TRANSCRIPT – HIT Policy Committee

The Health IT Policy Committee met this morning and release a draft definition of meaningful use. They will make recommendations to the National Coordinator for Health Information Technology (HIT) on a policy framework for the development and adoption of a nationwide health information infrastructure, including standards for the exchange of patient medical information.

You can access the slides from the presentation here.

The Meaningful Use Preamble is here. The matrix is here.

OFFICIAL MEETING TRANSCRIPT

DRAFT TRANSCRIPT:


Welcome to the second meeting to the health information technology committee meeting. This is a federal advisory meeting. It is conducted in public. We have audience listening in the room and — identify yourself as you speak. We are making a transcript of the proceedings and that will be on our website in about 10 days. Also, members on the phone, remember to mute your phones when you’re not speaking to reduce any noise. I’ll go around the table an briefly introduce ourselves and see who’s on the telephone. I’ll begin with Tony from CMS who is senior advisor.


I’m Tony from CMS. Senior advisor for today.


I’m Judy from [ Indiscernible: Speaker/Audio faint and unclear]


I’m Kristine for the national partnership of women and family. Jodi Daniel, ONC.


Connie delayny cool of nursing.


— school of nursing.


Paul with [ Indiscernible ]


Gail former state representative from Florida.


Adam Clark. Lance arm strong foundation.


Institute for family health in New York.


[ Indiscernible: Speaker/Audio faint and unclear] 1199 training and upgrading plan.


Veteran’s avaries.


On the telephone, we should have let Tania swee knee. Art Davidson?


Charles Kennedy?


They have all indicated they will be dialing in.


Frank. I’m here.


With that I’ll turn it over to Dr. Bloom anethol.


Thank you Judy. Thank them for being here for their work. You will see that quite a lot of work has been done since our last meeting. Their dedication and commitment is absolutely essential to a successful mission for this committee and to the success of the office of the national coordinator — agenda. President Obama speaks of having is big table for the discussion of health care reform. I think our goal is to have the same table with many seats for the discussion of this aspect of the health care reform agenda. That is the implementation of the President’s and the congress’ Agren da in the area of health information technology. This particular body T health information technology — gives the public and the members of the committee a chance to hear what’s happening in Washington and to contribute to that discussion.


A couple of announcements that are useful for starting points. I’d like to welcome polluting as co-chair of the health information technology policy committee. Paul is ahead of — chief medical information officer at Palo Alto medical group. A leader in the health information technology and someone who is always willing and able to help and extremely effective in that role. I’d also like to welcome the members of our sister agencies who have introduced themselves to these proceedings. This is the first meeting of the health information technology committee where we’ll delve into the very interesting and sometimes difficult substantive questions that are coming and will continue to come before this group. The work that we’re going be doing has been prepared for us, we’ve been prepared for it by several working groups who have actually contributed a lot of time in intensive meetings on very short timeframes in getting us ready for these — ready for these meetings. We appreciate that work. Everything we’re discussing here is a work in progress. We have asked a lot of those working groups and know that they are looking forward to the opportunity to continue to refine what they’re doing, based on the feedback that you all provide to them. At this point, I’d like to let Jodi Daniels talk from the [ Indiscernible ] Talk a little bit about how the health information technology committee policies work on the topics we’re going to be discussing today and the working group reports you’re going to hear fit into the context of policymaking under the high tech law.


Thank you. So I just want to remind everyone, this is a federal advisory committee and we have broken into three different work groups of this committee. The presentations that you will hear today will be presentations of those work groups. They will not be recommendations of the actual federal advisory committee. The discussion they will have today will be presented to you for consideration and it will be up to this full committee to make recommendations to the national coordinator. So again, just to stress that the products, particularly, the recommendations that are coming through the meaningful use work group for a fuller discussion and consideration. It will be up to this group to make any recommendations to the national coordinator. Now David said — wears few hats on this committee. He is the chair of the committee as well as the national coordinator who receiving any recommendations. That come out of this committee, Paul tang as the vice chair will make those recommendations to David as the national core nay for. Of course — coordinator. Can ingauge in discussions as a member of a full committee. We do expect the recommendations from the work group on meaningful use, we would like, as David had mentioned, to have a big table for gathering information and input on things that are coming out of this discussion. There will be a comment period. That will be based on the recommendations that come out of that work group an the discussion that we hold today at this meeting.


Would you say a thing or two about the rule-making process that follows?


Sure. Absolutely. This is all input into HHS. We’ll be engaged in a couple of rule making processes. There’s the requirement that HHS develop standards, implementations, specifications and certification criteria for electronic health records. We’re required by statute to have that rule out by December 31st of this year in an interrum final format. Will very much need to be informed by the discussions about meaningful use so this discussion will provide some input to us. CMS why Tony is sitting at the table with us on the definition of meaningful use. CMS will be working on a regulatory process for their inseasontive programs — incentive programs. So ONC and CMS are working closely together on that. That regulation will go through the full notice and comment rule making. Proposed rule with antient for formal comment and a final rule on that regulatory process.


Thank you. So this is the beginning of a conversation that’s going to last for some time. The recommendations of the working group, the discussion you will hear about the recommendation of the working group, I’m confident will be informative, useful. We will — the rule making process will be informed by them. But there is a long way to go before we get to anything like a formal governmental posture on the definition of meaningful use.


Okay. Before we begin the discussion and before we have the meaningful use work group report, there’s a couple of framing comments that I would like to make. You will hear these echoes in some of the report. In some sense, the first time we will be discussing health information technology in the context of our as rations. Not the end of it but the beginning of that discussion. You’ve heard about our deadlines — the government’s deadlines for policy development. Those are very tight deadlines. Placing an enormous amount of pressure on the committee and the government to make decisions quickly and in dealing with problems that are new and very challenging for the government and for the health care system as a whole. At the same time, we can’t allow those time pressures to short circuit discussion of the committee in dealing with some of the very difficult questions that will be coming before us. In a way, one of the first and most important things we have to think about together is what is the future state of the health care system that we hope our work will contribute to? What are we aspiring to? What is it we hope to accomplish? Where will meaningful use take us? We’ll have an opportunity to look very directly at that question today. We are on a journey, it helps to know where you’re headed toward if you want to be able to get there in the end, no matter how hard it is to navigate there. We have to have some directional sense. In that direction we’re going have to balance difficult tenses. Balance the need — tensions. Balance the need to stretch our health care system to higher performance but know how far we can stretch it without pushing it to the breaking point along the way. That’s a very important set of balancing considerations that we’ll be beyond the agenda discussion today.


We want to make sure that we have a definition of meaningful use coming out of this committee that is both ambitious and implementable in the 2010 timeframes that the policy we work under requires. We know we want a definition that is both simple enough to be understandable but specific enough to be meaningful. Illustrated today. We’re going to be engaging in a discussion about process measures and outcome measures if you allow me to fall back into the quality debate in the early part of the discussion about the quality of care. There were very avid camps that advocated for process measures like measuring what people do with — advocated strongly for outcomes that is what the health state was of patients who were treated by physicians or health care institutions. After years of contention, that debate sort of came to a resolution where people said, there are useful process measures an useful outcome measures measure and we shouldn’t take ideological measures on that. What constitutes meaningful use for health information technology. We should learn from history in that regard.


We’re going to talk in terms of the process that we’re going to engage in right now. We’re going to dive in first into the meaningful discussion. There are two other groups that are — certification and adoption. Other is health information exchange. Start with meaningful use because of its high visibility and its importance. We’re going to ask that Paul tang and [ Indiscernible ] Working groups on meaningful use to go through what the working group came up with. That will take I hope about 25 minutes to half an hour. Then we’ll have an hour of discussion. As you think about the discussion, there are at least two things that I hope we could accomplish today. I referred to both of them in passing. One is, to focus on where we want to get to. The other, is to focus on how the definitions that we are going to take into account today and think about could get us there over the timeframe that the law sets out for us. So with that I’m going to ask Paul and [ Indiscernible ] To come up to the front. John glasser who is a senior advisor in the office of national coordinator and has helped to facilitate this discussion is also going to join us.


Thank you David. Also committee members. Pleasure to be here in this momentos discussion. Who are the cochairs of the work group who led the conversations and will be reporting out to you. I have a couple of slides to walk through initially then we’ll turn it over to the substance of their comments. I want to start with — just remind you all, these are the work group members of the meaningful use work group. Here are the two cochairs at the top. [ Indiscernible ] Contributed time and effort and inelect to this conversation. Brought in from outside of the committee to contribute to our discussions. The economic broad charge that the work group has, if you take this paragraph and tease it apart. There’s three bullets in there. Over the course of the months ahead to — revision of meaningful use and national goals. Involving idea and you’ll see that in the comments that they make. In any given year in’s a need to establish or revise upcoming meaningful use definitions and we’re looking forward to doing that with the light process that we — right process that we engage the industry. To the policy committee. You may also recall in the legislation there were 8 national goals, ther are 8. In addition to those goals, subject to ongoing evaluation and evolution. First bullet develop over time by which we manage, maintain and develop these two ore yeahs in — areas in the years ahead. To work with the health care field over all, to front propose definitions of meaningful use and propose definitions of national goals. Asking them to lead the conversation which will produce definitions. See their first into that in a couple of minutes here. The third bullet is to give a definition is to define and outline standards that may need to be put in place or other policy priorities that need to be put in place to help make sure that this definitions can be brought to life. What standards or other related policies need to be put in place for this to occur. Refined a bit in a specific charge. The first and this is where they have been focusing for the last several weeks. They have done a remarkable amountable of in a short amount of time. You’ll also see an initial definition in 2015 although they have more time to refine that. That will be the work again that you see today. Moving onto the next one here, we hope that by the end of this year that they return to the first bullet in the broad charge and have a presentation to you all about the ongoing process. There’s a process done that produced good results but the way this was done in the last short period of time and we all recognize that and as the process — accommodate that in the years ahead.


Similar thing is to on an on going basis make recommendations regarding ther are 8 and the meaningful use. An elap ration of the broad charge. The last bullet here although we haven’t spent much time with them talking about this. Once proposed definition of meaningful use is how well is the con try doing in moving toward that vision as David talked about and will give a greater elaboration to. See whether there are barriers impeding the industry within the meaningful use. Those barriers could be lack of standards, property or patent protections. Got a good read on those and addressing them. Composition broad and specific charges of the work group. So let me just briefly touch on this and we’ll get into their process where we brought to them a wide variety of materials. As you know we had NCVHS testimony done by a wide variety of stakeholders. A range of opinions an thought pieces from various segments in the industry about how to tackle this. So these materials along with internal analysis were presented to the work group an they have worked quite diligently over a couple of meetings in a phenomenal meetings and phone calls. Seems to evaporated during — done a lot of work in leading to the conversations that you’re about to hear now. Start the discussion.


There’s the clicker.


