Joint Sunset CommitteeWednesday, February 24, 2010, 6:00 p.m.

Joint Finance Committee Hearing Room, Legislative HallDe Health Information Network Public Hearing

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JSC and Staff: Rep. John Kowalko, Chair; Sen. Bethany Hall-Long, Vice-Chair; Rep. Bradford Bennett; Rep. Thomas Kovach; Rep. Clifford Lee; Sen. Colin Bonini; Sen. Joseph Booth; Sen. Brian Bushweller; Sen. Michael Katz; Debbie Puzzo, JSC Executive Director; Judi Abbott, Legislative Council staff.

Absent: Rep. John Atkins

In attendance: Joann Hasse, DHIN brd.; Jim Lafferty, Mental Health; Greg Gross, DSCC; Joe Hauser, MSD; Mark Meister, MSD; Jose Ties, HP; Kim Gomes, Byrd; Wayne Smith, DHA; Prue Aubright, citizen; Kay Malone, La Red Health Ctr., Terri Steinberg, MD, CCHS/DHIN; Robin Lawrence, DHCC; Ed Ratledge, DHIN; Sarah Mathews, DHIN; Marene Jordan, NHA; Robert Jordan, citizen; Rebecca Little, Medicity; Audrey Brodie, Patient; Paul Lakeman, Bayhealth; Leah Jones, DHCC; Rob White, DHIN; Terry Murphy, Bayhealth; Timothy Wozniak, MD, Private Practice; Virginia Price, gingernet; Rob Kolodner, Nat. Coord. For Health Info Technology; Ron Sukumar, DPS; Rahal Sukumar, DPS; Christine Schiltz, Parkowski, Guerke and Swayze; Molly Coye, MD, California RHIO; Charles Case, Henrietta Johnson; Larry Windley, representing Senator Carper; Clint Laird, citizen; David Wolzniak, Bayhealth; Dr. Greg Bahtiarian, Mid-Atlantic Family Practice; Nancy Moss, Hematology & Oncology, PA; Robert Laskowski, Christiana Care

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Agenda:I. Welcome; Introduction of Members and Approval of Minutes dated 2/3/10II. Overview of the Sunset Process (JSC Chair)

Opening Comments by the DE Health Information Network (15 minutes) Question and Answer with JSC

III. Public Comments (3 minutes per person)IV. Concluding remarks (JSC)V. Adjournment

Rep. Kowalko called the meeting to order at 6:15 p.m.

I. Welcome; Introduction of Members and Approval of Minutes dated 2/3/10Rep. Kowalko welcomed everyone. The members introduced themselves.

The Minutes from the February 3, 2010 meeting were adopted.

II. Overview of the Sunset Process (JSC Chair)Rep. Kowalko explained the Sunset Review process, as well as the procedures for this Public Hearing.

Opening Comments by the DE Health Information NetworkMr. White made the following statement:

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My name is Rob White. I'm the CEO of Delaware Physician's Care, which is an Aetna Medicaid health plan here in the State of Delaware serving about one in every 10 Delawareans. I am here with you tonight more specifically in my role as the chairman of the board of directors of the Delaware Health Information Network, the position that I have had the privilege of holding since late 2006.

Good evening, honorable members of the Joint Sunset Committee, Chairman Kowalko, Vice-Chairman Hall-Long, staff, and committee staff, and assembled interested parties. We appreciate the opportunity to chat with you tonight.

In the interest of sharing a lot of information, we have put together a book that we provided to folks, a notebook with some additional information. There is an overview tab at the beginning which kind of gives you a very concise view of the Delaware Health Information Network, your basic four-corners presentation on two sides of a piece of paper. Following that, there is a presentation, a Power Point presentation that's rather lengthy and that we will not go into tonight because of the limited amount of time to present to you. But I will reference a slide occasionally, and we will leave it to you to view the Power Point later and absorb at your leisure.

Following that, there are some letters of support in the book. Many of the DHIN users wanted to be here tonight, but their schedules wouldn't allow it, and so they have provided their stories in writing. I will be addressing three of those kind of specifically during the course of my comments, the very first three behind that tab.

The next tab is biographies of three of our speakers who are coming to visit us from outside the State of Delaware, three community and national experts; Dr. Rob Kolodner, who is to my right and will be part of the formal presentation; Ginger Price and Dr. Molly Coy, who will be presenting later during the public testimony. And we have provided their biographies for your reference.

There is then a tab with the various boards and committees of the Delaware Health Information Network showing you the wide stakeholder participation in creating the product of the DHIN.

Then there is a tab with a bunch of articles, all of which reference the Delaware Health Information Network in one fashion or another positively, followed by a remaining tab that has some references. We cite literature from time to time. You know, you will see some of that information located behind that last tab.

We recognize that the purpose of the Joint Sunset Committee, if you kind of narrowed it down to two very specific items, is to figure out whether there is a need for the organization under review that's been created legislatively, and then secondly to see whether or not the current organization is meeting that need. So we are going to try and address those two specific items specifically tonight as we speak with you.

In 1997 the need for the DHIN was originally identified by stakeholders in Delaware. Physicians, hospitals, health insurers, health care providers wanted more complete information at the time and place of care to ensure better patient outcomes, resulting in lower costs as a result of fewer duplicate tests. Nationwide health care had lagged behind other sectors, such as the banking industry, in terms of using information technology. The result was the legislation that created the DHIN back in 1997. The process was stakeholder driven by doctors, hospitals, health plans, the Delaware Health Care

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Commission, the General Assembly, and then Governor Carper showed a great vision in passing this legislation which put Delaware ahead of the curve. And we have tried to stay ahead of the curve since then.

In a few minutes, I will be introducing Ed Ratledge, who will speak about the work done between 1997 and 2005 to build the foundation for DHIN's current success.

In 2005 the DHIN undertook a strategic planning process that was further evidence of our willingness and dedication to identifying the true need for the DHIN. We did an environmental analysis that included 80 stakeholders throughout the State, as well as targeted focus groups where we learned about the needs of consumers, of doctors, of hospitals, and of labs. And if you want to refer to slides nine through 11 in your book, they will address those issues specifically.

Throughout the presentation, you are going to hear about how the DHIN meets those needs and improves patient safety and health outcomes, enhances quality and efficiency, and reduces costs.

And I would like to kind of kick things off here by giving you two specific examples by reading a quote from a couple of the letters that were provided in support tonight. Both of these stories are from emergency room physicians. If you think about it, the ER is generally the intersection of acute care and acute lack of information, so it's a place where having a health information network and sharing information is very important.

The first is from Dr. Jamie Rokez, an emergency room physician at St. Francis Hospital, and here is what the good doctor wrote: "At St. Francis ER we cared for a patient who was complaining of abdominal pain as a result of a condition named diverticulitis. According to the patient, this condition had been diagnosed by a, quote, CAT scan at another Delaware facility just a few days prior. We used the DHIN to obtain the results of that test, and we found that in fact the patient had the test more than once at different facilities and that the results were in fact negative for diverticulitis. We also learned that the patient had multiple ER visits for the same complaint all over the State of Delaware. Thanks to the DHIN, we were able to avoid unnecessary testing and prevent further exposure to radiation and risk of complications for this patient."

The other quote is from Dr. Tim Shoe, who is an attending emergency physician at Christiana Care Hospital. And Dr. Shoe wrote: "I believe the benefits of the DHIN are most evident in the field of emergency medicine. Christiana Care emergency departments are receiving sites for patients from the entire state and surrounding regions. Many patients are incapacitated and unable to provide vital medical information. Where in the past emergency physicians were working blindly without this information, DHIN gives us realtime access to critical data that will save lives."

That kind of gives some feel for the need for having the organization. What has the DHIN done to respond to that need? The DHIN flexibility allows us to respond to the emerging needs of Delaware's health care system so that it's not a static thing; it's constant change in health care. The only constant is change, and we continuously evaluate the landscape and identify opportunities to meet those changing needs. This results in cost efficiencies, arising from the development of global strategies that make it unnecessary for action at the individual or organizational level; that is community-wide enterprise, not individual or organizational.

For example, we connect public health and hospitals for realtime standardized buyer surveillance reporting, such as emergency chief complaint data and laboratory reportable diseases. We make

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Delaware's immunization registry available through the DHIN for query and update. That's a project we are working on now. We help eligible providers and hospitals qualify for federal incentive funding by offering a low-cost alternative to an electronic health record system.

DHIN's approach will fully integrate with DHIN and offer such services as E-prescribing and quality reporting, among a host of other functions. So a lot of these thinks we have done. A lot of them are on the table for 2010 and thereafter.

DHIN was planned originally as a five-year implementation project. We are now in year three. We were up and running in six months from the time we signed the contract with our technology vendor in compliance with our agency for health care research and quality contract. And, furthermore, it was funding from ARK that got us started.

Doctors had two years of patient centric clinical history to query when we went live in the spring of 2009 with the patient search function. This ensured that information was and is available when the user searches for his or her patient and needs information.

We have known we had one chance to get this right as we created this functionality. Providers may log in once or twice to not find what they are looking for, but they are not going to come back much beyond that, if you can't do it right and be very methodical about adding your functionality and making sure that it really works.

The DHIN currently has 800,000-plus unique patients in its master patient index, so the likelihood that the physician user will find the patient they are looking for is extremely high. If you take a look at Slide 21, you can see that we are growing. As of January 2010, 160 practices, which is literally double what we had this past June. 1,300 providers -- providers being physicians, nurse practitioners, physician assistants -- are using the system. And that's three times what we had in June of '09. 2,400 users. That's including all of the above plus the office staff. And 800,000-plus patients, as I mentioned earlier, which is a 20 percent increase since June.

We are processing about 15 million transactions per month in order to deliver about one and a half million results to physicians. The DHIN was and still is the first and only statewide health information network. The national articles on DHIN are proof of its success, and you can find that in your book. And it's not lost on us that receiving federal funding is somewhat of a seal of approval that the DHIN is doing what it set out to do.

And, with that, I would like to introduce to you Dr. Rob Kolodner, who is on my right. From 2006 to April of 2009, Dr. Kolodner served as the president's designated leader for the United States E-Health Initiative as the national coordinator for Health Information Technology in the Office of the Secretary of the U.S. Department of Health and Human Services. In that capacity, he acted as the principal adviser to Health and Human Services Secretary on all health IT initiatives. And his responsibilities included developing, maintaining, and directing the implementation of the health IT strategic plan, as well as directing related national activities that were necessary to advance the nationwide adoption of person-centered interoperable health IT solutions.

Prior to transferring to HHS, Dr. Kolodner had a distinguished career with the Veterans Administration. I think many of you are aware that the VA is way ahead of a lot of other people with its health information technology. With that, Dr. Kolodner.

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Dr. Kolodner made the following statement:It's a real honor to be here and have the opportunity to address the Joint Sunset Committee.

It's especially enjoyable because you have, here in Delaware, one of the premier health information exchange organizations in the country. I want to highlight three aspects of the DHIN. You have heard some of the details; you have got lots of details in the book. But I want to give you kind of three points that convince me that you have a lot to be proud of here in Delaware. And I think and I hope that, after you do your review, that you will also agree that you have succeeded in Delaware in having legislation that has set up a dynamic, responsive health information exchange structure and a governance when other states are struggling to succeed and, in fact, a number of them have failed.

So, of those three points, first: The DHIN success in its growth and adoption stands out even among the select group of outstanding health information exchange organizations with whom my office and HHS contracted a couple of years ago to work to help develop a viable nationwide exchange strategy.

The DHIN is a shining star and is the epitome of what we envisioned in the federal government when we developed our strategic plan and a map for the exchange of electronic health information. That is, a public private organization comprised of multiple stakeholders and that's responsive to the needs of individuals, of health care providers, and of the community in general.

Evidence of that is that of the 37 of the 40 awards that were made just 10 days ago by the new administration and HHS for State health information exchanges were for planning activities. Only three of those 40 were for implementation.

The DHIN had succeeded and completed the planning phase back in 2005, so it's really way ahead of the curve and has made some outstanding progress. Because, after you have what looks to most people like a slow start, you get to take off. And it's very much like having crops and things where you don't see much going on, but there is a lot that's really underneath and laying a firm foundation.

The second point has to do with funding. Most of the health information exchanges that we dealt with were dependent on federal funding. What's amazing about the DHIN is that they were able to not only get federal, state, and private sector funding, but actually have a pretty even balance among the three. And that's something, first, that conveys the commitment that each of these sectors have. But, secondly, it means that as the economy changes and as the things are in flux in the different sectors, that there is a way of riding through that. And that's just tremendous.

The third has do with the governance. In order to accomplish this task, you really do need to have multi-stakeholder public private approach. In order to do that, what the communities have found is that they need to build up social capital. And it's clear from the success and the commitment that's here in Delaware that the DHIN succeeded in laying that groundwork and building that social capital. And, in fact, doing so in a way that, as decisions are made in terms of what is brought up, that again and again the acceptance and adoption show that they have been providing the functions and services and the information that their participants are needing -- health care providers, for example -- and that they have been able to even give the providers the ability to qualify for Medicare and Medicaid incentive payments by providing certain services that otherwise the providers would have to do themselves.

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Health information exchange, getting it right and getting it to succeed, is very difficult. That's why up till now relatively few have really succeeded, and most of the rest of the communities are really still in the planning phase.

And besides for the involvement and engagement of the community and building of that trust, which clearly the DHIN has done, they have had to overcome something that is beyond the control that most of us here in this room have, which is the perverse incentives that are still built into our health care payment system that work against sharing information.

So you have competing organizations, institutions that are competing for the population. And the idea of making it easy to get one procedure on one side of the street and another on the other side of the street doesn't come easily to those institutions.

The other is that the system pays us, as providers, to do more. And, yet, what we are talking about doing is putting something in where I don't have to repeat the test; I don't have to generate that income. In fact, I'm not supposed to. So going and convincing the institutional leadership and the providers who get paid for doing procedures, as well, to put this in and exchange and does less is an uphill battle in most cases.

The exchange of the health information is one component that we need for solving our health care crisis. And one of the aspects of the exchange is that it is for the greater good. It isn't to the advantage of a particular entity; it doesn't give them more income. And, therefore, it's very difficult for those who are making a profit to invest in that.

The government and the public sector has to be an active part of that to act on behalf of all of us. And it needs to be a shared resource with the lowest cost possible so that any dollars spent extra on health information exchange is a dollar away from health care or a dollar more of payments that we have to make in our premiums.

And so, in summary, you really have, here in this state, something that has served as an example to the rest of the country as to how to form the organization and bring together the community to do health information and exchange in the right way. Thank you for the opportunity to talk with you.

