Statement of Kenneth W. Kizer, M.D., M.P.H., President and Chief Executive Officer, Medsphere Systems Corporation, Aliso Viejo, CA

Testimony Before the Subcommittee on Health
of the House Committee on Ways and Means

April 06, 2006

Good afternoon. I am pleased to appear before you today to comment on how Congress might accelerate development of a national health care information infrastructure and speed up adoption of electronic health records and to do so at a substantially lower cost than generally thought to be necessary.

At the outset, I should acknowledge that I am cognizant of the large amount of testimony that this Committee has heard over the past two years about health care information technology and ways to improve the quality and safety of health care. I know that I have contributed testimony on at least two previous occasions (March 15, 2005 and June 17, 2004). Being mindful of this, my background comments are intentionally very brief.

Background

In the way of background, I would again note that few technological advances have held so much potential to improve health care, yet has so far realized so little actual impact on everyday patient care, as has electronic information management. This is especially ironic when one considers that modern health care is the most information-intense enterprise that human beings have ever engaged in and that many of health care’s diagnostic and treatment technologies are models of electronic sophistication. Unfortunately, the methods of maintaining and moving patient-related information along the continuum of care have remained much the same for the past 100 years.  

The absence of a national health care information infrastructure to support coordinated, continuous and comprehensive, patient-centered health care contributes to an unacceptably high rate of medical errors; hinders efforts to measure health care performance and improve known deficiencies of quality; and impedes improvements in efficiency.

I believe that the single most important thing that can be done today to improve the quality and safety of health care and to reduce soaring health care costs is to widely adopt electronic health records.

An electronic health record (EHR) should be viewed for hospitals, clinics and other health care organizations the way that enterprise resource planning (ERP) systems are used in other industries. In brief, the electronic health record is a mission critical enabler of consistent and predictable high performance. 

Unfortunately, the high cost of most of the electronic health records on the market today make them unaffordable for a large majority of hospitals and other health care providers.  

Being mindful of your deep immersion in these issues, I will forego any further comments on why a national health care information infrastructure is needed and what are the benefits of widespread adoption of electronic health records. I know that you are familiar with the reasons why we need to proceed towards these goals with a sense of urgency.

I would like to focus the remainder of my comments on three interrelated but stand-alone recommendations for how Congress could accelerate adoption of electronic health records at a cost substantially less than usually cited in this regard.

Make Selection of Open Source Software the Default Mode for Federal Funds

For the past twenty years open source software has been building momentum in the technical cultures that built the Internet and the World Wide Web. Open source has now established its viability in the commercial sector, and a major shift toward open source software is underway throughout the world.

Open source software is less well developed in health care than for some other enterprises, but open source software solutions for health care are now rapidly evolving.

In this vein, I urge the Committee to consider making open source software the first consideration in selecting any new software purchased with federal funds. This should be the case across the federal government – for health care and non-health care federal procurement alike. This requirement should apply to software purchases made by all federal agencies and purchases made by state and local governments and private parties using federal funds (including research funds).

Even in the absence of federal funding per se, I believe that the federal government’s policy should be to support and utilize open source software as the preferred option whenever possible because of its many advantages over proprietary software.  

When using the term open source software I refer to software that is nonproprietary, available at no or minimal cost, allows different IT systems to operate compatibly, and facilitates collaboration in order to improve and enhance the freely accessible source code.

Open source software had its genesis in the 1970s with the creation of Berkeley Software Distribution, which sought an alternative to AT&T’s Unix operating system. In the 1980s and 1990s the key network protocols underlying the Internet were developed using open source methods.[1] A particularly critical milestone in the history of open source was the creation of the Linux operating system in the 1990s. Linux demonstrated that open source development methodologies could deliver commercially viable technology to the market.

In recent years, a number of non-health care companies (e.g., Red Hat, MySQL, and JBoss) have demonstrated that open source is not only commercially viable but may well become the dominant model for creating software. This likelihood is enhanced by the support shown for open source by leading technology companies such as IBM, Hewlett Packard, Dell, Sun Microsystems and Intel.

Open source software differs from proprietary software in several ways. For example, while competition and the free market are very much a part of open source, the competition occurs at increasingly higher levels of value add. Businesses in the open source arena do not derive revenue from licensing fees, as is the case with proprietary software, but instead generate revenue from ancillary products and services that are tailored to the needs of the individual customer. Companies compete, and differentiate themselves, on the quality of their value add, whether that be in service delivery, product enhancements or other ways important to the customer, and not on the proprietary value of the software itself.   

In open source, the basic software is viewed as a commodity and its development is collaborative and shared by the community of users. Because contributions to enhancing the code come from many sources in an environment of collaboration, innovation is more rapid. Likewise, because of the large number of ready testers, evaluation and debugging of new developments is more rapid than with conventional software. Finally, open source gives users of the software much more flexibility because they can obtain software and services from many sources, not just one vendor. Indeed, open source is much more consistent with a true free market approach than proprietary products that entail the infamous “vendor lock.”

The health care industry is just now being introduced to this wave of open source innovation, with several new corporate entrants over the last year promising competitive EHS functionality at significant cost savings. 

I recommend Congress do as some states and other countries have done and legislate that open source software must be first considered when federal funds are used to purchase new software. If there is no appropriate open source solution available, then one could turn to proprietary options.

I am confidant that the federal government would save billions of dollars in licensing fees alone over the next 10 years by preferentially pursuing open source solutions. The government would likely also realize substantial savings through collaborative public-private projects and increased software functionality while harnessing a robust stream of innovation in the future. 

Leverage the Federal Government’s Existing Investment in Health Care IT 

In promoting the development of a national health care information infrastructure, we need not start at ground zero. The Congress should recognize that it has already invested billions of dollars in developing an electronic health record that currently operates the largest health care system in the nation.