Thank you. I want to acknowledge all the terrific work of the subgroup that not only brought a deep knowledge of all the various aspects of the components that we’re going to be talking about, but also brought about a real spirit in the sense of what it’s all for. The higher functioning health system that Dr. Blumenthal mentioned. What really matters, we found it to be absolutely ensensualessential to have that vision. The ultimate vision for us is to enable significant and measurable improvements in population health through a transformed health care delivery system. The key goals that we have listed here also translate to the specific charges to the national coordinator inner a and has been — convened by the national quality forum. They are to improve quality, safety and efficiency of health care. To engage patients in their family. Improve population and — must be to insure privacy and security protections.


Although, clearly health IT and adoption is not stuff to achieve as the specific objectives, we believe that meaningful use of health IT is an essential come point of the benchmark successes in delivering some of the outcomes that if extrapolated to the nation as a whole could result in these kinds of achievements. To prevent a million heart attacks and strokes by 2015. To make heart disease no longer the leading cause of death in the United States. Something that the kaiser per ma anyone they system has achieved. To have 50% fewer preventable errors. Reduce preventable hospitalizations and readmittizations. And make sure that preference for end of life care are followed more often. To provide our public health department with the realtime awareness of outbreaks that we’ve seen is so necessary.


How will we get there? Now that we have the north star of where we need to go, how will we navigate to get there? The committee came up with useful framework, that divided our goals and in the meaningful objectives timeline into three parts, the outcomes that we all seek, the advanced clinical processes that are necessary for achieving those outcomes, and the data capture and sharing. We looked at many different comments and testimonies that were put together. I pulled out this quote from the mark else foundation achieving the IT objectives paper. The effective use of information being needed to support better decision-making and better care processes. Improved clinical data capture that can support the morigerous and robust quality — more rigorous and robust quality. Enabling mechanism for achieving the outcomes.


Let’s look at a specific example of this. Our goal might be 85% of all patients with high blood pressure and cholesterol have it well controlled. That’s probably the most important thing we could do as a country for preventable and premature death. There’s plenty of evidence so that the right medications and lab tests get ordered consistently, can be helpful. Monitoring medication adherence will be critical. Patient outreach and reminders and quality benchmarking and reporting are all evidence-based interventions that have been shown to be an essential part of improving control. In order to have those advanced care processes operate though, you need to have blood pressure — laboratory tests an procedure prescriptions still have to be made available. We had a lot of discussion around how this relates to health reform and how can this enable health reform and affordability? There are some of the objectives that we have laid out here in the meaningful uses that might result in direction cost reductions. Form lair adherence, fewer redundant tests. The largest contribution we can make is to provide information infrastructure for health reform. Whether in clinical quality measurement, outcomes, for example. Whether it’s in care coordination that would be necessary to reduce readmissions under bundled payments or accountable care organizations. Appropriate care through decision support. Expanding primary care capacity, the work that kaiser has shown using — capacity and prevention.


I’m not going to spend a red light of time on these — a lot of time on these in the interest of time. I just want to highlight one item on this slide, which is, wherever possible to reduce the burden on clinicians, we are recommending that automatic reporting from electronic health records — while at the station will be required for some time and for some issues. It is true, that looking at 2013 and beyond, we will need additional metrics that can be generated automatically from electronic health record systems, part of routine health care. Appropriate use measures. Safety and care coordination. But critical come point of insuring the sustainability of meaningful use will be that these are not just a down payment on a new health care delivery system infrastructure, but it is tied to long term reimbursement reform. We thought that the transition from pay for reporting to pay for outcomes provided a useful mold. Thank you.


Thank you. Now we’re going to move into how do we get to this transformed health system enabled by the HIT tools that we’re striving to achieve. As far as I’ve mentioned, our eyes are targeted towards a state where we can continuously measure and improve the health care that’s delivered in this country. The work group thought of this as a series of steps, moving from the left capturing data in a coded format as much as possible, sharing it from the people who need it, include the patients, moving toward that platform to chair the care processes so we really focus on the patient and the patient’s needs. Finally, with that infrastructure in place, we’ll envision to measure and constantly improve our system.


So the law provided some mileposts. Admittedly 2011 would have happened anyway before the law, but there are some meaningful significance to these dates after the law, 2011, 2013 and 2015. Having described what we like to see health care be like in 2015 we’re working backwards. So we spin off a series of steps, hopefully they’re logical. They’re achievable though am by shoes — ambitious. Not about all of our limitations and nigh gnatly get — finally getting to the improved outcomes. We’re going to walk you through those. Talk about the tensions that David talked about earlier. To enable health and reform this. Is not a software project, but about the IT requirements to implementing health reform. That we do have to reform the payment system as well to align all the incentives. Acknowledging that is important.


The next point is that we — even though it’s labeled an HIT and meaningful use of HIT, it’s not about HIT. What’s the certified EHR? We quickly tavern perked our attention to what the software does to what the outcomes we want using that software. So you’ll fond that our measurements that we propose focus on the outcomes. In the earlier years focus on the process changes that are needed. I like what John pearl man said is that we’d like to pull with quality and push with certification. He said that in response to a national health collaborative panel with small providers. What you would like policy to do? Surprisingly they said help us with the quality measurements. That’s really the pull in this case.


Now as much as we’d like to have that achieved and also that achieved yesterday, we’ve got to meet the can’t realities. That’s where — current realities. The feasibility constraints. Want to implement these things by 2011 or 2012 there’s one time to develop this system but importantly time to implement these systems. Reallyhealth care providers that spend that blood, sweat and equity in doing so. Talking about capabilities that are available today in the commercial market. Balancing the sense of urgency against the calendar time it takes to get the job done. As a special consideration, we want to be stenstive to the issues of small — sensitive to the issues of small practices. We know the majority of Americans receive their health care from these small practices. They have a special issue with dealing with — accessing not only the financial capital but the human resources to implement these things. Finally, we talk about the time and money trade off. We have both the time and the money stated. The time is 2011 and the money sequence is front loaded. It gets lowered to — decreases over time. That’s to encourage early adoption but also becomes a constraint for us what we can move up as quickly as possible and be sensitive to the things we talked about.


This graphically shows for you the balance we have. The urgency of health reform. The desire to get the achieved outcomes and the realities of where we are. Focus mainly on 2011 since that’s the most pressing need we have in the proposed rule to come. We focused on five categories of criteria and objectives. One is improving the quality, safety and efferentcy of the health care system. Engaging the other partner which is patients and families. Health status of population. Five is the private security of both the systems an the data.


You’ll see first we talked about capturing data particularly in a coded format so that the machine can operate on that and help remind us of what we need to do. See things like the problem, medication list, vital signs, to measure and improve or reduce the disparities in care. You might thing these seem light straightforward things shouldn’t it be in the database for that? A different thing is cultural thing to make sure that problem is those medication lists are maintained in an up to date fashion every day, every encounter. That will take calendar time to implement and create the culture that keeps those fresh. That’s not — a non-trivial effort. Capture some things in non-coded format such as progress notes. CPOE — what we want to do is create a system where as you make decisions, you are informed by the things relevant to that decision. The only way to do that is to put that information in front of the face of the person that’s doing it at the time of writing the order. CPO is very important. We want it to happen and later on we’ve got to give the guidance and the decision support to the person doing that.


Finally we want to manage the population from this electronic system. You need to push a button and find out who is diabetic, how well are they controlled? Who do you have to reach out to? Those kinds of things. The accompanies measures get to be more quantitative. Some things are do you have the interfaces? Labs are so important. What per sent of your labs — will come in electronically and in a coded format. I mentioned how important the fact that the physician or the nurses entering orders, that metric which is how many orders are entered by the person issuing the order versus some work around, like writing it out on paper and having somebody else transcribe it. The only way the information is going to get to the person authorizing the order is through realtime interaction. We listed a number of metrics. Some of you will recognize but these are actually different than what you know. The little thing we have in paren that these, the HIT measures. But the fast majority are based on billing or claims data. Recognize may be the limitation of where we are now. It’s limited in the accuracy and liability. Remove some of those to being diaphoned bioclean call data out of an electronic health record system. We find that there are certain measures that we can take the existing definitions and “tweak” them in this calendar year. Change them into quality measures and derive data out of an EHR. Some things may seem straightforward. It’s not so easy to find out who a diabetic is if you only have claims data. Changing that to defining it based on clinical data is in fact a real change. It also means that you are using EHR. Aspirin — simple most of the systems get their med list from prescribing. Not only a system change but a cultural change on the part of the provider. These are so important and they illustrate you are using an EHR. In order to address the health disparities issue, we want to have the ability to report on how you’re doing on these based on the various patient characteristics. Engaging the patients and families.


Talked a lot about and typically focused on how we get information to the health care team. We rarely remember that it’s all about the payishment. So we would — patient. Abobjective to get patients access to critical information like labs, problems with medication lists an allergies. Like them to have patient specific educational resources and clinical summaries as a result of every encounter. Simply percentages of accomplishing those things.


We turn to care coordination. That’s getting everybody on the team access to the information so we don’t have these things falling through the cracks. Again, that colludes the patient — includes the patient. The objective is that we have clinical information provided to everyone that’s involved in that person’s care. One ampular of that is to make sure we reconcile the medications at each transition forral relevant encounters. The measures are percentages of accomplishing those. One of the measures we put up there is the 30 day admission rate. The key clinical problem, that it’s a key cost problem. A lot of it has to do with not having the information move around with the patient. So when a patient is discharged, does the patient’s PCP or other providers in the care get access to that information? We think not getting that information interferes with the quality of their care and contributed to being readmitted. One way of measuring the effectiveness of using these systems is to report on the readmission rate.


The next category is measure and improve the state of the population’s health and contribute to the public health functions. So we are proposing that the objectives be to be able to submit data electronically to immunization registries where they are required by law and where they are accepted. Nobody’s home. It’s a capability not a deliverable. The lab tests that are required by public health and the surveillance of [ Indiscernible ] Syndromic data. The accompanying measures are reflective of those measures. Submitted electronically and the ability to report up to date status of childhood immunizations as a start. Private security — comply with the HIPAA and the Recovery Act provisions. The objectives are comply with HIPAA and the local state laws as well as comply with the national privacy and security framework produced by ONC. The measurement side, one would potentially not complying with HIPAA that the entity that’s under investigation for a HIPAA violation would not be eligible for meaningful use of payment.


I’m going to mention briefly forward looking into 13 and to 15, I want to backtrack on something I forgot to mention in the 11 measures. Percent of diabetics who are under control. One of the concepts we had is have a two for. Many of those recognize measures that are already publicly reported. May be in fact P for pay or performance programs. To the extent that we’re going have the same measures apply to pay for performance measures and meaningful measures. Financial benefit to comply to these reporting requirements. In addition, one of the issues that practice is based the administrative burden of reporting on different measures. Consolidate — focus Enuclene call data — on clinical data. The same clinical definitions. It has a number of objectives. One is to be derived on clinical data and two is to be standardized.


