Statement of Testimony of David G. Schulke Executive Vice President, The American Health Quality Association Submitted June 17, 2004 to the Subcommittee on Health Committee on Ways and Means I am David Schulke, Executive Vice President of The American Health Quality Association (AHQA) which represents the national infrastructure of Quality Improvement Organizations (QIOs). The QIOs are a national quality infrastructure whose primary mission is to monitor and measurably improve the quality of health care delivered to Medicare beneficiaries and the general public by taking evidence-based health practices from the bookshelf to the bedside. QIOs, under contract with the Centers for Medicare & Medicaid Services (CMS), concentrate on systems of care, rather than the care delivered to individual patients. This systems approach improves the quality of care for all Americans receiving services from providers at health facilities that work with QIOs. The QIOs have become systems change experts focusing on effective ways to bring about transformational change in our health care system. We believe that, when implemented effectively, one of the areas that holds great promise for truly transforming our health care system and improving the quality of care is health information technology (IT). We applaud the Subcommittee for your work over the past few years that has recognized the inherent potential of IT, and we support your efforts to promote its widespread adoption and use. As you know, however, while the promise of IT is great, its proliferation to date is not. To this end, I am pleased to say that beginning next year, the QIOs in all 50 states and the U.S. territories will begin to focus intensively on promoting the adoption, implementation and effective use of health information technology, starting with small to medium-sized physician offices. Thanks in large part to the Chairman Johnson, a promising effort led by the California QIO, Lumetra, is already underway to develop and implement a successful model for achieving these aims. The Medicare Modernization Act promotes and supports IT adoption and use in several ways. In particular, Section 649 advances a previously unavailable avenue for promoting adoption and effective use – payment incentives for providers and practitioners to adopt and use IT to achieve better quality care. Under the Doctor’s Office Quality – Information Technology project, or DOQ-IT, which was codified and improved by Section 649, the QIOs in California, Utah, Massachusetts and Arkansas are working together to develop a model for improving office efficiency and patient outcomes by assisting small to medium-sized physician offices in their implementation of Electronic Health Record (EHR) systems. These QIOs are also working to ensure that practices use their EHR systems to the fullest capacity so that ultimately, physicians can use clinical data reports to monitor and improve their performance in several key areas of health care. In keeping with the Institute of Medicine’s Crossing the Quality Chasm report, the primary aim of this model is to provide no-cost support and assistance to providers such that their IT systems help them improve patient safety and quality of care through the practice of evidence-based medicine. Those that do improve can be eligible for additional reimbursement from CMS. QIOs have found overwhelming support for this endeavor from key national organizations such as the American Medical Association, the American Academy of Family Physicians, the American College of Physicians, the eHealth Initiative and the National Council on Quality Assurance. High level consensus to support the success of the QIOs’ work in this area is critical, and we have received not only support, but a high degree of teamwork and consensus building from these organizations. However, given the promise of positive outcomes, one of the questions we must consider today is why, when academic evidence exists that points to the ability of information technology to improve patient safety and health care quality, and to potentially hold down costs, is adoption so low? And how do we accelerate it? To be sure, several barriers play a key role in preventing health care providers and practitioners from adopting and using IT. Lack of standards, upfront capital investment, perceived high physician time costs and difficulty integrating a new system into a physician’s workflow and care process are obvious sources of resistance. The focus of my testimony today will be in the area of what the QIOs can bring to bear in helping to overcome some of these key barriers. QIOs serve as a national infrastructure for quality improvement in health care. These private sector organizations have strong local relationships with the providers and practitioners in their states. It is these relationships, coupled with the unique mix of skill sets, expertise, adaptability and proven track record of success that will enable the QIO infrastructure to help overcome some of the barriers inherent to the widespread use of information technology in health care – particularly in the area of implementation. As Health Information Technology Coordinator Dr. David Brailer wrote in a research paper published by the California HealthCare Foundation last fall, “Unless substantial support is given, physicians will not be able to configure their systems, train for their use, integrate them into their workflow, and support the transition of their staff. In other words, if left alone, most physicians will fail at CPR [computerized patient record] implementation.” In looking at those health care organizations that have not failed, but who have succeeded in implementing IT and in actually improving patient safety, patient outcomes and health care quality, we find that they share at least one thing in common – the resources and effort up front to assess problems and inefficiencies in their practices and to subsequently redesign the way they manage and deliver care in order to address those issues. In other words, these successful organizations have utilized IT as a catalyzing path to the solution, but not the solution in and of itself. Why is this process of systems redesign so important? Because simply buying an expensive IT system to integrate with an existing system that is inefficient and produces poor quality will only make for an expensive, inefficient and poor quality system. We must remember that the fundamental goal of IT is to achieve better quality outcomes for patients; its promise lies not in simply automating current practices, but in transforming them. To achieve this goal, providers and practitioners need support – support that goes far beyond what IT vendors can and typically do provide. They need support from systems change experts who can help ensure that core processes are redesigned with the aim of quality and efficiency in mind. Providers also need support to ensure that they are utilizing their IT system to its fullest capacity, helping them engage in the type of care management that improves quality. A 2003 research study by Drs. Miller and Sims of the University of California, San Francisco regarding the implementation of Electronic Medical Records (EMRs) indicates that the more time physicians invest in learning the system, making practice changes to complement the EMR and reorganizing their exam rooms and office workflows, the more financial and quality benefits they receive from EMR implementation. But perhaps the largest barrier in this area is a lack of resources to invest such time and energy. In fact, studies indicate that one of the largest barriers to IT adoption, after financial resources, is high physician time costs and physician resistance (Brailer and Terasawa, 2003. Miller and Sims, 2003). This is one of the primary areas in which QIOs can contribute. QIOs serve as a no-cost resource of systems change experts who, thanks to the DOQ-IT project, will have studied the most effective methods for IT implementation and will apply those methods in their work with providers. It is our hope that QIOs offering these supportive resources will help make significant headway toward overcoming some of the key barriers to adoption and implementation of IT – particularly by helping to decrease demands on physician time, improve workflow and care process redesign, and decrease productivity loss associated with such redesign. In other words, we believe that this additional assistance can ultimately result in more widespread adoption and effective use of IT. Finally, we must also be mindful of one potential adverse effect of promoting IT adoption and use. If left alone, without significant support or resources, it is likely that the locus of IT adoption will be limited to large physician group practices and health systems, creating a kind of digital divide where the promise of quality and efficiency offered by IT is realized only by those with the resources to support the level of effort required for effective implementation and use. Referring again to the research paper written by Dr. Brailer, the rate of adoption in large urban areas appears to be one and a half times greater than in smaller, non-urban areas. The size of the physician practice also plays a key role. As Dr. Brailer notes, “…there are separate concerns about the growing CPR adoption gap between large, urban organizations and their smaller, non-urban counterparts.” Importantly, QIOs can also play a mitigating role in this area by focusing initially on small to medium-sized physician offices. By utilizing their existing local relationships with these providers and practitioners, QIOs will work to encourage IT adoption and subsequently provide the kind of additional support these offices need in the area of planning, implementation and improvement. As QIOs achieve successes, we also hope to offer assistance to larger practices in the ambulatory setting and to providers of varying size and location in the inpatient setting. On behalf of the national network of QIOs, we fully support your work to promote the widespread use of IT to improve health care quality in America. We agree that health information technology holds great promise for improving patient safety and outcomes when implemented in a way that is integrated with care management and workflow changes. We urge the Subcommittee to support innovative and effective models for supplying the assistance that providers and practitioners need to ensure that IT delivers on its promise of transforming quality in our health care system.