Transcript – HIT Standards Mtg

I have posted the draft transcript of the HIT Standards Committee’s second meeting below.

Section 3003(b)(3) of the American Recovery and Reinvestment Act of 2009 mandates that the HIT Standards Committee develop and publish a schedule for the assessment of policy recommendations developed by the HIT Policy Committee. This schedule shall be updated at least annually. The schedule is posted here.

In anticipation of receiving recommendations originally developed by the HIT Policy Committee, the Standards Committee has created three (3) workgroups or subcommittees to analyze the areas of clinical quality, clinical operations, and privacy and security.

 Presentation materials from the meeting:

Health IT Standards Committee Draft Transcript:

Good Morning everyone and welcome to the second meeting of the Health Information Technology Standards meeting. Just a reminder that this is federal advisory committee and being held with the public. But have an audience here in the room as well as people dialing in on the telephone, and there will be an opportunity at the end of a meeting for the public to make commentator here in the room or on the telephone.

Also, members here in the room, please remember to identify ourselves as you speak. A transcript of this meeting which will also be posted on the ONC Web site in about five days.

Please go around the room if you could briefly introduce yourself and your organization. Janet Corrigan from the National Quality Forum.

Jeanie Ferguson, Kaiser permanent tea.

Was Johnson.

John [indiscernible].

Of West [indiscernible] Gardner.

And Castro, Lacross Blue shield of North Carolina.

[speaker/audio faint and unclear]

David [indiscernible] National coordinator.

[speaker/audio faint and unclear]

Mike [indiscernible]

Judy Daniels, ONC.

[indiscernible] male health clinic.

Dixie Baker.

David Macaulay, server corporation.

[indiscernible] union.

Linda [indiscernible].

[speaker/audio faint and unclear]

I didn’t see you.

The two have a number of members joining late and on the phone. We may have received Stevens from the Boeing company. Rick, are you on the line? He will be dying in styling in place. And Linda Tillman from Wal-Mart.

We have Anita.

With that I will turn it over to Dr. Blumenthal.

Good morning everyone. This is David Blumenthal, national coordinator. Again, I was like to thank you all for being here and welcome you to Washington. I would think you also for those of you that had to find an alternative commute this morning because of the events last night on the red line. I also want to thank you especially members of the Committee and Austin national coordinator staff for the incredible amount of work and dedication that you all are showing to the very demanding requirements for the high-tech provisions of that recovery Act, and at the very conspiring agenda that that piece of legislature has created for us.

The importance of the work of this particular group, the standards committee is becoming more and more evident as we get into the totality of the past that we face. — task that we faced. Have been doing things an office of the national coordinator which I expect will be come more apparent overtime. One of those which has already become public is that we held a second meeting of the Health Information Technology Policy Committee about 10 days ago. That meeting and the topic of that meeting was the [indiscernible] meaningful use criteria [indiscernible] policy committee. That formulation was discussed in detail and a lot of discussions were made. We are still entertaining public comments on those materials, and the Austin National coordinator and Medicare services are right now involved in an extensive series of listening sessions based in the regional offices for the Center for Medicaid services. We are soliciting the views of [indiscernible] and institutions around the U.S. concerning their views of this working group view of concept of meaningful use.

That definition will be reviewed again, modified and reviewed again on July 16th by the Health Information Technology committee. It will, I expect, the modified result in recommendations to the national coordinator and the Department of Health and Human Services which will be taken into account over the next few months.

Nevertheless, that preliminary view as just part of — the granular task that the standard operating bodies that work in this field will have to undertake in order to make the definition of meaningful use a reality. And I no there have been discussions, that Standards Committee, about where the gaps are, where the standards exist for elements of the meaningful use concepts that were put forth by the working group, and I think that those are illustrative of the task that this group will be asked to take on, and we are deeply grateful for that.

There are other things going on in that office of the national coordinator. We are calling on what is what we think is the optimal allocation of the discretionary funds available to the secretary under the high tech Act to provide support for the adoption had meaningful use of Health Information Technology, especially electronic health Mac records. And we hope this will be announced over the summer. We have already gone public with the description of an extension Center program which will be one of those possible spending plans which is under discussion.

The successful conclusion of all of this work continues to depend on the voluntary help of so many people, including those of you around the table. We literally just cannot bring this off without the entire information technology community, and many public and private groups, so this is critical part of the success of this high-tech agenda, and in many senses a part of the presidents long-term agenda to make our health care system a higher quality and more productive.

With that I will turn over the proceedings to the two John’s, as I have come to call them who have been providing terrific leadership, not only here but in other domains of public policy.

And unlike [indiscernible] to all participants who are part of this great national dialogue and I am helping to achieve as Dr. Blumenthal identified as much as the application of technology but that lead to greater quality and safety and greater productivity and health care.

Committee and would like to join everyone in welcoming them. Linda [indiscernible] is the [indiscernible] health standards participation and Department of defense. [indiscernible] is the director of information technology at the laboratory at and on it st and [indiscernible] [speaker/audio faint and unclear] Welcome to all the new members.

At the outset of the last meeting, we have acrylic described, Doctor Blumenthal described and picked up the task of meeting a very ambitious agenda, and I think I joked that this would be a highly decaffeinated group and leading the charge, and in retrospect that is quite [indiscernible] the national coordinator to us to describe the depth of activity, and let them know that there were conference calls that started as early as 6:00 a.m. Eastern and 5:00 a.m. Central and everyone was and is about reading about the task at hand. When we set our activities, [indiscernible] with its kaytoo with the puck would be and would try to indeed [indiscernible] there has been conversions. I think we are directionally aligned with what has come forward in the first iteration from the mining full use or group and would add our appreciation to the work group for a traffic start.

But this is two elements that we stress. And we need to [indiscernible] [indiscernible] our next meeting, I believe is July 20 first and we really need to be able to come together to describe standards that will support the implementations specifications. And it will refrain that aspirations for the teeeleven project work. We need to be clear about the gaps that exist that we need to put our heads together about the certification process.

I also want to beat very clear about this, this is a working meeting. [indiscernible] Office of National coordinator and a that process. Of hope that this is great form to bring together the work of the three work groups that will present today as well as an update from the meaningful use workgroup, overemphasize that no one should over read the discussions of the definitive policy because it is really just a working group, and the purpose of the Federal Advisory Committee is meant to be open and transparent. And those still the Parisians are all here and on line are participating and [speaker/audio faint and unclear] most of them are better. Most of the discussion particularly the second half of the meeting is really working [indiscernible] [indiscernible] and that the conclude my opening remarks by making everybody, not only for the work that has been done I think you can tell by the task that is ahead of us, the up-tempo that you will has been established. We hope that work continues. We hear from our cochairs today and they deserve particular credit for their particular leadership. Of that like to [indiscernible] Baker and her particular work on privacy and security, and it Janet Corrigan, extraordinary and leadership on the quality of clinical operations and clinical quality, and Jamie Ferguson and John [indiscernible] organizing around the clinical operations. And [indiscernible] continues to the SSL and will be describing for all of us to make sure we have a shared understanding of the evolution of concepts of meaningful use and preliminary definition of that and falling this presentation, we will go to the two liberation of the granular aspects of 2011.