Turning to 2013. We’re getting into areas we want to start pushing more towards the outcomes improvement we’re searching for. The improved quality safety and efficiency the decision report needs to be offered at the point of care. In engaging patient’s families, we now want to have secure electronic communication between the professional health care team and the caregivers. In the population health, not only are you submitting information to the registries, but you are receiving information back. You may be receiving alert from the public health agencies. Looking forward toward 2015 now, the bar is definitely arising. You are not only reporting on your performances we imagine or envision there will be levels of what you achieve with these measures before getting inseasontive payments. You can see that we’re increasing the availability of tools to support the patients and their family. Improve the population in public health. So we’re going to move towards essentially a realtime clinical dash board at the point of care for physicians. This came up in the NCV system. It’s nice for physicians to export data to some other registry or agency. It would be super nice to get the information and saw it and used it in the performance of individual care. The principles that we have for looking toward 2015 include the following. We want to move towards that goal of being able to constantly improve our performance, improve the outcomes. That’s more important than just measuring performance. We’re going to take steps from A to B.


By the time we arrive at 2015, we want to be able to push outcomes to the max. We want to as I mention align all of the reporting requirements to be based on clinical data and in the standardized way. We want to be able to prescribe the outcome but not necessarily the method. We in so way want to have any kind of recommendations or rules that would limit innovations on how to achieve the meaningful outcome. So constantly we want to be mindful this is all about the patient, the rules, the drive, the motivation should all be focused on maintaining patient incentiveness and improving performance.


In closing, this is a journey. It’s a journey not to implementing software but require we envision a migration that goes from capturing data in a standardize format using it to advance our care processes and finally to measuring and constantly improving our outcomes. Initially in 2011, we start with some basic measures, but it’s a balancing act of trying to get — consider the urgency of health reform to what we can feasibly deliver at this point in time. We see this as a meaningful precursor to a health reform that is contingent on financial health reform.


Thank you. Thanks to all the other working group members. I’d like to engage in a three part discussion at this point. First, I’d like to see if any of the working group members like to add anything to the presentation. Secondly, I’d like to ask this group to step back and think about the vision, not about all the feasibility steps, not about all the measures, to rise above, if you will, the percent of payishments who’s diabetes is controlled. Where clinical decision support becomes available and for what problem. To ask whether we can be more specific about the 2015 vision that facade and Paul talked about. Then thirdly, I’d like to go from that destinational conversation to an camp nation of the 2013 and 2011 content of the work group product. Let’s start first asking if the work group members would like to add anything to the discussion?


Connie delayny, university of Minnesota. Thank you for your outstanding work and presentation. I’d like to focus a question on — referencing slide 11 as the example for 2011.


Wow want work group — are you a member of the work group?


No.


Let’s start with the work group members.


Sorry.


Par tilt pate not guilty this — participated in this discussion. Anyone like to add anything?


Nothing to add other than to say you all presented both the work that you all had done in the back end very well. I very much appreciate coming from the privacy side of the house, the attention given to this issue. I look forward to hearing from the rest of the committee on feedback.


Sorry. Please go forward.


Connie university of Minnesota. Referring to the example as — to raise a question that might have an implication for the format for thinking about goal to the measurable outcome. In this example, one moves from goal to advanced care processes and then the implication for data capture. Might it be worthy of consideration to consider in advanced care processes basic or early care processes, such that one would be forced to preventive nature of such health conditions?


The goal is absolutely prevention and to address the clinical issues as soon as possible. This will require practices to change what they do. Currently, few practices, particularly small practices, engage in seasoning reminders to patients with high blood pressure that haven’t been seen. Few evidence-used base order sets. Few monitor medication adherence. These are the care processes that we are seek the work flows that we are seeking to encourage to the meaningful use criteria. Those the advanced care processes. The advanced fixes to the process rather than the care in this case. Yes. Absolutely.


Let me — we’ve moved from the work group comments now to the first element of the discussion. I’d like to just for — facilitating your discussion, focus your attention to slide 9, the achievable vision for 2015. It listed what looks like very important visionary goals, for example, a million heart attacks and strokes prevented. Heart disease no longer the leading cause of death in the United States. 50% preventable fewer medication errors. Diabetes control halved. I can count on my hand once or twice in my — I hesitate to say how many years in discussing these issues — stopped to ask what we could achieve if we set our minds to it? This is an opportunity to have that discussion here in this — in the hall of Department of Health and Human Services and to use it as a facilitation Forbe what I’m sure will very — for what I’m sure will be a very rapid discussion on technologies. I want to make sure that we have stretched ourselves on where it is that we want to go. It’s not an easy conversation to have because it land. S you out into the unknown and fills you with questions about what is achievable an it forces you — and it forces you to make a lot of assurances about processes and how people can change and institutions can change. If we don’t at least pause for a moment to have that discussion we’ll have no guidance as to whether we are moving fast enough or far enough as each step along the way. We can go silent on it and say these are the things we should be going to or we can elaborate on them.


Charles with a comment. First of all. I would like to say on slide 8, as the payer representative, let my applaud the notion of efficiency, however when we talk about our vision for 2015, although we talk about a more effective health care system, we don’t have the notion of efficiency specifically called out. Just given the financial challenges that payers and employer groups face, perhaps it is worthy in stretching ourselves to more specifically call out the need for efficiency. Secondly, these visions, I think, are all very compelling. I applaud them all, but I wonder by 2015 if we’ll have made annd to end improvement — an end to end improvement in any specific disease state? Might there be a consideration as we talk about a vision for 2015, this may be a little bit in the implementation side of things, we might look at a specific disease state, a chronic disease state that’s responsible for 60 to 80 cents on the dollar spent. Look at “transforming management” in a chronic disease state. Finally, I’ll make one last comment, when we talk about the power of health information technology, it’s the power of taking information and being able to boil it down to the individual and their needs. So when we talk about the individual, I think the vision might be well served through a notion of highlighting the empowerment of the individuals. So when we talk about educational resources, it may be one thing to put a generic PDF on a screen, it might be something else entirely to give someone information that’s understandable and relevant to their situation. I think this will increasingly become important as we think about genomics Enuclene call research. — and Clinical Research.


Thank you. Anybody else?


I really liked the whole list there. I like chronic diseases. I’m wondering if it can be expanded more than heart attacks and heart disease as samples — not mooning to be too funny but that hits the older men actually. How do we get kids to a better state of health so that over the years we have set up our country for greater health, dealing with things that — I think there’s more chronic diseases that can be put in as an example. Secondly, I think not only children but childhood obesity as well would be great to address in these.


David?


Endorse Charles’ comments to address efferentcy and cost in the system. — efficiency and cost in the system. Scarce and expensive resources efficiently. How to articulate that here. On the subject of appropriateness, it would be helpful to have some sense in here this one of the things we’ll target is a system that’s making appropriate decisions about care. The second thing that’s a thought about this is we are not going to achieve decision in a step function. The whole country won’t at once — transition into this kind of model. May already be doing many of these things very well. So I think we have to think of our steps of achievement with the vision — that is our theory of change asport of the vision. There will be early adopters and types of models of care in the country that captured the spirit of this vision. I think we have to have a sense of those that are able to move more rapidly down the path are successfully part of the vision. We want to capture them and give them recognition as part of the vision.


Neil?


I’d like to suggest a little bit of a modification for how we discus the vision. I — discuss the vision. I think it’s in terms of the categories but I they we ought to take out the specific references to heart attack an diabetes. Baa they are not specific disease references or anything in relationship to which medication errors, but I think what we really want to do is see a reduction in disparities across the entire scope of chronic illness. I don’t think a good goal is to not see heart disease be the leading cause of death. What would we rather see cancer being the leading cause of death? One cause of death for another. I think our goal is to see a reduction in chronic illness and preventable causes of death. So I think we should sort of broaden the vision. Having said that, I think we should consider putting efficiency in as a separate category. I think we need to sell this to the American public not just based on our health but as the discussion of health reform becomes more and more focused on whether we have the dollars to actually pay for it, it’s really critical that we show through technology and also through increased prevent efficiency is achieved. That if you do better care you automatically end 77 with more efficiency. But putting it in as a specific item that will bring it to our attention and keep us focused on those things that could potentially have early wins if the relationship to reducing costs.


Roger?


One thing speakers identify themselves for folks who are listening on the phone? Thank you.


Roger baker. I think from an individual standpoint, I thinkprivacy is key to adoption here. I’ve soon it in several — seen it in several areas. I think having that be part of the vision to recognize that the protection of the privity of the individuals that this information is about as part of that patient is a critical piece.


Gail?


That was exactly my point. I think privacy and security need to be foundational to everything we do. If you are going to incorporate you must incorporate that in our overall vision of whatever you are going to achieve. So before you have the conversation on any of the other things, you need to put that privacy and security element in there. You made my point exactly.


Kristine?


Two things. Under patients and families, I think we can do better, to your question. On the first one, I think access to information is an enabling mechanism. It’s not an outcome. The outcome is really how realtime access. You build in the timely concept throughout places in this. Help patients an caregivers to manage their care — the second thing I think we’re really missing is that one of our goals ought to be miserably improving the experience of care for payishments. We can’t be serious about both — patients. About how their experience is going which really informs both of those outcomes.


Yes.


To echo some of the comments that were made by Neil in regard — looked at specific diseases, can we try to find ways to expand on that and really let science try to drive the policy by looking at groups by the US prehaven’ttive services task force — preventative task force. Actually exists. We can App.ture that and have — capture that and have another bod by that has been able to weigh in on.


I think this group does tremendous job with the amount of information. On the same issue around the chronic diseases, does this have to be a national goal? Could it be more regional? If you did an analysis of what a problem is in a certain area, it might be different and may be more cost effective for that region to focus on something different.


Any — what we’ve heard so far is making broader reference to chronic disease as opposed to one. I’m sure that the work group would have agreed with that. These are just illustrations. They are illustrations in a sense that the question would be do you want to single out chronic diseases an make comparable quantitative agendas or objectives for each of those diseases. The comparable objective would be for childhood obesity to reduce it by X percent. I know that’s hard to do that on the spur of the moment. If bewant chronic illnesses to be mentioned in this vision, we have to at least think about whether we can imagine specific reductions that are realistic an achievable under optimal circumstances in those particular illnesses. Children clearly an important group to not to lose track of. The emphasis on efficiency. It would be helpful in that regard to have again, some specific outcomes related to efficiency. Privacy and security, that’s one that would be particularly interesting to try to quantify. Even if it’s only in terms of the level of confidence that the public has in our health information system. As a grade school, looking at what it is now and what we would like it to be.


Improved care would be another one to try to specify in some levels of experience with care improving them may be challenging, on the other hand some may be lower. There may also be some that are more important to improve than others.


I guess what I’m saying is what I’m mostly hearing from the group is we should be broader. We would welcome any comments that they would have about other quantitative achievements or goals that would inform our work going forward.


What I’m suggesting is that we adopt measure patient experience. When we think about 2015, first getting to even measuring it in the first place and certainly there will be areas for improvement. The boards are doing it now so there’s good evidence out there.


I think one of the things that you said in the very beginning which was extremely important is it has to be both ambitious and implementable. We have to stop, look at these, does it meet those two criteria.


Absolutely. That’s where we’re going to go next. So I think we’ve paymented a picture. It’s still — pated a picture. It’s still — painted a picture. We’ve begun to paint a picture. We don’t necessarily have firm end months yet — points yet.


