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March 16, 2015
The Honorable Lamar Alexander
Chairman
Committee on Health, Education, Labor
and Pensions
United States Senate
Washington, DC 20510
The Honorable Patty Murray
Ranking Member
Committee on Health, Education, Labor, and
Pensions
United States Senate
Washington, DC 20510
Dear Chairman Alexander and Ranking Member Murray:
On behalf of the members and the Board of Directors of the Healthcare Information and
Management Systems Society (HIMSS) we respectfully submit the following recommendations
and comments related to the committee’s March 17, 2015, full committee hearing - America’s
Health IT Transformation: Translating the Promise of Electronic Health Records Into Better
Care. HIMSS is a cause-based, global enterprise producing health information technology (IT)
thought leadership, education, events, market research and media services around the world.
Founded in 1961, HIMSS encompasses more than 58,000 individuals, of which more than twothirds work in healthcare provider, governmental and not-for-profit organizations, plus over 640
corporations and over 400 not-for-profit partner organizations that share this cause.
Health IT is an essential foundational element required to transform our nation's healthcare
system from its current volume based structure to a value based system. Continued bipartisan
support and previous legislation, such as the Health Information Technology for Economic and
Clinical Health Act (HITECH Act) of 2009 (included in American Recovery and Reinvestment
Act of 2009), have enabled the increased use of health IT in the healthcare system. The
Meaningful Use (MU) Program, implemented as part of the HITECH Act, has substantially
increased the adoption of electronic health records (EHRs) among healthcare providers.
Furthermore, health information exchange (HIE) among providers and facilities is continuing to
increase at an unprecedented rate. The continued expansion of the health IT infrastructure and
capabilities will enable the necessary transformation of healthcare in America by encouraging
greater patient engagement and empowerment, expanding healthcare access, improving
healthcare quality, controlling costs, and improving the availability and utility of healthcare data.
Discussion
Overall, providers and IT professionals continue to strive to harness the power of IT to improve
the experience of care, improve the health of populations, and reduce per capita health care costs.
However, we are witnessing mounting frustration across the healthcare community that
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Department of Health and Human Services’ (HHS) expectations are not realistic. While we
champion a vision of coordinated care leading to a positively transformed health system in the
United States, we want to express our concerns that the road to that goal has become rocky, and
we offer solutions to address these concerns. We must minimize disruption of healthcare to
patients and avoid an undue burden on providers by coordinating across all federal agencies all
mandated programs and health IT requirements, and program changes affecting patients and the
operations of providers, payers, and health IT developers and vendors.
The Value of Health Information Technology
HIMSS provides resources and analytical tools to help the healthcare community measure the
benefits and value of health IT implementation, measure the nationwide progress of adoption,
identify best practices and pathways to preparedness for interoperability. Two specific tools that
quantify such benefits are the HIMSS’s Health IT Value Suite and the HIMSS Analytics’
Electronic Medical Record Adoption Model (EMRAM)SM1.
HIMSS’s Health IT Value Suite is a comprehensive knowledge repository that classifies,
quantifies, and articulates the clinical, financial, and business impact of IT investments by
hospitals, clinics, provider groups, and public health organizations. Of the more than 2,000 case
studies, approximately 85 percent report improved safety, quality of care, or achieved
efficiencies. Increased savings and cost avoidance have been reported in 65 percent of the
cases. The most significant systemic cost savings will come when the majority of providers have
adopted and are meaningfully using EHRs and can exchange information privately and
securely. Published research by well-respected analysts predicts that national investment in a
technologically-advanced healthcare information infrastructure will result in significant return on
investment and quality improvements.
HIMSS Analytics is the authoritative source on electronic medical record (EMR) adoption trends
and has devised the EMRAMSM to track EMR use at hospitals and ambulatory facilities. The
EMRAM model scores providers (which includes all non-federal hospitals in the US) in the
HIMSS Analytics® Database through an eight-stage model on their progress in moving from a
paper-based to a paperless patient record environment. This model provides a snapshot in time of
the status of EMRs by states. This analysis is based on hospital level data collected by HIMSS
Analytics with the cooperation of individual facilities.