And [indiscernible] an extraordinary individual who really brings so much domain expertise and subject matter expertise to them and it is my pleasure to my pleasure to introduce John and I live and invite him for any introductory comments as well.

I do want to thank everybody on the committee and work groups for the extraordinary amount of work that has been done since our last meeting. As John said, today is a discussion, it is a work group. Pre decision all. So don’t take anything it is the inner presentation as it will be this way. In here a lot of strongman discussion. For example, how do we decide what work is done in clinical operations where [indiscernible] work group, versus squatted group because they are interrelated. How do we figure out the white of the standards as well as to when? There might be the perfect way to exchange data but none has implemented them. And so deciding by 2011 that those will be widely adopted is not realistic. Most of our discussion today will be that remark. How do we decide if there are meaningful use objective is defined and how are the standards for when will be a part of meaningful use? When will they be ready or deployed or implemented in 2011 and 2015.

The work ahead and run the next 30 days will probably be even faster pace than the last 30. Which implies that at our next meeting on July 20 first, we better have at least a glide passed to the finish between now and then and that tells and there will be a series of work group meetings to get us finished to that point. We will and short gather a lot of input and here from Manny stakeholders because our haunches, as you said, focused on 2011 and what can we do to get employment double standards that are ready for Fiat, primetime that can be achieved by 2011? And so today I look forward to our thoughts and the free markets and trajectory we are setting for the next 30 days today, discussing with the breaks are and where should refocus and how do we get two August first.

Thank-you very much. We have adopted a community warm, for a disclosure of any conflicts of interest, real or perceived, and I would like to go around the room either by the undisclosed indication that anything that could be real or perceived conflict of interest. But will start with the death toll in?

She is not in yet.

Jennifer, who will start at the left with you.

I don’t have any conflicts but I want to indicate I work with the National Quality Forum and we’re the group that sponsors the high-tech panel and imports the majors to this process.

No conflicts.

Are in Harris, no conflicts.

No conflicts.

No conflicts.

I don’t have any conflicts but I do work with HL7 and LOINK and I have no financial interest in those organizations.

Sharon Terry, no conflicts.

Less [indiscernible], no financial conflicts. I am a trust testy as CCH ITI.

[indiscernible] no conflicts.

I work for a provider Information [indiscernible] and I am on the board of India house which is a decision support service provider, otherwise no conflicts.

John [indiscernible] and work with a provider organization as well and I am on the port for the National Health collaborative.

John [indiscernible], no financial conflicts but I work for a provider and I am also a commissioner on CCHIT on long-term [indiscernible] Chris shoot, no conflicts.

To see Baker, no conflicts.

[indiscernible] David Macaulay, no conflicts. By work for a large HIT vendor.

No conflicts but I am also on the board of the nationally health collaborative.

Linda [indiscernible] no financial work for a provider of [speaker/audio faint and unclear] on the board of HL7 until the end of the calendar year.

[indiscernible] no conflicts.

Thank you very much. It is now time to get into the substance of today’s meeting and my pleasure to introduce Dr. John Glosser to give us an overview of preliminary of the preliminary definition of meaningful use. John, thank you very much for the meaningful use for group as Le as well as the Office of Court and air, with a forward to the war.

And may be coming down with a cold, so I will consult with a number of you on how to treat this at the break.

I have the lead of the Group of the policy committee so I will give you an overview of the work group recommendations that were presented at the HIT policy meeting last week.

And [indiscernible] it is under discussion through its results of public commentary and some conversations that occurred [indiscernible] so a great start, although it is filled with potential revision in the weeks ahead. David also mentioned in his comments that importance that you all do and work groups around the standards and certification criteria that will be necessary to ensure that both the clinical operations and quality of management or reporting and the privacy or a security infrastructure needed to be the bedrock of the Foundation for meaningful units are in place.

What I was going to do is give an overview, a short version, of the presentation that the cochairs of the work group gave at the last meeting. I will not do as could have a job as they did, but the reason for turning this is that many of you didn’t have a chance to see the presentation, and outlining it is a work in progress, it was suggested to the work groups that they center on this outline and make sure that whatever standards and criteria for initial thoughts they had were perhaps linked to the spring and definition a can of understanding evolution. So you understand that approached that appeared last week appear in a wide variety of the initial thoughts [indiscernible] see this multiple times. So if I have the slide, I am not sure how that is King done. They’re is a clicker.

Thank you.

This is a brief overview of the composition of this work group. You can see the two cochairs listed and a diverse array that talented and experienced and thoughtful and also not shy individuals who contributed to this conversation so that led to the slides you see here shortly. But I think a key point in the discussion is, well we are obviously centered on some very near terms challenges, 2011 figure front and center in a wide variety of our observations, it should not be lost, all of us. That point is it will transfer the health-care system into a substantive change and [indiscernible] the health of individuals within the population. And star. To make sure that whatever we do for 2011, 13 or 15 or subsequent years is moving as rapidly and effectively as we possibly can to the North star. Close to the ground conversation today, let’s not lose sight of the collective vision that we have. It can see within that-and some key goals and these we’re adapted per that * of the National partnership and these were used as a [indiscernible] meaningful use objectives and measures were fronted is 21 or more of these key goals that you see listed here.

An example of an achievable division to take that material in the press like or concrete is to oppose this as a potential outcome. This is not necessarily the policy of the federal government but illustrates the type of games and improvements that we’re capable of making as a country and particularly if we do our work well referring to the nucleus of electronic health records that inter operate, we ought to be able to achieve a wide range of outcomes listed here. I suspect all of us vaporous sitting here in a meeting in 2015 actually accomplished a slide [indiscernible] being very well done said this is again to open spring and be specific about what we might be able to do.

Now in achieving those aspirational goals, there is a recognition that we have to evolve the industry. Or even in organizations that have adopted at Partners HealthCare at times been an example of what the U.S. is that ought not to be. We have to move the industry stages and go with them and understand where we want to go but also understand the state and Anna [indiscernible] at that point. And also [indiscernible] viewing this as three stages for the fundamental orientation of 2011 of capturing data and sharing it and moving on in subsequent years for clinical prosthetist leading to improved outcomes. It is not inherently cereal, it does not preclude outcomes before that but it is the core of this is achieved by the hand to show the effect relationship between some of the specifics you will hear hear shortly and the current reform agenda which not only zeros in on access but also affordability is that our work collectively in addition, to put improving the quality of care should be able to be leveraged to result in meaningful cost reduction as you see here and also provide the kinds of data and kinds of analysis that will be necessary to truly understand the care process these and what is necessary to improve them.