Give you an indication how the work group discussed it and get your feedback. Try to measure everything for all diseases or the other is to make sure we have put in place the capabilities to affect all things. Another hedge was, we wanted to track national priorities project — is group that is trying to track what are today’s national priorities or today’s and the future national priorities. That may be one way we measure those things and keep tracking evolve as the situation evolves. So those are a couple of things we wanted to mention and get your feedback is that approach and measuring every disease or every outcome.


Yes. David.


I really support that Paul. I really do think though — I like the comment that [ Indiscernible ] Good scientific methodology and so on. National priorities partners is in between. It’s a policy-shaping body. We want to hitch a ride on the work of other established work. Whether it’s PQRI or preventative services or NPP. Taking the area we mentioned — one thing we would have to think hard about is — in 2011 do, we have in place the, do we have the capabilities in place that at 2015 we want to report on our progress. So we’d have to drive back to the immediate installations of tools to support our objectives and in general, I think that if we get clear about our 2015 outcomes, we should draw a thread back to each of those to 2011, are we going to be in a position to assess our progress?


That would be a vote for making sure that we get into installed systems, the data capture that we need. Am I interpreting that correctly? The other point I heard is the importance of making any measures that are part of the health information technology work consistent with those that are being used by other payers and other groups that are using different measures and policies.


I think that’s critical. We need to look at the various drivers to get us to those goals. Is only one — also not a mandatory program. It’s a voluntary program. So unless we include other drivers and other payers and other efforts that are going onto make sure we’re harmonized we’re not going to be able to get to these goals in the Medicare and Medicaid programs alone.


I want to clarify or highlight that the focus here was not what is it that we want to see in health in 2015? It’s what is it we think is necessary vision for us to — health IT can play a major roll in. That’s some of the challenges of child obesity, huge issue. In terms of interventions because there is no USTS intervention around child obesity that we can implement and seek adherence to. On the efferentcy front, magazine article to buy a tool, gather a lot of attention, that was remarkable on the absence of feedback of cost and efficiency over utilization information to providers. But the best source of that information is — the claims information that is potentially could be leveraged. We’d have to be clear about the goal for here, what we were thinking about, is what the is objectives that we think are important to guide our design — some of those, I think we’d have to be more creative about being able to receive — imagining capabilities to health plans potentially in a consolidated way to produce efferentcy measures but present that to providers maybe through the EHR — efficiency.


I’m not sure we have thought enough about that.


A comment on the phone?


Yes. Charles Kennedy. When I look at these vision statements. They are all clinically related. In’s not one technical vision statement. I think that might be something we want to correct. One of the things that worries me about our can’t approach or many can’t approaches that I see out there, you never see a single representation of the patient. You have multiple representations of the patient depending on who’s housing the record. Our experience — my experience in health department plans and other organizations is multiple remittations create significant problems when you try to use the data for analytics. We should try to consider some technical statement here about building a foundation that supports these things.


Thanks. Kristine?


This is one of the key — Kristine beck by the way. One of the intentions we had is drive the capacity to — improvements or do you try to drive the use of the information? One of the things that I think is important is that it is important to capture data structured and coded. It isn’t about meaningful data structure. It’s about meaningful use. The goals on the vision slide is that it does drive us to how information is actually used to improve health outcomes for patients. I used the example in the work group who uses an EMR. There is no difference. They collect the data electronically. They don’t reach out to me or remind me about care. There’s no difference. That’s what we have to avoid. Getting to the idea of balancing the tension and at some point I would like to go to slide 21 which has that teeter totter. I think it’s leaning the wrong way here. I think you mentioned — you left out two keepnets. I’ll do a Julia Roberts at the Oscars. The incentives come very early in the process. Think about balancing the intention to drive the use of information to get to clinical improvements, we have to think about providers adopting what is really meaningful data capture and walking away in the next year or two years later. To make those investments in work flow and process change. The second thing is the extention centers are a huge resource. They ought to be on the left side not underneath. It should tip it back to the left. Rant over.


[ LAUGHTER ]


Yes rich —


I had the same comment that Chris toon had, which was — Kristine had, first both to congratulate the group on the report and well thought out report. As it seeks to the other groups, one question comes to mind, are we sure that the current payment methodology will allow our phased approach to work? Will there be sufficient funding to continue that? Specifically to our certification and I adoptions work — adoptions work group. What comes to mind right away, if I install in 2011 or 2014, do I — is the system I still have still certified? Does it have to be recertified? I have to achieve a different level of mooningful use. I think these — meaningful use. For how one would earn funding under this if there’s sufficienten tentive to manage it. I aggrieve in the incremental approach. As we think about it and did you all contemplate that in your deliberations?


[ Indiscernible: Speaker/Audio faint and unclear]


One of the — there’s two issues going on here in terms of things on the right. Currently availability technology capabilities. That is calendar years, right? The technology is going to be more ready in 13 than in 11. Different practices are going to be going live on a system in different years. There is practice time an calendar times both of those are relevant. If I am going live on a system for the first time in 2014, you may have different — you may have the vendor criteria be 2014. What we laid out here is the 2011 for practice going live on or about 2011, we have not, I don’t think established whether the practice who goes live for the first time, for the first year in 2013 or 2015 would have to do all of the above. So I think we can — we have some time to figure out that issue. If that makes any sense?


It’s a very important question. One answer might be that the clearer we are on where we’re going, the more likely it is that vendors will be able to design systems that will be capability of getting us there over time. But I don’t think we can make declarative statements about what certification 2011 will mean for 2013 at this point.


I guess I was only wondering what the flexibility might be of this group or your office to make recommendations to in some way we think appropriate how these incentives are paid out [ Indiscernible ] In the future.


We can’t change the law here but we can make recommendations about implementations of the law.


Yes. David.


This discussion reminds me — I think it’s worth our considering. Stating very specifically our 2013 objectives and criteria and looking at 2011 — because of all the issues we just talked about sending to the vendors, providers to the congress and others that we have a set of milestones that achieve significant come point of this vision or increment of it. — we accommodate that in the 2011 criteria.


One point and it’s not really minor, I would like to brick to everyone’s a– bring to everyone’s attention. This vision establishing really, a road map of where we’re going for the internist, for the generalist. I think we need to also realize that the health care is also broken down into many specialty groups. I don’t think the vision for where we’re going to go for our surgeons, our pathologists, our — even referencing to mammograms for OB/GYNs. I think the vision needs to cone in on how all the players in the health care family are going to fit their pieces together and how they — I don’t know many pathologists who measure and when we get down to the specifics who are measuring A1Cs or measuring various components of the kinds of things that you are doing, you don’t fit together the whole health care puzzle and all the pieces. This is set for the internist. This is set for the medical home. It’s not set for all the pieces that have to come together that really is what happens in health care.


Yes Devon.


This is Devon McGray. I think you have a point although I’m not sure that we haven’t don’t that. I think we also need to think about where the priorities for federal funding ought to go with respect to improvement in the health care system. I had somebody come up and ask me what are the useful criteria for the dentists who are eligible to receive the funding under the bill? I don’t think there are Medicare dental reimbursement provisions, but fetch there were, I think realistically we need to think about what are the outcomes we’re trying to achieve? So therefore in what we’re trying to stimulate in terms of data collection and meaningful use from a realistic point of view. Medication errors is not just forists. That’s across the board. They’re definitely was a desire to be more broadly focused. I heard that. Care coordination with respect to reducing preventable hospitalizations that could be a surgeon’s measure as well if you do the operation right in the first place. People don’t end up having to come back in. There’s obviously more that has to do with that.


Let’s backtrack to 2013 and 2011. If we — the working group has presented a framework that we are comfortable with 2013 and 2011. Keep in mind that the general framework that they presented, which was mostly focused Enuclene call data capture.


Outcome.


David had just suggested that in some ways the immediate — very strong regulatory demands on the department on the government are to deal with 2011. 2013 could be a pivotal year for making sure that the transition that — working.


I’m not sure that I — what I would — 2011 would be a lot more aggressive because that’s where the money is. That’s my take on that. Could you clarify where the money is going to get hooked to? Is it objectives an that’s where the measurement is going to happen? Are the incentives going to be in the measures themselves because I think it poses a different question depending on the answer.


[ Captioner transitioning. ] The relationship of funding or incentives to meaningful use depends on the formulation of the definition and how the definition will be verified. So you need a definition, and indeed a way to measure the actualization of the definition for the metrics.


The definition — the metrics where the criteria for awarding. And so it isn’t in the matter is that you actually show that you were in the metrics for the meaningful use.


My feeling is actually a bland. I think of it like to — in 2013, we are now able to specify with great precision and fairly aggressively targets for 2013. I think I should draw a small number of those into the 2011. In each area, which is a very important fission that is coming together, which should communicate and draw some of those numbers metrics into 2011. For example think they’re should be something on decision support that shows you are doing decision support based on some connectivity in 2011. I would not overextend that given it is achievable, and avatar to our colleagues and each area, whether it is decision support for [indiscernible] in 2011 so we have something concrete and specific and meaningful. In 2013, I would have a full slate of stringent requirements of people know what is coming.


Neil?


I think what we’re actually doing is we are actually creating another incentive for people to adopt early, because, not only are me saying we get as many as time goes on, but the market’s higher and higher at the entry point. And I am not sure — for those of us who have implemented, there is a sequence to which we have to develop the capacity to the system permission. Versed in capture it and it needs to be captured for awhile before you can have anything you need to evaluate or look at in terms of quality and the new overlay a set of improvement activities on that if you want to be able to look a year or two beyond the road to see if the quality has improved. So what we really need to think about is whether or not we need to talk about first year of doctors, second years adopters, third year of doctors as an overlay of this, because — in the new world of electronic health records. And it will be unachievable because [indiscernible] — you can’t open up your patient portal on the first day you have the electronic health record in place. There are some things that require sequencing of these activities. So I hear us talking about two-time lines and I think we are confusing these in our conversation and I think it is making it difficult to new things down and one thing is, what I’d like our delivery system to be able to do and the other time line is, if someone puts the switch today, what can actually achieve in the first and second and third year of the use of the technology, and have liked to have busting through which of those we are talking about.


[indiscernible]


That was much more articulately put about but I tried to say earlier about the two-time lines. Thank you.


The legislation provides for funding for practices that go live in a given year is for up to five years. Cell, if you go live in 2013, and I don’t know that we have to answer that today, but we have to think about it today, because in the first year, the two-time lines are the same. In 2011, year one, the practices are ready, and your one incentives. We have some time to do that but we might want to have a year one, a year to come in years three, a year for, and the year 54 practices, and for that colewort escalating requirements.


One of the things that I don’t think we have ever discussed is this question of whether meaningful use, the timeline for meaningful use is calendar years for adoption years. It is not relate adoption years, it is meaningful use years. So if you more meaningful use your one is 2015, do you get rewarded for doing something that someone else did in 2013 and the second or third year? That is an interesting question. And it changes the clock, it is in some way it more realistic about what David called the theory of change. But some might say, Neil is wrong. In 2015, assistance is good enough so everything you did your first year that took you four years to do it is adopted in 2011.


