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1 Statement by Phyllis Teater on Health Information Technology and the Electronic Health Records Incentive Program submitted to the Committee on Ways and Means United States House of Representatives July 20, 2010 My name is Phyllis Teater, and I would like to thank Chairman Stark, Ranking Member Herger, and the other members of the Committee for having this hearing. I appreciate this opportunity to testify before the Committee today on the health information technology (HIT) electronic health record (EHR) incentive program. I am the Chief Information Officer at The Ohio State University Medical Center (OSUMC) which is part of The Ohio State University in Columbus, Ohio, one of the largest and most comprehensive institutions of higher learning in the United States. OSUMC is an academic medical center serving patients, students and our community to improve people s lives through personalized healthcare. The Medical Center is comprised of six hospitals with a capacity of 1,650 beds, and 53 ambulatory site locations. We have 2,269 full time faculty at the college of medicine and 12,000 total staff members at the medical center. In addition, the other Health Sciences are represented at OSU, including Colleges of Nursing, Pharmacy, Optometry, and Dentistry. OSUMC is a top ranked health system by US News and World Report, University Health System Consortium and the Leapfrog Group, which is a coalition of Fortune 500 employers seeking to improve the health of their employees and profitability of their firms. OSUMC is also a growing institution, caring for more than 1 million outpatients, 50,000 inpatients, and 120,000 emergency department visitors. In addition, OSUMC has created more than 3,700 new jobs in the past five years and is underway with a $1 billion construction initiative to build a new patient care facility that will create 15,000 new jobs and improve access to high-quality health care in Ohio. I am also here as a member of the Association of American Medical Colleges (AAMC), a notfor-profit association that represents all 131 accredited U.S. and 17 accredited Canadian medical schools; nearly 400 major teaching hospitals and health systems, including 68 Department of Veterans Affairs medical centers; and nearly 90 academic and scientific societies. Through these institutions and organizations, the AAMC represents nearly 110,000 clinical faculty members, 75,000 medical students, and 110,000 resident physicians. The Ohio State University Medical Center is a member of the AAMC. The nation s major teaching hospitals and medical schools see and value the potential of HIT to advance the nation s health care system by improving the quality of patient care, providing a valuable tool for research, and helping to teach the country s future physicians and other health care professionals. The EHR incentive funds are an important resource to all institutions, including those such as OSUMC that have already committed two decades or more and millions of dollars to the complex task of adopting and implementing an electronic health record system. For other providers who do not have a history of investment in electronic medical records and may find

2 implementation financially challenging, the incentives may be even more critical. Installing a new system to replace a paper record can be a much more difficult and costly endeavor than transitioning from an existing electronic system to a new electronic system. OSUMC serves as a tertiary care facility for many surrounding hospitals that would be unable to bring the benefits of electronic medical records to their patients without the promise of the EHR incentive funds. Today, I want to talk to you about how the importance of health information technology extends well beyond the adoption of electronic health records, but first I want to make some comments about the final rule that CMS recently published regarding incentives for meaningful use. I will begin by discussing two issues that we identified as major problems in the proposed rule, hospital-based eligible professionals and what I call the multi-campus problem and will then discuss some of the ways in which the final rule has been improved. Ohio State and the AAMC are pleased with the commitment by Congress and the Obama Administration to promoting HIT through the Medicare and Medicaid incentive program as set forth under the American Recovery and Reinvention Act (ARRA). Additionally, we are grateful that Congress passed subsequent legislation which clarified the application of the HIT incentive program to hospital-based eligible professionals, many of whom are faculty physicians. As a result, many additional health care professionals are eligible for incentive payments that would not have been eligible for incentives under the proposed rule. However, one decision CMS made in the final rule has reduced the number of hospitals that may be eligible to receive incentives; I am referring to CMS s decision not to recognize individual hospital campuses as distinct hospitals each eligible for meaningful use incentives when those hospitals are part of a hospital system with one Medicare provider number. The result of this position is contrary to Congressional and Administrative intent to provide incentives broadly, as meaningful use cannot be fully achieved unless all hospitals, health systems, and physicians adopt and implement electronic health records. As an example, a provider cannot exchange information with other providers through an HIE unless they themselves are electronic. This means that any provider that cannot afford to achieve the goals set forth by this Committee will constitute a hole in the electronic records for their patients, impacting patient care when their patients visit other providers. At OSUMC, we have a smaller hospital, University Hospital East, which is not able to receive an incentive due to this multi-campus exclusion since it functions under a common Medicare provider number with our main hospitals on Ohio State s campus. Located in an under-served community on the urban near east side of Columbus, Ohio, University Hospital East provides vital health services to a community affected disproportionately by heart disease, cancer, diabetes, and cerebrovascular disease. Statistics compiled by the Ohio Department of Health and the Columbus Health Department demonstrate that residents in the near east community served by University Hospital East have age-adjusted death rates from the above diseases up to 110% higher than the overall rate in Franklin County (county in which Columbus, OH is 2