This is a way of looking at this and then we will go into the specifics of 2011. I did not include the 2011 or 13 recommendations. Health ITI 588 as web site but you can see the reform era to write in the coming out in the 2011, 13 and 15 a proposed meeting please criteria which center on the trajectory that has been presented in the final slide.

And this — Paul tanking specifically this and will not spend a lot of time on this but to make sure we are framed and understand a variety of potential conclusions discussions on the part of the work groups as to how these are being met. If you go back to the NTP coal or those drafted from that within that specific meaningful use objective for 2011, you can see these been listed here. A heavy emphasis on capturing data in a coded format, we will not enumerate or less all of those but you get the general idea. You also make sure that there is an electronic documentation of the progress note with the proposal in 2011 centering on the opposition side and moving into provider Order entry across a range of ties and also Suncor abilities to manage to populations of patients such as object make a list of patients such as specific conditions and agree that there is further care needs.

In addition, to each objective that is listed in the work group analysis, they also propose measures and those are a mixture of quality measures which we are critically had poured into our efforts to reform the health system but also some measures that would be viewed as indications to the fact that meaningful use was occurring.

And you can see this here with the first two bullets being more a reflection of meaningfully it’s progress, and a third bullet and all of its sub bullets be more of a reflection on the improvements or care canes or at least identify where improvement is needed.

Clearly a lot of equality measures would require or be supported by the degree to which laboratory results for example are indicated well into the electronic health record.

Moving into the second category of engagements patient dumping patients and families [indiscernible] we intend to make. You can see three bullets here, fewer bullets in the Paris flights but no less substantive and their impact. Insure that we provide patients both access to educational materials but also giving them access to the types of data, their medical records and history and findings surrounding their care.

And again, you can see some measures that were associated with that, and the shares of the percentage of patients with access to this type of information or which encounters are summarized.

Care coordination which is a lot of the exchange, particularly for routine care operations will center. These two major objectives for that 2011, and has these proposed measures which would go with those objectives, both focusing on medication reconciliation but also for example in the last bullet, the percent of times in which a transition of care brace summary care record is made available to the receiving providers.

Population and Public Health, and his Nation records but also going all the way to the bottom, Center Max surveillance, which in the H1N1 crisis lightly you can see the achievement of those objectives.

Last but not least because this is the bedrock on which all of this press, I think if we rode the crest of the patient for the care system, virtually everything else we do if they are afraid to talk ordered engage in conversation with those of us who are their partners in providing care, so you can see the objectives that we’re listing here we will see some commentary about these later on, with some basic measures that were presented here.

This is the last slide. I could not have possibly captured the full impact, or thoughts that were conveyed during the policy committee meeting that I wanted to make sure that we all at least understood the free-market discussion occurring in the next couple of minutes.

Here is the summary which I think is important and well targeted then and yesterday and that is two realize that this obviously this transformation requires a week Gage and meaningful use of work and all of the workers and committees everybody else come together in a reasonably coherent and tidy and thoughtful way. We do have to evolve from a rich are now into this. As rapidly as we can but also as thoughtfully as we can, and in turn, which also of leverage and not ignore the traffic work that has been done by range of organizations not only involved in setting standards but also providers that have been implementing these systems also, and then the last point which is stated by us but also by the president, which is if we are engaged in the reform we in addition, the workweek to and the technology to discuss bedrock to all of that.

And with that I am done, and I appellate we have any questions or if you want to move into the panel discussion.

Thank-you very much. I hope everyone shares the sense of excitement. It is really not about the technology, technology is a vehicle. When I think about a rigid point where one advocates for their family, the difference between health care it today and the health care that is envisioned, this is an exciting proposition. I hope that beyond the national objectives, and a personal level people began to interpret what that looks like. The difference between filling out repetitively that clipboard and not having that information gets to the emergency counter or in the scheduling counter.

Let’s ask if there are any clarifying comments or questions at the group might have.

John, if you look like you might want to. A.

One of the interesting aspects people use is that it illegal for the next 60 days. And we as a group have to come up with the standards and certification a secretary that supports any evolving definition.

And so this of course gets back to where the puck will be.

John, I made the comment on the additional deliberation by the HIT policy coordination and work groups. Any advice I might have for the committee recognizing this may be an evolving set of criteria?

I think continue [indiscernible] contrite but it is true, that amount of work done in the last couple of weeks is exceptional. , you continue to do that.

And obviously what we need to do at ONC nic mixture used conversation as it works its way through two digest the public comment and to the degree it begins two alter its recommendations and make sure there is close coordination with small and such that if there is a passing added, let’s talk a path that because we need to make sure that we give you as an opportunity to contribute to that to is a degree that a path is being moved from a year to year or whenever it is, at the interaction both at the committee level but also at the work group level and that is our obligation and who will keep you guys closely in the loop as we can when the victim moves to coordinate and [indiscernible]. So that is one of the [indiscernible] we will see some short cycle iteration between the groups as we collectively converge on a set of recommendations they will make and as David reminds of us, these are recommendations 2HHS, but nevertheless the resulting set of recommendations that come from this and the meaningful work group coordinate well. So we will have a lot of cross coordination that will engage with to all of the next weeks.

Let me add a word to that.

We are all engaged in a process. It is an open process, and a very responsive process. The Health Information Technology Committee will make recommendations to us and to you. Those recommendations will provide important guidance, but not definitive guidance.

They will then be part of the material that goes into a rule making process, which will extend over months.

There is unfortunately no way that we can give you closure around a set of specifications that you should write standards for.

On the other hand, I suspect as you listen closely and absurd, being the very knowledgeable observers at Iwo it will begin to see a kind of consensus forming. A direction, a set of things that get mentioned a lot, and mentioned by lots of parties. And it goes, I hope sort of, directions, so that you can make a truly useful contributions.

But, you can’t obviously cover every eventuality. So this is where we are somewhat playing a percentage came here. Trying to find the sweet spot, but I think that, if you follow that set of directions, that set of rules, he will nevertheless be able to make a very important contribution.

Thank you David.

Questions comments from the group?

Just one. Let me just introduce Jim Walker.

As we plan a couple of what meaningful use means and what the standards are quantities to support that, I think it would be useful if we remembered that the way this is going to have healthcare organizations is at the project plan. And it will have a timeline, and costs, and the better we can do in terms of designing so that this can be transformed into a realistic project plan — in fact, I think we could use a project plan as a way of structuring our thinking. I think it will increase the likelihood that particularly small practices and small hospitals actually can execute this by 2011.