Mr. White made the following comment:Ed Ratledge has been instrumental to DHIN's success since its inception. He has provided technical guidance to DHIN's staff and the Board and has dedicated countless hours to ensuring DHIN's continuing viability.

He is the vice chair of the Delaware Health Information Network board of directors, as well as the chair of the finance work group and the project management committees of DHIN.

In his day job, Ed is the director of the Center for Applied Demography and Survey Research at the University of Delaware. The center conducts survey research and policy on a wide range of federal and state local government items. And he has been a member of the Delaware Economic and Financial Advisory Committee for many years.

Mr. Ratledge made the following statement:Well, it's always a pleasure to talk to members of this body. You have a tough job, and particularly at this time with the economy being what it is. But this is a pleasure for me to talk about. This

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project I have been on really since 1996, which was before the original legislation was passed in 1997.

I won't say that we knew exactly where we were headed in 1997, but what we did was put together a piece of legislation provided by the General Assembly that put the right players in the field. It was set up as a public private partnership. As we can often in Delaware, we can put the right people at the table. And that's something a lot of other states have a difficult time doing.

And one of the key things about the public private aspect of this is that the State actually takes care of the health care for one-third of the population. When you look at the retirees, the employees, and Medicaid, it's 265,000 people, give or take a few thousand.

As a result of that, the benefit the State gets by the work that DHIN does is to reduce the amount of duplication of tests, to improve patient safety, to reduce medical errors, and, more importantly in the longer range, to improve disease management just in general, which should mean lower costs and better outcomes. Those are all in the interests of the State, quite apart from the obvious interests that the private sector has in this particular area.

Now, when we started out -- and there is a period from about -- and I'm not going to belabor this, but from about in the 2001, 2002 area where we looked at a number of different possibilities of particular visions one might have of this. We looked -- we issued RFPs, we got requests for information, and we would always have some question that came back where either the technology was not there or the cost benefit was not there for the State, and at that point we moved our investigation on further to another title.

By basically 2005, where we received essentially our first money to do our strategic planning, we focused then on the clinical part of this, because we felt that there was a -- we could understand the cost picture, and we understand the value of what we were going to get out of doing this in the short run. Not even the long run, because long run we are out another three years, anyway. So cost and value are really very important items, and they still are. From our sustainability issues, we have to have absolute control over them.

Another very important part about the DHIN and a part of the public private partnership is that everything is voluntarily. If you check our legislation, nobody is really required to do anything. All right? So they are coming together as a collective because they think it's in their own best interests to do this. And in some cases early on you know there were always perhaps competitive pressures. People put that aside. Very, very important kind of concept.

That gave our governance structure that we have -- and it's the same one that you all set up in 1997 that's done well till today -- has really been to go back to the same words; trust and consensus. Trust and consensus. And the example I would give there is that for the last three and a half to four years, every Wednesday there is a teleconference between the project managers. Sometimes it's an hour; sometimes it's two hours, but it's week after week after week. And on that we have all the players on board and we discuss our problems, and I would say very honestly, very frankly. We talk to the consultants who are involved, the technology people. We have put the heat on them as well. And it's all in the open. And then, when we decided what we are going to do, that's the way we move. So it's always born of consensus. And you all know about getting consensus in that, and sometimes it's not easy.

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All this time is really an investment in and of itself, because all these people are putting in what we call "sweat equity." Millions of dollars probably has been spent by the hospital in the lab staffs working on this. Because they have done all the testing; they have approved every piece before it goes in the field because we can't afford to be wrong. Now, obviously with technology periodically you are going to get into that problem.So what you come down to, then, is you have basically it's a jointly held vision of where this operation is going by all the players. And remember we are expanding. We have just picked up St. Francis. We will have Nanticoke. We add smaller players all the time. So everybody understands that.

Another thing that's going to happen very shortly is that more and more doctors are going to electronic medical records. You have seen that in all of the newspapers and so forth. Well, what we can do -- what we do is we can directly populate those what we call EMR -- or EHRs with our data without them having to -- without their staff basically having to do that. That's an important advantage for them.

Finally, everyone on the team is on an equal footing. Our players, they sit as equals at the table, even though some are very, very large and some are smaller. That's the way we play the game. That's where we have gotten so far in the last decade. Thank you.

Dr. Kolodner: The next couple of things we want to do, there is a letter in the -- under the town I mentioned earlier from Aaron Grace, who is the project officer for the agency for Health Care Research and Quality. Furthermore, the ARK folks are the ones who got us started with $4.7 million worth of funding several years ago.

And I want to read into the record a portion of that letter which I think is pretty telling. Ms. Grace writes: "The purpose of the five-year, 4.7 million contract was to support statewide data sharing and interoperability activities on a state or regional level to improve the quality, safety, efficacy and effectiveness of care. Although each project used different approaches with differing technical basis and governance models, each project was required to meet certain milestones and key deliverables, including identifying and convening key stakeholders, identifying core clinical data elements and core data sharing entities, analyzing the ability of the Medicaid program to utilize the statewide data sharing and interoperability activities, developing and implementing an evaluation plan meeting 100 percent of the core-data sharing within three and a half years of the contract start date, and developing a sustainability model.

During the past four years of the contract, DHIN has made steady progress on each of these deliverables, including meeting 100 percent of the proposed core-data sharing almost one year ahead of schedule.

ARK awarded multiple contracts in order to allow demonstrations of different models and different settings across the country, to allow the multiple contractors to work with and learn from each other and develop models for others to learn from. DHIN has played a key role in each of these areas, serving as a model in many ways for the other five regional demonstration contractors and for other health information exchanges across the country.

In particular, the public private partnership governance model adopted by DHIN has been a model for other developing HIEs. In addition, concern has been able to forge unique and important

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partnerships with various entities to ensure cost-effective exchange of lab information and is currently developing a sustainable model for exchange of prescription medication information.

Similarly, DHIN has negotiated with key EMR vendors in the State so providers pay incremental costs for installing interphases between the EMR and DHIN instead of every provider paying the full cost duplicatively of developing that interface.

Over the past four years, DHIN has been able to leverage the State and ARK funding to build additional functionality to meet the needs of Delaware providers. Building on their successful startup implementation, DHIN was subsequently awarded one of nine contracts, which was again another $4.7 million, and prototype -- excuse me, the National Health Information Network, and was recently awarded the State Health Information Exchange grants from the Office of the National Coordinator. That's the additional 4.7 as the State designated the entity for Delaware.

And these are just a couple of examples of how the DHIN has been able to build on the successes from the ARK contract. So here is the folks that started this with the money and, you know, their read on what we have managed to accomplish.

In conclusion, if I could point you to Slide Number 34, you know, we have tried to be responsive to meeting the needs of providers. That's very, very key. We try to get things right the first time. We are very methodical with bringing up functionality. We have it on good word from folks around the country that we are, in fact, a leader in the nation and arguably the most successful health information exchange in the nation. And we have built this on the true public private partnership with all the stakeholders at the table.

We have been an example for other states to follow. We have had seven different states come and visit us and try to see how it is that we are doing what we do. We actually were visited by the emperor of Dubai, as well, who came in to see how we had done this and subsequently hired the same vendor that we use to create a health information network for their country.

We have leveraged the State's investment. We think it was a very wise investment. The legislature took it upon itself to make available $9 million over a multi-year period in bond bill appropriations a number of years ago. We have drawn down 8 million of that 9 million so far, and we are hoping that the ninth million will appear in the final budget this year. That money has all been matched by private sector money leveraging those dollars from the State with money from hospitals, labs, and even investment from Blue Cross/Blue Shield. And we think that we are meeting the needs of the public and private health care organizations.

In conclusion, I would simply offer up to you that a picture is worth a thousand words. If anyone would like to avail themselves of seeing a quick demonstration, we can certainly make that available to you, and in 30, 40 minutes time I think we can probably show you exactly what it is we are talking about. We thank you very, very much for allowing us to be here today.

Question and Answer with JSCRep. Kowalko: Okay. All right. Thank you, gentlemen. We appreciate it very much. At this time I would like to make a few points regarding this review. The DHIN is a very complicated organization and, as such, in order to conduct a thorough review, it's imperative that this committee focuses its initial attention on the following -- and that's the initial attention tonight, as the chair has decided that this is paramount in moving forward with this review -- and that would be a review of

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the current functionality of the DHIN as it is today and the current structure of the DHIN as it is today and how funding is channeled.

Only after this entire Committee agrees they have a thorough understanding of the DHIN can we entertain discussions about where to go and how to get there. I'm not lecturing. I'm just saying that we are going to do this process because it is complicated. And myself, as a chair, I have to certainly assimilate the information.

So, to accomplish this, we are going to proceed in the following manner: Because we are now into our review phase of the report before this committee, and we will review Pages 1 through 11 and the audits. We will then review Pages 20 and 21, ending with the chapter entitled work groups, Pages 30 to 33, fiscal information.

Once this information has been discussed and there is a clear understanding of these aspects of DHIN by all the committee members, in agreement by all the committee members, we will return to Page 11 and move through the rest of the report.

So at this time I would ask the committee members to turn to Page 3 of the report and we will proceed from there.

The JSC proceeded to review the Draft Report.

Sen. Sokola: I'm not in the committee, but I did have a question. And I have highlighted some items under key objectives and strategies for accomplishing the objectives. I just noted that number two said “reduce administrative costs, number four, information on quality of outcomes.” But then, under strategies, it talks about health spending reports but it doesn't talk about how to determine whether or not they are accomplishing the objective of reducing -- I wasn't really able to clearly make a tie there.

If our friend from the national group is here, I haven't heard that we have any significantly lower increase in health costs than everybody else in the nation. And, if we are way ahead of everybody like he kind of suggested on this thing, can you comment on that?

Dr. Kolodner: The health information exchange by itself needs to be complemented by the change in incentives to drive down that cost. If you have the incentives and you don't have the ability to exchange information, you are not going to get the effect, so.

Sen. Sokola: His example gave a clear cost saving. Here's a guy in another state who would have probably had another evaluation for diverticulitis and another emergency room, and here we didn't. And it would seem to me that we should be able to show in real numbers somehow that, you know, how we are saving money.

Mr. White: I would offer up that it may be a little early to be able to aggregate that data. We don't have enough longitudinal, you know, from a time-period standpoint, nor do we have kind of a hundred percent adoption in the state yet. We are still adding functionality; we are still adding data senders. We are still adding data receivers. But over time I would think that we would see some evidence in the trends. It's obviously very, very hard to measure things that don't happen. It's an extraordinarily difficult task, and that's one of the dilemmas of being able to prove this kind of an endeavor.

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Sen. Sokola: And if you don't mind, since you are here and you had experience with the VA. I had read about the VA, and one of the things I read that I thought was fascinating was they were able to show -- and this is under number four, quality and outcomes -- people with similar condition and different care protocols had significantly different results, and that was what basically exposed Fen Phen and Vioxx issues -- is that correct -- from the VA? That was in one of the things. It wasn't in one of these reports. It was in something totally unrelated that I had read. And I'm just wondering if we have developed any information that's at all remotely related to something like that as far as helping for patient information.

Dr. Kolodner: What we found are that there really are phases of implementation. One is to get the growth and the use. And after that's in place and people are comfortable in delivering that as an integral part of their care process, then you will see that additional add-on. It doesn't occur immediately; there is a lag between it. And if you expect to see it immediately, especially when you don't have in place the electronic health record adoption, which is what VA needed to get to so that in realtime you could feed back the decision support to the provider and change the way that the pager occurred, it's going to be difficult to find something that's measurable. It doesn't mean that it's not happening amongst some of those who now are kind of at the lead, but you are not going to be able to measure it by looking at the broad statistics.

Sen. Sokola: Thank you.

Sen. Bushweller: Let me just follow up on that. I think Senator Sokola raises a very good point. I think one of the great frustrations of many people over the decades is that it seems like every time there is a proposal or an initiative that's going to save money in terms of medical care, it either doesn't save money or it's impossible to tell whether it saved money. So I sort of share his concern.

But I do wonder whether -- and I would ask you to comment on this -- whose responsibility would it be. After, as Dr. Kolodner said, after the DHIN is implemented enough so that it would be reasonable to expect to see some of the savings somehow, would it be -- I guess the first question is would it be possible to segregate out the DHIN as the entity that caused a savings or, if the costs continued to go up, is it possible to segregate out the DHIN and say well, they would have gone up even more? That's sort of question number one.

Question number two is whose actual responsibility would it be here in Delaware to assess, I guess, maybe the overall cost of medical care to begin with, and then what the factors are that are influencing increases in those costs, and what the factors are that are influencing decreases in those costs?

Mr. Ratledge: Well, you guys have gone directly to the most difficult questions, of course. But I mean it is certainly of interest to this state as well. As I said, there is a lot of money going down for the state.

We have done the first stage of an evaluation of the DHIN. Okay? Right now, if you saw it from the data we saw, we only have 56 percent of the providers in, and this is basically growing over time. Once that basically stabilizes, theoretically what you should be able to do is to go back through the data and find the frequency of where you got incidence of tests which have been repeated too often within a particular time period. And that, theoretically, should be measured by the data that we know is in the database right now.

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But the trouble is you don't have a good base yet because you only have roughly, well, half -- as I say, half of the physicians, so we don't have all the tests in there at this point. As we build out, we should. But you theoretically should be able to go back and do that. Whether you can then turn it into a dollar thing is a little more difficult. I mean you can always put a dollar thing on anything. I mean it's not every day in the newspapers, but I think we have a way and we laid a lot of this out in this evaluation. It was finished -- I don't know -- three or four months ago. And we are going to see how that is going to be implemented later on, as soon as we get this ramped up.

So I think in one case I'm ducking your question. But do I think it's possible? I think it's possible for at least some of these, the duplication in particular. Perhaps when we -- There is an experiment going on this year, and once again in the EDs, the physicians themselves will be able to tell us themselves whether they found information at the point that made any kind of difference in what they were doing when the patient came in. So there is a variety of things we are -- It's not an exact science at this point, but I think we can make a start. Because everybody wants to know the answer to that. I want to know as a taxpayer.

…

Sen. Katz: I would just like to ask you again a little more detail about the administrative costs and the quality improvement. How does the current system with DHIN functionality incorporate administrative transactions?

Sen. Bonini: That's part of two, reduce administrative costs and improve quality, under the seven key objectives.

Mr. White: I guess, to some extent, that could be how do you define administrative costs? Is administrative costs, for instance, for the hospital or a major lab company to deliver a lab result? You know arguably, that is an administrative cost. The labs and hospitals are paid, are reimbursed, not only to do the test, but to report out the result.

One of the reasons why our provider community is embracing the DHIN is because they recognize that this is going to be a more efficient, administratively, this is going to be a more efficient way to deliver results, in any event, than the current methodologies for delivering results.

