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IsMeaningfulUseDeliveringMeaningfulResults? AnExaminationofHealthInformationTechnologyStandardsandInteroperability SubcommitteeonTechnologyandInnovationoftheCommitteeonScience,SpaceandTechnology U.S.HouseofRepresentatives,November14,2012

SummaryoftheTestimonyofMarcProbst,ChiefInformationOfficerandVicePresidentofInformation Systems,IntermountainHealthcare MynameisMarcProbst,andIamtheChiefInformationOfficerandVicePresidentforInformationSystemsat IntermountainHealthcare,anonprofitintegratedhealthsysteminSaltLakeCity,Utah.Iamalsoanappointed memberoftheHealthInformationTechnologyPolicyCommittee(HITPC). WithrespecttothefirstquestionposedintheSubcommittee'sletter,whichaskswhatprogresshasbeenmadeasa resultoftheHITECHActtowardsgreaterhealthinformationtechnology(HIT)interoperability,myanswerisyes, progresshasbeenmade,butitisonlyabeginning.Wemustsetaclearroadmapandsupportanexchange infrastructureandtheadoptionofstandardsthatwillmakeiteasiertosharehealthinformationsocliniciansand patientshavetheinformationintheformandtimetheyneedittomakeappropriatehealthcaredecisions.Presently, welackasharedinfrastructureandlongtermplantomakethispossible. TheAustralianrailroadprovidesausefulexampleoftheimportanceofstandards.InAustralia,railroadsdeveloped independently,onebyone.Whiletrainsandtracksdidgetbuilt,therailroadsystemwasconstructedwithmany differentgaugesofrail,preventingrailroadcarsononesetoftracksfromrunningonothers.Aftermanyyearsof subpartrainservice,expensiveworkarounds,andincreasingcosts,Australiadefinedastandardgaugesystem.The processofstandardizingthegaugeswasexpensiveanddisruptive,butefficienciescontinuetoberealizedtoday. ThereareparallelsbetweentheAustralianrailroadexperienceandAmericasHITexperience.OntheHITPC,work beganalmostimmediately,andrequirementswerecreatedwiththegoaltoincreasetheMeaningfulUseofelectronic healthrecords(EHRs)acrossthecountry.ThevastmajorityoftheseMeaningfulUserequirementsdealwithfunctions thatanEHRshouldbeabletoperformandrequirementsforwhatfunctionsordatashouldbesharedbetweenEHRs. TheexistingHITsystems,betheyvendordevelopedorselfdeveloped,alsowerebuiltonebyoneandapplied differingstandards(thegreatthingabouthealthcarestandardsistherearesomanytochoosefrom).Althoughvery effectiveforeachinstitution,heroicsarerequiredtoshareevenbasicdatabetweenthem.Wenowessentiallyhave ourownAustralianrailroadandfixingitwillrequireleadershipandinvestment. ThegoalsofARRAandMeaningfulUseofhealthinformationtechnology(HIT)encourageaccelerationoftheadoption ofElectronicHealthRecordtechnologyinourcountry.MeaningfulUseandcertificationrequirementshavestartedus downthatroad.TheHITPCandONChavefocusedonleveragingavailabletechnologiestosignificantlyadvancethe gatheringofdigitaldataandincrementallyintroducestandardstosupportinteroperability.Whilecontinuingto supportthecurrentmomentumcreatedbyMeaningfulUse,wemustleveragealloftheexpertiseinthefederal governmenttodevelopalongrangeplanandarchitectureforanationalhealthcareinformationtechnology infrastructureandoutlinethepathwaytocomprehensiveuseofmeaningfulstandardsthatfacilitatenational interoperability.Thiswillimprovehealthcaredeliveryquality,andsignificantlylowerhealthcarecosts.Successfully achievingthattransitionwillalsorequiresignificantadvancedplanning,phasingandeducationalsupportofhealth careprovidersastheychangesystemsandworkflowstoadoptthenewstandards. Ibelievewithtrueleadershipandacommitmentforlongrangeplanningandsupportfortransitions,appropriate standardsandexchangeinfrastructurecanbedefinedandimplemented.Ifthisisdone,innovationinHITwill skyrocket,costsfortechnologyandaccesstoknowledgewillbesignificantlyreducedandqualitycareacrossthe countrywillimprove.