I would agree, Jim. Sitting with to have here, having — one having ONC and the provider organizations, and have to get concrete at some point and the sooner the better for various reasons. I think that takes two forms in your deliberations and realizing some of the comments that David made, what is the clarity of direction. So it is clear what we’re going to do or what needs to be done, etc. And the second is, as to balance the various criteria and standards, etc., that which can be effected now versus that which will require more discussion or more work. And obviously, two years is not a lot of time. So without undermining the whole process, the closer we get to that which can exist and be affected now the better. Not to say, once it exists, we can’t touch it, that is not the point. It is to make at balloted [indiscernible] you actually act on some of that stuff here and I think that will factor into the conversation which is targeted for 11 versus 13 and 15. Obviously in the years that followed there is more time for engaging conversations [indiscernible] the vendors have not had enough time to bring that into this — pushing the system so it’s it’s as if that’s upstream but also getting the part that is achievable for the wide range of sequiturs we have.

— stakeholders back we have.

One follow up to that. As we plan all of this, we probably have a rough idea in our heads, or maybe we don’t, what percent of health-care organizations we expect to succeed in 2011.

And I would think that that would be a measure of success for us to expected to be 95% of health-care organizations that meet meaningful use by 2011, to expected to be 70%, to be expected to be 40%.

Let me come back to your forced point come at the idea of project plan. That resonates very well with Ancaster’s point of the last meeting. The whole [indiscernible] provided peeling off, it helps to develop specific concrete and objectives. It helps to provide the first iteration of the project plan, and I think your point about the project plan, your point about success or [indiscernible] lands, people need to know where they are going and I think that graphic is a metaphor for translating from what they feel at certain times is like the ambiguity but nevertheless embraces a set of principles and helps to define to some degree the opportunities for standards. And I think we see that frustration very successfully in the activities which pressure means another cut in regularity.

I think it is beyond the purview of this community to identify, but I think what is within the purview of this committee and the policy committee is that the idea is to embrace a set of standards that supports meaningful use, such that, we can help support a transformation to health care.

And at the beginning of the health care that we have been kicking around a little bit, Paul Tang and I have discussed a little bit, that initially it really describes the use of technology. You saw in John clauses description that have two have a technical and fish Archer for things to a cure. — technical infrastructure for things to Kippur, for her. And you have two have [speaker/audio faint and unclear]. I think, unless we can come up with the degree of specificity that we need to set the stage for people to achieve the goals of transformation which were intended.

In a perfect world, everyone will achieve what we want to come up with for a set of standards that are clear that motivated organizations vendors, the environment, that increases consumers can adopt, because it is a rational pathway where it’s putting in the infrastructure for, not as meaningful use, but purpose directed meaningful use ports better health care.

I don’t think it is possible to state, in all, action. If we don’t gain traction, we haven’t supported the Office of National coordinator with their actions.

If we don’t define standards or we choose areas for 2011 that are gaps and not existing standards, we don’t determine additional capacity for implementation.

We want to make it not just theoretically but practical for motivated organizations and individuals to be part of the use of technology towards better health care.

And I don’t know that there is perfect. It will have to satisfy since it’s part of the reason for the Constitution of this group broad constituency and a very open process is to put good minds together and formed in a very open way about a pathway that supports and aspiration and very granular level of detail that can help get the maximum achievement, and it remains practicable. That remains to say that we are practicable, but the technologies exist to make it possible within that time.

They wish I could be more specific on that and I also don’t think that we can, or would be able to ask others to define. I think our goal is to be as clear as granular and as effective to attract the greatest process and greatest capacity for adoption possible.

John, anything you would like to data? Do want to comment on the actual numbers you like to achieve? ARRA that that something like 70 percent of hospitals and 90% of doctors and achieving Cristobal used by 2014?

It wasn’t your words.

Well, the goals that have been laid out that the legislation are all Americans will have access to an electronic health record by 2014.

But, I think in the office of the national coordinator, we feel an obligation to get as many providers as possible a fair crack at the incentives that becoming available in 2011.

So we want to service as many providers as we possibly can, but without sacrificing the long-term goal of changing and improving the performance of our health system.

So there is attention there, but I think it would be premature at this point to try to resolve that tension by putting out a specific member.

So this is Rick Stevens, and I apologize I am on the phones I can’t see the dynamics in the room. But what is our process as a Standards Committee to document what are measures of success are, recognizing that they will continue to evolve? And where I struggle as a committee member, I don’t know where that information is. I’m I’m missing something or is it not on paper work where do I go to see something like that.

I think HIT [indiscernible] to identify standards as well as gap that support for need for their work for 2011 or 2013 or 2015.

I think you have to take the obvious question, it has been alluded to the connection of many pleas and incentives it’s a hurdle and there is an operational aspects of implementation, and really, that is not only beyond our immediate consideration, but I think it is safe to say that the office of the national coordinator and the policy can providing input for have to assess guidance in terms of Patrick’s. And at a broad sense, I think it goes back to Jim Walker’s Point, and Dr. Plymouth Falls commentary that we want to provide the framework for the most people, not just provider side in supporting not only the use but they use pulling towards improved health care care in bracing consumers incorporating privacy, and advancing quality specifically.

And I appreciate that.

I guess my struggle is I am a guy with a business that has 160,000 people and PR recognizing that we’re trying to influence several million across the nation greater specificity, because as one looks as a System architect, we have some top level requirements and we start flowing those down. So I am struggling with our process about how we are going to in fact work our way down to get to the greater level of specificity, because the point that was raised earlier, eventually this has to turn into a program plan that will get implemented by health-care providers employers and Paris, and I am struggling with the process.

I can’t justify it.

I think those are good points. Just again, to sort of take the first highlight that our test today will be very granular and specific about standards that support the immediate task of 2011 as Really described in the meaningful use, but let me turn to John Glasser to give another cut on specificity.

I think it is a fair question and to prepare a question for this community to devise ways by which it would organize that success of understanding there is a broader set of reform conversations and health care outcomes etc., but how does this community know whether it is doing well and whether it’s recommendations are kidding the kind of traction that — and adoption. I think that is it fair discussion. We are at this point in an anomalous time and that is we’re trying to get a large amount of work done in a short period of time Port 2011. And to all large degree and for example and I suspect you’ll will discuss the standards and criteria do exist and so we sort of pull it off the shelf and put it in play.

And there is immediate which is the end of August tickets some conclusions time.

Major attraction in the work we have been asked to do it to the degree that shifting from a motive pulling stuff off of the shelf to new standards and new criteria, or whatever, what is the process for that? And I think that would merit some discussion that that is I think a task that might be early fall where something along those lines that might meet some engagement.

This is David Blumenthal. I would encourage the committee not to take the weight of the world on his shoulders, but to define a doable task and judge itself according to that doable task, and I think the immediate task ahead of us is to break the standards that are required to implement the standard of the meaningful use.

Which is an evolving definition.

I don’t think this community has to decide that make a policy about health reform, or how many providers ought to adopt what constitutes success for the office of the national coordinator for the president.