Analysis of EMRAM scale reveals that beginning with the first incentive payments from the
Medicare and Medicaid Incentive Program in 2011, U.S. acute care hospitals achieving EMRAM
Stage 5 or Stage 6 have increased by more than 500 percent. Stage 7 hospitals – at the most
sophisticated, comprehensive level of health IT use – have increased by 300% from Q2 2011 to
Q4 2014. Hospitals at the very lowest Stages of 0, 1, 2, and 3 have correspondingly decreased by
at least 240%. The HIMSS Analytics EMRAM scale is the standard to measure hospitals’
adoption of health IT. This data clearly demonstrates that the HITECH Act is achieving its
intended result of encouraging increased implementation and meaningful use of EHRs among
hospitals. This monumental progress has been achieved in just less than four years of the MU
Program.
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HIMSS Analytics EMRAM information available online at: http://www.himssanalytics.org/emram/emram.aspx
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Important to note, HIMSS also calculates EMRAM scores on hospitals in Canada. Having no
EHR Incentive Program, Canada has experienced little if any movement in their EMRAM scores
over the same period of years.
Meaningful Use Program / EHR Incentive Program
Despite the clear progress and demonstrated value, we still have profound challenges creating
interoperability to exchange health information. HIMSS is helping answer questions such as:
How can healthcare providers more effectively and efficiently utilize the benefits of EHRs in
their day-to-day practice? Who has access to people’s sensitive health information? Lastly,
what is the best way to encourage and incentivize different EHR providers to share information
with each other? HIMSS has recommendations in each of these areas.
For eligible hospitals, eligible professionals, and critical access hospitals not in their first year of
the program, the 2015 requirements for 12 months of MU reporting are daunting. HIMSS has
consistently recommended that the MU Program must be reasonable and manageable for all
affected stakeholders. We have urged flexibility in the timeline, urged addressing certification
challenges, and expressed concern over the increasing fluidity of the quality reporting structure.
Such challenges present barriers to greater success in the program.
We are encouraged by CMS recent announcement that they will be providing flexibility for the
Meaningful Use 2015 Reporting Period in upcoming rulemaking. We remain committed to
working with the government and health IT stakeholders to providers and hospitals continue
their journey toward Meaningful Use.
As we prepare for MU Stage 3, we want to keep the government and the private sector focused
on practical and realistic expectations, thus enhancing the probability of achieving the intent of
the MU program in supporting healthcare transformation. We support the notion that the next
phase of the program should include a less prescriptive measure set that fosters data sharing and
programmatic growth.
As the Committee reviews the health IT landscape and reviews potential legislative updates,
HIMSS respectfully offers recommendations in the areas of Interoperable Data Exchange,
Patient Data Matching, Information Sharing Incentives, Patient Engagement, Telehealth
programs, and Payment Reform Models.
1. Enhance Interoperable Data Exchange Essential to Healthcare Transformation. The
ability to efficiently and securely exchange health information among healthcare stakeholders is
fundamental to promoting patient safety, achieving quality outcomes, and controlling costs.
Interoperability and standardization of data and transmission rules are essential to the exchange
of health information. As a nation we have not achieved the necessary level of standardization to
reap the full rewards of interoperability.
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Recommendations:
a. Ensure that existing data definitions and transmission standards are implemented
consistently nationwide and accelerate development of standards timed to support the
EHR Meaningful Use Incentive Program Stages
b. The federal agencies must be encouraged to take a leadership role to facilitate a publicprivate an accelerated collaborative effort to achieve the necessary level of
standardization.
2. Develop a Nationwide Consistent Patient Data Matching Strategy – Lack of a Strategy
is a Major Barrier to Widespread Interoperability.
Each year since the 1999 Omnibus Appropriations Act (PL 105-277) the Labor, Health and
Human Services, and Education appropriations bill has included a provision prohibiting
appropriated funds from being used “to promulgate or adopt any final standard…providing
for…a unique health identifier for an individual…until legislation is enacted specifically
approving the standard.” Since 1999, three successive administrations have interpreted the
Appropriations language to mean no study, no standards, and no criteria, i.e., not addressing the
issue at all. Others believe that the language simply means no attempt to finalize a rule or
solution until HHS reports to Congress on how any proposed solution will protect patient privacy
and security. HIMSS Continues to work with the HHS’s Chief Technology Officer on a
Nationwide Consistent Patient Data Matching Strategy.
