Witness Testimony

I would like to thank Chairman Bilirakis, Representatives Barton and Dingell, and the other members of the Subcommittee on Health for this opportunity to address you regarding Health Information Technology and the role that the federal government can play in facilitating its efficient and effective deployment in this country. I come to you both as a physician who has taught and practiced in academic hospitals and clinics and as a biomedical computer scientist with extensive experience in the design, development, and implementation of clinical information systems. A fellow of the American College of Medical Informatics, I have served on the Board of Regents of the American College of Physicians and on a variety of government advisory groups, including the President's Information Technology Advisory Committee and the National Committee for Vital and Health Statistics. After spending 30 years at Stanford University, I currently am at Columbia University's medical school where I chair a department of biomedical informatics. Our faculty members have built, and continue to be responsible for, the management of a variety of successful and heavily used clinical systems at the NewYork Presbyterian Hospital.

Those of us who have worked with health care information technology are pleased by the recent attention that has been directed at this topic, both within government and in the private sector. The unfulfilled promise of information technology in support of health and health care has been clear to some of us for many years, and those in the field have often been dismayed to see a widening gap between the implementation of information technology solutions to pressing problems in other segments of society contrasted with their limited penetration into health care settings. On the other hand, a variety of factors have recently combined to heighten our awareness of what is possible and of the need for active intervention and promotion of solutions. I know I speak for others in the health care computing community when I say that we are grateful for that recognition and eager to help in any way that we can.

As I reflect on the past five years, I see a number of forces that have come together to create the current enthusiasm for health information technology solutions. Simply stated, these are safety and quality, costs, and privacy. Although the health care community has long been concerned with all three of these issues, certain recent landmarks events greatly broadened our awareness of their dependence on information technology solutions:

• A series of three influential reports from the Institute of Medicine ("To Err is Human", "Crossing the Quality Chasm", and "Patient Safety: Achieving a New Standard of Care"), all of which made strong cases for the role of IT in addressing problems with medical errors and enhancing patient safety
• Federal advisory activities, including seminal contributions from the Workgroup on the Health Information Infrastructure from the National Committee on Vital and Health Statistics (NCVHS) and two important sets of recommendations (first in 2001, then again this year) from the subcommittees on health within the President's Information Technology Advisory Committee (PITAC)
• Employer concerns regarding the burgeoning costs of health care, leading to the creation of the Leapfrog Group and its active promotion of more effective implementation and use of information technology in health care settings
• The privacy, security, and transaction rules that were announced by DHHS in response to the requirements of the 1996 Health Insurance Portability and Accountability Act (HIPAA) and that in many respects require informed technological solutions in order to be compliant
• The influence of the Internet and the World Wide Web, which has greatly increased the access to health information by the public and transformed their familiarity with, and expectations of, health information technology in the settings where they seek care.

The list could be much longer, and would certainly include the large number of recent reports, from a variety of public and private sources, that reiterate and refine the recommendations that have come before. Seldom have I seen more consensus on the need for action and the promise that awaits us if we do this right.

But, as always, the devil is in the details, and that is the challenge faced by all groups with a stake in enhancing the use of information technology in health care: Dr. Brailer in his new role as National Health Information Technology Coordinator, hospitals and other provider organizations, payers, and individual health professionals. I realize that the Congress is particularly concerned with what role the federal government can and should play in encouraging more effective and efficient implementation and use of the technologies that we discuss today. My colleagues on this panel will have addressed this issue in some detail, illuminating for you both the promise and the challenges that face us and the opportunities for effective federal and other governmental action.

I would like to highlight the perspective of the individual physician who practices in this country, recognizing that they are an important element in any solution that we propose but that their ability to participate effectively is highly constrained. If I may, then, don my physician's hat for a moment, setting aside my activist interests as a health computing professional, I believe that there a variety of important issues that need to be understood and considered in formulating any incentive programs or implementation plans for health care IT. Recommendations for federal action follow in part from these observations.