Is Meaningful Use Delivering Meaningful Results?:

An Examination of Health Information Technology Standards and Interoperability

SubcommitteeonTechnologyandInnovationoftheCommitteeonScience,SpaceandTechnology U.S.HouseofRepresentatives November14,2012 MarcProbst,ChiefInformationOfficerandVicePresidentofInformationSystems IntermountainHealthcare www.intermountainhealthcare.org

IsMeaningfulUseDeliveringMeaningfulResults?: AnExaminationofHealthInformationTechnologyStandardsandInteroperability SubcommitteeonTechnologyandInnovationoftheCommitteeonScience,SpaceandTechnology U.S.HouseofRepresentatives November14,2012 TestimonyofMarcProbst,ChiefInformationOfficerandVicePresidentofInformationSystems, IntermountainHealthcare MynameisMarcProbst,andIamtheChiefInformationOfficerandVicePresidentforInformation SystemsatIntermountainHealthcareinSaltLakeCity,Utah.Intermountainisanonprofitintegrated healthsystemthatoperates22hospitalsinUtahandIdaho;morethan185clinics;andaninsurance plan,SelectHealth,whichcoversapproximately500,000livesinUtah.IntermountainsMedicalGroup employsapproximately900physicians,andabout4,000otherphysiciansareaffiliatedwith Intermountain.Intermountainhasabout33,000employees. Nationally,Intermountainisknownforprovidinghighqualitycareatsustainablecosts.Onewaywe achievethisisbyidentifyingbestclinicalpracticesandapplyingthemconsistently.Researchreviewed byDr.JohnWennbergofDartmouthshowedthatIntermountainisthebestmodelinthecountryof howyoucanactuallychangehealthcareforthebetter.Dartmouthestimatedthatifhealthcarewere deliverednationallyinthewayitisprovidedatIntermountain,thenationcouldreducehealthcare spendingforacuteandchronicillnessesbymorethan40%.EssentialtoIntermountainsabilityto deliverhighvaluecoordinatedpatientcareistheeffectiveuseofhealthinformationtechnology. InadditiontomyworkasIntermountainsCIO,IamalsoanappointedmemberoftheHealth InformationTechnologyPolicyCommittee(HITPC),createdbytheAmericanRecoveryandReinvestment ActtoadvisetheNationalCoordinatorforHealthInformationTechnology,currentlyDr.Farzad Mostashari,withrespecttotheimplementationofanationwidehealthinformationtechnology infrastructurethatpermitstheelectronicexchangeanduseofhealthinformation.Iamproudtobea memberofthishardworkinganddedicatedadvisorycommittee.Lastweek,Iattendedthe42ndin personmeetingoftheHITPChereinWashington. IwanttothankChairmanQuayleandothermembersoftheSubcommitteeforholdingthishearingand invitingmetotestify.Withrespecttothefirstquestionposedinyourletter,whichaskswhatprogress hasbeenmadeasaresultoftheHITECHActtowardsgreaterhealthinformationtechnology(HIT) interoperability,myanswerisyes,progresshasbeenmade,butthisprogressmustbethoughtfully accelerated.Wemustleveragealloftheexpertiseinthefederalgovernmenttoacceleratetheadoption ofstandardsthatwillmakeiteasiertosharehealthinformationsocliniciansandpatientshavethe informationintheformandtimetheyneedittomakeappropriatehealthcaredecisions.Presently,we lackasharedinfrastructurethatwillmakethisinteroperabilitypossible. AreportissuedrecentlybytheInstituteofMedicine(IOM)entitledBestCareatLowerCosthighlights thissituationandcallsforadramatictransformationinhealthcaredelivery,sayingAmericashealth