I urge the Committee to consider how it might capitalize on the sizeable public investment that already has been made in VistA, the electronic health record used by the Department of Veterans Affairs and increasingly also by the Indian Health Service. A variant of VistA is also used by Department of Defense health care facilities.

The Veterans Health Administration began developing an EHR in the early 1980s when few clinical options were commercially available. Over the ensuing years, several billion dollars of federal funds were spent developing the VA’s electronic health record, which was named VistA in 1996.

Today, VistA is the most widely used electronic health record in the world, as judged by the number of facilities and health care providers using it on a daily basis. It is also the most successful electronic health record in so far as its use has been linked to dramatic improvements in the quality and safety of care, as documented in numerous peer-reviewed articles and other reports in the medical literature.

In the past two years, VistA has been successfully deployed in both the private sector and in health care facilities run by state governments.

As the person who implemented VistA in the VA in the 1990s, I will certainly concede that VistA is not perfect and would benefit from improvement in some areas, just as would all of the proprietary systems currently available. However, even with its limitations, VistA is markedly better than what exists in most hospitals today.

It is unfortunate that this successful product developed by the government with taxpayer dollars cannot be made more available to benefit community, rural and public hospitals. It is also unfortunate that improvements in VistA that have been made in the private sector in the past two years cannot be given back to benefit the VA.

To address these two issues, I urge the Committee to consider redirecting 5% of the funds annually appropriated to the VA for research and development of VistA for 5 years to create a public-private partnership whose purpose would be to promote the use of VistA by supporting the open source development of the VistA code, bi-directional sharing of enhancements, interfaces with proprietary systems (especially legacy back office systems), standards of interoperability where needed, and validation of improvements so that this public domain product could benefit both government and private health care providers.

At the end of 5 years, the partnership should be expected to be self-sufficient. Even before that time VA should be able to realize substantial benefits from improvements to VistA that should obviate much of its need for software development funds to support VistA. This should result in much lower IT funding needs for the VA on an ongoing basis.

This relatively small initial investment should result in marked savings in the long term for VA and IHS. 

Given the large number of physicians and other health care professionals already familiar with VistA as a result of their training at VA facilities, the large number of current VA and IHS users of VistA, and the nascent commercial community of VistA users, this public-private partnership could provide the formal structure needed to catalyze widespread adoption of an electronic health record.

Under this scenario, instead of VA being the sole developer of the VistA code, as is now the case, it would become a contributor to the code among a community of public and private users.  In this scenario, everyone in the community would be collaborating and contributing to improving and enhancing the VistA code. This arrangement, as an open source project, would enable the VA to leverage its budget, increase collaboration with private sector adopters, and enable a community of users to coordinate their efforts around a common platform. In brief, everyone would benefit under this scenario.

This public-private partnership might be envisioned to function like the Eclipse Foundation currently does in advancing “the creation, evolution, promotion and support of the Eclipse Platform and to cultivate both an open source community and an ecosystem of complementary products, capabilities, and services.”[2] Eclipse is a software platform that IBM released into open source in 2004.  Other conceptually similar open source collaborative models exist , including the highly successful Apache, Mozilla, OpenOffice and MySQL projects.

Make use of an EHR a Condition of Participation for Medicare

As was seen with hospital reporting on quality metrics a couple years ago, participation in the Medicare program, and even very small changes in Medicare payment rates, can serve as a powerful catalyst to change health care provider behavior.

In this vein, I urge Congress to set a date after which use of an electronic health record will be a condition of participation for health care providers who wish to participate in the Medicare program. Recognizing the need for an adequate lead time before such a requirement went into effect, I would suggest a two phase process.

To be generous, the year 2015 could be set as the year when use of an EHR would become a Medicare condition of participation. However, to encourage more rapid adoption of electronic health records, beginning at an earlier date – say 2011 - providers not using an EHR would receive an incrementally lower Medicare payment rate than those who used an EHR. Each year until 2015, the difference in rates would increase.

        If such an approach were taken, then Congress would also need to specify what would qualify as an electronic health record. Without getting into elaborate detail here, I would suggest that the core set of attributes necessary to qualify as an EHR include the following:

1. Have functionality across the continuum of care;
2. Be scalable across the continuum of care;
3. Have integrated applications that all access a common data base;
4. Have a comprehensive suite of application functionality;
5. Incorporates standards of coding and interoperability;
6. Is platform (i.e., hardware and operating system) neutral;
7. Has a demonstrated ability to improve quality, safety and efficiency; and
8. Incorporates the national consensus standards for healthcare performance measurement endorsed by the National Quality Forum.

The basic attributes of an integrated electronic health record listed above would no doubt be the subject of considerable debate, and I would urge the Committee to keep them at this general level of specificity – specific enough so that they are meaningful but not so specific that they are prescriptive or anti-competitive.

Conclusion

Madam Chairwoman, as a final comment this afternoon I would again note that I believe the single most important thing that can be done to improve the quality and safety of health care today, and to concomitantly constrain the inexorable rise of health care costs, is to widely implement affordable electronic health records. However, the piece of the health care IT solution that has not been previously adequately considered is open source software.

I believe that the future of health care IT lies in open source solutions, and Congress could do several things, as noted above, to promote the development and adoption of these highly cost-effective alternatives to the currently available  proprietary products.  

That concludes my testimony. I would be pleased to answer any questions that the Committee might have.

[1] Forrester r\Research. Open Source Software: A Primer for Health Care Leaders. California Healthcare Foundation. Oakland, California. 2006.

[2] Eclipse Foundation Bylaws. www.eclipse.org