An informed nationwide patient data matching strategy will enhance, not compromise, the
privacy and security of patient health information. Technological advances now allow for much
more sophisticated solutions to patient identity and privacy controls, including patient consent,
voluntary patient identifiers, metadata identification tagging, access credentialing, and
sophisticated algorithms.
Recommendations:
a. The FY16 Labor, Health and Human Services, Education, and Pension appropriations bill
should eliminate the prohibition on appropriated funds from being used to develop or
study a unique patient identifier.
b. The highest priority should be placed on developing nationwide consistent patient data
matching strategy by a public-private sector collaborative.
3. Create Incentives to Promote Health Information Sharing. Today, the technology exists
for secure sharing of health information. While there has been substantial progress to date,
including enhanced EHRs, developing and use of data and transmission standards, and HIE
capabilities, the lack of appropriate incentives for providers to share data is a prominent gap in
our healthcare delivery environment. Additionally, there is not yet legal clarity around who owns
the patient data. The patients think they own the data because it is about them; providers
sometimes act as though they own the data because they created it; and the payer/insurer
sometimes acts as though they own the data because they pay for some of the care.
Recommendations:
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a. Direct, on a priority basis, development of payment systems, starting with Medicare, that
reward providers for sharing decision making with patients, patient-centered care, and
better clinical quality outcomes.
b. Clarify once and for all, that the patient owns his or her own data and that providers and
payers have the legal obligation to share that data in accordance with the patient’s
directions.
c. Promote public and private incentives that encourage patient and provider utilization of
electronic health information, while also protecting the privacy and security of individual
health information.
4. Promote Patient Engagement and Empowerment to Control Costs and Improve
Quality. Patients must play a central and accountable role in their healthcare. Timely and
accurate health information is the fundamental enabler of this personal accountability. Health
information must be shared with patients to support patient-clinician collaboration and individual
responsibility for healthcare decisions. Patients must receive clear information about their health
status, healthcare costs and quality, and options for care. Health IT tools, including EHRs,
personal health records, electronic health information (EHI), mobile technologies, and data
infrastructure is critical to empowering patients to participate as essential, accountable members
of their care teams.
Recommendations:
a. Promote public and private incentives that encourage patient and provider utilization of
EHI, while also protecting the privacy and security of individuals’ health information.
b. Develop payment systems that reward providers for shared decision-making, patientcentered care, and better clinical quality outcomes.
c. Encourage public and private payers to make available EHR portals, personal health
records (PHRs), and payer based health records (PBHRs) for their beneficiaries that are
interoperable with EHRs across the community via standards-based HIE.
d. Support the use of health IT, portable technologies, and social media to promote
consumer awareness and participation and aid decision-making.
e. Facilitate the innovative development and operation of private and secure interoperable
systems that allow patients to view and contribute patient notes to their complete clinical
record, as well as control how the information is shared and/or used for secondary
purposes.
f. Support and enhance consumer engagement, health literacy, privacy and security, and
coordination with publicly-funded and other health programs.
5. Facilitate Nationwide Telehealth to Improve Access and Help Control Costs. In 2013,
Medicare reimbursed less than $12 million for telehealth due to limitations on telehealth
reimbursement.2 These limitations include allowable sites of care, allowable interface, state
licensing, and the lack of a federal standard. There is an ever-growing and complex body of
empirical evidence that attests to the potential of telemedicine for addressing problems of
2
Center for Telehealth and e-Health Law, http://ctel.org/2014/04/cms-reimburses-nearly-11-8-million-for-telehealth-in-2013/
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access to care, quality of care, and healthcare costs in the management of chronic
conditions.3
Telehealth technologies can eliminate travel time and reduce stress and expenses for the patient.
Telehealth also increases patient-to-clinician interaction and satisfaction. This increases patient
compliance, which leads to better clinical outcome at lower costs. For the past 25 years,
telehealth in the United States has enjoyed explosive growth despite major ongoing public and
private sector policy barriers.
Telehealth is good for the patients and can help improve the quality of care by leading to earlier
detection of disease and lessening patient delay in seeking care. Telehealth will save money
overall and supports the value proposition of quality care at a controlled or lower cost. By
expanding the definition of originating sites and recognizing advances in technology, CMS and
Congress begin to set the stage for continuity of care and not just episodic fee for service models.