Sen. Katz: How does it, in a physician's practice -- A good number or a good amount of the patient care interstate actually happens outside the large facilities that you referenced in your support letters. How does the system currently help those small practices in the community now?

Mr. White: We kind of take the physicians wherever they are on the technology curve. And we have physicians up and down the State, all three counties, primary care, specialty, small practices, large multi-office practices.

At one end of the technology curve they might have an electronic medical records system, and the DHIN information automatically goes into that record. That's where you get a real bang for your buck because you are using an EMR and getting the benefits of the health information exchange.

But if somebody does not have that technology, we deliver their results to their printer, if they are in a completely paper practice. So it's a more efficient way to deliver it if they are still using it in the

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paper practice of medicine. Or we can deliver it to an in-box in their computer where they can do things with it and have certain functionality before ultimately, probably once again, printing it down and incorporating it into a paper medical record.

Sen. Katz: And what metrics have you implemented that quantitate that progress and those savings and cost efficiencies? …What metrics have you currently implemented that demonstrates those cost efficiencies and savings for those physician practices?

Mr. White: The documents for the individual physician practices?

Sen. Katz: Yes. When you implement them in the physician offices, what metrics have you used to monitor your progress and to show the savings that you are gaining?

Mr. White: Well, right now what we are measuring is adoption. We are still at the adoption phase. We are not at the measuring results phase.

Sen. Katz: Okay. Thank you.

Sen. Booth: You mentioned earlier that 56 percent of the providers are connected, and yet you have 800,000 patients.

Mr. Ratledge: You may have information being reported into the system that a doctor is not getting through that system yet. Our providers are still in a dual mode in many of the practices. They are sending information the way they did before and sending it through the DHIN for some of the patients. But you need to have, if you are going to have an inquiry function that's robust, all that information has to be in there when people join. So the information that goes to a doctor who is not connected to the DHIN yet is still going in there and resides in that database so that, when they do join, the information will be there and there will be some history.

Sen. Booth: If you have 800,000 patients, what's the population of Delaware?

Mr. Ratledge: Today, 891,000.

Sen. Booth: All right. And 56 percent of them are providers, I'm having trouble connecting the dot between those --

Mr. Ratledge: A practice might have 30, 40, 50 doctors in it. I don't know right off the top of my head, which is different than a practice that only has one doctor. But the reason -- The other point of that. The 800-plus, remember we are talking about over a period of time. So every year you have roughly 25 to 30,000 people leave Delaware -- a different 25 to 30,000 come in. That's particularly in Sussex County. And you also have about 7,800 deaths. So their records are still in there. …At that point. So you get something that looks like it's actually approaching the population, but it's really not.

Sen. Booth: Thank you. Another question. On sticking with the same seven key objectives. I was wondering if you can help me understand how you plan on gauging patient satisfaction with the health care system.

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Mr. Ratledge: At the time that this was, this legislation was put together, we participated through the Delaware Health Care Commission. They had the CAHP study, Consumer Assessment of Health Plans. And that was run every year for about -- I guess about four years. But that was done by actually the Health Care Commission. I would like to see it started again, but -- And we have actually looked at that, but that's not one of the -- That was done by the Health Care Commission. Also the spending reports that they were talking was also executed by the Health Care Commission itself.

Sen. Booth: So if you have an objective to look at patient satisfaction with the health care system, my question would be how do you plan on doing that if you are not doing a study that you just mentioned?

Mr. Ratledge: The question of outcomes would be, from their experience with the health care system, would be one measure. But, systematically, that particular study involved about 1,200 interviews a year. They were done basically as telephone interviews, and it was done in that kind of a fashion.

Sen. Booth: Well, I know one of the key things that I have always struggled with or I think many of us struggle with is that if you are trying to get to where you want to improve something that we mentioned about with the, you know, cost and whatnot, and somebody gets a bill and they have had repetitive services done on them, et cetera, they might not be satisfied with the system. And, you know, it's a pretty good topic for today, anyway. If we can't find a method that gauges the satisfaction down to more of a practical nature, then how -- I'm just wondering how you are planning on moving forward with that.

Mr. White: If I could speak for a second directly to the items that we have under discussion. I would with like to point out that the objectives we are talking about are the objectives from a study by the Delaware Health Care Commission with regard to health care at large in the State of Delaware. Only one of the recommendations that came from that commission was creating the health information network. There was no anticipation that all of these things would be satisfied by the creation of a health information exchange.

So that all the items that are listed there at the bottom of Page 3, top of Page 4, by the time you get down to the strategies, you will note that strategy number three out of six is promoting the use of electronic data interchange. So there is a much broader undertaking that was discussed by the commission in 1994 than simply the health information exchange.

Sen. Booth: Well, I know that -- And, for point of disclosure, I served on Beebe's Board of Directors, and I know that we tried to gauge our customer satisfaction. And, you know, I just saw that on there. And I know that's very difficult to do if patients aren't filling out forms or if you call somebody and they don't have time to answer; or, as we had discussed, if somebody is not satisfied, they are not going to give you another moment of their time.

You know, but you are not sure how they are recorded. And I saw this in there. I was just kind of curious of, you know, how you were going to do that.

Mr. White: Your point is a good one. The reality is that a year or a year and a half from now there will be patient awareness of what we are doing. At this point what we are doing through the Delaware Health Information Network is delivering results that it's kind of behind the scenes from

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the patient's perspective. The patient has no idea that this information is being sent electronically rather than through the U.S. mail or by telephone or by fax.

Sen. Bushweller: I just want to emphasize that last point, because I didn't understand that until you said it. But I think your point is that most of the time the patient may have no knowledge whatsoever that they are in the emergency room - They are being treated successfully - They don't know that the emergency room doc got all his information off the DHIN and that's why they are able to treat so successfully. So it's entirely possible if you ask the patient, "Are you satisfied with the DHIN?" they are going to say, "What's the DHIN?" You know, "Are you satisfied with the doc?" "Yeah, he took care of me, and I'm better."

Sen. Bushweller: And again it was a helpful clarification to me that these various strategies and this list of key objectives and strategies were actually more broad than just the DHIN. As a matter of fact, as Rob White just pointed out, only strategy number three directly relates to the DHIN. But I think that -- and this is sort of more broad than the DHIN. Someone, I don't know whether it's the Health Care Commission, the Department of Health and Social Services. I don't know who it should be. A consortium of medical groups? Someone ought to be focused on the larger questions of quality of health care, cost of health care, success of certain initiatives in health care, and so forth. So I share your concern in that.

Sen. Katz: (referencing page 3 - Laws and Policies, Background - the legislation creating the Delaware Health Information Network signed into law July 15th) I would like to spend a little bit of time on this is because I think the Code really helped set the framework of where the DHIN is coming, where it's been, and where it is currently, and where it's going. So I would like to -- and I think it also probably would be a good opportunity for some education for many of us to better understand sort of the roles and the rules that it operates.

In section 9920(a), - Purpose, it refers to the DHIN under the direction and control of the Delaware Health Care Commission. And what I am trying to understand is the governance control. Who makes the decisions in the DHIN? Ultimately, it says that it's under the direction and control of the Delaware Health Care Commission. So are all the decisions made ultimately by the Delaware Health Care Commission?

……

Sen. Katz: (page 4) I'd like to actually talk about the information on the quality and outcomes of treatments by setting in providers of care. And I was wondering if you could just explain a little bit about the progress that you have made over the last several years with the DHIN and what the current status of that is. That's your objective number four.

Mr. White: That's not the DHIN's objective number four. That was the Commission's objective from their study back in 1994, not relevant to the Delaware Health Information Network. Our piece of this is number three, the use of electronic data interchange.

Sen. Katz: So you are not actually addressing those issues?

Mr. White: -- but these are not the goals of the DHIN.

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Rep. Kowalko: If I might answer that, Dr. Katz, these objectives, key objectives, were key objectives of the Health Commission.

Sen. Katz: Understood.

Rep. Kowalko: And the formation of DHIN is precipitated by enabling the Health Commission to meet some of these objectives. Not all of these objectives through the DHIN, but some of these objectives by the creation of DHIN. This is just a background of why DHIN was created, not to fulfill these objectives, but that is part of the objectives to be interpreted as the necessity of forming DHIN. Does that make sense?

Mr. Ratledge: That's correct. When I said I was involved in 1996, it was this particular piece of work to kind of identify these issues of data that was in that report where medical staff was helping us out.

Sen. Katz: I think if you actually look to the Code of the DHIN, these issues are actually in the Code as roles and responsibilities of the DHIN. So if you look on the second page of the Code, many of these issues are part of the roles and responsibilities of the Code.

Rep. Kowalko: And we can certainly ask that question when we get to Page 10.

Rep. Kovach: (referencing pages 5-6) I just wanted to try to get a little better understanding of this process. I understand the information and the direction the information flows as far as the data about the patient's treatment. But I have heard some earlier questions today about measuring the efficacy or cost savings of such a program. And would an additional step or an additional directional communication conceivably be warranted? You send out information to a doctor. If they use that to not perform an identical treatment that had been performed somewhere else, couldn't there be a check box or a, you know, a place to click to say, "Hey, thank you for this information. It stopped us from performing an additional procedure." Should the information kind of be flowing a little bit more in both directions in this network?

Mr. Ratledge: The example I was giving about the ED docks that were in the current thing which deals with medication was exactly that type of study. But it's only -- What you have is individual studies would be implemented rather than -- before we can decide what the effective management procedures and reports ought to be and whether we can get that done or not. I'm sure that there is probably ways of doing it. It would be a cost item, obviously.

Sen. Katz: and I've got to tell you, as a physician that deals with these issues every day, and my colleagues, it's very, very important. So I think the devil is in the details. And as we are going through this, I just want to make sure that --

Rep. Kowalko: Absolutely.

Sen. Katz: -- we are learning and answering the questions. So I apologize for continually interrupting.

Rep. Kowalko: And I apologize for my haste.

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Sen. Katz: On Page 5 you talk about at the most basic level the DHIN technology replaces current processes for how doctors get the results for tests they order for their patients. I was wondering if you could just help us a little bit understand at what stage you are with that and what you have actually accomplished to that extent and how it actually impacts physicians in practice in the community.

Mr. White: I think Senator -- The question is with regard to physicians accepting the results through the DHIN, is the report of record. We now have about -- I think we are up into the twenties now -- oh, thirties. Up to 32 percent of use of the DHIN as report of record by physicians' offices, and sign-offs are continuing the pace.

Sen. Katz: Was that percent 32% of?

Mr. White: 32 percent of practices out of 160.

Sen. Katz: Could you explain a little bit about the types of practices that have designated it as report of record? Which ones have signed off?

Mr. White: All kinds of reps have signed off.

Sen. Katz: Can you give us a little bit of detail? Are they family practice? Are they hospital-based? What's the distribution, the segmentation of those practices?

Mr. White: I don't have that off the top of my head. I can't answer that question, but --

Sen. Katz: Could you provide that for us, please?

Mr. White: Sure.

Sen. Katz: Thank you.

Mr. White: That number is obviously going to be very fluid and very changing. We have doubled the number of practices accepting report of record within the last 30 days.

Sen. Katz: Do you know percentage wise what percent of those practices are hospital-based versus independent private practice?

Mr. White: Zero are hospital-based.

Sen. Katz: Zero. Okay. So, as far as the emergency room physicians, are they included in that number of practices?

Mr. White: No. The emergency room physicians are using this for inquiry purposes.

Sen. Katz: Okay. How about the specialists, as far as cardiologists, pulmonologists? Have they signed off on this?

Mr. White: Yes.

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Sen. Katz: Can you tell us which practices?

Mr. White: We can provide a list of those practices. Once again, it's very fluid. It has doubled within the last 30 days.

Sen. Katz: Thank you.

Mr. White: We are at that critical juncture now where people are, in fact, signing off as report of record.

Sen. Bushweller: I don't know what a report of record is. Could you tell me what that is?

Mr. White: It's basically the physician agreeing that this is the report that they are satisfied that this is getting them everything they need and they wouldn't be unhappy if the hospital or the lab who is providing that information in some other fashion in the past turned that off.

Sen. Bushweller: Stopped faxing.

Mr. White: Right.

Sen. Bushweller: Stopped U.S. mail.

Mr. White: Ultimately, the return on investment for your data sender is when the report of record is accepted by everybody and they are able to lay down the parallel systems. And we are now at the point where we are making that transition to report of record.

Sen. Katz: Senator Bushweller actually brought up a good point. Are they all electronic, or are some of those report of records fax?

Mr. White: All types.

Sen. Katz: Okay. If you could provide that distribution, as well, that would be helpful.

Male Speaker: No fax.

Mr. White: No fax at all, actually.

Sen. Katz: No fax. Okay.

Sen. Sokola: Thank you, Mr. Chairman. I noted about the current functionality when they were asked if the current functionality is a centralized data model or federated data model. And I didn't really know what either of those were, but the answer said the confederated model which best suits the DHIN's needs. And I was wondering if you could explain a little bit of that.

And it also kind of stuck out, and the reason I highlighted it was is it the DHIN's need that we are trying to suit or the patients' and physicians' and the hospitals' and -- you know. I want to make sure that we have the right mindset when we are looking at what we are doing with things and why we are doing them.

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Mr. Ratledge: The key part of the DHIN legislation basically says that the senders, themselves, own all the data. Okay? It's not part -- It's not the DHIN's data. So all of the data -- For example, for Christiana Care, it's isolated and it's in what we call a data stage, and they have absolute control over the data. And the same would be for each of the other senders that are in there. So that's what we would call a federated as opposed to something where you are basically putting all the data together.

Sen. Sokola: Okay. Thank you.

Mr. Ratledge: That's the simplest way I can put it.

Mr. White: No commingling, but DHIN knows where all the data is when somebody inquiries it.

Sen. Katz: Where does the data actually reside for the different practices?

Mr. White: With Pero Systems(?) in Leno, Texas, with the duplicative set of info elsewhere.

Sen. Katz: And do you have different practices data residing on the same server?

Mr. White: Separate data stages. I'm guessing that's separate servers as well.

Male Speaker: It's not practice data. It's data senders' data.

Sen. Katz: So it's all hospital data and lab data that you are transmitting at this point, essentially?

Mr. White: Yes. Right.

Sen. Katz: And do any hospitals have data on the same servers, or do they each have their own server?

Mr. White: Separate servers.

Sen. Booth: (Page 7-8) Quick question. It says four of the six hospital systems in Delaware.

Mr. White: A. I. DuPont and Nanticoke are not yet on the system.

Sen. Booth: And it says you are negotiating with them?

