January 12, 2004 Remarks of Senator Hillary Rodham Clinton on The Health Information for Quality Improvement Act As Prepared for Delivery Thank you so much Dr. Pardes-the New York Presbyterian system has done so much in the area that I'll be talking about today. In fact so many of New York hospitals and others are so far ahead of the curve on quality that we have got to bring the rest of the system up to speed to support and reward you, and to emulate the work you have done. And with the research and work that Jim Tallon, Karen Davis, and others have done and will do in this area, New York really should become the white hot center from which the issues I discuss today will spread all over the country. Today I'd like to talk in some detail about improving the quality of our health care system to enhance affordability and accountability. We have the most advanced medical system in human history--the finest medical institutions, the newest treatments, the best trained health care professionals. Through medical breakthroughs, the development of vaccines, new drugs, and public health efforts we have nearly eliminated many of the major life-threatening diseases of the past-smallpox, malaria, polio. New York's hospitals and academic medical centers have, from the very beginning, been leaders in these achievements. In the 1930's, one of the first modern clinical trials happened in New York City at Bellevue, spelling the dawn of a scientific revolution for medicine. There are many accomplishments that have come with this scientific revolution. The Director of the NIH recently testified that we've reduced the mortality of acute heart disease and stroke by more than 50 percent in the last few decades, while new cancer therapies have prolonged life to the point that over 9 million people are now cancer survivors in our country. In the course of a few decades we have dramatically increased life expectancy. And through the human genome project we have mapped the code of life. Soon therapies will be tailored to the individuals, given their particular risk profiles and genetic features. We are on the cusp of incredible breakthroughs that are likely to radically reshape medicine over the coming decades. But, as everyone here knows, our health care system is far from perfect. While we can boast the best medical advances in human history, it can sometimes feel like we also have one of the most complex and confused systems of health care. When provider, patients and purchasers, alike, look at our health care system it can seem fragmented, redundant, inefficient, and bureaucratic. Yet, often we focus all of our effort on quantity-getting more money for coverage, and more people covered. These are critically important issues, issues that I have long been involved with. But I believe that we need to examine the quality of the health care system overall, as well. The aspects of the system that hamper quality improvement-the complexity and inefficiency of the system--contribute to the rising costs of healthcare. And clearly, these costs are spiraling out of control. Right now, health spending accounts for 15% of the nation's economy, and is expected to exceed 17% by 2012. Just last week, HHS said the health care spending increase last year was the largest in more than a decade. To put it in real dollar amounts, in 2002 we spent $1.55 trillion on health costs - that's $5,440 a person. Unfortunately, a lot of this money is being spent on bureaucracy and not on improving patient care. The American Hospital Association found that for every hour spent on patient care, an additional half an hour at least was required to fill out paperwork. It's wasting time, and money. Administrative costs alone consume up to 25 cents out of every health care dollar. We need to change so that doctor and nurse can focus on the relationship that matters most - the relationship with their patient. The health care delivery system should be designed to serve that relationship, but instead it is creating distractions, and as a result, patients suffer. According to a recent study in the New England Journal of Medicine, patients in the U.S. are receiving the care they should only 55% of the time. For example routine peak flow measurements are conducted in only 28 percent of pediatric patients with asthma. And only ½ of diabetics receive an annual eye exam. With paperwork and increasing financial pressures, providers are being asked to see more and more patients, with less and less time for consult, even as the flood of new scientific discoveries means clinicians must stay on top of exponentially increasing medical knowledge. But instead of helping clinicians manage their information needs, the fragmentation of our health care system poses barriers to communication between hospitals and practices, and between practices and research facilities. With the push of a button, a doctor should be able to receive the latest scientific articles along with his patient's chart, or prescribe a medicine and send it to the pharmacy. But often, the systems are not in place for them to do so. These barriers to communication don't serve physicians, and they don't serve patients either. I recently heard a story about a family from Maryland that was visiting New York when their child, who has hydrocephalus -- or water on the brain -- became sick. This child has a shunt, and anytime a child with this type of shunt becomes sick, the first thing to rule out is shunt malfunction. That requires comparing a C.T. scan of the head with older scans. Thankfully for the child, the parents carried old films with them. They take them everywhere they go - on vacation, on day trips, everywhere. The surgeon was able to see the change clearly, and the shunt was quickly replaced. But in this day and age, should a child's life depend on whether his parents remembered to pack his CAT scans along with his toothbrush? Clearly, we need a better way to share information, so that a patient in New York can have access to test scans done in Maryland. We need a secure and accurate system that enables communication while protecting privacy. But it's not just patients who are affected by the fragmented system. Providers deal with the resulting problems everyday. Imagine you're a