Current restrictions overlook the value of information (such as patient generated data or other
types of platforms which store information for use later) that is not gathered during a videobased telemedicine visit. Patient generated health data is routinely highlighted as an enabler of
engaged, patient centric models of healthcare.
Recommendations:
a. Direct CMS to address issues associated with existing definitions of technology for the
purpose of telehealth interventions.
b. Eliminate the restrictions contained in Section 1834(m) of the Social Security Act which
greatly limit patient and provider access to telehealth technologies and, in effect result in
increased overall costs and limit access to care.
c. Expand reimbursement mechanisms including for live (real-time) voice and video
between clinicians and between clinicians and patients, and expand approved bundled
payment models.
d. Amend the allowable sites of care beyond those currently stipulated by CMS to include
interactions with patients from wherever the patient is located, including the home. Such
included sites of care beyond hospitals.
e. Update Current Procedural Terminology (CPT; maintained by the American Medical
Association) and Healthcare Common Procedure Coding System (HCPCS; maintained by
CMS) to explicitly cover in-home monitoring or clinician/patient non-centralized
exchanges, including shared decision making for Medicare and Medicaid enrollees.
f. Support enhanced broadband access for rural and underserved populations.
g. Facilitate the harmonization of the varying federal and state privacy laws and regulations
related to personal health information.
6. Utilize Health IT Essential to Updating Healthcare Payment Models. Prospective
Payment Programs need to be enhanced by moving to value-based purchasing systems enabled
by health IT. Healthcare payment models must be improved to encourage the delivery of high
3
Bashshur, Rashid L., et al. "The empirical foundations of telemedicine interventions for chronic disease management." Telemedicine and e-Health 20.9
(2014): 769-800.
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quality healthcare, help control costs, and promote system-wide sustainability, including a valuebased purchasing structure (e.g. outcomes-based payment, aggregated risk-shifting and shared
savings/risk models, bundled payments, capitation, and accountable-care organizations for public
and private payers who require health IT systems to function).
Recommendation:
Direct the Administration to begin immediately evaluating the Medicare Payment
Structure to facilitate health IT-enabled, value-based, and risk-sharing healthcare
purchasing mechanisms to take advantage of updating healthcare payment models
including telehealth.
Health IT Stimulates the U.S. Economy through Health IT.
Finally, as we move forward with health IT supporting healthcare transformation, we must not
lose sight on the impact health IT has on the economy. Health IT supports workforce
development in the U.S. and exports opportunities abroad. The Bureau of Labor Statistics
expects a need for thousands of new health IT jobs over the next decade. Workforce
development programs need visibility and connection to the Administration’s programs on job
creation and Congressional support for funding to expand community college, university-based,
and non-profit programs. Policymakers need to work with non-profit associations and the
business community to launch and support internships, apprenticeships, and fellowships that give
students and transitioning professional’s real-world experience. Federal agencies should work
with U.S. companies, healthcare organizations, and non-profit associations to document lessons
and best practices from the MU Program and apply them to overseas markets.
Conclusion.
HIMSS supports more rigorous congressional oversight of the Meaningful Use Program and
achieving nationwide interoperability as appropriate. HIMSS has consistently expressed its
strong support for a more flexible approach to interoperability in the Meaningful Use Program
Stage 3 soon to be released by the Administration. As Congress moves forward, we encourage
any new legislation should focus on improving telehealth, payment reform including incentives
for sharing information, and cybersecurity protections. However, any legislative approach
should maintain the existing MU programmatic structure, not be overly prescriptive or technical,
and not stifle innovation.
HIMSS appreciates the opportunity to share our perspective on some of the many challenges to
transforming healthcare in America. We look forward to continuing the dialogue between our
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members and the Committee to ensure the continued success of health IT as a transformational
force in the betterment of healthcare for all Americans. Please address questions to Richard M.
Hodge, HIMSS Senior Director of Congressional Affairs at 703-562-8847.
Sincerely,
Paul Kleeberg, MD, FAAFP, FHIMSS
Chair, HIMSS Board of Directors
Chief Medical Informatics Officer, Stratis Health
and Clinical Director, Regional Extension
Assistance Center for HIT (REACH)
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H. Stephen Lieber, CAE
President/CEO