3 located). Access to care, due to lack of insurance in the near east community, remains a concern as evidenced by an uninsured payor mix of 10.5% in addition to a disproportionate share percentage of 38.8%. In addition, the Medicare and Medicaid rates at University Hospital East are higher than other providers in central Ohio, at 30.9% and 27.5% respectively. University Hospital East is very involved in the community they serve. As an example, they work with the neighborhood schools to provide much-needed supplies for extra-curricular activities as well as with the Columbus Health Department in a program entitled Healthier Neighborhoods which works to improve community health. University Hospital East also hosts numerous community events, including a very well attended Community Health Day which is a health fair for local residents. University Hospital East is making a difference in its community and certainly represents the kind of provider the incentive program hopes to impact. Ohio State expects the difference in our incentive to be greater than $5 million because we cannot include University Hospital East in our calculation as a separate provider. This difference may impact the scope of HIT adoption at this hospital. This aspect of the proposed rule creates difficulty for all providers with multiple locations because the costs to deploy an electronic medical record are significantly higher at geographically disparate locations. EMR systems are frankly so invasive to the workflow of clinicians and providers that much of the programming is specific to a provider location. Questions like which patients belong to which unit and which clinic rooms constitute which care pods as well as which teams are responding to which code blues are programmed into the software to ensure that staff can respond to patient needs in a quick, safe, and efficient manner. Additionally in our case at OSUMC we have two emergency departments, one at University Hospital East and one at our main hospital campus. The programming for an emergency department, because of patient flow and critical response times, is highly dependent on the layout and specific staff of the emergency department. We will bear this overhead of programming emergency room workflows twice, however, our incentive payment will not reflect these additional costs as our two emergency departments count as one in the incentive calculation. These programming costs aside, the cost of training, support, and staffing impacts are inflationary by location. We will need a full training infrastructure including rooms, computers, trainers, and schedules at each location. Moving 12,000 staff through training at OSUMC is a daunting task in a 24 hour, seven day a week operation and we will need two sets of training infrastructure to address our multi-campus environment. Our support structure, both when the system is first used and also for ongoing support, will be significantly higher with two campuses. When a physician needs immediate support in performing a clinical function, we cannot ask him to wait while a support person gets in a car and drives to his location. Under the policy finalized by CMS, a health care system such as OSUMC with multiple hospitals, but a single Medicare provider number will be at a disadvantage, and ultimately may be subject to HIT penalties at the system level even if, for example, only one of the system s multiple hospitals was found not to be a meaningful user. CMS already looks at individual 3

4 hospitals within a hospital system for other payment purposes and could easily do so for this program as well. On other issues in the final rule, both OSUMC and the AAMC appreciate that CMS considered the thousands of public comments submitted on the proposed rule and that the final rule has adopted requirements that offer providers more flexibility to become meaningful users and receive incentive payments. In particular, we are pleased that the final rule has abandoned the all or nothing approach to meaningful use and that providers now have some choice in which meaningful use measures they report. Without this flexibility, the purpose of providing these funds would be stymied. At OSUMC, we had hopes that we would have been able to reach the previous higher bar for meaningful use, but it was quite challenging and again, we have been at this for over 20 years. I believe it would have been impossible and is, in fact, still quite challenging for other hospitals and providers, especially small and rural providers and critical access hospitals, to have met the requirements. That higher bar would have simply been out of reach and certainly prevented many of these providers from receiving any funds. We also appreciate the way CMS changed the process whereby meaningful use requirement thresholds will be met, thus reducing the administrative burden on OSUMC and other providers, and that CMS has signaled to providers and vendors some of what the Agency intends to require for the second stage of meaningful use. Additionally, CMS heard the problems associated with requiring the reporting of clinical quality measures that have not been specified for EHRs nor adequately tested. We appreciate that the final rule revised the hospital and physician quality reporting requirements by reducing the number of quality reporting measures for Stage 1 and adopting only those measures that have electronic specifications that are posted on the CMS website. Understanding the depth of OSUMC s commitment to HIT, and the breadth of our HIT activities may be helpful as you consider the totality of the rule. Our current implementation is a replacement for our inpatient system and a new implementation for our outpatient environment. This combined initiative is estimated at a cost of $100 million and we believe it will prepare us well for meaningful use. Our inpatient acquisition had been under discussion for three years, but was not funded until the spring of 2009 when the stimulus monies were announced. It is my belief those monies and the national commitment they represent provided the additional impetus needed for our project to be funded and begin. Our outpatient initiative was funded and began in 2006 and is still under way, but with the economic downturn, I believe we would have had to slow or perhaps even stop our rollout without the promise of the upcoming incentive funds to offset the cost. The implementation process here at OSUMC has been a true partnership between the health system, clinicians and staff. The outpatient electronic medical record is installed in 80% of our approximately 53 clinics and includes computerized physician order entry, electronic documentation, medication, allergy and problem lists, vital signs, physician office workflow, and 4