Mr. White: We are talking with both of them, yes, regularly.

Sen. Katz: Just to follow up on Senator Booth's questions about the senders and the locations. Are the senders pretty much institutional senders, or do you have practice senders as well?

Mr. Ratledge: Coming from docs in?

Sen. Katz: Yes. You say what percentage of overall potential data sources does this group represent?

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Mr. Ratledge: The definition of data senders is people who have done a test and need to report that out to the ordering physician.

Sen. Katz: Okay. But I guess the question is your percentage of overall data sources, what is that number that you have integrated or implemented at this point as far as the overall population?

Mr. White: I'm not sure I understand that question.

Sen. Katz: Let me try to read the question. "What percentage of the overall potential data sources does this group represent?" That's under data sources section. And so what I am trying to understand is what percentage of the overall population of sources that can send data in the state.

Mr. White: I think, if I understand your question, the answer on laboratory would be approximately 85 percent of the outpatient laboratory testing is now flowing into the DHIN.

Sen. Katz: Okay.

Mr. White: Is that the example of the question?

Sen. Katz: That's with lab. But you have multiple other sources, x-ray, pathology. You actually have medical data from practices, which it doesn't sounds like you have yet tackled. So what I am trying to understand, if you could qualify what data you currently are sending to what population, what percentage of that population you currently have captured.

Mr. White: I'm not sure precisely how to measure that. I mean if you are talking you could have two boutique shops. One is a very, very small one, and a great big one that say did 20 times this boutique shop did. What would you count that? As two?

Sen. Katz: Well, it's an important point, because the success of an integrated health information system is the completeness of all senders.

Mr. White: Absolutely.

Sen. Katz: And right now you have done a nice job getting the institutions involved, getting the hospitals. And that's giving you a lot of data with a few hits. The harder part to get is getting the more -- the greater population of hits that's going to provide you a little bit of data. But when a patient comes into an ER or into an office, you want to be able to get complete information.

So you are working on the big hits now, a few of those, that you are going to get a lot of data from. But what I am trying to understand is what is the total possible number of senders that are out there that you need to accomplish. You have mentioned the hospitals right now and some of the labs, but what is the total population of senders that you are ultimately looking for?

Mr. White: Mr. Chairman, if we could perhaps address this question to our Executive Director -- Gina Perez …. that would certainly be helpful.

Rep. Kowalko: Certainly. Step up to the microphone, please. Identify yourself.

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Ms. Perez: I am Gina Perez, executive director of the Health Information Network. I think there are several ways to answer that question.

First of all, and I think foremost, is that we have just received funding from the federal government to develop a directory of services. That is one of the requirements under the new HIE state cooperative agreements that we have received. And in doing that, we will be able to identify what is the universe of organizations that can contribute data to DHIN.

And there are a lot of factors that go into the ability to deliver data to DHIN. They have to be capable of using standard transactions. They have to be capable of holding electronic data, transmitting that data. So there are all kinds of factors that go into that.

We also are having lots of conversations with small laboratory providers who do business with the State of Delaware. For example, we have a lab provider who has a contract with the Department of Correction, and they do a lot of services and would like to participate in DHIN. So we are working with them as well to get them on board.

So it does take time to negotiate those contracts and to get everybody on board and to establish the understanding of the appropriate technologies and the appropriate data. And so I think over the next year we will be able to answer that question with much greater certainty than we can today.

Sen. Katz: So you don't have a number at this point?

Ms. Perez: I don't have a number at this point.

Sen. Katz: Thank you.

Ms. Perez: But I think it's also important to consider that we have a significant portion of the medication data coming through the system, and that's from multiple sources of data through a single aggregator. So we are also looking at ways to get multiple sources through a single interphase, which cuts down the costs and creates greater benefits to the users.

Sen. Sokola: When I saw that they had a contract with Mississippi Coastal, it just occurred to me, I was wondering if that went back to before Katrina. And, if that were the case, did they have any problem with information retention? And, if not, if you don't know, maybe we can get that some other time.

Ms. Little: Thank you. I'm Rebecca Little, Senior Vice President with Medicity. The contract with the Mississippi Coastal Health Information Exchange was basically created from Katrina funding and is a result of Katrina. So basically the purpose of the project there is to ensure that in another -- in the event of another emergency such as Katrina -- that they do have information available and electronically available in the case of another disaster like Katrina.

Sen. Katz: Could you describe the ongoing metrics you use to monitor the performance of your vendors? You have had a relationship with them for a few years, and you have milestones. What sort of metrics have you been using to quantitate performance? And what sort of performance measures have you been utilizing?

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Ms. Perez: The way the contract is managed is through the project management committee process. So we establish a project plan at the beginning of each project, new project with DHIN. And so if you think of each new function that we implement in DHIN as a new project -- and it has a project plan -- and through that project plan we establish deliverables. Those deliverables have funding that go along with them. So basically Medicity bills us as they meet milestones, and we only pay those bills when the project management committee approves that we have met and that that has been a successful milestone met. So that is how we monitor their progress and ensure that it is moving forward in a positive and appropriate manner.

Sen. Katz: Thank you. Another question. You refer to the health information technology vendor supplying commercial off-the-shelf software. And you also mention that all solutions are owned intellectual property of Medicity, but DHIN does not have any ownership stake in any of Medicity's intellectual property. Has any of the work performed for the DHIN by Medicity been customized, or is it all off-the-shelf?

Ms. Perez: It is all off the shelf.

Sen. Katz: So there has been no customization?

Ms. Perez: It's configured to meet our needs, but it is off the shelf.

Sen. Katz: Okay. Has there been any charge for customer development or modification of the technology.

Ms. Perez: We pay for implementation, license, and maintenance.

Sen. Katz: I think we are on Page 10, but as we are trying to follow along -- The questions with the Code, which is Chapter 99, Title 16, and it gets back to my question of trying to understand the organization of how the DHIN is currently structured. Is it managed solely internally, or is the oversight and management or decision-making processes ultimately in the control of the Health Care Commission?

And the reason -- Who ultimately signs your agreements, reviews them? Where does the buck stop, essentially?

Mr. White: All of our contracts are signed by the Chairman of the Board and also by the Chairman of the Health Care Commission.

Sen. Katz: Okay. And so ultimately who has veto power or who states that you can sign something or you cannot? Who approves it ultimately? Who ultimately approves your decisions?

Mr. White: I'm not sure I understand the context of the question. The signers on contracts are the --

Sen. Katz: The reason why I'm asking, in Section 9920, Purpose (a), it says it's “under the direction and control of the Health Care Commission.” So is it ultimately under the direction and control? Am I reading that right?

Mr. White: We report regularly to the Delaware Health Care Commission, and we are under their purview.

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Sen. Katz: Thank you.

Mr. White: They appoint a significant number of the board members, and we report regularly there. Unfortunately, I don't have Chapter 99, Title 16 with us tonight, so we are at a little bit of a disadvantage to respond to questions.

Sen. Hall-Long: Can I ask a question for clarity? Ms. Perez, would you agree with his response? Would you agree that is how it works?

Ms. Perez: The way that it works is the contracts go through a review at the DHIN. The DHIN Board of Directors approves them. It then goes to the Health Care Commission. The Chair of the Health Care Commission can ask questions, as can the Health Care Commission ask questions or possibly request changes, if that is under their desire. And it is signed by both organizations.

Rep. Kowalko: Still on this subject on Page 10, powers and duties.

Sen. Katz: The question is, is it appropriate at this time to go through questions in the Code, or do you want to stick to specific topics within the Code?

Rep. Kowalko: We are going through Page 3 to 11, and right now we are not going to stray from that. You know, we are going to go through the entire report after this, but right now I just want to get through what I think is appropriate for a grasp of what DHIN is and what it means.

Sen. Katz: Got it.

Rep. Kowalko: And we will certainly go into details, and you will have that opportunity. But until this committee -- Until I feel that this committee has assured me that they have a grasp of the subject matter enough to move forward, then it's futile to go forward into unknown areas and details that we are not going to be able to understand the nuances of anyway. So, Senator Sokola, did you have a question?

Sen. Sokola: In this Committee over the years have looked over, the report and then -- I mean we have always had a copy of the Code there for reference purposes. And often our recommendations will include “comply with this title” orsomehow modify it. Sometimes our recommendations will just be able to be done by recommendation by whatever entity we are reviewing, and sometimes they will require Code changes, and sometimes they will require more attention to the Code that we feel, as a Committee, maybe have been ignored or not complied with in the manner of the legislative intent when the --

Rep. Kowalko: No, and we absolutely will be reviewing that part tonight.

Sen. Sokola: I had a question on that under powers and duties, that first bullet dot. And what really kind of stuck out to me was the patient clinical and then the words "and financial information." And I was wondering why that and financial information is there. Is this health financial information, or is it the patient's financial information? And that kind of threw a little red flag up for me when I saw it in the report that way. Can somebody comment on that, please? (First bullet point under Powers and Duties)

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Mr. White: Ultimately, the Health Information Network will be the repository for or the conduit for moving administrative data, insurance data, claims data.

Sen. Sokola: So the patient financial information is relative to the health?

Mr. White: Oh, yes. Absolutely.

Sen. Sokola: Okay. I just wanted to make sure that that was clear.

Mr. White: Absolutely.

Rep Kowalko: …. Madam Director, is there a question or a response on the fact that there is an audit going on that we have not gotten a response from?

Ms. Puzzo: I contacted the Auditor's Office and asked them for a status. As of today, I have not heard anything back…

Rep. Kowalko: So we are going to have to defer that question to a later date, if that's okay with the committee. You know, we will get that information from the Auditor's Office.

Rep. Bennett: (page 20) I had two questions. The first one is it states that the Board can include13 to 21. Currently there are 17 members on the Board. Has that been pretty consistent? Does it fluctuate a lot? Why are there 17 members?

Mr. White: The vacancies on the Board right now are for one health insurance company and some vacancies that would be appointed by the Delaware Health Care Commission, other than that one vacancy for health insurance.

Rep. Bennett: Have those always been pretty much open, or are they trying to fill them now?

Mr. White: There has been some flux, yes, up and down, but we have been static at that number for a little while now.

Rep. Bennett: And the other question was about the removal of a member of the Board. It takes, what, the majority of the Board to remove somebody for cause?

Mr. White: I don't remember, to tell you the truth. Debbie, do you have an answer?

Ms. Puzzo: Yes. It says that your regulation also provides that a member of the Board may be removed for cause by the majority of the Board members with confirmation by the Delaware Health Care Commission.

Rep. Kowalko: I have a few questions here on Page 20. We have the reference language "shall be appointed, shall be appointed, shall be appointed," and "may be appointed." I just was curious because they do have, in legal ways, they do have a different meaning. Certainly, a good lawyer would use those. Could you give me an explanation as to why those are designated as "shall be appointed" and "may be appointed"?

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Ms. Perez: So these are for the appointments that are state representatives, and they may serve in their capacity or appoint someone in their seat.

Mr. White: All of those that are listed as appointed are state offices where they can have a designee.

Rep. Kowalko: Okay. In other words, they can't opt out. They are appointed, but they may be a representative of that office that's appointed? That's what the "may" implies?

Mr. White: Yes.

Rep. Kowalko: And I did notice here in this 21 membership that there are no members of the public, which is often a good idea to have -- The complexity of this organization, certainly, you know, it can be overwhelming to a layman or a lay woman, but I think that members of the public may be a direction we want to include.

Mr. White: Mr. Chairman, we have included a member from the public appointed by the commission all along. Joanne Hasse has been that member and reminds us constantly of our obligations to the general public and also reminds us that we are also all patients so we all have an obligation to fulfill that responsibility as consumers as well.

Rep. Kowalko: But a lot of times in these cases -- and I think certainly this does apply here -- that we have a representative from each county, a member of the public because there is a diversity up and down the state of interests in New Castle County and in Sussex County.

And I do know that you have an appointment, you've done due diligence in that regard. But perhaps we should we be looking at a requirement that there be a member of the public from each county?

Mr. White: To consider that, we can certainly –

Rep. Kowalko: We certainly can rely on the integrity of this group that's representing DHIN now and that's running it, but, you know, you always have to worry about are we … are we mandating what we want appropriately for the representation of the public?

Mr. White: A lot of the work product of the DHIN is done at the committee level. Yes, there is oversight by the Board, but at the committee level we do have a consumer advisory committee that Joanne chairs that has widespread, up and down the state, participation by advocacy groups and, you know, the seniors, the disabled, the mental health population, and wide diversity geographically.

Rep. Kowalko: Okay. I appreciate it. And the reason I ask that question is I want the committee members to consider that when we do mull over these discussions.

Rep. Kovach: Just following up on the composition of the committee, and we are talking about the vacancies that are present and this "shall" and "may." It doesn't appear, unless I am not reading this correctly, that one of the vacant positions is a "shall appoint" position, and that's a member of the health insurer appointment. I mean is there not a member available from the health insurers that would want to be a member or -- it looks to me it's not necessarily a discretionary but maybe a mandatory under the current wording of the statute, and it's been vacant since August of 2007.

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Mr. White: Yes. I'm not sure that there has been a strict interpretation of that wording as requiring that somebody be there at all times. You know, there is an ebb and flow.

Sen. Katz: When you have members join the Board or you are identifying members for the Board from the different areas mentioned, do you have criteria and skill sets that you are looking for from each one of the people that you offer a position to?

Mr. White: We are certainly mindful of criteria and wanting to have people with a wide range of offerings to the board, yes.

Sen. Katz: Do you have a review process where you almost have a job description where you are checking off whether or not you have certain skill sets representative on the Board?

Mr. White: Most of these appointments are delegated, Senator Katz, so the board doesn't have that flexibility.

Sen. Katz: Okay. What about the ones that you can appoint?

Mr. White: We don't appoint any.

Sen. Katz: What about the ones from the Health Care Commission? Do you know if they have a set of criteria for skill sets that they are trying to have represented on the board?

Mr. White: I'm fairly certain they pay attention to that. I can't tell you that they have a written criteria for appointments to our board, no.

Sen. Katz: Thank you. Just another question: The establishment of staggered terms for the board chairperson and members is mentioned. Do you have term limits for members on the board?

Mr. White: We do not.

Sen. Katz: All right. Thank you.

Rep. Kowalko: I just want to reference one thing for consideration by this Committee, and that is in regard to the removal of members. No regulatory Board under Title 24 has the authority to remove, nor does any board or commission to which the Governor has appointments.. I see the DHIN response that is due to the sensitivity of individual patient information flowing through DHIN, the DHIN Board, with concurrence of the Health Care Commission, believes it's important to have this authority for removal of members. I want this Committee to seriously consider looking at that when we make recommendations.