If you can just define a set of objectives around developing standards that enabled that imitation of a definition of meaningful use, help us think about the certification process and the petition of certification process, those with the incredibly important accomplishments about which you could feel very good.

This is Mark. I think to put words in jems mouth, in doing the task of trying to do that modestly sculpt set of objectives that you described, one of the factors that we have to consider is how far we want people to get, because they interact and they are not independent.

In other words, the standards and measurements that we end up recommending would be different, if we were willing to accept a 10% — let me just make up numbers — versus 90 percent. They will be different.

And I think that is perhaps where Jim and others are coming from or that aspect of our thinking.

The response I would make is, advise us of the consequences of your recommendations.

Sure, it is at that point. And one of the things we will talk about today and the next agenda item is rating the standards readiness of the clinical operations standards and grating where we can achieve meaningful quality measurements. So the point about not only asking the, what, but the, when, is achieving the maximum use, and let’s be open about some discussions I have had with several members of the group. If we were to declare Perth a charge of the workgroup on clinical operations, laboratory, radiology, report Exchange, and I think that this will be our work today, there are ways to achieve that on invisible short term. There are national organizations that could assist with that. If we could acquire a fully functional health information exchange for every place in America by 2011, that may be starting the bar a little high. And so as we put the matrix to get there that looks at meaningful use and capabilities, and a creation of score of, what is the likelihood we could achieve this by 2011 and help us figure out, it goes into 2011 and 13, it looked as more meaningful use and what we would suggest. And it will be our charge because our major [indiscernible] meaningful use and how many transactions are falling.

I think this discussion is intractably productive in terms of seguing into the next set of discussions because I think the struggle of trying to find things in the abstract, I think they’re could [indiscernible] assuring that because there is an interaction and Interoperability between those concepts.

So let’s take one last comment on this and then segue so we move from one abstract to another, and then come back to why this is such a useful set of activities.

And Castro?

I just wanted to observe that the meaningful use description as it is today looks like a 2015 for 2011.

And I think how to reset [indiscernible] allotted and our need for project management and are desperate attempt to see the elephant so we can keep it one bite at the time is, this sounds like the world. And when we are in our work groups, I am only responded to privacy and security. Not the whole thing unless I go to public or private, but connect. And by holding is, this is huge for 2011. And what it impacts from my impression of the system requirements, the burden on the vendors, I think we will be fine on the standards. We will define the caps and put them together because there are thousands of people working hard on this topic that we don’t know or see. But I have a big concern about the whole context of the meeting full use by 2011, and I don’t know when we are going to talk about that.

That is a perfect segue because we are heading there.

Just one comment [indiscernible] every Jeff opinions so talking to an artificial tally takers we have received about 150 comment letters and I suspect we will see a flurry before the week is up.

Two that degree at all, and I don’t know whether it will or won’t, things move from 201-12-2014, you all do the work, that is a work that you will leverage whenever it occurs whether it is even or subsequent years, conversation goes on, what is the right balance, the work that you have is good work which will carry forth virtually intact but and regardless of the conversation we have to use series of discussions we have in the week ahead.

Now as the famous philosopher Yogi Berra advised, if you don’t know where you are going, he may not get there.

It really does that a direction that is very inspirational. And it is concrete in terms of 2011 what some of the components are.

I think we have heard that we need a road map. We heard that from Rick Stevens in terms of their operational realities, we need to know where we are going. So this needs to be reduced to some of the incremental pieces. And I think the graphic that was prepared for as Billy give some branches and forks and not roadmap that get attached in 20112 more concrete standards, and 2013 and 2015 to things that are respectively concrete. More aspirational, 2015, to your point.

I’d think David Bloomenthal has been very constructive in his advice to us. Don’t try to boil the ocean or construct the major issues of health reform. We have that formidable task. And that is reassuring reassuring that that limits our work to only 24 hours a day instead of beyond.

With that in mind and with cognizance, Jim Walker and Mark [indiscernible] [indiscernible] [speaker/audio faint and unclear] the capacity for adoption and it is our church to advise the readiness to facilitate adoption in 2011.

I will turn back to John Glasser to introduce the charges for the three work groups, and the cochairs of all of those groups as we now embark on that exercise and report, and, to your point, that just the extension of work that has been going on between the cochairs and a number of individuals that are sort of cross pollinating, but of course today emphasized that this is a working meeting to emphasize some of those interactivity is. And have a discussion on what has been accomplished, and that in the second half of the meeting to really dive deeper into the feasibility and concrete readiness for adoption.

John, I will turn to you.

And, and don’t know if the cochairs want to sit here or versus where they are?

It is kind of lonely appear.

We should do that so the rest of the group can have dialogue. Because he might not be able to see people to your left or right.

And having some colleagues appear.

Thank you I appreciate that.


Let me make sure I have the sequence here right.

Okay. But the walk through the charges and members of the three groups and then we will turn over the program to the cheers and cochairs that will lead us through.

This is the critical operations group, Jeanie Ferguson and [indiscernible]. And you can see the numbers listed there, and Deborah folks drawn from the committee here in editions and individuals that have been added to the committee to round out the base of expertise experience that is necessary to do the work that we have in front of us. And you can see the ever popular John Glasser there as ONC lead.

You can see the broad and specific charges that the systems work groups, so we are looking put the recommendations coming out of them to you all regarding standards specifications and certification criteria related two clinical operations, and there will be fussiness to the boundaries but it for example would be documenting care or writing a prescription of the transition of terrace of the prosthesis that underlie the day in and day out activities that the hospitals and physician practices and other care facilities we all serve.

And [indiscernible] that is given a preliminary outline of minutely is is to identify the certification criteria standards and implementations specifications not only for that initial description of meaningful use but also two recognize that there was in the legislation eighth national priorities for the country in health care, and they are required to map also hinted that workfare.

So we have a relatively short time frame of two months in which that dates to occur.

Janet Corrigan who is the chair of the clinical quality work group, again, a terrific set of individuals working with her to undertake the charge they have in front of them, and a similar private charged with a major substitution from their expanding clinical operations is to deal with the measures that should be gathered and also reported and more importantly used by providers and others engaged in health care system the kinds of care that we intended to make here.

And also have a fairly short term charge which is to get the recommendations in place which we mentioned before by the end of July.

And last but not least is that privacies security by that [indiscernible] family as cochair and again, a nice blend of a great talent, working with them.

And there is Judy ONC lead for that group and a similar charge on this time centered privacy and security.

So it is a Mary parallel pride and specific charges all of them focusing on the specific and clear terms what we have. And not only extraordinary cherries and cultures but also team members.

Station here which will be it led to my colleagues at the right.


Why don’t we start with the clinical operations work group and Jeanie will give you an overview of the two meetings we have had.