physician in the ER and a patient comes in with symptoms of depression. He's never been to your hospital before, so you spend an hour getting faxed copies of his paper chart from his primary physician's office. Even then, the record is incomplete, poorly organized, and barely readable, being Xeroxed and faxed multiple times - not to mention being written by another doctor. You talk to the patient and he doesn't remember his medications. You're left trying to determine the best medication to give him without knowing what has and hasn't worked in the past for him. You give him a prescription, send him home and arrange for follow-up with his primary physician. Two days later, the patient shows up again, only with a high fever and toxic symptoms. This time, he brings his medication list. After painstakingly looking up each drug in the Physicians' Desk Reference, and running a Medline search and tracking down a journal article, you find a potential interaction between the new medication you prescribed and one of his old meds. You immediately admit him to the hospital for an expensive stay that could have been avoided. This scenario occurs all too often in our hospitals today. What our medical system requires of providers is a little like asking pilots to routinely land planes without any information from the control tower. They are denied critical information and then are asked to make life and death decisions. We need a better way to share information. We need a better system so that physicians have at their fingertips all the information they need to do their job - including patient history, the latest research, drug interactions, and everything else they need. Clinical decision tools, like hand-held computers, exist that would allow doctors to pull up the latest research information immediately, right at the bedside. We spend billions of dollars a year in medical research at NIH to produce that information; but it is worthless unless the doctor can retrieve it at the bedside. In a recent test of one particular hand-held, 50% of the physicians who were surveyed reported that use of the device prevented 1-2 errors per week and saved physicians significant time. But without widespread adoption of these needed tools, doctors, nurses, and hospitals will have to continue propping the health care system up, preventing utter collapse by sheer, heroic, force of will. Rather than clinicians supporting the system, we should build a system that supports clinicians so they can in turn support patients. I believe information is the answer. Information, in the hands of the right people, at the right time, drives quality and value. We need to empower patients and health care providers to make the right choices. And to do that, health care decision makers-providers, payers, and patients -- need to have access to the right information, where and when it is needed, securely and privately. Information technology has radically changed business and other aspects of American life. It has radically changed the workplace, and improved our productivity. It's time we use the power of the information age to improve health care. If we do, I believe we can radically improve the quality of care we all receive in this country. Average information technology spending per employee among all U.S. industries is nearly $7,000 per year. The banking sector spends almost $15,000 per employee. Yet health care invests only $3000 per employee per year on IT. Despite evidence that greater investments could yield monetary returns for society at large, as well as individual providers, the health care industry has been slow to adopt. In the coming year, I will be working on legislation that will change our health care system, not only to improve the quality of care, but to make it more affordable in the long-run. I hope to increase the amount of information generated in and about our health care system, improve the dissemination of that information to everyone who needs it, and help to build the IT infrastructure that will make that possible. To accomplish these goals, my legislation incorporates a 5 point plan 1) Increase research on quality of care. Approximately 80% of the care delivered today is not backed by clinical research. It is physicians doing their best, often in the absence of solid data. That is why we need to do more research, and see if the care we provide today has sound justification in science. Part of that is doing more comparative, or head-to-head, trials of drugs and other therapies, so consumers can decide based on which drugs are the most effective, not which ones are most advertised. And research should not just focus on the newest surgery or drug to improve care. My bill will task HHS to also focus research on the very system designs I speak of today, and on reengineering of workflows in the Operating Room, and on better methods for organizing nursing care. 2) Provide the public with a standardized reporting system that allows consumers to reliably compare provider performance Right now, hospitals use different measures - or none at all - to evaluate their performance. We need standard, consensus measures for hospitals, physicians, and long-term care facilities in all states, so that the information they report can be compared to the performance of their counterparts across the country. Agency for Healthcare Research and Quality, Medicare, the hospital association, the National Quality Forum and others have begun to create these standardized quality measures. I propose to ensure that this work continues, particularly in the 20 areas the Institute of Medicine has identified as priorities. My bill also directs the federal government to lead by example, adopting these standardized measures, and ending the current confusion that occurs when FDA, Medicare, Medicaid, the VA, and the DOD use different standards. New York's health care sector leads the nation in so many areas, and quality reporting is no exception. Twelve years ago, New York began a revolutionary program of public reporting on heart bypass surgery, and just last year New York issued it's first statewide hospital report card. In this early stage of public reporting, NY's hospital report card and coronary surgery reports rely on less-than-perfect data -- sometimes from billing forms--because better clinical data is not in electronic form. In addition to developing and adopting standardized measures, steps that I propose include: Ensuring that more clinical information is in electronic form so that it is easier for hospitals and providers to collect, And risk-adjusting the data so that we do not penalize the doctors and facilities that treat sicker patients. New York is making the effort, and my proposal would give them the tools to do it right. 