All right. Are there any questions from the Committee members regarding fiscal info on page 30?

Sen. Katz: Yes. Basically the revenue reports that have been provided are kind of reviews. Can you give a little bit of information about what you have done as far as cash flow analysis? Pretty much formal accounting reports, annual accounting reports? Can you give a little bit of information background on that and what you have done going back to the past few years?

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Mr. Ratledge: Well, we have put a financial work group together to get a series of -- to find what the series of working reports that come out to the board were. We reported back to the board in -- I think it was December, the December meeting. And we have a fixed set of reports now which look at budgets and also flow of funds, variance from the budget. All of those are put together.

There is now a financial person at the DHIN who is in charge of putting those together. And then we will have, probably at the next board meeting, a formal financial committee will be formed to look at that and review those reports on a regular basis.

Sen. Katz: So over the past four years, five years, have you been doing financial accounting and reporting?

Mr. White: Yeah. Let's just point out that historically we do not have an incorporation. The business of the DHIN is done through contracts. The contracts are administered by OMB, so all of these finances have been kept by the Office of Management and Budget, now being done through Department of Health with the transfer of the commission to the Department of Health this past July 1.

Sen. Katz: When you actually look at the reports from OMB, where does the DHIN accounting fall? How is it reported when you look at the reports from OMB?

Mr. White: Under the Health Care Commission.

Sen. Katz: Okay. And what line items are showing on those reports that are attributable to the DHIN?

Mr. White: It's basically contract administration.

Sen. Katz: Okay. And if you look at the OMB, if you look for the DHIN line item, you are pretty much only seeing a single line. Is there any more detailed accounting that's been conducted that shows more clearly where the money is coming from and where it's been going over the past five years?

Mr. White: DFMS. The word is coming to me that I should say DFMS.

Sen. Katz: All right. And that's what I am saying, though, when you look at the accounting system -- And, granted, part of the problem is that the State's accounting system is a mainframe system very antiquated from the eighties, so it's difficult to wade through.

But what I am trying to understand is there a place or have you been doing, over the last four or five years when you have been expending the dollars, how have those dollars been clearly shown? How do you evaluate them when you meet in your board meetings? How have you been looking at your cash flow, the money coming in, and where it's been going? And how do you evaluate it on an annual basis? And how have you reported that over the past four or five years to the Health Care Commission, who has ultimate control or decision making powers of the DHIN?

Mr. White: All contract administration of state budget. We don't report that….We don't touch the dollars.

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Mr. Ratledge: We don't touch the dollars.

Sen. Katz: Well, I'm not saying you are touching. How have you been monitoring and watching where the dollars are spent?

Mr. White: Well, that's fairly easy because it's all at the contract level. It's monies in from the state from the federal government. It's contract administration.

Sen. Katz: So you have no spreadsheet, no annual reports that you have been doing monitoring that?

Mr. White: If you don't have an incorporation, you don't have a balance sheet and a profit and loss statement. We have contract administration.

Sen. Katz: But departments and divisions do do that, so if you consider that you are a department or a division or an entity under the Health Care Commission, that's common business practice to do financial reporting to whoever has oversight over you.

I'm trying to understand what the oversight process has been when you report to the Health Care Commission annually. You have X millions of dollars that you have been receiving and spending. How has the Health Care Commission been making those decisions on spending the money and tracking the dollars to make the decision whether or not the dollars are being spent appropriately?

Mr. White: The accounting is done within OMB. I'm not sure I know how to answer your question, Senator. We are not a corporation.

Sen. Katz: So the Health Care Commission has not been tracking the expenditures of the DHIN?

Mr. White: I'm sure they are. Yes. The Delaware Health Care Commission, we are a line item within the Delaware Health Care Commission.

Sen. Katz: How have they been monitoring?

Mr. White: I can't speak for the Health Care Commission.

Rep. Kowalko: Excuse me, Senator. I would like to call Paula Roy to maybe enlighten us on the questions that are being asked, if you don't mind.

Ms. Roy: Good evening. My name is Paula Roy. I'm executive director of the Delaware Health Care Commission. Certainly, the books are kept in OMB. They are reconciled to the Delaware financial management system. There are certainly spreadsheets that are kept.

In terms of evaluating how the dollars are matched, we do rely very heavily on the project management committee which was described to you, which is a committee of the people who are, you know, not only the public, but the private sector, who are putting the money in, managing the projects, making sure that they are delivered to the satisfaction of all of the contributors and participants of the DHIN.

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We rely on that process very much because those are the people with the technical expertise. Certainly we are following the dollars. But the commission is not in a position to understand how those -- how that project is unfolding on the ground within the hospitals, within the labs, within the physicians' offices. We do rely on those people to share that information with us.

Mr. Ratledge: The contracts, themselves, basically have deliverables in them, and there are payment schedules associated with those deliverables. So when the project management team sees that the deliverable is there, we have been able to do the appropriate tests through certification and also through production. Then that task is completed. At that point the bill can be paid. An invoice will come in, and OMB will pay the bill.

Rep. Kowalko: And I think that was mentioned earlier about goals being met and payments being made only after those goals have been met.

Ms. Roy: Correct.

Sen. Katz: Just so I understand. I apologize for asking again. So OMB is the entity that actually tracks the dollars and does the reporting?

Ms. Roy: That's where the major bookkeeping, yes.

Sen. Katz: Is there current capability within the DHIN now to do financial reporting and to track the dollars essentially? Is that --

Ms. Roy: There is, but in terms of managing all the dollars, remember this, it is still going to go through state financing. Even the private funds come in. All the invoices will be submitted to OMB and paid accordingly.

Sen. Katz: Okay. And who does that currently for DHIN?

Ms. Roy: OMB.

Sen. Katz: No. For DHIN.

Ms. Roy: For DHIN?

Sen. Katz: Yes. Do you have a finance person?

Ms. Roy: We do have a finance person on board with DHIN.

Sen. Katz: And is that a state employee?

Ms. Roy: That is a contract employee with Advances in Management.

Sen. Katz: Thank you.

Ms. Roy: In accordance with the bond bill.

Sen. Katz: Thank you.

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Rep. Kowalko: And I might add too, like some of the senator's concerns, there is an ongoing audit or there has been an ongoing audit taking place.

Ms. Roy: Absolutely.

Rep. Kovach: Thank you, Mr. Chair. I had a question on the chart, the revenue chart at the top of Page 31. It talked about the matching component and the dollar match requirement. And it looks like from years 2006 to 2009 that the private money does indeed match on a year-by-year basis, match or exceed the state-funded amount.

In the budget amount for 2010, the private amount, it looks like it's slightly lower, although not significantly, but by $100,000 lower than the state-funded amount.

Can you, I guess, explain that as far as the matching requirements or if the matching requirements are cut off at a certain point or?

Mr. White: That's a question of the timing of the transfers. If you note the paragraph underneath the block that you are reading from, it should be noted state revenue reflected above is not equal to state bond appropriations due to the nature in which state funds are transferred to DHIN. Income is recognized for accounting purposes after work has been completed and invoices submitted. And the foot notes there I think address the --

Rep. Kovach: So even though it says "budgeted" here, obviously you are still planning, then? Your answer to the question, I think, is the amount from private will match or exceed the state?

Mr. Ratledge: Absolutely. The State won't pay us unless we have matched it.

Paula Roy: It's pretty straightforward.

Rep. Kowalko: Let's get into Page 11, the Administrative Procedures Act. Any questions on that? The Freedom of Information Act? Any questions on that?

Sen. Katz: Actually, under Freedom of Information Act, it disclosed several executive committee meetings and where you have met in executive session. Is that inclusive to date?

Mr. White: I believe it is.

Sen. Katz: Was there an executive session that took place on September 3, '09?

Mr. White: Senator, I have no idea.

Sen. Katz: Well, maybe you may want to go back and look at that, because I don't see that date on here.

Rep. Kowalko: At the request of Senator Katz, will you get that information to us?

Mr. White: Certainly.

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Rep. Kowalko: My compliments, by the way, gentlemen, on getting that money from the feds, that grant.

Mr. White: Thank you.

Rep. Kowalko: And I appreciate the patience of everyone here. Thoroughness is certainly imperative here. Anything on Page 13 through the top of 14 on proposed State legislation. Any discussion, committee members?

Sen. Katz: Towards the bottom of 13, it talks about SB-201, and it states that you are working to move for a permanent governance structure as it transitions from a developmental phase to its operational phase. And it states, soon thereafter, that the legislation keeps intact the current board, the DHIN's assets, its rules and its regulations, with certain specific changes designed. Is that a good thing? And could you explain why?

Mr. White: As we went through a very long process of examining governance through a committee that was chaired by Rich Hefron and had broad participation by stakeholders, the exercise included, at the recommendation of Mr. Swayze, who provided us with good counsel, that we try to capture the elements of what we were doing now that we wished to protect moving forward, and that we tried to figure out what we wanted to have when we were finished that we don't have now. And one of the things that was at the top of the list of things we wanted to protect was some continuity in the current leadership so that we don't kind of drop the thing on its head.

Sen. Katz: Under "specific changes include," it mentions that you are interested in establishing a not-for-profit public private corporation. Could you explain the type of entity you are looking to establish? Is that a 503-C?

Mr. White: It's a state corporation.

Sen. Katz: Okay. And how, specifically, would that differ?

Mr. White: Are you familiar with -- There are a number of state corporations. Riverfront Authority. There is Port Authority.

Sen. Katz: Yes.

Mr. White: So we looked at some of the benefits of those kinds of structures. Those are primarily where the public private partnerships reside in the State of Delaware.

Sen. Katz: Have you chosen a specific model that you wish to use out of those?

Mr. White: It's not a dead ringer, but it's probably closer to Port Authority than anything.

Sen. Katz: Okay. Under representation on the board, if you go to the specific language of the bill, it says that you have representatives of Delaware's health consumers, hospitals, physicians, business health insurers, so forth.

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The line where it has physicians actually states "physicians or health providers." So the way it's written currently, there is a potential that you could have health providers without having physician representation.

Mr. White: Yeah. And I think that's something we probably want to clear up. The intention there was to make it possible for physicians to be represented not only by physicians but also by practice managers, or perhaps even by Mark Meister, who has served for a long time on the DHIN board of directors, and having language that simply said we would have physicians would have precluded that.

Sen. Katz: Okay. One other question: Maintaining the same immunity from suit and limitations of liability as in the current statute when establishing the DHIN. Can you explain just a little bit more in detail about the immunity from liability that you were trying to accomplish?

Mr. White: It's the same immunity that exists in the current statute. It's immunity for the organization itself and for its board of directors.

Rep. Kowalko: Excuse me, Senator Katz. I just want to interject here for a moment. I don't want to belabor this point, but I do want to point out that this legislation submission was made -- and I will defer it to the Executive Director.

Ms. Puzzo: Just as a point, one of the discussions was that each bill would not be talked about. … Well, that's the synopsis of the bill, so ...

Sen. Katz: Yes. Actually, if you would like, I can actually -- since Mr. White has referred to the current code -- I could actually go directly to there and ask my question under section 9923, immunity from suit, limitation of liability. Under Section B, second sentence, it states, "No person who participates or subscribes to the services or information provided by the DHIN shall be liable in any action for damages or costs of any nature in law or equity which results solely from that person's use or failure to use DHIN information or data that was imputed or retrieved in accordance," et cetera.

So the immunity, in my understanding, is only, for instance, if there is a physician using just information solely from the DHIN, they would be immune. But typically when you are caring for patients, you are looking at physical exam; you have other tests and studies and reports that you are referring to. So you are really -- it's multifactorial. So what actual immunity would that provide a health care provider if they are not actually practicing solely from DHIN information? Where does the immunity come in?

Mr. White: The immunity is for the DHIN as an organization. The only benefit that would accrue to providers would be if they have, in fact, relied solely and to the extent that they have relied on other things that might have caused them to understand that they didn't have what they needed through the DHIN. You know, a physical exam, for instance, it can't be ignored, you know, in the course of looking at the conduct of a physician.

Sen. Katz: So practically --

Rep. Kowalko: Senator Katz, I want to interrupt here. I am going to rule from the Chair that the intention of including this proposed state legislation into this discussion was not to have a debate on

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particular bills and not -- that would be a more appropriate place after the bill is filed than where it is at committee.

It's not the purview of this committee, as we review DHIN and we review the aspects of DHIN and whatever recommendation we make, that we get into specifics of legislation unless we crafted it in this committee and under a mutual, certainly, agreement of the committee members, you know, by vote.

And also that debate should be more appropriately placed -- I am not trying to cut you off on this, but I do not want to have this -- The appropriateness of this committee's view and purview is not in debating individual bills. So I would like to cut this discussion off now.

Sen. Katz: Sure. Understood.

Rep. Kowalko: And I will do that.

Sen. Katz: And, actually, my intent was only to refer to the specific changes recommended. I'm not referring to --

Rep. Kowalko: Yeah, but these are not -- these are specific changes not recommended by this committee. They are for us to review -- we certainly can -- but any specific bills have got to be taken into context. And I should have interrupted a lot sooner, and I apologize to my fellow committee members that I did not. But we are not going to have a discussion on or a debate on efficacy of particular legislation at this time. I don't think it's appropriate. I don't think that the retorts can be vested in any kind of a knowledgeable way off the top of their heads.

This Committee is here to review the DHIN and whether or not we see anything that may come from this review that we can recommend to improve or accept what it is.

Rep. Kovach: Not relating it in any way to the proposed legislation, but I'm just interested in hearing did we get a close on the discussion of the liability issues of the -- under the current act as -- I didn't see --

Sen. Hall-Long: We should be getting to that on pages 34 to 40.

Rep. Kowalko: So there will be a discussion on liability as it applies to the current DHIN structure. And my apologies. My apologies, certainly. I should have stopped that discussion a lot sooner.

Go to performance in the mission. Any questions in that area? Page 14, top of Page 15. Seeing no questions from committee members, we will move on to accomplishments. Any questions for committee members under accomplishments.

Sen. Katz: Sorry, once again, to continue to ask questions, but there are a lot of details here. Under accomplishments, it talks about LabCorp and Quest Diagnostics. Could you discuss a little bit your relationships with both of those entities, when they started, and their level of satisfaction with current performance?

Mr. White: LabCorp was an early adopter. Quest was a little later adopter. They are both supportive of the initiative, and we are in the process of transitioning into a relationship that will

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enable them to have a similar relationship with the DHIN to what they anticipate having on a national basis as nationwide organizations.

Sen. Katz: And have you -- Do you currently work with them with a level, service level agreement, or how does that relationship work right now?