So you are right, the systems may be able to do it but the delivery systems can’t. The HIT systems can but the delivery systems can’t. So this is about providers becoming comfortable with the systems and transitions and using it to improve quality and not only connect with public health accuse the public health information to that is really what their goal is and it takes awhile to get to that goal with you have that most advanced technology on Day one.


You mean there are humans involved here? Is that the problem?


Just one or two.


2D Do you have a clarification?


With two-time lines, we are also talking about things that have to happen as incentives can. One is to have to adopt a certified System and a half to be meaningful users. So it is possible the technology has to continue advancing by calendar year but meaningful use is based on adoption year for when the doctor kicks and so the technology is continuing to advance. But, that the provider might not have have to demonstrate the outcomes at the first year. So that is something to play into discussion.


Just to clarify, you can have different tiers of meaningful use. The meaningful criteria set in 2013 whether you are a first year user or three years years there is the same, so that is maybe a disincentive for someone to join up in later years and that is the way the law is written and it is an up or down type of thing.


Paul?


This is Paul. There is another objective we need to keep in mind which is by 2014, to have two have universal usage of that electronic health records. So we don’t want to make it impossible for a provider that that has not adopted yet to use records that are 2013. So I believe there is a number of challenges here and I am not sure what the right solution is, but there are a number of challenges.


Scott white. Tony took my comment, but it would go with Dr. Neil ‘s comment, we would almost have a catch up in a meaningful uses because we extend out the criteria to the point where there is such a disparaging between the doctors’ offices, you’d have two have a five-year, and if you came in in year three, I think it would be too difficult but Tony’s, it turned to me completely.


Let me try to get us focus a little bit.


The comment that the that made it was the only comment that we have actually made that sort of looks at the criteria in a general sense, and it says, that are in 2013 that [indiscernible] is that a general sense —


Judy?


A couple things, inpatient is generally terracing and there is a surprisingly little amount of nursing in 2011. And the electronic MAR which is in 2013 was part of the standards that was out earlier, and a lot at the vendors are ready to that, and I think that could be moved without many adverse problems.


Also, if you look at — what is it — record clinical documentation and the impatient, I don’t know of any of the major systems that don’t do that. I think that could also be moved in.


The thing that worries me about what is already in there is some of that reporting that is going to require an awful lot of physician or organization time, and that I think it’s a little scary. Some of it is step such as% of lab results delivered electronically. If we look in there, I think we will see the stuff that is delivered electronically versus stop that is not. Had you keep track of things that books paper counter as well as an electronic counter? Here is a number of things if you look at them more deeply, if there is a lot behind the scenes and people will have to keep track of people more. And there is another concern that I have also in what may be should be moved out. In at the picture on screen 24, present surgical –% surgical patients receiving B to E prophylaxis, I assume you mean [indiscernible] but does it do any good to give everyone a set of those test dockings and say, okay, how they got it. But what does it mean two do those things and do them right? I am nervous about the extra time spent from the provider organization and the individual provider. Some things I think could be moved in without a problem and some things I think when we look at are going to cause big problems.


Are those things okay to demand or should be moved out or are they problematic at any time?


I think there are some things that the discussion on exactly how do you and payment and achieve this, and what overhead it doesn’t have and how will you do it in a way that would give you a lot of the same results but will require that organizational overhead.


Yes?


I agree, absolutely, with what Judy is saying. I think we have to look at what is achievable.


This is a very aggressive model that I am looking at here. As I look at this and just having been to the University of Florida and talking with the positions and the medical system with three different hospitals and many physicians, they run 35 clinics. They are very concerned about the timeframe of doing this, because they are looking now to do a physician order entry system in their clinics. It is going to take at least a month of training for each of those clinics and they’re going to do its sequentially. Your talking 35 bunts out there to get their positions up and doing this. They are then anticipating from prior experience at least a 33% drop in productivity for 3 to 6 months before everyone is comfortable in doing this. This is very very aggressive. Great concern that it is within the timeframe, to be very difficult to achieve, and how many — our goal is to have widespread adoption by 2014, 2015, when one of positions to be using electronic health records. We then have to say, do we have the power structure in the state — the infrastructure in the state to do the change. And when you look at the definition of the electronic health record, it implies exchange outside of your enterprise. Buy-in not sure, as opposed to the electronic medical record which would be within your enterprise. So, are we setting goals that are unachievable.


Would have infrastructure to handle the exchange of the physician orders. I think this is very aggressive and I am afraid we will set ourselves up for the year if we are not a little more specific and take smaller bites of the apple.


Mark, and then it meal.


We all see the world through whatever when we are looking through. When Judy went through her this, I could see exactly where she was coming from. As I go through that list, the data items are relatively straightforward and items that we could get two, but then I look at things like CPOE and then I look at the change departments that deal was talking about and it becomes very difficult. One of the things I was looking at, and I liked the concept of data gathering and each of the pieces and what we went through, but if you buy a system, you buy more than it did at gathering. You will do it mayoress documentation and all these different components, and what we’re trying to do is get people on the road, and I think it was stated that said we’re all getting on on different on ramps throughout this. I think we have to keep that in mind but I still really liked the structure and I think there is some discussion that needs to be had because some organizations have approached it differently, and some of these may be more easily attained and for some, it will be significantly more difficult and we will just have to clear that in across this plan. Pushing this forward where we could achieve very little.


Me?


I wanted to address scales comment. I don’t think that we should create policy based upon one organizations conjecture of what they think is one to happen when they begin to implement electronic health records and their rollout timeline over 36 months. To me, what that says is, there is an organization that is not concerned that 36 months from now, one of their major facilities is still not going to be supported by electronic health technology, which Jimmy is a very serious deficiency. I will just tell you that our own experience was, we experienced a 20% reduction in productivity for four weeks, and since then we have had a 20% increase in productivity since Titian of two HIT versus the entire time before, so if you start thinking of that as a model, it changes your perspective and an organization would look at that by months from now across our entire organization, so I think it depends a lot on how we protect this and I think that is why it is so important for us to focus on places and models that have worked as a way of driving this technology because we all know places — and I am not saying this about your visit, but we’ll know places where there have been disastrous based on bad advice, data management and bad systems, that everything. I think we are beyond that and we now have lots of models where there has been good management and good and mentations with good products and experiences and we need to focus on those and say, what are we able to achieve because that has to be the vision that drives us. Otherwise we will be at this record and I don’t think that is the goal.


Comments on the phone?


This is Art Davidson. I thought the committee was going to follow the suggestion from David Polanski which was to take the vision and work our way backward from 2013 and 2015, session, it sounded like we needed a statement in the 2015 fission about deficiency.


I think the most recent discussion points to maybe reiterating what Charles said as well about the technical vision statement about 2014 and having EH are available to all Americans and maybe we will throw into that as well, PHR. And also a statement on the vision of 2015, Mike, think about what David Polanski said about change. Change will not happen between now and 2015 and be done, we could create some vision statements that deal with efficiency, some technical statement, and then this process of change, then we can start moving backwards, because I don’t know that we are one to achieve identifying things in the 2013 and 2011 until we have fully tag those things to our vision for 2015 but we expect to happen. I try to look back at the 2013 slide, and it doesn’t seem like we have all of those things in vetted at that time, and we need to take these incremental steps. But it seems like the excellent work that foresaw the and Paul have done it leading as for the 2015 statements could be tweaked, and then we could take what I thought was the effort now was to go backwards in time and it tags things that bring us toward that vision.


Are there some specific things that you think should be in the 2013 or 2011 s closer or do you think we don’t have a clear enough direction yet?


Well, there were some comments in David — from David in some emails earlier about efficiency, and we might ask Charles as well what he was thinking about, but David had mentioned things about using the right medication or write test, and less duplication of testing, those sorts of things could be majors of efficiency that we would consider at this point, and making sure that we have a system that is capable of making that mission and. If I don’t know that we have even got to the point of.


And that might be something we could consider to start collecting data for 2011.


Do you have any specific thoughts for 2011 or 2013? Efficiency by here for 2013. Anything in 2011 that should be there that is not?


I don’t have anything in particular right now. Sort of put forth the meaningful use decisions and descriptions that we have that Paul and Farzad have put forth, we did not have time to deliberate on that. The comments from the group have not particularly to this point David?


I have tried to collect some of the examples in the efficiency area and I think there are some things that we could use to populate the 2011 and 2013 cell. But the other thing I am thinking about is taking a category like drug safety, we don’t have very good data routinely on practice within the setting of the enterprise on terms of adverse events and at voided adverse events. I think we could enable that data capture from the outset, and I would want to talk to Tony about ways CMS examining or auditing that data capture and avoid those adverse events. But if we have a goal of 2013 or 2015 adverse medication and defense, systematically, since we would be strengthened in our ability to avoid medication errors by having access to the dispense medication data external to practice which is available through our tax hub surest grips or medication depository. If we took a threat like that, 2015 to the present and enhancing and enabling the connectivity to an external set of data which the one practiced this not have an enabling capturing data which is a great public interest and ultimately there is also cost savings as and Farzad ‘s example through one scene. And I think we should look at a high public interest already connected to the E prescribing publication that data has established. In other words, there is a marriage of convergence and if we export them threat this whole matrix we will get a lot of leverage. As the neck Mark probes chicken. David, not sure if this is what you said, but couldn’t we in 2011 close the loop is? 2D brought it up earlier, medication administration is bar coded and that is embedded in these systems. Could we end of 2011 closed some of these loops? If we were doing order entry, which could not close that loophole the way around and it would have tremendous benefit and probably is achievable from what we can see.


Was that similar to what you were saying?


Maybe we could get Offline about what that actually means for the many police definition rather than clarifying it here.


Christine?


I am looking at patient family engagement, and I just had a couple of things that we could slide around or consider.


In the first bullet around providing patients with electronic copy or access to their clinical information, I think we need to add the word, timely. I think we also need to move secure provider of messaging capability from the 2013 into 2011. And then, I would like to see added to 2013 the ability to incorporate [indiscernible] generated by the patient themselves, height, weight pressure, well, the things that don’t change, and also being able to make more robust the peace at — more robust than 2013 where it really is, some sort of — I do think we would use, PHR, it may be PHR but it would evolve but some sort of consumer information tool for backup a better word. The last thing, I think in 2013, we have to begin assessing patients experience of care.


We are now looking at the 20 objects in — active medication less, particularly for cancer patients as well as other groups out there component. Will there be a capability to capture patients who are on a new drug in a new trial? Do we see this as something in 2011 and moving forward?


That is a question for the committee.


Again, we are talking here about the general population versus specific illnesses. Long term-short-term burden of on implementation, balanced against other considerations. So if you ask me personally to identify patients in clinical trials would be an important feature of an electronic record. I would say yes, having the ability to identify patients who are eligible for clinical trials would be important, having the ability for a physician to decision support, take a patient with a diagnosis and see displayed for him or her the trials that are relevant to the patient’s condition would be terrific. Whether he would want that to be a 2011 definition of meaningful use is it different question.