3) We need to build an information technology infrastructure that enables information sharing. Despite numerous studies showing the advantages of information technology systems, some hospitals and physician offices are understandably wary of spending millions of dollars on systems that may not talk to other systems, or that might become obsolete in a few years. Federal leadership is needed to encourage the adoption of health care information technology that promotes interoperability, assures affordability, and reduces barriers to IT adoption. In 2002, 90% of the primary care physicians in Sweden were using an electronic health record, nearly 60% in the U.K, but only 17% in the U.S. While only a small percentage of providers use electronic records, those of you who do find you can't transfer records from one hospital system to another, or to an outside pharmacy, lab or physician's office. Something as simple as the lack of common terminology can stand in the way - which is an example of why "interoperability" standards are so crucial. A patient with high blood pressure could be coded in one computer as having "elevated" blood pressure, while another might coded as having "hypertension." Government must lead by example and push the development of interoperability standards, so that all systems speak the same language, and electronic health records in New York can be read in Maryland. One of the many goals of implementing an interoperable electronic information system is to reduce paperwork, which will save time and money. Most of the paperwork is duplication, as physicians have to document patient information in the clinical record, then again for the insurance forms, then again for public health reporting. By using electronic records, paperwork can be all but eliminated, allowing physicians to spend more time with patients while cutting the costs of paper-based records. An efficient Healthcare Consumer Response assessment study claims that electronic information systems could cut processing costs in half, which total $23 billion. Government must lead by improving its own information systems. Now, when three different parts of the federal government -- say FDA, CMS, CDC -- ask for information, they may ask for it in different forms. So a provider has to generate 3 different reports. My bill would assure that all federal agencies adopted interoperability standards so that one piece of information or one report can be understood by all the agencies who need it. The government should also help ensure that IT is affordable, for small or rural providers, and for safety net providers. I've supported funding this, perhaps through a revolving loan fund, and I think we should be encouraging innovation in business models for how to make this affordable -- maybe instead of having to purchase an entire system, then upgrading when that is obsolete, the professional societies could offer a subscriber service, and a small office could pay a flat fee each month. Finally, I believe that sometimes government can serve a very important role simply by getting out of the way. Let's write in safe harbors, so that the health care industry knows from the outset that electronic health records don't violate antitrust, or anti-kickback laws. Let's assure people that innovation won't trigger regulation. 4) We should give patients and providers information in real time so they can make effective decisions The success of our health care system depends on patients taking charge of their care, and becoming active participants in maintaining their health. Yet patients often lack the tools to do this. We need to give patients the information, including access to their health record, and the tools to manage their care better and communicate more efficiently with their health providers. For example, my legislation encourages telemedicine, and promotes methods for patients to communicate with their doctors by secure email when visits are unnecessary. Similarly, it supports moving toward a system where patients can get their lab results online, record their daily blood sugar levels in their electronic record, receive prompts to take their asthma medication, and check reliable health websites at the touch of a button. Consumer advocates and others have looked at the effect of electronic information on patient health outcomes and patient privacy. Many health outcomes improve, and an information age health care system has the potential to actually allow patients to protect their privacy even more securely than they can today. My legislation taps that capacity for increased privacy by establishing authentication and security standards that would allow patients to control, and know exactly who has accessed their files. Let me be clear, we must ensure privacy of these systems, or they will undermine the trust they are designed to create. We also need a better system to get information to the health professionals so that they can make the right clinical decisions. Studies have shown some procedures are performed even when the patients have not met commonly accepted criteria for the procedure. For example, an article in the February 2000 issue of Obstetrics & Gynecology, found that of all the non-emergent, non-cancerous hysterectomies performed in this country, only 30% percent meet the full medical criteria for necessity. On the flip side, in situations where the benefits of an intervention are clear, many patients do not receive the recommended care. Very few hospitalized patients at-risk for bacterial pneumonia get the vaccine during their hospital stay. Yet research shows that when physicians receive computerized reminders in many of these areas, statistics improve dramatically. These can take the form of an alert in the electronic health record that shows the hospitalized patient's record shows no previous pneumonia vaccine. Of course patients should never receive cookie-cutter care. But in areas where evidence is clear, care should not vary illogically from place to place. My legislation orders a study to look at the question of where we need more clinical guidelines, as well as areas not susceptible to guidelines, and how to foster, standardize, and disseminate guidelines when they are appropriate. And because the legislation encourages interoperability standards, my plan will ensure that the guidelines that do exist can be downloaded in a form compatible with your hand-held or computer, no matter what system you have purchased. 