Generally there is for bodies of work. Would want to take that meaningful use matrix and add to it to granular standards and describe the work that has been done by [indiscernible] implementation guide writers and [indiscernible] and there is some [speaker/audio faint and unclear] services that are very usable.

So list that granular detail. And then put a major of maturity and Industry readiness.

And we have been talking about readiness this morning in order to achieve implementation.

And then it really understand what work the clinical operations versus the work that the clinical quality should do because some elements from clinical quality come out of clinical operations.

Today we plan to outline, not a finished work project, but a straw man of how we are taking through the framework and some examples.

We will start with Jamie.

I think that John has just gone through essentially the streams of work we have in process.

We have held two meetings today.

I will dig into one of the ideas we have been discussing which is about the relationships of the different tasks and deliverables of their respective work groups.

And the basic idea of this chart which is included in the materials takes the majors and objectives across the top in the stops circles, and it says, in the clinical quality work group, they will devised the standards and certification criteria for the clinical quality meaningful use measures, but there are aspects of clinical quality measures and objectives that have to be supported by EHR clinical standards which would be determined by the clinical operations workers and also by privacy and security standards which would be determined by the privacy and security work group.

So in this case, the clinical quality obviously has aspects of the standards which would be developed directly buy that work group that there would be aspects of this clinical quality measures which would be developed by each of the other work groups in a supporting role. Patients, we in the clinical operations work group would have the primary responsibility for the standards and certification criteria for our own the majors, but there are a good number of related standards in the privacy and security arena where we would rely on the work of the privacy and security work with two support our particular measures.

Then essentially the sum of all of those would form a cohesive body of standards and certification criteria.

So that is the basic framework for the relationship of these that we have been discussing in the clinical operations work group, and to some extent, we have had discussions embers of the quality work group on that and I will go into that in more detail shortly.

In terms of the taxonomy of readiness and ability to implement the standards that have been subject to some of the discussion here today if you don’t mind, and will turn it back to you to describe the actual taxonomy years since it was the brainchild. But I will say a couple of for its, the taxonomy here is based on the maturity of standards and are estimated the ability of the industry to deploy the standards within these various two year-before year-six your time frames, but it is also important to note that in terms of things that might be implemented in 2011 or 2013 according to our recommendations, we are not only looking at what is widely used today but it could also include stretch goals, some not just things that are a slam dunk, essentially.

To put this in simple terms, imagine, say, Mark, I would ask you, how widely used is HL 72. X and LOINK in the industry today? And if you’d probably say they are pretty mature stands and their widely deployed.

So the first tier one would be, if with the rest of this as part of the meaningful use matrix, it would not be a lot of argument from the pairs or providers, they would say this is a standard that is mature and has been shaken out in use. There are millions of transactions.

Now there may be a category two where the standards harmonization has been done, so let’s say it was done two years ago, and there are rollouts that are beginning and could implementations that exist, but if he were to ask most of the EHR manufactures and peers and providers, are you exchanging those transactions every day? They would say, it is in the project plan and will be getting to it in a couple of months.

And then there is, we harmonized the standard yesterday. We have the standard but it has not been tested in the world world or in the marketplace yet.

Than there is the clean in the eye.

It is the kind of we know we need a standard and not sure how we will get there but in and year were to so it would put these categories next to what our recommendations will be, that gives us a sense of what will do in the 2011, 2013 and 2015, and what are the gaps.

Thank you.

On the next slide, we show an example of applying this taxonomy to the actual selection recommendation of standards, so I have taken the liberty here at adding several columns to that meeting for use matrix that was distributed.

As John mentioned earlier, in addition, to showing a specific candidate patterns in terms of the excepted and recognized HITC HITSBY a newer version of the same standards, a column for camps, where there are space gaps for meeting the particular measure, and then for combs for the different categories of standards where, to implement this measure, what are the different standards that could be considered in categories one through four.

Majesty couple of words on the example here, the example I have put that is to generate permissible descriptions electronically. There are 83 constructs and HITSBY capabilities that defined standards for ambulatory inpatient as well as long-term care prescribing.

And have controlled substance orders listed in the gap.

Some people would say, that is not permissible, there is some discussion about variability in terms of state boards and pharmacy and so I have listed that as a calf trying to be determined, if not trying to wade into the LOINK will quagmire, but just to say there may be some determination of standards that need to be there.

There has also been some discussion about the completeness of the standards in terms of immunization workers, so I have that listed as a possible Kappa.

And then, because the standards, the scripts and so forth are generally defined and well accepted, that would go into a category one.

Category two would be possible refinements for immunization orders, and then somewhere between category three or four, 2011 and 2015, would be the controlled substance orders those are permissible.

So that would be the standards of applying this taxonomy to particular measure.

Poor example, if the DEA or other agencies decided that to write a controlled substance prescription, the physician would need to get a message to their cell phone with a pin code, therefore it is not only something that you know, a password, but something that you have, a device, set of standards around that. And there are but we haven’t harmonized that because there is the workflow yet.

So we are hoping to have a discussion on this concept later in the meeting in their proposal would be that all work groups could adopt this format or something similar for drafting their standard selections.

One other thing that we wanted to — I’m sorry, yes?

I have a question about the concept of the pliability, which is necessarily a judgment about how fast something that is agreed upon can be made practical. And I wonder how you think about that time frame issue? Because obviously, as you said, you use some illustrations, John, reuse said, we have had it for two years, but no one is using it. To put it off to 2013.

But maybe in the new world of high-tech, people can to learn to use things faster. I don’t know. How do you make that judgment?

A lot of this is the subjective judgment call of the wisdom of the community based on their experience in that industry.

And if you could certainly ask technology questions, is the nature of the technology standard. Close to things that are widely used and therefore it is a small incremental improvement in therefore, it is easy, or is it something so knew that there is not a lot of felony theft and not a lot of products that would be able to support it.

I wish I could come up with completely objective criteria of how we could classify each of these, and I think the answer will be, one would be pretty clear because they are widely used. Two and three will be judgment calls based on the experience of the people in this room.

Jim Walker I think had a question.

I love the categorization, but I would suggest another dimension for category one and two.

In our experience, one of the critical things about a standard is how much it requires of other people using the standard, how much control we have.

So there are some standards, both maturing standards, but some that we can implement would plug them in and they just run.

There are others, like the most work we did setting up E transmission, we were already doing electronic entry, was preparing pharmacies to use the standards.

So I think that is an important dimension.

This is something — Is it something that is plug and play or is it a standard with issues around the standard which would make deployment require a lot more resources?

That is a good point, and that is generally what we meant when we talked about, it is it seen as deployable? Those are certainly some considerations.

But I would say their is big difference between a standard that is widely deployed, so everybody knows how much it costs and what you have to do, and you just do it and Carradine, purses what is deployable, and the new start deploying it relies it is deployable and once people deploy it and don’t understand how to use it, you start teaching it and all the issues around it in terms of the effective use.