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caresystemhasbecomefartoocomplexandcostlytocontinuebusinessasusual.TheIOMsfirst recommendation(TheDigitalInfrastructure)focusesontheimportanceofhealthinformationsystems andhighlightsacrucialaspectoftheirdevelopmentthatistoooftenoverlookedtheissueof interoperability.Willtheindividualsystemsthatarecreatedbeabletoworktogetherefficiently? Itsanenormouslyimportantissueforhealthcarebroadly,anditwilldeterminehoweffectivethose systemscanbeonanationallevel.Atpresent,healthcareprovidersacrossthecountryarecreatingor enhancingtheirhealthinformationsystems.Insomecases,likeoursatIntermountainHealthcare,those systemshavealonghistory;webeganinstitutingelectronicmedicalrecords40yearsago.Othersare earlyinthejourney.Butallarebeingdevelopedessentiallyfortheirowninternalneeds.Interoperability istoolowoneveryonesprioritylistandrequiresnationwideplanningandcoordination. Fivehealthcareproviderswhohavebeenintheforefrontofusingelectronicmedicalrecordshavebeen collaboratingonthecreationofaCareConnectivityConsortiumtopioneertheeffectiveconnectivityof electronicpatientinformationacrosstheirsystems.ThosefiveareIntermountainHealthcare(basedin Utah),GeisingerHealthSystem(Pennsylvania),GroupHealthCooperative(Washington),Kaiser Permanente(California),andMayoClinic(Minnesota).Buteventhisgroundbreakingeffortwillresultin amultiprovidernetwork,notanationalone. WhilewearealreadylearningagreatdealfromtheCareConnectivityConsortiumandthatlearningcan bebroadlyshared,itsanationalnetworkthatweultimatelyneed.Onlyatrulynationalnetworkwill allowtheefficienttransmissionofsecurepatientinformationtobestservepatientsinmultipleways.It willservethemwhentheymove(changingdoctorsorproviders,travelingtemporarilyorrelocating permanently);itwillenablebestpracticestobesharedacrossthecountry;anditwillallowthebroadest researchandlearningtoadvancehealthcaredelivery.Itwilltrulyallow,allshipstorise. TheIOMreportrecommends,inpart,thefollowing:TheNationalCoordinatorforHealthInformation Technology,digitaltechnologydevelopers,andstandardsorganizationsshouldensurethatthedigital infrastructurecapturesanddeliversthecoredataelementsandinteroperabilityneededtosupport bettercare,systemimprovement,andthegenerationofnewknowledge.Herestandardsettingisthe key,andagoodanalogyfortheproblemcanbeseenintheevolutionoftherailroadinAustralia. InAustralia,railroadsdevelopedindependently,onebyone:someformovingnaturalresourceslike coal;othersforcarryingfreight,andstillothersfortransportingpeople.Whiletrainsandtracksdidget built,therailroadsystemwasnotconstructedwithcommonstandards.Manydifferentgaugesof railroadevolved,preventingrailroadcarsononesetoftracksfromrunningonothers. Toovercomethisobviouschallenge,therailroadsbuiltnewstationsandinventednewcontraptionsto movecargofromonesetoftraincarstoanother.Theywerecleverindeed;excellentengineering,for sure;andIveincludedsomepicturesoftheworkaroundsinmytestimony.Buttobesure,each contraptionandtransferstationslowedthetransportationsystemdown,addedriskofproductloss,and increasedthecostofshippingbyrail.Aftermanyyearsofsubpartrainserviceandincreasingcosts,