5) Move toward rewarding performance. Today what I am calling for is simple. Let's do the research on medicine that can improve health outcomes, let's measure those health outcomes-with appropriate risk adjustment, share that information with patients, providers, and insurers, and ultimately, let's pay for performance. One out of every 7 dollars in our economy is spent on health care. This bill will help us become better purchasers of care, and help us take the first steps toward aligning the incentives so that higher quality is rewarded. Medicare has done some pilots to test out how this might work. The chairman of MedPAC, the expert panel that advises Congress on Medicare payments, has concluded that Medicare's payment system is at best neutral and, in some cases, negative, in terms of quality. We must do better, and my bill will establish more demonstrations and evaluations of payment methods in Medicare and the private sector that incentivize quality. This five-point plan represents the first steps leading to a vision of health care, one where we've eliminated repeat tests and x-rays, one where the complete medical record is always available, and clinicians have practice guidelines and research results at their fingertips. Let me take a minute to quickly describe some of the benefits of this streamlined and modern system. For the benefits are great, and go far beyond the obvious benefit of improved health care quality. This will help the economy, not just in health care, but in all sectors. With high-quality health care, made more affordable for employers, U.S. businesses will be more competitive, and more productive. I have found that employers and businesses don't mind paying as much if they know they are paying for the best care-and that's why they'll send their employers to New York for treatment! But let me return to the immediate benefit that will arise from increased efficiency of the system. For every American who is worried about rising premium costs, which have increased for U.S. families by 50% since 2000, for every taxpayer who is looking at the state and federal budget growth for Medicaid and Medicare, health care quality is the truly promising place to look for health care savings. Investment now can produce enormous future gains. By reducing paperwork and by ensuring better, safer and often cheaper medical procedures and drugs, we will help lower the spiraling costs in the health care system. Those spiraling costs are contributing to the higher and higher premiums that every American is paying. It is my hope that real cost savings will be realized by every player in the American health care system, including consumers. It's too early for precise estimates but the order of magnitude is clear. Studies have concluded that tens to hundreds of billions of dollars each year could be gained in efficiency. If we can just capture a portion of that money, we could go a long way to solving the problem of the uninsured-which, as you know, is another health care problem I haven't given up on either. The list of potential benefits that make health care more affordable is long and impressive: Eliminate duplicative x-rays and tests Reduce paperwork, pay for less staffing to handle claims, and handling medical records, less money for the paper storage minimize expensive repeat episodes reduce medical errors and therefore decreased malpractice costs. This bill liberates health professionals from the burdens of administration and litigation and allows them to do what they want and what they're trained to do-improve patient health. As great as these savings are, if they come at the expense of privacy, they are not worth the cost. Health privacy is the threshold question for me, and that will be written into any proposal I support. But I think we can accomplish vast improvements in quality, affordability and accountability not only without sacrificing privacy, but in fact strengthening consumer's ability to secure their privacy and control access to their sensitive medical information. In the meantime, computerizing the prescription process alone could save $44 billion annually in national health expenditures. If we merely eliminated preventable medical errors, the nation, according to IOM, would avoid about $17 billion annually in direct and indirect costs. And this bill is not just about the drug prescribing process. It's not even just about addressing medical errors, which in my view is simply getting the health care system to live up to normal average standard of the status quo. After all, the status quo health care system is in the words of Paul Ellwood, is haunted by "unrealized potential and uneven execution." Instead, my vision is to raise the bar on the status quo and realize the full potential of the scientific, genomic, and information technology revolutions. My plan takes the first few steps toward this vision by creating an information technology supported system that uses research, reporting, and information and brings it to decision makers. This transformation will not happen overnight. But when it does, the improvements will be enormous. The vision I propose today is not just pie-in-the-sky, impractical dreams. The technology to make this vision a reality is already here. My goal with this legislation is to move us along the road to achieve this vision, to make sure that we fully realize the true potential of that technology to revolutionize health care and the true potential of the greatest medical system in the history of humankind. Thank you.