It’s on site those are considerations for what is the determination between 2011 and 2015 that we will have discussions on.

I think of HIPPA and friendly all had to do initial certification, its eligibility. Well, a lot of people did that. And we use the X1220 [indiscernible] things like referral authorization and clean status inquiry and all these other transactions are part of a lot of interaction among a lot of parties. And also there was a standard, it wasn’t so different in terms of eligibility, there was an ecosystem issue is judgments will be taken into account as we debate these authorizations.

Let’s take some comments here. We will go around and get comments.

There are also dependencies between standards. And they need to be — and their dependencies between standard and architecture, especially in privacy and security. Leg SAML.

The pp 20 depends on SAML. And somehow we need to capture those as well.

Good point.

I think there are two kinds of barriers to be overcome in creating Interoperability and implementing the exchange of the information. One is the exchange between that which looks really good, and there have been some trials, and that which is widely used. Gardiner, across all kinds of technology, not just standards, generally makes the judgment that when 20 percent of the market is using it technology, it has reached what we call the Plateau of productivity, which means it is implement double for a predictable cost in a predictable time frame. The element of adventure has gone out of implementing it.

By today’s standards, that it’s a high benchmark team need for any kind of Interoperability.

But it is a cautionary tale that if we set a date, for a criterion for meaningful use, even those standards that look really good and have the potential risk associated with them.

The second one that Jim commented on is the ecosystem issue. Anyone who has been in any meeting with Pharzad ‘s [indiscernible] has heard about his experience giving clinical results to his in the users. The lead handles it and he has about 38 percent of his physicians getting the lab results.

And the reason is, there are various reasons why the that the center consists on a very elaborate sort of certification process, that they won’t even undertake for practices that did not generate a lot of lab orders.

So here is the question. Do we penalize practice that has the right software that is working with the right partner, but still is not able to get that Interoperability billing? Or do we and sent them to try harder and pick the right — going, or do we incentivize them? And that is, one of the problems that Pharzad has is it sometimes takes six callbacks to get a practice to fill out the paperwork to get the data to the lab. So an incentive, it ought two and sent people to do the things it takes to achieve Interoperability is easier to buy something on and get lab results. But it is something we need to take into account.

So what you hope is the meaningful use incentives would get clinician’s motivated EHR and Interoperability that we are after together and in plant. And hospitals and HIT E centers would connect and help these folks, so one hopes that we can set a metric for Interoperability that is achievable based on existing technology and the partners in the ecosystem and create incentives to get the work done.

And if we have a choice between how much incentive is helpful and how much incentive is a disincentive for me.

Yes, basically.

I had a comment about — I think we need to be concerned about, not that we can determine the standards or the technologies available, I think we can clearly articulate and put that forward. Effect on the providers that will need to use all of these new technologies and new standards simultaneously to get the incentives, and more importantly, to get the quality we have hoped for.

So what I am saying is, if you have 25 pages of standards that, even though they are available and technology and the standards have been said, to use just let results or to E prescribing, who are asking them for a cumulative change in the work process. So as we set forth the standard, keeping in mind meaningful use and what year, we need to take truly into account cumulative effect.


I was just going back to the concepts that David is bringing up with deployable presses use, and we were discussing E prescribing and test to give an example of that difference between deployable and use, we have vendors that are doing prescribing in the pharmacy at the work world that represent 952 to 948% of the pharmacies in the U.S. About 95% descriptions electronically.

There are approximately around 120,000 breast physicians now the shares Scripps network being able to do prescriptions electronically. So being able to do — standards around E prescribing have been deployed so far are deployable, but the use is very different, and well we have to be careful about the standards and making sure that use is part of our standards, I think our charge is to make sure they are deployable. Because I think next year will have around 10% of prescriptions will [indiscernible] 2010 will run about 10 percent of the prescriptions that will go electronically. So while you have 120 prescriptions and volume have the availability of these standards to be deployable, the U.S. is still rather low.

— prescribing is, as we think about that granular individual states, teewuns script, that is deployed. But– are X Norm, that has a lot of promise and has been deployed but not broadly. What about structured say for how to take the bed in? We probably need that, it is a good standard, but not implemented it widely. Those are the kinds of debate we have two have.

A lot of this has been mentioned already, but I wanted to make sure, but we think about making this notion of deployable, sometimes it is not just about technology. And although that is sort of our charged, I think it is important to notice that there are social, cultural and workflow issues involved with this. One of them in which we would like to be able to compare drug formulary activities. If you have someone that has not verified their insurance, you do a drug formulary check to discover later that their insurance has changed or the drug formularies has changed and you don’t have the time available to make that check.

So we have to think of this NA Systems way simply and sort of an isolated standards way.

I have to leave shortly because I have a downtown obligation, but before I go on wanted to thank you all again. This discussion has been very useful and informative the distinction between available and deployable is a distinct one. And your advice by your information about that will be extremely valuable.

I would encourage you not to put off the riding of standards because you don’t think that standard is deployable in its current form. I think we have two at least hold open the possibility that with the availability of incentives and the availability of support through extension centers and other means, the things that were deployable warmly with years of effort in the past could be deployable, quickly in the future, and that therefore, we should not constrain ourselves and breaking standards which make possible change by historical assessment of the tunneling implementation.

Billing to a judgment about this too is extremely DuPont but don’t constraint the world of possibilities, puissance of what the individual for a cumulative effect of implementing the standards might be.

What we are committed to doing is making the standards available for those that wish to take on this task.

If people want to push the envelope, our job is to make it possible for them to do that. And there may be people that wish to push the envelope, so let’s make it possible for them to do that.

That we thank you, Doctor David Bloomenthal for your leadership. And I think that it’s a perfect segue back, this discussion has provided a great insight into another of other characteristics not only this afternoon to work but the work groups, deploy ability purses [indiscernible] and used and the ecosystem and availability of incentives to try adoption and remember that that may create a different social construct than the historical construct, and that the point was made that it is not just the technology, but the broader social aspects including workflow and everything else that surrounds the implementation.

I think those are good asterisks to add to a taxonomy the next tranche of work.

Let me turn back to John and Jamie two continue on with this. We will take some comments again, because I want to make sure we not only have time to get through the stage setting but to the work that is meant to follow. Thank you. There’s one other idea that I wanted to present to the committee, and this is getting back to that previous diagram slide showing the relationships of the different Workgroups to the other.

This is an example of how that might be used in a practical sense.

In this case, this particular example, we have a major of the percentage of reported a lab results that are submitted electronically, and we have looked at, what is the delineation of the past and deliverables for that major between the clinical operations work group and clinical quality work group. And so we would say that the charge of the clinical operations having to do with EHRs and clinical operations, that the And the protocol would be a responsibility of the critical operations work group to determine develop standards. But the quality work group would be responsible in this example for defining reportable labs in the threshold percentages for the reporting of the measure. And rather than the rising essentially a one size fits all set of rules to define the responsibilities of the workgroup we are suggesting that we could quickly agree on the tasks by a measure by measure basis. And we could walk through all of the proposed measures, probably very quickly.