My concern is, make sure it does get included because I think we will miss the mark and I know pediatric populations were brought up early [indiscernible] so many of these children are on clinical trials, an avid like two at least bring it up, a point to consider that at least some court set ways to capture that.


Christine?


I agree with that but I think it is part of a larger discussion that we should have around making some improvements in the areas of patient decision support, shared decision making and educational resources could in connecting with clinical trials. I think there is some confusion in the document about what each is for patients and more of an acute situation versus and more chronic condition focus, I think there is work to be done in the next few weeks to clarify those.


Judy?


A little bit on what Mark said a little bit earlier, Mark, you mentioned it was time to bring it over, the one thing I want to say on that is, but separate with the vendors can do separate from what that organizations can do. Vendors can do part coding, that is fine. But [indiscernible] also pharmacies are changed to enable the bar coding within there, so I would say moving the EMER back down there and [speaker/audio faint and unclear] does it add minutes to the patient and does it mean that the organization has to keep paper records because comparatively it is or is not computerized. So separating what they can and can’t do is really hard for the organization to accomplish.


Okay. Yes, Gail?


I would like to go to the improved care coordination section again and really look [indiscernible]. [indiscernible] what you can do on paper versus what you can do it electronically, when you talk about at the [indiscernible] for which cemetery records are shared, whether they are backs or paper records or whatever, that becomes more time consuming for offices if they have to count how many faxes, they said, let’s be realistic about what is achievable and let’s Not Drive people away because they fear that that is something may have to do. Make sure that we are not putting onerous burdens on people who want to do the right thing, and want to become part of this. But when you make it impossible or difficult for them to do, they may not choose to do it.


[indiscernible]?


One thing, we had a lot of discussion about [indiscernible] between 2011 and 2013 is the use of order sets and decision support, and order sets are a kind of decision support. And obviously, it has huge importance for the appropriate care guidance as well as potential efficiency and medication safety.


In the small workgroup, we kind of had it genuine differences, and I would love to hear in terms of specific guidance, David has proposed moving it sooner to 2011 sinner in this group, but what do other people feel about that?


Neil?


I had that circled as something that I thought we should move up to 2011. We are not saying the decision support about everything everywhere, but I think beginning to use decision support as a tool in improving care is an important piece, and can be moved right up front. There are some types of decisions supports you cannot move until you have a history of data in your system, so you can ask somebody to remind you if you haven’t had something if there is no history of the system yet, but I think there are other kinds of decisions supports around in rule flu vaccinations and things you can use and have been shown at least in our practice to be very effective.


The other thing is, of its support being in a clinical documentation on the inpatient side 22011, but I think that it’s important on those of us that have tried to make rounds on borders that are partially implemented the borders are in one place, the lab results are in another, the nurses’ notes are bedside and it is madness and did invites the probability of clinical disasters taking place and I like to see that move as part of the 2011 initial and the mentation and I think the vendor products are there.


Richard?


As it relates to decision support, I would echoed Doctor [indiscernible] words. And one thing I think we should consider is the inclusion of another term that is an enabling technology, which would be for lack of better term, clinical Data repository which means it is a precursor you could build some of the clinical decision support, hypothesis or plants.


I also think that because additional systems that are there today, we should strongly consider moving into 2011, Electronic medicine and administration and we should debate the five rates which brings in that identification concept for positive identification, the right patient, the right time, the right dosage. I also think the nursing process in its entirety and clinical documentation should be brought into 2011 because it is already there today in most conventional systems, and it would be the enablers for the achievement when you begin to set specific goals on many of the measures that the outcome.


But the productivity is specifically in the nursing process automation and the elimination of 33 percent of the paper based chart that you can get to in the interaction between the departments to eliminate manual processes. That is the productivity improvement. And if you have ever seen a time consuming process, one of them would be a hot acting chart at its tracks and that is why I speak to the clinical [indiscernible] for those queries and questions. So that which would allow, I would echo that part of the chart that would need to be automated that would allow physicians to visit the chart prior to doing rounds in and impatience heading, and to formulate some of their questions and maybe contemplations and interventions going forward with the kind of the minimum. Because that is the state of the art today is just not implemented everywhere. Those would be recommendations.


I would say that, on the whole, and we are coming up against the time limit for this discussion. The tendency has been to increase the demands on the 2011 definition and somewhat increased the 2013 definition. And I think that is perfectly reasonable set of individual reinforcements. Think when we actually it lists all of those things and all the requirements and see them all together, we will then have to reconsider whether these are feasible as a way of getting people started.


I don’t know, some of you have spoken to the human element of this process, and, that is going to be a think an important question for us to continue to contemplate.


David?


There was a comment regarding getting more efficiency measures, and I was on mute and did not respond, so if before we move on I could offer quick measures in the space. Patients per a given time. The physicians could see. In other words, a given time nature. In other words, how embedded is the EMER in the overall performance of the positions daily activities. And three, the Department of the patient may be an external access St. Pete where awesome and outside is accessing a data record. And I will just leave it at that, for now.


Judy, last comment?


[indiscernible] session after lunch or it is this the end of the discussion?


Is there any more of the general stuff like this after lunch?


We will go to the other working groups.


I will make a couple comments. There are a few places as I look through it where there could potentially be patents. One is on device interfaces and one is on specific educations to patients. Within PHR and wish to think about that.


It will be hard to implement and third, I am concerned about the state’s and hippa because, if you have one state that has archaic rules that were based on paper, and it has and and in there that has to be HIPPA and it meeting state regulations, nations, if they are vague, if they are archaic, and lots of other things, then we get into a group in New York and a group of Pennsylvania may do exactly the same things and may be eligible, but one does not get it and one does, so the state law, I am concerned about those.


Tony, just one final thing. There is separate incentive programs. There is one for hospitals and eligible professionals under Medicare and then there is Medicaid, so in looking at these, we need to think about is there any differentiation that will create a disincentive if we apply this across all of these different types of incentive programs, poor example, the Medicaid program as opposed to the Medicare program.


Judy, I think we need to do something with respect to these recommendations, and we have the option of accepting or rejecting were tabling them for future discussion. Do you have any procedural recommendations at this point?


I think we want to table them and bring it back.


So I will propose, unless there is objection, that we tabled these recommendations with taking the working group for a superb presentation and an enormous amount of work and bring back a revised set of recommendations for the next meeting of the above Health Information Technology Policy committee.


Any objection to that?


Terrific. I think you all have earned lunch. Judy, are there any —


Let me say there is lunch available for purchase in the lobby, sandwiches and soda for the audience and I will bring sandwiches for the group here, and you may also purchase your sandwich and soda. Thank you. [laughter]


And if we could get back here and a half an hour please.


(HIT Policy Meeting is on a lunch break until approximately 11:40 a.m. CST).


Could I asked the committee members to take their seats again please?


I neglected to take care of one procedural matter at the beginning and that was to put forth, or put on the table, the minutes from the past meeting. And I’d like to know if anybody has any problems with the minutes, and if there was not, I would entertain a motion to accept the minutes.


Judy, one of the public commentaries is misidentified.


I got that, so I will change that.


There was a motion to accept, do I have a second?


I second.


All in favor? Any opposed?


Minutes are accepted.


That was so rewarding to accept those minutes.


All right. I mentioned earlier, we had a very intense discussion of the meaningful use workgroup recommendations. I want to clarify that, when we said that we tabled them, we didn’t mean that we had put them in the circular file. Far from it. We just — that was a procedural matter to keep them before the committee until we can bring back the revised set of the recommendations. So the work group will go off and take into account and modify and bring them back for your consideration at the next meeting.


So it is going to come back.


We will talk about the modification and adoption of work group, and this is just as complicated a topic as the last one. But I think that we are a little earlier in the timeframe of the work of this group. Not to say it wouldn’t be important to move it, quickly, but we haven’t gotten quite as far along. I’d like to invite John Glasser and Mark protest to go up to the front. And talk about the work they have been doing.


Who would like to start?


I think and starting. I am Paul, and what I want to do is take you briefly through the information about what the IT certification and adoption group is all about. And it is interesting, Doctor Blumenthal said it is just as important as the meaningful use discussion in the legislation, there are indeed to other hurdles that an institution or hospital has to go through to get the incentive payment. One is they have two have a certified system and achieve meaningful use. So this is important. The group is called the certification and adoption work group. It deals not only with certification policy but also issues involving adoption, which includes things like work force training issues, because fundamentally, the challenge that we face with these systems is not really a technical challenge as much as it is a people challenge in terms of how we get people organize around the systems and how we could then deployed. You see on the board there and the slides, the list of the cochairs beside myself, park a protest from intermountain Health Care is the co-chair and we have John Glasser from the office of the coordinator. And then we have in this year, so as the example of training — this one, thank you. Agreed. Work-force training.


The members are Rick Chapman, Dam Park, Charles Kennedy, Charles White, but Tonya Sweeney, we have Steve Downs, to a set-who is the chairman of the medical association, and we have to. But McCaw is the chief information officer at CIO of the state of California and as I said, John is the lead from the office of the national coordinator.


This chart here shows a little bit of the private charge that we have. As it says here, we make recommendations to the adoption of certified electronic health records that includes the issues of supporting meaningful years and issues relating to certification and the extension centers and work force training.


We have some very specific charges. The first one says here to review the existing certification standards setting processes or months.


Now a couple of things, one is that we are involved with processes and policy. We’re not making recommendations on specific items, so we are not saying specific features but rather, the processes and policies involved with standards, and with cert. And then it also says here, for months, how John attended her first two conference calls and was so impressed with what job it the work group was doing that we decided we would complete our first recommendation in one month, so we will be doing a recommendation on certification policy by the next meeting which is July 16th. And we will be providing periodic annual assessments of the performance of the revised certification standards that in processes.


Than we are also involved with the extension centers and work force training. Now, has been said about the extension centers yet except that it is an extraordinarily important and powerful resource, so we will be involved with monitoring their performance and improving it, and we will also be involved with monitoring over the longer term the overall adoption of electronic health records that support meaningful use.


So the discussion we had this morning about issues, when the defense from 2013 through 2011. Does that raise the bar to high and will people adopt the systems? Me assuring all of that as we move forward.


Those are the specific charges we have it. We have a flow diagram that shows how it all fits together. It starts with this concept of meaningful use feeding into the standards and certification process. Basically there are additional feeds into that process because of course we want to make sure that the standards and certification process reflects all of that security and privacy and patient access rules that are in the legislation, so in number of things will feed into the standard and certification process. That is sort of like a front end to the technical assistance we will be providing, and you see the arrow pointing down, workforce development and all of those things together imports adoption. So that is an overview of what we have done so far in the work group is to start to do information gathering together ideas from various stakeholders as to what should and should not be done in this process and Mark will tell us about that.


Will give you a quick status on what has happened. We Premier Li for getting organized and looking at the scope of what it rule looking at, and we came up with a series of questions that we wanted to ask to get information from various groups and organizations and peers and industry. So we have gone out and then personal interviews, as a last asked questions three emails and that type of data gathering. And luckily, there is very fertile controversy or input into this process. Everyone seems to be well aligned. [laughter]


So now we have about 35 pages worth of input that we have organized into various categories. And I will give you the questions we have been asking and that will open up for the discussion we may have today or the input we might have.


