The education of Capitol Hill

Members of congress are getting a crash course on the economics and politics of health IT

Most health care issues have proven to be divisive with lawmakers, but health information technology has so far been the exception, with a recent flurry of bills in Congress that carry bipartisan support.

The recent legislation has given the health care community hope that Congress will support its cause and facilitate progress toward a National Health Information Network (NHIN) despite concerns about the lack of attention directed at funding and other matters such as privacy and security of electronic records.

"I think this certainly has to be one of the most significant legislative initiatives that this Congress has taken on this year," said Craig Orfield, spokesman for the Senate Health, Education, Labor and Pensions (HELP) Committee, which recently voted out what will likely be the lead Senate bill on health IT.

The recent bills also show signs that lawmakers understand the subject.

Dr. David Brailer, national coordinator for health IT at the Department of Health and Human Services, said the evolution of health IT bills in Congress shows that staffers and lawmakers are becoming more aware of the issue's importance.

This is apparent, he said, in the sophistication of current health IT legislation, compared with bills introduced last year, and also reflects HHS' behind-the-scenes work on Capitol Hill.

"This is an issue [Congress] is now conversant with," Brailer said.

Although he said he welcomed recent action on health IT bills, he said he was also concerned that congressional action would slow the Bush administration's efforts to develop prototypes of a NHIN, establish a health IT advisory board, or make progress on health IT privacy, security and certification projects.

Orfield said the Senate is aware of those issues. Any time you draft legislation that affects such a broad community, it will be a challenge and a big undertaking, Orfield said.

House action on health IT has been somewhat lighter than in the Senate, partly because progress in committees has been slow, a staffer said, and because of concerns about Brailer's admonitions. The House also has concerns about drafting legislation.

Despite such concerns, people realize advances in health IT are unlikely without government action.

Other industries, such as banking, have managed to develop IT standards and policies largely on their own because of some overarching financial incentives, said Doug Peddicord, vice president of Washington Health Advocates. But the health care industry is a much more fragmented and complicated marketplace.

"Because of this, while there certainly is a level of apprehension about Congress stepping into this area, many folks have indeed argued that the government does have a role to play," Peddicord said.

Several bills that would promote the adoption of health IT were introduced earlier this year by Sens. Edward Kennedy (D-Mass.), Jim Jeffords (I-Vt.) and Chris Dodd (D-Conn.).

But the pace picked up in June with heavy-hitting bipartisan bills, such as one from Sens. Debbie Stabenow (D-Mich.) and Olympia Snowe (R-Maine) which, among other things, would fund $4 billion over five years through grants to hospitals, clinics and other practitioners to help offset costs related to acquiring health IT systems.

Sens. Bill Frist (R-Tenn.) and Hillary Clinton (D-N.Y.) also filed a joint bill. A bill by Sens. Mike Enzi (R-Wyo.), chairman of HELP, and Kennedy followed in June.

Those bills offer similar funding programs for adoption of health IT through matching grants and language promoting the development of interoperability standards.

Sens. Charles Grassley (R-Iowa) and Max Baucus (D-Mont.) of the Senate Finance Committee introduced their Medicare Value Purchasing Act.

Although it does not strictly addressing health IT, it rewards health care providers through higher Medicare payments if they deliver care that meets or exceeds quality expectations, which presumably could be achieved through health IT.

Meanwhile, on the House side, Reps. Charlie Gonzalez (D-Texas) and John McHugh (R-N.Y.) were first in the fray with a bill that would promote the use of additional Medicare payments as an incentive for small health providers and other entities to adopt health IT.

Several weeks later, Reps. Tim Murphy (R-Penn.) and Patrick Kennedy (D-R.I.) followed with a bill that would authorize as many as 20 three-year grants to help regional health information networks (RHIOs) with their development of health IT programs.

Many of these bills focus on a concept that would "incentivize" the adoption of IT and received praise from industry representatives.

"We do need to raise awareness about health IT, and the value that accrues from such things as the adoption of IT standards," said Janet Marchibroda, president of the eHealth Initiative, a nonprofit consortium of organizations in a health care community. "But then we need a way to direct incentives" for adoption of health IT.

The biggest problem with adoption in the United States is in small physician practices, said Don Detmer, chief executive officer of the American Medical Informatics Association. Most hospitals and other large facilities do not necessarily require grants or loans to help them with this, he said. However, small practices will need financial support — for example, through much larger Medicare pay-for-performance incentives.

"Smaller practitioners usually run on such tight margins that they do need some help with this," Detmer said.

Girish Kumar, founder and vice president of sales and marketing for eClinicalWorks, a provider of clinical information systems, said that to get to 100 percent adoption of electronic health records (EHRs) in the United States within a decade, you would need 60 percent to 70 percent penetration in the next five years.

Fewer than one in four doctors currently puts information into an EHR.

"Physicians need to get their own skins into the game rather than [organizations] buying these systems for them, otherwise they won't use them," he said. "The best thing Congress can do is to use such things as the Medicare fee schedule as an incentive, where doctors can take advantage of it straight away."