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Australiadefinedastandardgaugeforitstrainsystem.Itwaslikelyahugeexpensetomakethischange, buttheefficienciesgainedcontinuetoberealizedtoday. TheparallelisobviousforAmericashealthinformationtechnology.Weneednationalstandardsto ensure,astheIOMrecommends,thatthedigitalinfrastructurecapturesanddeliversthecoredata elementsandinteroperabilityneeded.Thefederalgovernmenthasmadeamajorinvestmentin electronicmedicalrecords,havingcommitted$20billionfromthestimulusbilltoit.Wemustnow ensurethat,asthecapacitiesofmanyindividualprovidersgrow,theyevolveintoanefficientand effectivenationalnetwork. WhileIamnotrepresentingithere,asnotedearlier,IserveasamemberoftheHealthInformation TechnologyPolicyCommittee(HITPC).TheHITPCisahardworking,dedicated,experienced,and intelligentvolunteergroup.Ihavebeenhonoredtoserveonthiscommitteewithsuchfineindividuals. ThefirsttaskoftheHITPCwastodefineMeaningfulUseandtherequirementsforcertificationof electronichealthrecords(EHRs).Workbeganalmostimmediately,andtherequirementswerecreated withthegoaltoincreasetheMeaningfulUseofEHRacrossthecountry.Themajorityofthese requirementsdealwithfunctionsthatanEHRshouldbeabletoperformandrequirementsforwhat functionsordatashouldbesharedbetweenEHRs.Itistimenow,however,fortheHITPCtofocusmore onthelongertermplanandactivitiesoutsideofMeaningfulUsethatareneededtofulfillourmandate providedinARRAtomakerecommendationstotheNationalCoordinatorrelatingtothe implementationofanationwidehealthinformationtechnologyinfrastructure. ItshouldbenotedthattheefforttoachieveMeaningfulUseishard.Itisdifficulttodevelopandadopt electronichealthrecordsthatdoallthatwewantthemtodo,areeasyenoughtousethatclinicianswill usethem,andthatmaintainandimprovethepatientprivacythatissoimportant. Indeed,despiteIntermountainslonghistoryofsuccessusingelectronichealthrecordsandour sophisticatedandlargelyselfdevelopedinformationsystems,Intermountainhasnotyetreceived MeaningfulUsepayments.Intermountainisontrack,however,toreceiveourfirstMeaningfulUse paymentsnextyear,andwehaveaplaninplacetoearnthemaximumMeaningfulUsepayments achievable.Moreimportantly,frankly,ourplanwillallowustoavertthepenaltiesforfailingtoachieve MeaningfulUse. IsharethisIntermountainexampletohighlighttwoimportantfacts:Achievingtherequirementsofthe MeaningfulUseprogramisnoteasy,andtheMeaningfulUseprogramhasveryrealpenaltiesattached toit.ProvidersandspecificallyCIOsacrossthecountryareincreasinglyfeelingthepressureswhich MeaningfulUseiscreating.CoupledwithprogramssuchasAccountableCareOrganizations,ICD10 requirementsandtheneedtoensureprivacyandsecurityofnewlycreatedpetabytesofdata,thelack ofcomprehensivestandardsisexacerbatingthechallengesofHITacrossthecountry.Whatmayseem likesmallstepsrequiredbyMeaningfulUse,areactuallybigeffortsforproviderorganizationsandifnot donecorrectlywillnotonlyfailtoachievegreaterefficienciesforhealthcare,butcouldultimatelycreate lesssecureandlesssafehealthcaredelivery.ThestagesforMeaningfulUsestartedfastandcontinueto berolledoutataveryquickpace.TheworkeffortswhichMeaningfulUsedefinesinmanyaspectsare
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cumulativeandwedoneedtobecarefulthatfuturestagessuchasMeaningfulUseStage3are appropriatelytimedtoallowthemajorityofourhealthsystemtodoallthatisbeingaskedofitthrough thesetransformativetimes.Becauseofthedifficultyandcomplexityoftheprogram,Iamconcerned thattheRequestforCommentonStage3isexpectedtobereleasedthismonthwhilesomanyhospitals andphysiciansarestilltryingtoachieveStage1,andtheStage2finalrulewasonlyofficiallypublishedin September.Ialsoworryaboutthoseproviderswhohavefewertechnicalresourcesthan Intermountain,andstartedfromalowerlevelITadoptionwhowillbeleftbehind?Withrespectto theSubcommitteessecondquestionaboutlessonslearnedfromStage1informingStage2and suggestionsforStage3,itisstructurallyimpossibletofullybenefitfromlessonslearnedinearlierstages whentheMeaningfulUsetimelineissocompressed.Further,everyonecouldlearnfromasystematic, independentevaluationofexperiencetodatethatlooksattheimpactonsubgroups,suchasruraland frontierproviders ThegoalsofARRAandMeaningfulUseofHealthInformationTechnology(HIT)encourageaccelerationofthe adoptionofElectronicHealthRecordtechnologyinourcountry.MeaningfulUseandcertificationrequirements havebeensuccessfulinachievingthesegoals.TheHITPCandONChavefocusedonleveragingavailable technologiestosignificantlyadvancethegatheringofdigitaldataandincrementallyintroducestandardsto supportinteroperability.WhilecontinuingtosupportthecurrentmomentumcreatedbyMeaningfulUse,we mustalsofocusondevelopmentofalongrangeplanandarchitectureforanationalhealthcareinformation technologyinfrastructureanddevelopthepathtocomprehensivemeaningfulstandardsthatcanfacilitate nationalinteroperability,whichwillimprovehealthcaredeliveryquality,andsignificantlylowerhealthcare costs. AtoneHITPCmeetingnottoolongagoIstatedtherewereprobably510actions,whichcouldbeledby theHITPCandotherswithexpertiseinthefederalgovernment,thatifdonecorrectlycoulddramatically improvehealthcareintheUnitedStates,achievingthegoalsoflowercost,increasedaccess,andhigher quality.Theseactions(seethesevenenumerateditemsbelow)remainvalidbutrequirethefederal governmenttodefine,set,andenforceacoresetofstandards(recalltherailgaugeinAustralia).Many ofthesestandardsalreadyexistandcouldbeselectedquickly.Othersmayrequireashorttimeto finalize.Clearly,wehaveseenthatvolunteerprocessescantakedecadestodefineandselectstandards thisismuchoftheproblemandthebasisforwhyIbelievefederalleadershipisrequiredforsuccess. Ibelievewithtrueleadershipandacommitmentforlongrangeplanningandsupportfortransitions, appropriatestandardsandexchangeinfrastructurecanbedefinedandimplemented.Ifthisisdone, innovationinHITwillskyrocket,costsforinteroperabilityandaccesstoknowledgewillbesignificantly reduced,andqualitycareacrossthecountrywillimprove.SoinresponsetoQuestion3aboutthe effectivenessofHHSandONCinestablishinglongtermgoalsandbenchmarksforHITadoption, interoperability,andprovisionofcare,importantworkhasbeendone,butthereismuchmoretodo. AsforQuestion4,whichasksforrecommendationsforfederalpolicymakers,theareasIbelieveshould befocusedon,wherestandardsshouldbedefinedandimplementedinclude(andthislistmaynotbe exhaustive):