The first question we should ask is who should conduct certification, and it that would be a wide variety of groups. Obviously CC HIT comes out as an early organization and we have a lot of information from that. Should there be more than one certifying body? Given the complexity of what we’re likely to have to do from certification is one body capable of doing that or would we need capable bodies?


What rule should CC HIT play? How should non vendor systems be certified, so self developed systems for Open Systems, how should they be certified in the process. And questions such as research and development, what might happen for research and development through certification of some of those of developed certifications.


Questions such as fairness and what are we certifying four? But is the purpose of certification? Those were all questions that came up as we discussed the topic.


Should certification be viewed as a seal of approval process or even further, how often should one be certified or is this system changed enough to be certified? Should certification be broad based or a specific? So we have an idea now where meaningful use is going, and should that be the boundary for certification or is certification more broad than what many will use suggest? How should cert apply to privacy aspects of the 8RRA, and also shook the certification process also certified vendor fitness and provider readiness? So those are the questions that we have gone out, and we gathered a lot of information and in our last call we got through to were three of those questions in the two hours. So we do have a lot of work left two do as we look going forward.


Star next steps right now are on July 14th and 15th, and we will hold a meeting here to get a series of testimonies from various organizations that would like to do certifications or would be applicable to do cert, talking to physicians or people that would purchase or have recently purchased a system requiring certification, and from that meeting, continued to gather our recommendations for the Committee on July 16th. And I am sure that we will have several conference calls as well over the next month. So that is a status of where we are and the things we’re doing.


What you put some really tough questions to us. [laughter]


Can we change the acronym? [laughter]


Any comments or thoughts about either the work direction or the questions?


Gail Carol. I would like to add some more questions to the list if you do not mind.


Is there on the products out there were specific groups that are looking for an EHR that are certified, how are you going to deal with that? For instance, if you are and ob/gyn, there is no electronic health record that is certified that meets the needs of an ob/gyn practice. How are you going to address that it in order to meet meaningful use and need reimbursement he must have a certified Project?


With no agenda in the next two years for CCHIT two do certification of that. But what about pediatric records.


I no there is a process going forward with that. What about some of those other specialties out there, whether they are surgery practices, pathologist or radiologist, where are you going with that? What kind of integration is the certification process going to require for a set specialties cracks.


Questions or comments?


On the privacy and security issue with respect to certification, at CDT, we have done a fair amount of thinking about this because I think the tendency is sometimes — there is a lot you can accomplish through privacy and certification whereas we tend to think that it is a rule that we could play that it is not a replacement for policy. I would be happy to share those with you if you take it.


Okay.


That is a good point, because when the asking that question, that is the response we get a lot, that is an issue for policies and procedures and health-care organizations and perhaps those issues can be dealt with by the accreditation organizations. They’re is a role on the certification, and the certification is a chance where we get to talk about the software and we can talk about it there.


Right. Two the extent that technology actually allows us to do things on the privacy and security side that we can’t do very well in the paper based system, that is one place where certification can play a role.


Yes?


As we move forward, and you look at certifying bodies, if you stay with just one certifying body that exists currently, if you opened the door for more certifying bodies, what is the process to certify the certify your? So that, because this becomes difficult. You could have groups that come together to certify, and you wind up really not meeting standards.


So, who is going to authorize the certifying bodies? Is that the role that zero and C is going to play? Is that a rule that CN as is going to play? Who is going to certified certified as?


Those are good questions, all of them, and one of the options that this group will look at is to what degree he seventh developed a criteria that other certify against and to a degree that mottled emergence it all. They’re needs to be an accreditation process that deems someone capable of a certain fire. We have agreed that [indiscernible] has a lot of experience in getting help people think about this and the pros and cons. One of the mansions of Mark and Paul that on the 14th and 15th will hear from the and I ask folks that if you do that, that is something you ought to consider. It will have to address the questions you just raised.


I was wondering if you have given any thought to the adoption side of your work, beyond — is that a series of questions related to certification. Any plan related to the adoption part?


It is a great question, because the adoption part is the biggest challenge we have.


We don’t really have a technical challenge, but we have the people challenge facing us.


All we have done so far is simply to listen to presentations from ONC about the plans for extension centers and worker training, and we have been trying to address the short-term needs to produce some certification policies, because defenders need that and it is needed for the regulatory process, but that is an area that we will be focusing in after July 16th.


I don’t think we are doing this in a vacuum, so we understand the adoption criteria and requirements but we are focused on certification.


David?


I just wondered how long are thinking about, I will call it broadly, innovation or unanticipated innovations in the technology, and for example, the people that will testify, how is the work group thinking about capturing the unpredictable and the opportunity for some of Japan bought back to be met with technology or vendor is that are not on the scene yet and it not locking in a set of incumbents because that is what know about today?


That is a very good question. So far, all that we have considered its concerns that a certification process might somehow throttle innovation. It might create a barrier to entry for smaller organizations. So that has been raised as an issue, if there is more that we should be doing, and would love to hear your feedback.


I would encourage that whoever is on your cast of presentations next month, to include people from cloud and mobile computing and might want to see if there is a way for certification to accommodate them. They may not have a full suite solution that they might have some other value to add.


Okay.


Any other questions or comments?


If not, thank you to the work group. The look forward to your next presentation after your additional work. And it will move on to have the information exchange work group present.


We have to change the name tags up there.


Brilliant. I thought we were making history. [laughter]


We have Nikki [indiscernible], debt and McGraw, and Kelly Cronyn.


Obviously, our cochairs here are Devon and Mickey. Devon is known to the full committee and Mickey is the current CEO of the Massachusetts Health collaborative and prior to that was the information exchanges. As many of you know that is one of the leading health information exchanges to the country and he brings a lot of practical and strategic thinking to the work group.


Just to briefly review our work group members, we have seven full committee members. And then, we include four additional people to round out this experience phase of the group and bring in different perspectives, including three different state leaders who are involved in advancing Health Information Exchange within their state in all three instances happen to be within the state government. They come from very different states at very different stages of development. Then, Steve sax from the AMA.


So we have both a broad and specific charge. The broad charges to make recommendations to the full committee on policies. Governments, sustainability, architectural and a petition abilities to enable the exchange of information and also increase the capacity for information exchange over time. Excuse the typos, we were rushing to get these done. The charges to make recommendations within a full six months that were necessary in the short term exchange of IT health information to the implementation of high tech and also to make recommendations to the full community to inform and provide guidance on the implementation of the nationwide Health Information Network. So, we’re looking forward to working with the work group on this effort. Obviously there is a lot of close coordination with ONC two know what we’re thinking about internally in terms of our implementation and Planning around relative programs and high-tech part taken into account as we move forward.


Thank-you, Kelly. We have met twice as a work group. The first meeting, we spent much of the time looking at the draft charge and refining it a bit and we had a fair amount of discussion on what we mean when we say Health Information Exchange, and are we talking about the formal exchanges that we know are out there today and that we would like to build future, and we are also talking about the exchange of data that occurs not necessarily withinthe formal HIE for infrastructure that we met both and that we would be coming up with information related to the formal exchanges as well as particular discrete issues that involve the exchange of health information that may not necessarily be occurring three formal body. So that was the first meeting. The second meeting really dealt with some general discussion about the grants to states or state designated entities for health information exchange, which is under Section 3013 of the high-tech Act, and what we might hope to get from a general standpoint again without talking specifics, what are some general goals that we might want to accomplish through those grants and I will talk a little bit about the discussion we had there, and then we spent also some time on Health Information Exchange and how that facilitates meaningful use, and so I will talk a little bit again about our discussion on the grant program and it and Mackey will talk about meaningful use. The topic du jour.


In general, again, we were somewhat confined to talking in more general terms about what really should be in the grant criteria, partly because this is an ongoing initiative and there are likely several participants on a work group who might be potential grantees, Information Exchange across the country that beverages what we have got in existence today, and then supports for the capacity building in areas where there really isn’t anything, or it is on the ground, and certainly the statute creates vehicles for that. But I think it will be a challenge in the implementation phase to grow those exchanges that are at a fairly high functioning level today while sure that you are seeking either those that don’t exist that are in the beginning stages. But again, with the overall goal being enabling the information flow for a patient centered evidence based and performance driven health-care system which is also what we’re doing on the meaningful decide. So we are all aiming toward the same thing here, which is good.


Some of the other concerns that are likely to come up and that will need to be addressed through these grants is that, we want them to be interoperable track the states and regions that are created but also ultimately trying to create a national system here, and that is no small task.


Skill ability, sort of similar issues bear with respect to what you are creating again, out of State Warren said national level and being able to scale back, and then of course the privacy and security issues that are raised which might actually be somewhat unique to formal exchanges purses exchanging data on a 1 to 1 basis which has been characteristic of our health-care system for decades.


So, we have identified some key issues that needed to be addressed of all along the way. Obviously, the states and regions are one to need to figure out what works best for them, and at the same time, we do have national goals and priorities that we are trying to set here, so kind as bouncing the flexibility and not trying to create a one-size-fits-all approach while also facilitating the creation of the system here is an ongoing challenge.


Governance issues, this is a discussion that began over the last four years and — talking about formal exchanges in states or regions but also again on the national level and it’s closely related cousin, accountability. It is not just about accountability for the receipt of federal funds and how you spend it, but also if you are one to set standards and criteria for these organizations to me, how are you want to make sure they are meeting them and how can we help them meet them. Also, we want these things to be sustainable over time without needing to depend on public dollars, and that has always been a big challenge and I think we hope the grants will give us some — I think some of us hoped that the grants will give us some flexibility to try out different models of financial sustainability. And please add if I forgot anything.


I think we covered it and we can cover it in the discussion as well.


I will talk about the second part of the conversation which it was about [indiscernible] and because meaningful use was not available in sort of a form for the work group to discuss. So we are at a high level thinking conceptually about the interrelation between them. Protest describe with certification group — particularly in privacy and security, there’s no issue there and they’re ready to Petty of the final presentation and move ahead. The.


Do things to note, because there is no real consensus coming out, just a conversation to get people’s perspectives about what these connections might be, understanding of the work group was that HIE in the fundamental group was connected. And they are not programmatically connected, but there are fundamentally connected. It is hard to discuss one without discussing the other in one way. So we recognize that and left as a place holder the further meatier discussion that will happen once meaningful use is out there in a definitional form as it relates to health information exchange.


The second part of the discussion, and we have put in bullet form hear some of the things we have talked about related to the importance, the way they are connected, the importance of setting high-level recommendations for HIE over time and if you look back at the recommendations that Paul and Farzad layout, you can see how those connections started to form but you want to make sure there is an element there that is happening. But the last two bullets speak to the fact that it is already happening in the number of states. HIE whether it is a noun or a verb is making a tremendous amount of headway in a number of states. This is not just caught the clutches happening now, these are organizations doing real things and developing overtime. So in a way we are parallel trying to-up but also the appearances of developing the small peak as — how we deal with this point forward as those states and organizations are developing governance policies, technical approaches, that we don’t want to be undercutting because I think most of us would agree that they’re actually doing the right thing and they want to make sure that we are setting objectives that they can keep moving forward on, because as we were talking about with the provider organizations, you have certain amounts in health care and Apollo also organizations that have moved ahead recognition in part of the conversation about that.