Mr. White: We have a service level agreement between the DHIN and our vendor, Medicity, and there is ongoing discussion right now about trying to arrive at a consensus, commonly worded service letter agreement between the data senders and the DHIN so that the data senders can rely upon that service level agreement and turn off parallel systems.

Sen. Katz: Okay.

Mr. White: That's the next stage.

Sen. Katz: When will that be implemented, do you expect?

Mr. White: We anticipate we will have that in place by July 1.

Sen. Katz: The SLAs?

Mr. White: Yes.

Sen. Katz: Okay. And where are you currently with labs? My understanding from previous reports, that was supposed to be implemented a year ago. Is that up and running currently?

Mr. White: Gina?

Ms. Perez: Well, I'm going to go back to something that Dr. Kolodner said, that this is not easy stuff, and what Rob said about we have one chance to get this right.

Order entry is very complex. It requires us to be able to work with various electronic medical record system vendors. It requires us to ensure that, when an order is placed, that it arrives where it's supposed to be and that the response to that order is received back through DHIN and is appropriately directed to the ordering provider.

We have looked at options, and we have gone back and done some more homework. And we are in the process of implementing a demonstration project with a handful of practices who are willing to work with us to do that. And we are looking at the next six months to have that demonstration up.

Sen. Katz: So you expect that order entry will be up and running or implemented?

Ms. Perez: In a demonstration project with a handful of practices.

Sen. Katz: And what type of practices will those be?

Ms. Perez: There are both specialty and primary care practices, and they have to have an electronic medical records system.

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Sen. Katz: Can you -- as long as you are there -- and I'm not sure you are the appropriate person to ask about this. As far as meaningful use status, what are your plans to help the medical community with that important issue?

Ms. Perez: We have an electronic health record light or primer environment which we are in the process of rolling out. That will allow health care providers who are not interested in right now making a big investment in electronic health records systems to take a baby step. It is interim functionality which allows them to meet meaningful use.

It is also fully integrated with the Delaware Health Information Network so that it has the integrated query function. The order entry function, when that's up and running, will be integrated. It will have electronic prescribing, reporting, charting, all the necessary components.

Sen. Katz: And can you -- Are there deadlines required for meaningful use?

Ms. Perez: Organizations will -- Basically, it starts July, June -- I'm sorry -- January 1 of 2011.

Sen. Katz: And when does that have to be completely implemented by?

Ms. Perez: I'm sorry. I don't -- By who?

Sen. Katz: The providers. When do they have to --

Ms. Perez: The providers have to have electronic health record systems in place. I believe it's September 2011 is the required deadline for the first round of incentive dollars. But the incentives don't begin until 2015.

Sen. Katz: And how do you plan to implement that statewide? I mean, currently you are working with --

Ms. Perez: We don't. It is not our intent to replace electronic health record systems. If an organization wants to purchase an NEHR -- and many already have them, and many are in the process of purchasing them -- they should do that. This is for those who -- We've heard from some practices that are close to retirement that they don't want to make that big investment. This is, again, that interim step that helps them have an affordable opportunity to gain those incentive payments. So we are rolling it out statewide in the next couple months, actually, and we will support those who desire to have it.

Sen. Katz: Okay. And you make a good point. I mean, many of the physicians practicing throughout the state are in small, independent practices and smaller rural communities. How will you outreach to capture that population?

Ms. Perez: We are developing that plan right now.

Sen. Katz: Okay. And you feel that you can get that done by the deadline in 2011?

Ms. Perez: Absolutely.

Sen. Katz: Okay. Do you know --

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Ms. Perez: Well, it is actually up to the practice to decide when they want to implement it. They don't have to implement by 2011. They can implement by 2014. They just get fewer dollars.

Sen. Katz: Right.

Mr. White: I also might add that those deadlines are not carved in stone, even though they are published. Even the definition of "meaningful use" has changed within the last week.

Sen. Katz: Great. Thank you.

Ms. Perez: There are other components to meaningful use that we are also addressing. There is support that we are providing to hospitals to allow them to demonstrate meaningful use in various ways.

There is a continuity of care document exchange which allows us to get data from physician EHR's into the network for the ability for other users to see that information.

So there is a lot of work being done to support health care providers in Delaware to be able to grab those incentive payments.

Sen. Katz: I have a question.

Rep. Kowalko: At this time I want to -- We have a lot of public commenters signed up, over an hour of public comment. I would entertain a motion from the committee that we move forward with the public comment and then re-enter into this discussion with the committee after that in case there are -- You know, I don't want to have the public sitting here. I think that it would be, you know, unfair. Certainly, that they have the time to speak; we have the time to listen to that. And then we can get back into what may or may not be a quicker move --

Sen. Hall-Long: We can do a second meeting too.

Sen. Bushweller: Mr. Chairman, I would like to make that motion.

Rep. Kowalko: A motion has been made. And I just appreciate that --

Sen. Hall-Long: Do you want a second for that?

Male Speaker: Thank you. I will second.

Rep. Kowalko: Okay. All in favor of -- The motion on the floor, Representative Bennett, is to allow the public comment to take place now, and then we will get back into the discussion afterwards; or, if it's required, we will have another meeting another day too, if we run too late. But I do want to get to the public who have traveled from various places.

So, if that's agreeable, I ask for a vote on that motion. All in favor? Any opposed? (All in favor – Motion adopted) Thank you, gentlemen. We will be getting back to you

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Sen. Bushweller: This would be an appropriate time for me to just remind the Committee, if I may, as we begin public debate, or presentations, that the State Chamber of Commerce submitted a letter, I think, to each of us individually. And I believe it is -- I talked to Mr. Gross beforehand. I believe it's their intention that this letter be entered into the official record.

Ms. Puzzo: Could they forward a copy to me?

Sen. Bushweller: Sure.

Ms. Puzzo: Actually, electronically, so that we can put it right in?

Sen. Bushweller: Sure. Yep. I'll arrange it.

Rep. Kowalko: Okay. I appreciate that, Senator Bushweller. As a reminder, there is a three-minute limit for each person from the public to address the committee, five minutes if you represent an organization. Again, we won't stand here with an egg timer. We certainly, when you get to three minutes, though, we hope that you don't go much longer than that. I will try to remind you.

I would also appreciate if you e-mail your prepared statement this evening, if you have one. Or, if you don't have enough with you or you don't have it, e-mail it -- I'm sorry -- to Ms. Puzzo at Deborah.Puzzo, P-U-Z-Z-O, at state.de.us.

III. Public Comments (3 minutes per person)Mr. Laird made the following statement: My name is Clint Laird, and I'm a resident of Delaware and a taxpayer. I'm here as a citizen. I appreciate the opportunity to address the Joint Session -- or Joint Sunset Committee on the DHIN.

Before 1999, by business insights in health care were limited essentially to my experience as a board member of the Blood Bank of Delmarva, where I was a board chairman at one point, and my tenure on the Nemours Foundation Board of Managers.

In 1999, my experience curve became vertical as I invested in and worked with two health care startups. CapMay was a personal health record company based in Delaware. We sold it in late 2003. And, subsequently, it's been sold twice since then. It's currently owned by FIS, which is a New York Stock Exchange listed company.

In selling CapMay, I became involved in Universata, which launched its private medical records solution -- exchange, that is -- in October of 2003 with a one-physician practice in Montgomery County, Maryland.

Last month, I ended three years as a CEO of this company. Currently, our exchange is operational with over 500 health care providers; 7,000 payors; 5,000 government offices; 32,500 legal entities; and 7,500 other business entities have used this exchange for over six years. We have source data sites in 21 states and have processed over 2 million medical record transfer transactions, totaling over 60 million pages of medical records. It's in this context that I offer my comments as a lifelong resident of Delaware and a taxpayer.

I believe that the DHIN -- that there is a public need for an entity like the DHIN. However, I'm deeply skeptical that this agency, the DHIN, is effectively performing its mission. My skepticism is

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based on dollars, the actual money involved, and what I see as either a disrespect or an ignorance for outside solutions that can provide quick and dramatic value to the DHIN.

I don't know -- I cannot figure out from these numbers whether the DHIN has gone through $14 million or $24 or $23 million in the last four or five years. I don't know what that number is. I'd be curious if someone would tell me. I can't figure it out. At any rate, it's a lot of money.

The primary care for the failure -- The primary reason for failures of RIOs and HIEs in the United States has been the absence of sustainable revenue models. Critically, the DHIN management has provided no detail on its revenue strategy. Is there a business plan for sustainable revenue? It appears that the DHIN needs $5.3 million to operate in the last fiscal year, and I would like to know where that money is coming from for the next fiscal year.

Grants provide -- Grants and private contributions, in my judgment, are not revenue. Grants are not a revenue model. I would like to know what they have tried. I would like to know what the plan is. I would like to know if there is a business plan.

I think the DHIN should seek solutions that -- Pardon me. I think the DHIN should search for third-parties who would have a business reason to underwrite and score health care improvements, such as enlightened employers who invest in wellness programs. I think that's critical.

The accomplishments. This has been very interesting. And I will speed this up. I thought the DHIN had nine practices that have signed off. Now, if you look at the definition of "signing off" in this report, it's a little different than what I thought I heard here at this table. But whether it's nine practices or 30 practices, frankly, I think it's a small number. Either metric, I say it fails at the price level.

What is the price going on here? They cite 40 million transactions. I would like to know what a transaction is. 40 million transactions a year is a lot of transactions. What's a transaction?

I think, in general, I think the accomplishments, which I found confusing, earn them a failing grade. If you balance that against five years and $14 million, or maybe it's $23 million, I think if they were in the private sector, the management team -- this management team would be under serious scrutiny long ago. And this scrutiny is now the responsibility of this committee, and I'm delighted they are doing it.

HIE development operation should be nimble and curious. Management and governance should seek new ideas, models, and appropriate technology. Unfortunately, the way I see the DHIN operating, like many HIEs, is they seem to express a technical vision rather than a market vision of their mission. Electronic health records are important, but they are not the center of the universe.The DHIN should be a vehicle for value-added services, such as eligibility and benefit access and better claims processing. I think they should seek solutions that include practices that are not ready to embrace technology. I was interested in Ms. Perez's comments that they have a light version. I didn't know about that. That's good. There are solutions out there that do this now, and they are free. But they are not engaged. They are not -- They don't have traction at the DHIN.

Patient privacy and security. These concerns are seen as a challenge when some companies see patient privacy and security concerns as an opportunity. And I think, frankly, you should have a discussion with those companies.

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The last sentence. I don't enjoy coming down here and talking this way critically, but I see this enterprise going the same direction as other enterprises around the country that have gone -- shoop -- up and then down real fast. Well, I will e-mail my remarks.

Mr. Lafferty made the following statement: My name is Jim Lafferty. I'm the Executive Director of the Mental Health Association in Delaware. Our office is located in New Castle County. However, we provide services statewide.

Senator Hall-Long, Representative Kowalko, members of the Joint Sunset Committee, thanks for the opportunity to be here tonight to give you a few comments about DHIN.

First, I'm here to support the Delaware Health Information Network. I must say that when Herb Kneeling, who at the time was a member of the Health Care Commission and the first president of the DHIN board, proposed a five-year roll-out plan, I thought the plan was overly optimistic. I knew Herb from DuPont where he was a DuPont finance department director. And so I spoke to him about what I thought was too short a time frame to do what needed to be done. Well, I'm here to say I was dead wrong in my assessment.

DHIN progress has exceeded my expectation in terms of implementation, progress, and functionality. I wish Herb could be here to see the vision become reality. I have been a member of the DHIN Consumer Advisory Committee since its inception. The DHIN project worked very hard to gain an understanding of consumer concerns. And, as you might imagine, one of those concerns was privacy of data.

Detailed presentations were given to the committee. You have a chart in the report that you saw. We saw the whole Power Point. We met with the technical folks. We were pretty well schooled in how the network would work. That was done so that we could all understand the DHIN, where the data resided, the types of data that would be available, and security of the information.

The Consumer Advisory Committee was instrumental in defining DHIN's privacy policies and developing consumer-focused messages. How do you explain to people like me what this is all about, and what is the benefit to me as a potential patient and as a taxpayer in the State of Delaware?

One of the particular concerns to the committee was mental health data. Historically, mental health patient information has been treated differently than other medical data. Organizations like the Mental Health Association have worked and continue to work very hard to make mental health parity a reality in this state, in 1999, and worked very hard at the federal level for the same equality.

The premise for mental health parity was that psychiatric disorders are no different than other medical conditions and need to be treated equally from the standpoint of insurance coverage. When concerns are raised about accessing mental health data, I argued that we, advocates, people who have psychiatric disorders, and have and are being treated for them, cannot on the one hand fight for equal insurance treatment of these medically treatable illnesses and at the same time treat the medical information differently.

In other words, we can't separate mind from body. As hard as everybody tries, it can't be done. We are trying to get into the 21st Century here, and so I guess that's why I'm a big supporter of DHIN.

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The whole point of me telling you this was the Consumer Committee fully discussed the concerns people had -- not just of advocates like me -- but others had in the end, and there was agreement regarding the need to include this important data.

In my own case, I want my medical history available, including my psychiatric history. I have had two trips in my life to an emergency department. And, believe me, it is very difficult to recall medical history and medication history when you are laying on an examining table in an ED experiencing chest pain. You don't -- It's the last thing you think about. I want the emergency medicine physician to have full access to my data rather than relying on my own memory. I want that physician to be aware of all the medications prescribed by my primary care physician and my psychiatrist. I want that physician to be aware that in the past I was treated for major depression and I take psychiatric medications.

There has been a lot of talk about costs, savings. What I want is I want the physician who is treating me to more quickly be able to make a diagnosis and begin to treat me. The last thing I want is to undergo duplication in testing, particularly colonoscopies, Dr. Katz. (Laughter)

Delaware is nationally recognized for the work it has done on the Delaware Health Information Network. I want to congratulate the DHIN board and the DHIN team and all of the hospitals, labs, and physicians who are using the network for their collaborative work in making the Delaware Health Information Network a reality and a success in Delaware. I want to thank you very much for your time.

Dr. Case made the following statement: I would like to thank the committee for this opportunity to provide comments on how the DHIN impacts my ability to care for patients. My name is Charles Case, and I am the Chief Medical Officer at Henrietta Johnson Medical Center, the oldest of four federally qualified health centers, FQHCs, in Delaware. The center grew out of the efforts of several Wilmington doctors who were determined to make something positive grow out of the 1968 riots that plagued Wilmington following the untimely and violent death of Dr. Martin Luther King, Jr.

Henrietta Johnson, like the other three Delaware FQHCs is fortunate to be able to operate in the electronic medical records system, having gone live in August of 2009. Once all of our patient records are scanned into the electronic records, then I, as a health care provider, will have access to the health record of every patient who receives care at our facility. All I need is a laptop computer. I can be on site, or I can be at home.

