because I've seen it in real life myself, and have visited lots of hospitals, and what I just mentioned to you, you guys didn't talk about at all in any of your testimony. So it's a great concern to me.

It all sounds great. I want great medical records. It's great to have the medical record in your hand, but if the hospital goes broke, that access to care is not there either.

Dr. Farzad Mostashari: The...

Rep. Dan Benishek: I think my time is up, thanks.

Chairman Ben Quayle: Answer that?

Dr. Farzad Mostashari: Yeah, it-- The program is designed and legislation passed by Congress and in HITECH does not have a mandate that the-- It's a voluntary program, and if providers sign up for the program--as 75 percent of hospitals have already done, and more than half of providers have done--then they can earn the incentive payments, and if they don't it basically says that the government feels that Medicare is not getting 99 cents on the dollar value for the care that we are buying from the providers.

So, it is the way the legislation was set up, and I believe that it is an important step towards getting a national infrastructure that can public health, that can help research, and that can help patient care.

Chairman Ben Quayle: But-- Just-- I just want to be real clear-- But it is true that if you don't participate, you get cut your Medicare, Medicaid reimbursements. Is that correct?

Dr. Farzad Mostashari: Yes.

Chairman Ben Quayle: OK. Thank you.


  1. Additional coverage:

    Mostashari defends progress of meaningful use, interoperability
    Before a Congressional hearing, the National Coordinator for Health Information Technology defended the progress of the meaningful use, arguing that the pushing interoperability and standards-based exchange too aggressively would run the risk of alienating stakeholders in EHR Incentive Programs, chiefly providers and health IT vendors.