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 1.Standardterminologies. 2.Detailedclinicalmodels. 3.Standardclinicaldataquerylanguagebasedonthemodelsandterminology. 4.Standardsforsecurity(standardrolesandstandardsfornamingoftypesofprotecteddata). 5.StandardApplicationProgramInterfaces. 6.Standardsforexpressingclinicaldecisionsupportalgorithms. 7.Patientidentifiers. Withtrueleadershipandfunding,basedontheexcellentworkthathasbeenperformedalready,I believethesestandardscouldbedefined,developed,andmechanismsformanagementputinplace. OrganizationssuchasHL7(HealthLevel7)havelaidmuchofthegroundwork.Oncedefinedand developed,withmechanismsforsupportandmanagementinplace,realisticbutaggressivedatesshould besetforadoption.Successfullyachievingthattransitionwillrequiresignificantadvancedplanning,phasing andeducationalsupportofhealthcareprovidersastheychangesystemsandworkflowstoadoptthenew standards.Mysuggestionwouldbe10yearstogivevendors,healthsystems,andotherdevelopersthe timetochangetechnologiestomeetthesestandards.Hasteisnotwiseinthehealthinformation technologyarena. Australiahadavision,onethatwouldcostmoneyandtaketime(andlikelywasmoredisruptivethan helpfulduringthetransition),butlogicassuredthatbymakingtheneededchanges,railwaysinthe countrywouldbeefficient,savemoney,andimproveservice.TheUnitedStatescanhaveasimilar visionthatwillbedisruptiveandcostlybutwilllaythefoundationforhealthcarequalityimprovements andcostsavingsforgenerationstocome. IbelievethatitwouldbeappropriatefortheHealthInformationTechnologyPolicyCommitteeandthe HealthInformationTechnologyStandardsCommitteetobechargedwiththemissiontofocusonthe developmentandadoptionofcomprehensivestandardsacrosstheindustrystandardsthatwould improvepatientcareandallowinteroperabilitybetweensystemsandproviders.Thiswouldthenallow theeffortstoachieveMeaningfulUsetoreachtheirfullpotential. Informationandinformationsystemsinhealthcarehavetremendouscapabilitiestoimprovepatient care.Movingfrompaperbasedtodigitalsystems,asencouragedthroughtheeffortstowardMeaningful Use,isacrucialstepinfacilitatingthesharingofknowledge,butlongtermplanningandongoing supportforwidespreaduseofadequatestandardsareneededtoallowfortheubiquitoussharingof dataand,ultimately,enhancedknowledge.Thepotentialisenormous,ifwesetthestandardsthatwill providecommontracksonwhichthisrailroadofinformationwillrun. Thankyouagainfortheopportunitytoparticipateintodayshearing.Ilookforwardtoworkingwiththe SubcommitteeandallwhoarecommittedtothesuccessfuladoptionofnationalHITstandardsandthe realizationofasharedinfrastructurethatwillenablenationalinteroperability.