First bear in mind that the vast majority of health care in this country is provided by physicians in ambulatory settings, and most commonly in relatively small offices. Our view of what is needed cannot be overly skewed by the perspectives of those who practice in large, multispecialty practices or in clinics associated with academic medical centers. Although well implemented IT in a single institution can provide major quality and cost benefits for that entity, it is in the integrated penetration of health care IT throughout essentially all practice settings that the nation's health stands to gain the most. This means creating an infrastructure, both regional and national, into which all practice settings can tie, but also helping the individual practices to make wise decisions and investments.

Viewed from the perspective of a clinician in a small office, the issues we discuss today are overwhelming in many respects. It is too easy to say that physicians are simply resistant to change or overly committed to antiquated approaches to data management. We see many examples, in fact, where clinicians have embraced new technologies rather quickly. But information technology presents some special problems for practitioners. It is not their area of expertise, and they are uncertain how to evaluate the options that are provided to them. It is not a part of their education, and seems foreign to the major thrusts of their professional interests. System implementations are often disruptive to office operations, at least in transition, and too often physicians find that major investments have resulted in inadequate systems solutions that fail to meet expectations, integrate poorly with other systems, or are difficult to adapt to the special needs of a particular practice.

Physicians need help in making informed choices and in dealing with the logistical and financial hurdles that have until now often made it unattractive for them to invest in IT solutions. Many physicians tell me that they have no innate objection to electronic medical records, decision support technologies, or other aspects of office automation, but they do not know where to start and are not sure that they can justify the expense for the benefits gained. There is no certification process that allows them to be sure that a product that is offered is compliant with emerging national standards for connectivity, data storage and exchange, privacy, and security. Indeed, such standards are still evolving and there is as yet no coherent and well-accepted process for bringing such standards to a broad consensus that allows all stakeholders to adopt and comply with them. Consultants often seem as confused by the options as the physicians are, and the expensive failures of "recommended systems" are legendary. It is small wonder that clinicians are looking elsewhere for assistance.

In addition, the arguments for implementation of health care IT are too often viewed by clinicians as being primarily directed at health systems, payers, and patients, with much less direct benefit appreciated by the physicians themselves. They understandably ask why, in a financial environment characterized by significant regulatory and reimbursement challenges for physicians in practice, the doctor should be asked to invest in medical record systems whose primary systemic beneficiaries are elsewhere. This misalignment of fiscal incentives is often cited as a major barrier to widespread dissemination of information technology into the practice settings where, ironically, the primary data are gathered and where decision-support capabilities could most beneficially be utilized. Solutions need to recognize that physician offices are not only sources of key information (required by payers, health policy makers, researchers, and large institutions), but also vitally important users of information that a robust information infrastructure could be delivering directly to their practice settings - rural, suburban, inner-city, or academic. When physicians experience clear benefits from their IT investments, and see efficiencies and cost savings as well as enhancements to information access, a major barrier to suitable investments will have been overcome.

The problems being discussed today, and the exciting opportunities that will accompany their solution, are clearly much broader than the single issue of how best to distribute information technologies into individual practice settings. Yet there are several steps that federal agencies could take in facilitating solutions to the issues I have identified.

First, there must be a suitable alignment of financial incentives so that those who most benefit from the investment in health care IT are the ones who are expected to invest most heavily in its dissemination and implementation.

Second, federally facilitated programs to enhance the process for setting and adopting standards (a shared public-private effort) are sorely needed.

Third, a mechanism for assuring rigorous certification of vendor-provided solutions is required so that individual purchasers can be assured that a given product is compliant with the emerging requirements of a National Health Information Infrastructure.

Fourth, we must recognize that expertise in health care information technology is more than expertise in information technology itself. There is an important, unique discipline at the intersection of health care and computer systems, and we need to nurture the training of experts who can be the researchers, designers, developers, implementers, and evaluators of health information technology in the future. Short-term programs to enhance the production of such individuals are needed, as well as increased support for academic training programs and well-defined career pathways. The National Library of Medicine has been a leader in this area, but its resources for training are limited and the nation's need far exceeds the ability of current NLM programs to produce the people who can provide the leadership we need in this burgeoning area.

Members of the subcommittee, I am pleased to have had a chance to share some of these thoughts with you today and welcome the opportunity to answer any questions you may have regarding my testimony.