The medical record is only as good as the individual pieces of information that comprise it. I can make the case that, as a result of the DHIN, the patient's record is a better and more useful document. Why? Well, for example, when I was recently on call on a Sunday and needed information regarding a recent hospital admission at Bayhealth here in Dover, I was able to access the data immediately. Without DHIN, several telephone calls would have had to been made to get the same information.

In another instance, and again on the weekend, it was necessary to obtain a test so that a possible urinary tract infection could be treated properly. In keeping with that time-honored adage that, "Above all, do no harm," the visiting nurse was able to submit the urine specimen in a timely fashion. The Christiana Care lab was able to identify the pathogenic organism on Sunday and

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identify on Monday which antibiotic would successfully treat that infection. No paper report was generated, and no telephone call by either the hospital or myself was made.

The necessary information arrived in my mail on the computer on Tuesday morning. In wonder of wonders, I sent the prescription to the drug store via the EMR before getting ready to go to work that morning. The end result was that the patient was treated properly and faster because of the DHIN, because the DHIN brought the automatic delivery of important information into the electronic medical records. Without DHIN, perhaps the patient would have wound up with an unnecessary hospital admission or an unnecessary emergency room visit.

I have pointed out two examples where DHIN was instrumental in providing care outside of the routine office visit. I will say, because of the DHIN, the staff at Henrietta Johnson is able to perform both its clinical and support duties at in a much more efficient manner. Time is money, and we are caring for our patients in less time. DHIN electronic medical records have been invaluable to us in carrying out our mission. Thank you for your time and consideration.

Mr. Fried made the following statement:Good evening. My name is Jeffrey Fried, and I'm president of Beebe Medical Center. I'm also currently serving as chairman of the Delaware Health Care Association. Beebe Medical Center has participated with DHIN going back to the strategic planning process for creating a DHIN since 2005. Over the last four years we have invested $943,000 to support the implementation of the DHIN.

That figure does not include contract labor costs and our own salary costs to develop interfaces between Beebe Medical Center and the DHIN. When adding those costs to the total, we have invested more than a million dollars to support the development of the DHIN.

Because we understand the value of the DHIN and the benefit it offers to our patients and our community, Beebe committed to be one of the pioneering hospitals and has been a partner with the State of Delaware over the past five years to ensure the success of the DHIN.

Our emergency department was the first emergency department in the state to go live with the DHIN query function. What this means is that our ED physicians can look up on the DHIN previous encounters patients have had at a participating hospital or any of the participating outpatient centers for laboratory and imaging.

If a patient recently had some kind of diagnostic test, those results are available electronically and immediately on the DHIN and there is no need to duplicate the testing, which is not only more costly but can also potentially delay treatment.

If the patient has been treated in another hospital, our ED physicians can access that information on the DHIN and have access to critical information that would not otherwise be available. Without the DHIN, our ED physicians would have to first contact medical records personnel at another hospital; medical records people would then have to locate the record; the medical record would then have to be sent to our ED; and then our clinical staff would need to spend time assembling the information from other hospitals and/or provider locations so the information could be readily used in the diagnosis and the treatment of the patient. This process could take minutes or much longer, depending upon the time of day. And, depending upon the patient's condition, it could have an adverse impact on patient outcomes.

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For Beebe Medical Center, the DHIN has had a very positive impact on our own resources. Prior to the DHIN, our IS department would have to write and maintain interfaces with every physician office if we wanted to be able to exchange information electronically back and forth with that office. This is not only costly but very time consuming. With the DHIN, any office that has an EMR can now access information through the DHIN, and we only have to maintain the interface with the DHIN instead of with multiple practices and multiple software programs.

The foundation for DHIN's success is that it truly is a public private partnership in which all participants have an equal opportunity for input and all decisions are made by consensus and consider the points of view of all stakeholder groups -- hospitals, doctors, patients, laboratories, et cetera.As one of DHIN's key private partners, we have invested significant financial and human resources and are pleased with the result of our investments. There is certainly more that we hope the DHIN will be able to do going forward, but at least the DHIN offers that possibility for us.

Without the DHIN, we would be taking a huge giant step backwards, and critical patient information would have to be faxed, communicated via telephone, or simply not be available to our doctors and nurses when they need it.

This would be a huge disservice to all who have participated in the DHIN to date. But, most of all, it would be a disservice to all Delawareans because the ability to rapidly communicate medical information would be lost, and the cost of ordering duplicate or unnecessary tests would undoubtedly increase.

With every hospital and doctor in the state looking to move to an electronic medical record, why wouldn't we want to have the ability to utilize the DHIN technology and infrastructure to facilitate moving that critical information where it can be best utilized to improve patient care? In terms of the use of medical information, Delaware is certainly one of the most progressive states in the country. It would be a shame, with health care reform on the horizon, to lose such a critical and valuable resource. I hope that you will continue to support the DHIN. Thank you for the opportunity to speak with you tonight.

Ms. Price made the following statement: Good evening. My name is Ginger Price. In January 2010, I retired from federal service as the director of the Nationwide Health Information Network.

And I want to tell you how much I appreciate the opportunity tonight to do public comment at this Sunset review for the DHIN and to share my experience with DHIN as the thought leader and collaborator in advancing interoperable health information exchange on the national level.

In August of 2008, I accepted the position of the director of Nationwide Health Information Network, the NHIN, and my primary goal was to move the NHIN from trial implementations to limited production status. My partner in achieving this challenge was the NHIN Cooperative, which was a group of nine contractors, six grantees, and several federal agencies in the health information exchange field. DHIN was one of the contractors.

I soon found out that DHIN was well positioned to help the Office of the National Coordinator for health IT, to make that transition from trial implementation to production. Some of the reasons:

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DHIN met all the contract deliverables on time with high quality. They demonstrated national use cases, laboratory, consumer empowerment, and bio-surveillance, and they did so while meeting the operational needs of the DHIN providers. In fact, it was just this practical operational experience that proved extremely valuable in forming the structure of the consumer empowerment NHIN service and the opt-in, opt-out business roles.

At the NHIN's foundation, health information exchange is all about trust. The challenges to the NHIN: How were we going to establish that trust on a nationwide basis? We needed to develop the common denominator of trust fabric that would allow HIE organizations like the DHIN to exchange information with independent delivery networks, such as Kaiser Permanente and with large federal agencies who have different requirements, like the Department of Veterans Affairs, the Department of Defense, and the Social Security Administration.

So DHIN's maturity in this field brought much to the policy practicum where over 20-plus diverse organizations slugged it out: What do we really have to do to come up with that trust fabric so that we can share information with each other? The result was the data use and reciprocal support agreement that has been signed and ratified as the basis of Nationwide Health Information exchange.

DHIN participated in self-organizing groups to develop the interoperability specifications that are at the basis of NHIN exchange. Their deep knowledge and rich experience in the tri-state information exchange resulted in specifications that went deep and addressed these needs.

A distinguisher for DHIN is their excellent relationship with their technology partner. When I put out a request for emergency pilot proposals for the NHIN, they collaboratively developed innovative ideas on how to expand the use of the NHIN in our operability specifications, not only within the NHIN framework and network context, but to give added value to the Delaware Health Information Network providers.

In short, DHIN is an example, I believe, to the other participating HIE organizations in the NHIN contracting world in two ways: The first is how to build a stable financial sustainability model for health information exchange. This was one of our deliverables, and the financial sustainability model that DHIN submitted was excellent and has served as a model for others.

And the second is how to build a strong trust and collaborative relationship with multi-stakeholder groups as well as with the technology partner. Collaboration at this high level ensures that everyone involved is successful. And I appreciate their collaboration with me in making me successful in my venture. Thank you so very much for your time.

Sen. Bushweller: Ms. Price, I understand you are not a Delawarean?

Ms. Price: I am not. I'm from Maryland.

Sen. Bushweller: From Maryland? And I just want to express my appreciation to you -- and I think from the whole Committee -- for your willingness to come out on a night when we are going to get some bad weather. And, you know, it's not a good night to be out, but it's very good of you to come. And I appreciate it.

Ms. Price: Thank you very much. I like Delaware. I might move here.

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Sen. Bushweller: Good. We are always looking for more good people.

Dr. Coye made the following statement:Thank you, Mr. Chairman. It is a honor to appear here for this Sunset hearing and particularly to talk to you about the impression from other states of the work of DHIN and the experience that we have had with their leadership.

Just a very brief background. You have my full bio. But I'm a physician. I trained at Hopkins. My most recent relevant experience close to Delaware was I was commissioner of health in New Jersey for five years. I then went on and was the director of health in California. So I have had experience in a lot of states.

I also very briefly have run a multi-hospital system, a large medical group, and an IPA, an early Internet disease management company, and a health technology research company. And I have been very active over the last decade in all the information technology development and quality and standards activities.

The reason I was very pleased to have the opportunity to come and talk here is I believe state roles are very important in developing the path forward when we have an area where there is real opportunity to improve quality and efficiency of services.

And the Delaware Health Information Network was a very important model to us in California. Four years ago, I founded the equivalent in California of DHIN, the attempt to develop a health information exchange in California. And three years ago we invited Delaware to send a delegate to California so we could learn how they were already bringing up services and doing things that no other state was doing. And they came out and generously, Gina Perez and her staff, gave a great deal of advice on the phone as well, and helped us put together part of our strategy.

And so when I had the opportunity to come here and tell you a little bit about the leadership that Delaware has provided, especially to think California doesn't usually, you know, come across the country to talk about how some other state has done a better job, but that is the truth here. (Laughter) And so I just want to very briefly state the reasons why I think that DHIN has made so much progress and is so important.

First of all, they were really the first to show that this could be done. I don't know if you realize how few states in this country are really exchanging information today of this nature. I mean this is still a forefront accomplishment. You still are in the front of the other states.

Secondly, you showed that it could be done incrementally. It didn't have to be one fell swoop. You could build it with getting the hospitals and the doctors and the laboratories and the pharmacies to see the benefit at each stage.

Thirdly, you are building it with an economic sustainability model. And we did learn from that, and other states are looking very closely. This idea of combining public private sector in the public state and federal funds but knowing that state and federal funds are not going to be there to finance it forever, that it has to grow up into something that's economically sustainable. And I think that DHIN is showing us a very important pathway.

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And, lastly, because it showed that you could have collaboration between competitors. In many other states the legislatures are, quite rightly, given who comes before them and lobbies, they find it hard to believe that you can get the physicians and the hospitals and the health plans and all the different organizations, including competing laboratories, pharmacies, to come together and say yes, this is good for everybody and we will all help in this. And that is a very important step forward.

So the contributions of the DHIN for the rest of the country are in the leadership. You have more usage, more adoption of health information exchange than any other state in the country. You have a broader functionality. You don't just do one type of service, but you are slowly, incrementally expanding how you can provide benefit to the physicians and to the patients.

You are contributing to knowledge because you are participating, as you just heard, with the development of the NHIN, but also Delaware pioneered in public health reporting in surveillance of the emergency room so you can tell if there is an infectious disease outbreak, and that came out of Delaware. And we studied that, and we proposed to copy that in California.

And in physician adoption. That almost 60 percent rate of physician adoption here is really stellar, and so we can study and learn from that because we are not close to that, and most states aren't yet.

And, finally, I thought it might be worthwhile to say that a lot of the work that you have done here is building the scaffolding for understanding what the business models will be going forward. When we took some of the experience in Delaware to our Medicaid agency, they produced their own analysis saying that they thought that they would save 25 million in the first nine months of adopting it. Just from the emergency room savings of not having to repeat lab tests and not having to admit people for watchful waiting when you don't know the diagnosis, so you can't be sure of what's going on, but if you have something like DHIN you can see what actually happened a week before or two weeks before.

So, because of all of that, the Mercer Consulting Firm in Watson Wyatt were asked by our state pension benefits group, Cal-Pers, to do an assessment of us, and they did a complete top to bottom of our technology and our business model and everything. And they said that particularly the vendor, which we shared -- we did a procurement process and contracted with the same vendor that Delaware has used -- that the technology could not be questioned and that it was a very, very strong proposal. And they thought that, for the taxpayers of California, it would save on a five-to-one ratio basis.

We actually thought that was more than we would have estimated. We would have said two to three to one. But, for all those reasons, I think that you have an absolutely stellar program. You have the best vendor on contract in the country. And the work that they are doing with the feds, with Office of National Coordinator and the NHIN, is groundbreaking. So I hope very much, for the sake of the rest of the states, that you keep moving forward.

Sen. Bushweller: Again, the same thank you to you for taking the time to come. Thank you very much.

Dr. Bahtiarian made the following statement: Good evening, Mr. Chairman and Committee members. My name is Greg Bahtiarian. I'm a family physician and president of Mid-Atlantic Family Practice, a private practice group which is located on Route 24 in Lewes. Mid-Atlantic Family Practice is one of the largest primary care groups in

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Sussex County with six providers, including four physicians, a physician assistant, and a family nurse practitioner. Our group currently cares for over 10,000 patients, and we had over 25,000 office visits last year. We practice out of a large office, and we have 20 employees.

I speak as a user and a full supporter of DHIN. I have been practicing in Delaware for the past 12 years, and I am one of the founders of Mid-Atlantic Family Practice. When we opened our doors in January of 2004, we were a paperless, in quotes, office. We were fully implemented with an electronic health record system. We were one of the first practices in Sussex County, and probably in the State of Delaware, to fully adopt a complete electronic health records system.

We were also one of the first practices to work with DHIN. And I have personally participated on DHIN's clinical advisory group. This advisory group was established to ensure providers' perspectives and concerns were addressed as the system was created and implemented and as new services and features are added.

They listened carefully to the providers' concerns and made corrections and improvements based on some of these comments and discussions. Mid-Atlantic Family Practice currently utilizes and relies on DHIN every day with almost -- with most, if not every, patient encounter. It is working, and in our sense it is working well.

Within our office, it is almost invisible to the patient, as the senator suggested. At this time our practice could not function the way it is functioning currently without DHIN. I believe they have done an excellent job creating a very, very complex system which, as far as I understand and has been described before, is well beyond any other state.

One of the most important features of our electronic health records system is receiving and organizing results of medical tests, including labs and imaging studies. We currently receive almost all of these results for most of our patients directly through connections or the interface between our health records system and DHIN.

As Mr. Fried had said before, we did have individual interfaces that we were able to turn off once we had this one interface with DHIN, and I think that speaks to some of the efficiencies that you will see down the road.