5 voice recognition capability. This system has been quite difficult to implement as it is a direct impact to the physician workflow in their clinic. We have seen a decrease in many clinics in physician productivity, most markedly during the live event, but in some practices it has been quite difficult to return to full productivity. A number of variables impact a physician s ability to return to full productivity including their new patient volume, number of support staff, and variability in patient population to name a few. These costs are some of the hidden costs that must be offset by the EHR incentive funding. In addition, OUSMC has a patient portal that is currently in use by approximately 10,000 patients. This portal provides online access for patients to communicate with their physician, review test results, request an appointment and refill a prescription. Our patients love this system and we believe we are seeing positive results as patients become more engaged in their care. We believe these systems position us well to achieve meaningful use for our eligible professionals and would allow us to qualify in the first period. Our estimated available incentive for our eligible professionals is $12 to $15 million. Our inpatient functionality currently includes physician order entry on an older system. This system is being replaced, bringing new functionality across the care continuum and automating some areas that are still on paper. This new system will link up to the outpatient system and provide a seamless view of our patients records across all care environments. In addition, the patient portal will expand to cross both inpatient and outpatient environments, as well as payment of co-pays and viewing of appointments. This system will also provide us the capability to share information with other providers through HIE functionality. These systems are set to go live in October 2011, achieving meaningful use for our hospitals. Our estimated available incentive for our hospital is $10 million under the multi-campus exclusion, but would be estimated at $15 million if we were able to report on our University Hospital East separately. While these patient care systems are the center of the discussions in the EHR incentive plan, at an academic medical center, HIT covers a spectrum of activities, including teaching, research, and a commitment to community involvement and education. An important component of our electronic medical record implementation has been to prepare the next generation of physicians and clinicians, as we teach residents, medical students, nurses and many other allied health providers how to care for patients in an electronic world as well as to meet new accreditation requirements. Our shared goal is that physicians and other clinicians just starting their training will never work in a world of illegible paper charts. This training mission is not without its own costs. Providing clinical skills labs that are outfitted with electronic medical record systems that utilize virtual patients, as well as providing specific teaching workflows in our live patient records system to allow students to interact with the care team on their clinical rounds in a safe and efficient manner, are two examples of additional costs that electronic health records bring to the teaching mission of academic medical centers. 5

6 The research mission of an academic medical center also has HIT as a cornerstone of its discovery of new knowledge. Without the electronic information surrounding the outcomes of patients to aid in comparative effectiveness research, discoveries are next to impossible due to the lack of discernable patterns in a paper world. The explosion of data and discoveries in the field of genetics would simply not be achievable without HIT. There are also many community services that are impacted by HIT. Ohio State is working with the Ohio Department of Regional Corrections (ODRC) to install an EMR in two primary care prison clinics in order to extend quality care to the inmates of Ohio. OSUMC has a telemedicine program with ODRC to provide physician specialty services to inmates. Ohio State also spends significant planning and resources to serve the multi-lingual nature of our community through electronic access to a wide range of interpretive services to ensure language barriers do not prevent access to care. The final rules released last week make many improvements over the proposed regulations, but continue to pose significant challenges to the nation s teaching hospitals and faculty physicians as we all invest time and resources in this technology to improve patient care and the efficiency of the delivery system. The Ohio State University Medical Center, the Association of American Medical Colleges, and the AAMC s other members will continue to serve in a leadership role working with Congress, the Administration, CMS and ONC to create an incentive program that helps all providers adopt the meaningful use of HIT. We again thank the Committee s members for their foresight in this area. I welcome any questions you may have. 6

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