Paul C. Tang, MD
Epic Systems Corporation
and
Palo Alto
Medical Foundation
Thank you for inviting me to testify on this very important NCVHS activity to develop recommendations regarding computer-based patient records.
I know many of you already, but since I last presented before the full committee, I have changed jobs, and I will be speaking from my new responsibilities today. I am currently Vice President of Epic Research Institute, a division of Epic Systems Corporation. Epic is a vendor of health care information systems, including computer-based patient record systems (CPR systems). I also serve as Medical Director of Clinical Informatics at the Palo Alto Medical Foundation, a 200-member multi-specialty group practice affiliated with Sutter Health. Sutter Health is a large nonprofit integrated health system in California. My role between the two organizations is to bridge the needs of health-care provider organizations with the tools developed by information technology suppliers. In this role, I hope to accelerate the transfer of technology tools to help providers serve the health needs of our covered population.
I look at your Work Group as trying to accomplish a similar objective – to accelerate the pace with which information tools are applied to improve the effectiveness and efficiency of the US health care system.
My interpretation of what the HIPAA legislation asks of NCVHS is for a set of recommendations for how the federal government can accelerate the development and use of computer-based patient records serving patient care, research, and public health. The legislation talks of standards for data. After reviewing the list of presenters at this two-day hearing, I was certain that the need for specific data standards would be addressed thoroughly. Consequently, for my contribution, I thought I would take a broader approach to the term “standards,” and concentrate on your question about the role of government.
I do believe there is a definite role for government in bringing about the routine use of CPRs and the data standards necessary for them to inter-operate. Let me suggest three potential roles:
The first approach is for government to set the bar for health care – for those who provide care, those who receive care, those who pay for care, and those who measure care. The common denominators for the health-care industry are quality and cost. Government can exert its influence, and effect change in all sectors of health care, by influencing either of these common denominators. So far, government has been effecting change primarily on the cost side, through setting reimbursement rates and conducting billing compliance audits (both of which have had far-reaching effects). Since I am a firm believer that if we measure and improve quality, cost will decrease, I will concentrate on quality today.
As a public health trustee, government could require, or cause to be required, reporting on quality using standardized measures. Naturally, standardized reporting will require standardized data and their exchange. But, I think a mostly private sector effort in collaboration with government, can work out the details for the individual standards provided it is driven by a timeline (such as those provided in legislation or reimbursement policies). As in many human endeavors, deadlines are necessary and good.
I believe the effect of national standards for quality measurement will cascade down to reward providers by giving them a tool to attract and retain consumers in a way that benefits the health of the population – by competing on quality. For example, General Motors has demonstrated the market power of providing consumers with data by setting HMO performance expectations and measuring health plans against those expectations. Using a rigorous review program, including site visits, GM scores HMOs based on quality and cost (weighted 50/50). They use the scores to set employee contributions for each plan. They publish the reports on their employee Web site and employees use the information to choose their health plan. Year by year, GM employees have migrated from lower quality plans to higher quality plans. Using standardized data, consumers, the ultimate beneficiaries, can reward provider groups for their efforts in service and information. In effect, I am proposing that the government set precise quality reporting standards, and let the needs accelerate a public/private process of creating specific data-content standards.
The next way government can effect change is through incentives. Probably one of the biggest impediments to the rapid deployment of CPR systems is the fact that the cost of implementing CPRs are not being shared by all those who benefit. That is, the risks are not well aligned with the rewards. Let me illustrate with an example. It is well known that giving flu vaccines to people over 64 years old reduces admissions, reduces mortality, and reduces costs –- by approximately one-half in each of those parameters. Yet, despite our best intents, and our perceived exemplary execution as health-care providers, we immunize approximately one-half of the eligible population. We also know, because of the work of people like Dr. McDonald and others, that providers’ behaviors do change, when reminded of their intent at the point of care. And that it makes a difference in all the above metrics. What’s wrong with this picture? The primary entities that pay for the system, say for example the capital-enabled hospitals and the capital-challenged provider groups, may not benefit directly from the savings achieved through this simple intervention. In the hybrid health-care reimbursement system – neither fee-for-service nor capitated – hospitals live largely under discounted per-diem rates, a system that does not necessarily reward fewer admissions. We also do not have a well-defined mechanism for some of the major beneficiaries (e.g., payors) to share in the costs of implementing or maintaining CPR systems which house the data upon which we all depend. As the largest payor in healthcare, government could provide incentives for providers to gather and report on their compliance with quality standards. Sharing the cost of implementing and maintaining CPR systems among a broader segment of the beneficiaries would accelerate the dissemination of this tool.
A third way government can accelerate the pace of change is to jump in and just do it. Perhaps nothing works better to get real work done real fast than a real project under a hard deadline. For example, I look at the GCPR project as a standards acceleration project. It was established in response to a federal mandate, in the form of a presidential directive, to develop a comprehensive, life-long medical record for those who served in the military. To execute this directive, the DoD, VA, and IHS have established a project to accelerate the development of standards to help them exchange data between the DoD and VA health information systems. I think the project-driven nature of this standards-development effort helps focus its scope on the needs of the application and will hopefully speed the delivery of useable standards. Having funding for the project doesn’t hurt, either. The GCPR project is a good example of a goal-oriented project that is driving the creation of standards in collaboration with the private sector. Here again, deadlines and funding are enablers.
In summary, I believe that the sooner we put credible, meaningful, standardized data in the hands of all beneficiaries of health data (including consumers), the better we can deliver appropriate care to patients. I see an important role for government in catalyzing the flight to quality. Government could: 1) set the bar for quality with precise, standardized reporting requirements, 2) implement mechanisms to reward collection of quality-driven data, and 3) initiate and fund projects that require the use of data standards.
I applaud your efforts to accelerate the deployment and use of computer-based patient records. Like you, I believe routine use of CPRs can fundamentally change health care in this country by facilitating the delivery of patient care, the creation of new knowledge, and the development of rational public policies. Thank you for the opportunity to provide input to your process.