When one of my patients goes to the lab at Beebe for a blood test, as soon as that result is available on the computer at Beebe, it is sent through the DHIN, to the DHIN, and from DHIN into our computer, and immediately into my patient's chart. It will be in my in box for me to review immediately, and I can address any problems pretty quickly. This process is extremely efficient and significantly improves patient care and reduces some costs.

And I know cost is a big issue. This technology, obviously, the technology that is needed that is seemingly invisible and extremely efficient is also highly complex and expensive to create and maintain. And I think that's the problem.

And, most importantly, it really needs to occur without any errors, since patients' health care is at stake. Our practice currently -- Our practice and our patients really need DHIN to continue, and we hope it will continue to expand. Thank you.

Ms. Malone made the following statement:

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Good evening. My name is Kay Malone. I'm the CEO of LaRed Health Center in Sussex County in Georgetown, Delaware, and we are the youngest of the four federally qualified health centers in the State of Delaware. Because you have heard so much profound information this evening, what I thought I would do is suggest, let you have a little peek at our practice, what it was like pre DHIN and post DHIN.

As part of our practice when I first came two and a half years ago -- and what is part of every practice that I know of in my more than 10 years in community health -- is a patient would come in, a test would be ordered, a piece of paper would be given to that patient. That patient would go to the lab or the x-ray or whatever. That test would be performed. Then, either through the mail or through fax, the results would come in. The patient would be appointed to come back to get the results of the test.

We would go to the paper record, open it up. Whoops, it wasn't filed yet, or perhaps it hadn't come through the fax, or perhaps the fax was out of paper that day, or whatever would happen. So a patient may have come in and never have gotten -- we hadn't gotten the results, or the patient could have had a serious condition that was not addressed as quickly as possible.

As we started on the journey with DHIN, we also started on the journey with electronic medical records, and the two of those certainly were a wonderful marriage. As we began with DHIN, we started using our Internet system to find instant results for laboratory tests. So we had a situation where we had access to a database where we could pull off information if a patient called on the phone. We didn't tie up clinical staff when a patient came in and we didn't have the results, so a nurse would have to go and get the results verbally if they were normal or abnormal, and then they would have to send the paper backup copy. We could instantly go to our computer, pull up that, and we had the backup fax machine copy to be placed into the paper record.

Now we are at a point where we don't use paper at our practice. Dr. Case alluded to this in the -- that we have spent the past year flowing into electronic medical record. Now, not only do we have the results instantly available to us, but it flows into the providers' in box in their computers so they can access this when they are on call at home, or they can go through their lab results in a very timely manner and at the same time it's flowing into the patient's individual clinical record. So it's instantly available if that person were to call 911 and have to go to Beebe or -- The most exciting thing -- And, no offense, but the most exciting thing I have heard tonight is that Nanticoke is coming onto the system. Half of our patients go to Nanticoke, and that has been a real struggle for us because that hospital was not participating in DHIN up until this point.

So now we will, with either one of those hospitals or Bayhealth, if a patient is in an accident, they have instant access to our laboratory results, our clinical information.

I'm also looking very forward to the fact that pharmaceuticals will also be available. We all know patients perhaps will go to one doctor and then, oops, I forgot to tell Dr. Smith that Dr. Jones prescribed this, so that there is a duplication in medication. The DHIN cuts down on that and allows us to give safe clinical care to our patients.

The other thing that I have heard from people who are not familiar with this system is that, "Oh, I don't want everybody knowing everything about me. I don't want all of this information out there floating around about me." I think, for those people who are on the other side of the exam table or the other side of the reception desk, what they don't realize is in a paper record we have no tracking

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mechanism. Your relative could be working in our practice and pull your medical record and go through the whole thing. It happens. Within the DHIN system, within EMR also, every single person who touches that information is identified. We have a very solid audit trail. So that if a person is in your information inappropriately, we know about it. People have lost their jobs over that already. So it is -- I can't overstate the fact that it is a very, very secure system.

And there is one more thing that I would like to say. And that is I have been in community health for a long time, and I have been working for a long time. It has impressed me that this organization is, proudly, one of the most customer-friendly organizations that I have ever worked with. You call with a question; you call with a concern; you call with a problem, and you are not left alone until there is a solution. Thank you very much.

Rep. Kowalko: Thank you. Is it safe to assume that LaRed Health Center, is that like a West Side up in --

Ms. Malone: Yes. It's the youngest of the four.

Rep. Kowalko: I want to take this opportunity to thank you, on behalf of the committee and this entire state, for the venture that you are in. You know that we have a health care crisis in this country and that we are growing more dependent, unfortunately, on centers such as yours to provide health care for us. I just want to thank you and Dr. Case who spoke earlier. This is so important that the public know and acknowledge and your lawmakers know and acknowledge your reference. Thank you so much.

Dr. Laskowski made the following statement: I'm Dr. Bob Laskowski. I am the President of Christiana Care Health System. And thank you for enabling me to chat with you this evening. I want to compliment you in your thoroughness for going through things. It's been quite a thorough process here.

Christiana Care, we have been major investors in the DHIN over the years, and invested several million dollars in cash and also the equivalent of several million dollars in kind donations of executive talent and management expertise.

The reason for this very substantial investment is quite simple. It's our belief that the free flow of information, the medical information, is critically important for us to carry out our mission of service to our neighbors in our community.

We believe, as a matter of principle, that medical information should flow freely and be available to the people who are caring for patients and in an easy fashion.

Our experience with the DHIN -- and we have been advocates for the DHIN and critics of the DHIN over the years and very, very active in the process, and we have seen very real benefits and are very pleased with the progress of the DHIN.

Just a few examples, in the interest of time: One is the reduction of paper flow. And we have seen that to be actualized as we speak. There has been some discussion of cost savings, and we have estimated that, when fully implemented, the DHIN will save Christiana Care and the public that we serve indirectly about $400,000 a year just in paper costs. So that was with the further development of that.

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A second issue example is the ease of the coordination of important medical information throughout the state, specifically with state agencies. And Dr. Coy mentioned that in her remarks. The ease of reporting infectious disease information from emergency departments, which exists today, is very important in the understanding of the potential spread of infection throughout the state, and that's a reality.

But the most important thing -- and I speak here not only as the president of Christiana Care but as a physician. I'm an internist and geriatrician, and that's what I think first and foremost of, are the stories, many of which I have heard tonight from my physician colleagues. And when they tell me and I ask them, "Does the DHIN make a difference in your practice?" they emphatically say yes. That matters most to me.

We believe at Christiana Care that we are at the threshold of a tremendous transformative change. We worry that inadvertently we could derail that change by taking the DHIN off of its mark, and we encourage the committee not to do that. We believe firmly in private public partnerships and see this as a prime example of that.

We are very happy, very happy with the large investments that we have made and plan on continuing those in the future. And we endorse the great work of the DHIN board and the management team. And we believe that they have made Delaware truly the first state in the sharing of medical information in the country. Thank you very much. We really appreciate it.

Mr. Murphy made the following statement:Good evening. My name is Terry Murphy, and I serve as the president and chief executive officer of Bayhealth Medical Center. I'm a resident of Kent County. Bayhealth Medical Center has been represented on the DHIN board since 2005. Bayhealth has, as well as Beebe and the folks at Christiana, committed thousands of hours to DHIN in leadership, as well as over $1.2 million to ensure its success.

From Bayhealth's perspective, it has been money and time very well spent. This investment provides Delaware's health care providers and patients services that few health information exchanges can claim. It saves the hospitals from having to build direct interchanges, interfaces to every individual physician practice and their EMRs, as well as the various state systems.

If we had to rebuild a new system at Bayhealth Medical Center, our IT staff estimates a five-year cost of between one and a half and two million dollars and 12 to 18 months to get to where we are today. An industry goal, which has been supported by the federal government, is to have all providers adopt health information technology. This makes DHIN's connectivity to electronic medical records even more important to the physicians, hospitals, labs, imaging providers, as well as the State of Delaware.

They have mentioned a number of ways that I will not go into how it has improved efficiency. But one of the things I recognize, particularly with the size of the State of Delaware, is the number of health care providers that from early on have come forward to work together. And I think, if you were to look at most of our mission statements, it's to improve the health of our communities. And a very important piece are the federally qualified health care centers that are going to continue to expand over the next several years. And like LaRed, like West Side Health Center, Delmarva Rural Ministries, this exchange of information is extremely important.

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The foundation for DHIN's success is that it is a true public private partnership in which all participants have had an equal opportunity for input on all decisions, and those decisions are made by consensus and consider the points of views of all the stakeholder groups.

We are supportive of the process undertaken with the collective input of the key stakeholders in determining the future direction of the DHIN, and I appreciate your time tonight. We think it's a viable model for health information exchange, and we are very supportive. Thank you.

Ms. Hasse made the following statement: I'm Joanne Hasse, and thank you for the opportunity to speak. I'm a member of the board of the Delaware Health Information Network, a member of its executive committee, and chair of its consumer advisory committee.

I previously served on the Health Care Commission's data committee, which was referenced in Pages 3 and 4 of your report, and those were the recommendations from that committee which recommended the formation of the DHIN, and then served on the committee which wrote the DHIN enabling legislation. I am a long-retired nurse and was the primary caregiver for four children and, for several years, for my mother-in-law.

Unlike some of the immediate past speakers, I have not contributed any money to this (Laughter) but I have devoted hundreds of hours of volunteer hours to the DHIN because I firmly believe that it can facilitate the provision of better and safer health care for the citizens of Delaware.

As a former nurse and from my own experience, I know that people under stress frequently are not able to provide full and accurate information about their medical histories and their medications. This is especially true in emergency situations, but it occurs even in more routine encounters with the medical system.

Having accurate, up-to-date information is critical to good decision making, both by the providers and by the patients and their families when they evaluate their treatment options. The DHIN is key to providing this service to Delaware citizens.

I have taken my role on the board as a consumer representative very seriously. Although all of us are potential health care consumers, the other board members also wear other hats and primarily represent those constituencies. I believe the DHIN must continue to be a patient-centric organization and that consumers must continue to be regarded as primary stakeholders along with providers, insurers, and payors. And I have not hesitated to prevent the consumer viewpoint in our conversations, as I'm sure my fellow board members would agree.

In fact, the Consumer Advisory Committee played a key role in discussing at length and finally recommending to the board the privacy policies which the DHIN has adopted. I cannot stress enough how valuable the various viewpoints of its members were to this process. Differing life experiences and encounters with the medical system made for lively discussions. And I believe your packet includes the members of the committee and shows which groups they represented.

In summary, I think the DHIN will prove far more beneficial to the health of Delaware's citizens than those of us who served on that original data committee ever dreamed, but getting to that point

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will require more hard work. If this were easy to do, everyone would already be doing it. Thank you.

Dr. Steinberg made the following statement: Hello. My name is Dr. Terry Steinberg. I'm the chief medical information officer at Christiana Care Health System. I'm a member of the DHIN board of directors and a member of the DHIN executive committee.

I'm a practicing geriatrician, and I'm here tonight to speak for my patients. I see patients in their homes who are housebound and cannot receive medical care outside their homes. They can't leave their houses. My patients are among the most frail and vulnerable patients anywhere. If not for the ability of doctors and nurses to visit these patients, they would be in long-term care facilities or other assisted-living facilities. And every one of these patients is in their homes through the commitment and diligence and love and care of their family members.

Last week, I was seeing a patient in her home who had a very serious illness where she had not enough sodium in her blood; hypernatremia. She had been hospitalized for that. She was pretty sick. I was worried about her. Her daughter said that she had had a blood test in her home recently but she didn't know who did the blood -- which lab had come to do the blood work, and she really couldn't give me much information about this.

I had a laptop in the patient's home. I went to the DHIN website. I broke the glass to establish a proper relationship and reason for reviewing this lab test. I immediately got the lab test I needed, took care of the patient, changed her medications, and avoided a hospitalization. This patient's outcome would have been very, very different if not for DHIN. Thank you.

IV. Concluding remarks A JSC Committee meeting was scheduled for March 10, 2010. The Committee will finish its review of the Draft Report.

Ms. Puzzo provided the members with an update about the March 1, 2010 Public Hearing regarding the Newark Housing Authority.

V. AdjournmentThe meeting was adjourned at 9:45 p.m.

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Letter from the Delaware State Chamber of Commerce:

February 24, 2010

The Honorable John A. Kowalko, Jr.134 N. Dillwyn RoadNewark, DE 19711

Dear Representative Kowalko:

It has come to our attention that the General Assembly’s Joint Sunset Committee will be reviewing the Delaware Health Information Network (DHIN) this session. This letter is to express the Delaware State Chamber of Commerce support for the DHIN because what has been accomplished by its management, and the importance of the DHIN continuing to build a statewide network for the electronic transfer of medical information.

Since the late 1990s the Delaware State Chamber of Commerce and its 2,200 members have been active in supporting the efforts of the DHIN. One of the principal issues for the State Chamber has been to find the means to control the cost of health care while ensuring that the citizens of our state receive the best possible care. The United States Chamber of Commerce and Chambers across all fifty states agree with President Obama that a national electronic medical data transfer network is an important component for improving quality of health care and lowering costs.

Fortunately, Delaware has the first operating statewide electronic health information network in the country. This has been accomplished through the investment of millions of dollars by the federal and state governments in conjunction with their private sector partners. The establishment of the network has included years of dedicated service by employees of the DHIN and providers including physicians, hospitals, labs and health insurers. Along with these efforts, hundreds of hours in volunteer service have been provided by people from all sectors of the Delaware community representing government, medical providers, academic institutions, business and the consumer. What has been accomplished to date by this public-private partnership in achieving efficiencies in the delivery of health care, cost containment and information sharing is beyond what, many thought was possible when this effort began in the 1990s. The fact that other states regard the DHIN as a model for the establishment of their own health information networks is a testament to all those who have made the DHIN what it is today. DHIN has again put Delaware in the national spotlight, as we are largely regarded as the leader in health information exchanges. The recent announcement of $4.6 million of federal stimulus money for the DHIN is further testament to DHIN’s success. While 40 states received funding under the State Health Information Exchange Cooperative Agreement, Delaware is 1 of only 3 that received funding for implementation. The other 37 are still in the planning stages. As Senator Carper said in announcing this award, “This is more than recognition for what DHIN has accomplished – it is the ‘seal of approval’”.

The development of the DHIN has not been easy. Much hard work and special attention to detail was necessary, and there is a lot more that will need to be accomplished. But, the rewards are worth the time and effort. That is why we urge the Joint Sunset Committee members to carefully consider what the DHIN is and what it can be as they hear testimony and review the information before them. The Delaware State Chamber and its members are proud that they have played a role in establishing the first state wide health information network in the country and look forward to completing a process that will benefit all our states residents.

Sincerely,

A. Richard HeffronSr. Vice PresidentGovernment Affairs

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