Some direction seemed to be forming with the bills in July, when the Frist/Clinton and Enzi/Kennedy bills were merged into The Wired for Health Care Quality Act.

The legislation would codify Brailer's office in HHS, establish a collaborative to adopt health IT standards, offer two grant programs for individual providers and for the development of IT consortia, and authorize appropriations for all three major grant programs.

It also would establish clear standards for measuring the quality of patient care, which the Baucus/Grassley bill also promotes.

It was marked up and voted out of the HELP committee July 20, with 25 co-sponsors, giving it the possibility of swift passage on the Senate floor.

"Because this is a truly bipartisan bill, and one of the principal sponsors is Sen. Frist, we think the chances of this bill passing are very good, possibly before the August recess," Orfield said, soon after the HELP vote.

The health care and IT industries are hoping Congress passes legislation soon, which could clear up the confusion of the many bills and give some certainty about lawmakers' intent.

"The degree of bipartisanship on these bills is unusual for such a high-profile issue, which we think is motivated by the fact that Democrats and Republicans have so far failed to get much progress elsewhere," said Adam Kovacevich, spokesman for the IT Industry Council. "But industry is anxious to see movement on this."

Despite the bipartisanship and support, this may not be an open-ended process. Because the midterm congressional elections are in 2006, there may be no more than nine months to get anything done on health IT, said David Merritt, project director of the Center for Health Transformation.

"But the longer it goes, with the midterms just around the corner, the less likely anything will get passed," he said. "Bipartisanship is great unless you have to run against somebody."

However, the fact that anything at all is happening is a bonus for some.

"It's so hard to get things through Congress, and so much can come up to capture the agenda," Detmer said. "But what's funny is that when we started into this session, there was a sense that not much at all was likely to happen on health IT. Now we are cautiously optimistic that something will."

A big HIT in Congress

Here is a list of health information technology bills introduced so far during the 109th congressional session.

Senate

Wired for Health Care Quality Act of 2005 (S. 1418)

  • The bill was introduced July 18 by Sens. Mike Enzi (R-Wyo.), Edward Kennedy (D-Mass.), Bill Frist (R-Tenn.) and Hillary Clinton (D-N.Y.). The Senate Health, Education, Labor and Pensions Committee passed the bill July 20.

Better Healthcare Through Information Technology Act of 2005 (S. 1355)

  • Sens. Enzi and Kennedy introduced the bill June 30. It was added to the Wired for Health Care Quality Act of 2005.

Medicare Value Purchasing Act of 2005 (S. 1356)

  • Sens. Chuck Grassley (R-Iowa) and Max Baucus (D-Mont.) introduced the bill June 30.

Health Technology to Enhance Quality Act of 2005 (S. 1262)

  • Sens. Frist and Clinton introduced the bill June 16. It was added to the Wired for Health Care Quality Act of 2005.

Health IT Act of 2005 (S. 1227)

  • Sens. Debbie Stabenow (D-Mich.) and Olympia Snowe (R-Maine) introduced the bill June 13.

Information Technology for Health Care Quality Act (S. 1223)

  • Sen. Chris Dodd (D-Conn.) introduced the bill June 9.

Patient Safety and Quality Improvement Act of 2005 (S. 544)

  • Sen. Jim Jeffords (I-Vt.) introduced the bill March 8.

Affordable Health Care Act of 2005 (S. 16)

  • Kennedy introduced the bill Jan. 24.

House

21st Century Health Information Act of 2005 (H.R. 2234)

  • Reps. Tim Murphy (R-Pa.) and Patrick Kennedy (D-R.I.) introduced the bill May 10.

National Health Information Incentive Act of 2005 (H.R. 747)

  • Reps. Charlie Gonzalez (D-Texas) and John McHugh (R-N.Y.) introduced the bill Feb. 10.
Health IT and the state of the states

Although much of the development of health information technology is at the local level, state legislatures have not yet tackled health IT issues.

That may be because local governments are waiting to see how Congress will act on funding and other matters.

Earlier this year, for example, the National Governors Association called on Congress to establish a National Health Care Innovations Program to fund up to 15 state-led demonstrations on health care reform, including how IT could be used to improve services.

But other problems exist for organizations at the local level, and they will need state action, said Rod Piechowski, vice president of technology leadership at the National Alliance for Health IT, a broad partnership of organizations from all sectors of the health care industry.

"There are legal and policy barriers to how organizations can transfer data across state borders because of differing state regulations," he said. "More and more states are talking among themselves to see what they need to do to overcome those obstacles."

Other issues relate to how organizations in different states can work with one another to build compatible and compliant health IT systems. Federal laws prevent hospitals and other medical facilities from providing medical practices and clinics in their vicinity with health IT and infrastructure, which eliminates one way of pushing the rapid adoption of technology.

Many of the recently proposed congressional bills seek to define exemptions to the laws to create safe harbors under which local health information exchange networks can operate.

— Brian Robinson

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