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Contacts
MarcProbst ChiefInformationOffice/VicePresident IntermountainHealthcare 36SouthStateStreet SaltLakeCity,UT84111 W(801)4422000 marc.probst@imail.org www.intermountainhealthcare.org BillBarnes DirectorFederalGovernmentRelations IntermountainHealthcare 36SouthStateStreet SaltLakeCity,UT84111 W(801)4423240 bill.barnes@imail.org KarenS.Sealander McDermottWill&EmeryLLP 500N.CapitolStreet,NW Washington,DC20001 W(202)7568024 ksealander@mwe.com

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RailGaugeinAustralia

Variationsingaugestandardshavebeena problemforoverahundredyears.

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Marc Probst
Chief Information Officer & Vice President Information Systems Intermountain Healthcare, Salt Lake City, UT

MarcProbstistheChiefInformationOfficerandVicePresidentatIntermountain Healthcare,anintegrateddeliverynetwork(IDN)basedinSaltLakeCity,Utah. Additionally,MarchasbeenappointedtoserveontheFederalHealthcareInformation TechnologyPolicyCommitteewhichisassistingindevelopingHITPolicyfortheU.S. Government. MarchasbeeninvolvedwithInformationTechnologyandHealthcareservicesforthe past23years.PriortoIntermountain,MarcwasaPartnerwithtwolargeprofessional serviceorganizations;DeloitteConsultingandErnst&Young,servinghealthcare providerandpayerorganizations.Marchassignificantinterestintheuseofinformation technologytoincreasepatientcarequalityandlowerthecostsofcare.Heis experiencedininformationtechnologyplanning,design,development,deploymentand operation. MarcisaBoardMemberoftheUtahHealthInformationNetwork(UHIN)aswellasa BoardMemberoftheUtahFoodBank. MarcisaresidentofUtah.PriortolivinginUtah,MarcandhisfamilylivedinReston, VirginiaandinTampa,Florida.Marcismarriedwith5childrenwhospaninagefrom27 yearsoldto7. MarcisagraduateoftheUniversityofUtahwherehestudiedFinanceandhehasan MBAfromGeorgeWashingtonUniversity.

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