The second topic recovered was really just the beginning of the conversation have, but might be some HIE enablers of meaningful use. And we put just a few bullets to give a flavor of the different things we talked about. We don’t want to represent these as consensus conclusions were ones that have higher priority than others, but more as just the sampling of things we discussed to give you a flavor of the things that we’re probably going to be discussing going forward as we think about HIE and meaningful use.


In terms of where we are headed, the immediate next steps are two sets of prairie areas.


I will back up to say that I think the first step will be laying out in a more concrete form what are the various dimensions of HIE and privacy that we want the group to focus on, and laying out those dimensions conversation about what the priorities are, and now we have a meaningful use conversation that we can bounce up against. And I think an important part of all of this will be aligning the interdependency is with the other pork groups as we think about all the other work groups, from standard side and a policy side to make sure that is lined up and and timeline and mountains in deliverables and all those kind of things we have to get to.


We may be the one worker to it doesn’t have an enormous deadline looming over our heads. Not that we don’t have to move relatively quickly on a number of things, but, will we have something by the next work group meeting? We will definitely have something to report but again, we are not under the same high pressure that mind, which is actually Nuys.


And to know if any of the other members of our workgroup better here with like to add anything.


Comments from other members of the work group?


Thank you very much.


The only thing of it like to add to what has already been said if, and I would like to commend our leaders especially for everything they are doing to pull the group together, but one of the things that needs to be discussed perhaps a little bit more is, here again, the need for that national model and having that National connection, yet you want to keep the caldron of information going on down in the state, and we don’t have a Model that everyone can agree on and look to that is the model for everyone.


So do you have that dichotomy again to make sure that, if I live in Florida, will my record be available when and live in Washington? And at some point that will be exchangeable. However, we need the flexibility and I think that is where we need to go to make sure that we maintain that level of flexibility, and make sure that the states and local regions are able to connect at some point, and we have not set deadlines or timetables for that yet.


Perhaps this group can give us a better direction as two, when the come to be in full use, and this is where meaningful use connects directly with HIE. Are you going to say in meaningful use, do we have two have that connectivity, that Interoperability, in order to achieve meaningful use cracks outside of your enterprise.


In other words, if you have a hospital system that is exchanging data within their system, to achieve meaningful used simply by doing that in 2011? 40 and a half to exchange outside of your system? So I think our group meets some direction from the meaningful use group as to how we set up that timetable and make it incremental to achieve the meaningful use. I don’t think at the state level, by 2011, we are going to have the infrastructure in place to have a complete Interoperability.


Neil?


I guess I will start with the question, and then maybe make a comment.


My question is, are there people in your work group who have different visions of the then sort of the traditional regional health information exchanged while all tying into some national exchange pacts are there people in the work group who are bringing other additions to the table other than the one that we are currently marching down?


The reason I am asking the question is because, I think that some of us, will only speak for myself, have less confidence that that vision is the one that will actually rule the day at the in that time. They think that, in every single slide, including Norris, the business model things, and we sort of always it raised its so there is no business model or a difficult business model, but we don’t ever come up with real solutions for what that looks like at a national level. That is one thing, and the other thing is, looking at the experience in New York. Gail is talking about will come true, somehow these changes have to connect every single person in America, and that is sort of like, letting flowers bloom wherever it they may thing is a Model that will somehow connect every area, and somehow this desperate will happen and everyone will end up being connected, so I think there are other models being proposed for the vendors to play more of wall, like using the Internet to take more of a will and people are beginning to conceptualize of the ways of sharing information, the PHR stuff coming out and people wanting more control over their information and I think in this workgroup in particular it would be incredibly it important to have people at the table who have different visions of what the and point might look like summers down the road because I am not convinced that the current model we’re working on will take us there.


Neil, you are welcome to join.


I don’t have the answer to the question.


I don’t know what the answer to the question of where the spectrum is and that is certainly something to consider if we feel that there are certain strong perspectives that are under representative. I just think we have restrictions of who we can invite to join the work group. But I would point out as a point of reference hysterically, if you look, in one of my presentations I have an article from The New York Times at 1905 that talks about the telephone exchange market, users in the U.S. And about two-thirds of them were covered by the Bell company at the time.


And then it points out in the article that the other one third, about 700 phone users, or covered up by about 2800 independent exchanges across the United States. I checked that to make sure it wasn’t a typo. And you have seen the way the phone system is developed today, we don’t think about it. It was an network. A .2. that work for a long time. I have just pointed out that we are at a moment in time but I think your point is a very good one.


And I think, you know, we didn’t actually pull people to get them to put on the table with their particular preference was for Exchange, but — and perhaps I did not make the point strong enough. Is– the work group is not just dealing with exchanges now. And this was discussed a fair amount just to ensure there was no one model to exchange as a bird. We want to facilitate information sharing in the health-care system and it doesn’t necessarily mean that it has to take place through a particular exchange in the model. You can imagine the first meeting, the where Exchange was flying all over the place. And I do think we are going to want to be mindful of that but I think we have to consider the topics we took on in the first two meetings, one being a specific grant to the state for that HIE program which is not the same as the amount of money that is going out to them meaningful use which also involves the health Exchange permission as we have just discussed for the last few hours. And we are also thinking about if we don’t have enough implementation for the groups that are looking for a 1 to 1 model as well as a formal exchange infrastructure to have that input, but I don’t believe at this point, I don’t think it is settled the case that they are tilted toward the one model.


And also at think, if we have recognized for awhile there is an evolution for a governance model and mechanisms. Right now a lot of communities and states and regions have tried to organize in a multi stakeholder group that has been called a lot of things over the years, so that has been a model of governance providing the continuance over many years. And sell what we have talked about is trying to figure out what will mature overtime and what forms of governments or forms of technological approaches and Policy or privacy and security policies will have to enable all not only the exchange of the summary record between the hospital and physicians office, but General can activity that works across the community and across regions and states overtime.


Adam?


Adam CART, Lance Armstrong foundation. Discussion, student Madison recent it released a report on the privacy HIPPA rules when it is strong recommendation that we needed to differentiate between what is personal health information, so the information discussed between a patient and care physician, versus other information that is really for the Public Health record. Disease management, or screen innovation over time. And trying to figure out different policy for different areas.


Since we are still coming up with R deliverables, I don’t think we can say at this point but at the policy exchange data and what does that data look like in different contexts, so I suspect it will be and will at least be able to report on that at the next meeting, what we’re going to do.


Paul?


Recent exchanges that we have identified in the patient, and I am curious if you are addressing this issue of whether there should be in national patient identification number?


[laughter]


We are at the very beginning of what we are one to talk about, and that patient identification is one of those models and a support model for driving an exchange. Whether that presents the question of a national identifier comes a point of conversation which I think will be up to the work group as we think about patient identification as a category.


That is great, because I really liked the analogy of the telephone exchanges, but I think we all know why it works well the way it does right now, and that is because everyone has one phone number and you can find the person. So part of the reason why I need to have all the state oriented systems is difficulty identifying patients.


Although, I actually have had several phone numbers, and it has changed over time but is still worth the conversation.


[laughter]


David?


Party it for me to say something nice about the phone company.


I would appreciate it if the workers at some point would provide some high-level overview of this space, because of the issues that we have just in the last few minutes brought up, and I think the people that have done this work, in general there is a lot of confusion about what is meant by the Health Information Exchange and there are three areas that I hope they can speak to at this point. When is, what is meant by Exchange? Is it a .2. sharing of document or summary document for primary Data, or is the receive at the other hand by computer perform, and just try to lay out for us whatever number of varieties that we should be considering as we look at policy consideration. Suntans the policy is very broad and the reality is very granular.


The second thing is the business model that deal was referring to. [indiscernible] performance programs will become the business model for information sharing, but we have not done and not to bring this together even in this morning’s discussion. When space meaningful use subcommittee work on connectivity has been very skillful. It would be nice to connect your work and meaningful use works of the incentives provided by the HIT incentive money provide a reason to stimulate among the health care professionals which is generally lacking today.


And there is trowels Kennedy’s point this morning, I think about for whichever of our group secreting part of a vision statement around a technical layer, because again, whether it is real for big repositories or PHRs or health banks, I don’t think we have a set of pictures in their collective heads about what is the technical layer Ordovician going to be that all of us will contribute to as parts of the network, and if you could lay out some pictures for us about what the options would be and how we all fit in, that would be helpful.


Christine and Judy?


Recovered a big chunk of my point but I will get slightly more specific on the second point, and that is, I think it would be helpful if the work group booked at the definition of meaningful use specifically and told us, this is the implication for HIE. As I was going through is, I thought to myself, why don’t know if this Will Drive the business models were decreased the business model, I think we need to know that. I think we would also benefit from understanding, if we look at some of the details around care summary, what does that mean? What is possible now and what should be a realistic expectation from 2011 persist to. What can we really do? I think we need to know more before we can’t really finalize the meaningful use definition, so to the extent the group can dig into that and help us understand what are that key implications, that would be great.


I think Neal and David were sitting opposite things. Neal, is seen to be saying, let’s not define technology, that’s the that opened two whatever works well, and David, you seem to be saying that lets make sure we have a vision statement about what the technology statement should be, and I am curious if they are opposed and which one is the right one. And I will put in my own opinion, which is, we are much safer and saying, here is what needs to be done and how it is on his left up to however it evolved. [indiscernible] [indiscernible] the record going from Washington.


Let’s pick a state, how about New York tax were okay, Washington. I don’t know how that fits into the rules. The implementation of townships there will be how the states have HIE Wills, and will the organization be able to send it to Washington or New York and Washington and Oregon York be able to send it back if they have all those combinations of rules.


The icon and backs.


— may I comment?


Sure.


I think that is part of the challenge. Then you also combine the privacy issues state to state. Because what is required, but that kind of consent that is necessary it in Florida are not necessarily the same as in New York, especially when you come two mental health issues, you come into secateurs take medications, and you come to HIV status, STDs abortion, a whole variety of things of this sort that is where it becomes a sticky wicket. And that is where we have to establish establish a policy that will mesh together. But yet, within the confines of how things are done, novation to happen at the state and local level. So it is a large issue that will take some time to work out, and it certainly is not without controversy.


At this time, due to the overrun of this event transcript ended

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2 Responses to “TRANSCRIPT – HIT Policy Committee”

  1. ICMCC Website - Articles » Blog Archive » TRANSCRIPT – HIT Policy Committee Says:

    […] Article Brian Ahier, Healthcare IT, 16 June 2009 SHARETHIS.addEntry({ title: "TRANSCRIPT – HIT Policy Committee", url: "http://articles.icmcc.org/2009/06/16/transcript-%e2%80%93-hit-policy-committee/" }); […]

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