And with the framework in devising the measure, that is probably some of the quality, the transmission of the commuter data elements, the lab, the Med, the time stamp, that is probably critical operations. And then you guys have to decide together if there are a summary standard with new leaders and denominator’s — numerators and denominator’s and we could achieve that end mostly to finish this we will proceed rapidly.

So to wrap up and in terms of the critical operations work group, in terms of our next steps, we would like to reach a agreement including the taxonomy and the discussion that we had and our approach to document in the standard selection and using the extended matrix with those extra columns in a consistent way. And then, if we can agree, on the deliverables and tasks and have them coordinated in terms of the work groups, that would set the stage for both Cross work group sessions for determining that coordination and then our workgroup session to craft the recommendations.

So comments?

You have — we have a comment from Jim Walker. Let me bring him in and then I think we will go to, one more comment and then we will go to quality. I want to make sure that we preserve time for the next tranche of work.

May be one of the ways that we can categorize standards is that the likelihood that an organization wants to execute them, can. So in [ Indiscernible ] experience which has and one of the best organizations put together in the country, and only what, 62% of the people that do everything that they need to do to receive lab reports electronically can do so. I’m sorry, I thought it was 38% did not have it, okay, only 38% can do it. And the 15% of pharmacies that are participating, I can tell you who they are, and Kevin can correct me if they are rural independent pharmacies that don’t have resources and are unlikely to be any more connected in five years than they are now. Many of them will go out of business if that becomes the break point for them. So if we can identify what the likelihood of a ruling organization that puts a reasonable amount of effort into it can execute a standard. And then how these people will document that. The sort of like when I don’t given aspirin to be patient because the decline in the aspirin. I think those would be too useful ways to approach the metadata about the standards. And by the way, we bill to every standard that is either mature or in development and our health information exchange, or EHRs, and 100% of everything that happens in all our organization is done electronically. Almost 100% of e-transmission of medications. So we have been very grateful for your harmonization and development of standards that we have regarded as critical to going forward. My concern is about organizations that don’t have remotely as much resource as we do knowing how hard it is and how much resources it takes for us to implement standards. So that as we roll this out yet anyone seen it in a way that really does get us — we are nuancing in a way that really does give us as quickly as possible.

This may be a security specific concern, but it may not be as well. There are standards that will be applied to a product that is implemented like security standards that are applied to a EHR product that sold and there are standards that would be applied to the infrastructure and which that product would be integrated. And I think the maturity of those two, we may be allowed in a little difference between the two. And that may apply to all three, I’m not sure but I note it applies to securities.

And AP EHR has a complex a authentication method — but if it has a complex authentication method in your using one password, that is not a product fault, it’s a implementation fault. So we have to provide some best practice guidance as well.

Right, and the standards for those best practices and the technology that they implement. You should make it illegal easier especially for small practices. you should make it easier especially for small practices and how easy it is for them to implement agreed not to make it harder on the product company as low.

And we will end up even in clinical operations declaring Best practices because if you need a code problem list you better start doing electronic problem list that are not free text. And if you want to report blood pressure you have to play in numerical text and not come here know, 120 mmhg or something that is not permissible.

Two environments.


If we were something that this was a dynamic process, great example of that. Let’s move now into the area that is the point, which is the improvement of health care. And I want to thank Jim and John and all of the members of your work group and I know that we had some discussions about interactions and relationships and the taxonomy there is great diagrams in particular that shows the interrelationships that is ongoing that I think is very valuable. And Janet brings the recent work with the clinical quality group and this is a terrific say click of where we are on going and quality — a terrific segue and we look for to your reports and discussion.

Thanks, John and let me think the work group members of the quality work group. We have had to call so far and I am sure there will be more in the next month or so. We have our work cut out for us. The work of the quality work group is focused to a great extent of the identified in the standard EDS Quality measures that can be used to operational lies the measured description and policy the committee put board. For those of you who are not familiar with the quality measurement world, the National Quality Forum endorse a standardized quality measures that are used extensively by public and private purchasers and others. And there are about 500 standardize quality measures that have been endorsed by NQF and for the most part those have not been specified properly to be used in a EHR environment so the enumerators, denominator’s, a good deal of work needs to be done to retool or respecify those measures using EHRs and PHRs. Fortunately the Health Information Technology expert panel under the guidance of pol who chairs that for us, they are very familiar with this work. And they have been working now for about a year and a half and are essentially in the second phase of their work to identify not for me what data types need to be captured with an electronic health records to be able to support quality measurements but also to specify in much greater detail in many ways to define a quality measure and its various characteristics that can then be used as feed back to the stewards of these measures to go through the process of retooling and respecifying. So there is a parallel effort and a lot of activity going on to retool the standardized measures and a meaningful use. What I will cover today is three things in my comments. First I will touch more of the work of the Health Information Technology expert panel and where its that and how it feeds directly into the quality work group. Secondly, I will talk about a meaningful use matrix that is being constructed by the work group. That essentially takes the quality measured concept that the policy committee gave to was and identify the specific endorsed standardize quality measures that correspond to it and in turn trace that over to the capability and to the certification criteria that will be needed and I will give examples of measures and this is the current thinking of the work group and it will evolve as we go forward. So far in its first phase of the work is essentially took high priority measures, a subset of measures, a few dozen or so better be used by CMS for public reporting purposes. And then trade them down to did categories of data types that are within the electronic health records and the measurement of that information. And essentially there were 11 categories of data that were defined during this first phase and in term the lectern there were 38 data types. And this is what needs to be there — and in turn there were 38 data types. In addition to this a lot of work has been done in the last six to eight months or so to identify a standardize quality data element. And this is really the core work that is needed to provide guidance to all of the measures to words and there are dozens of groups that own the various and take responsibility for maintaining the various standardized measures that are used by public and private-sector programs. Quality data element, and this is an example of one that corresponds to the standard element of diagnosis, given the example of diabetes and hear what you see is that there is a quality data type whether its active or inactive diagnosis and it also involves specifying a concept which is the ICD9 in this case and a list used to specify that quality data element. And word is also under way to identify where and how out in the data flow of actual work this information should be captured. Some of them using once again, the example of diabetes, and here we need to know that we need to do this and ICD9 and in addition to that what they are doing is to identify the best source of this information and in this case it’s the clinician and who should be responsible for recording the information and the setting to which it is applicable. And here the example is ambulatory and where one would find this information, what field and in this case it would come from the problem list. There are other examples that you see where we talk about diabetes and a vacation dispensed out — and medication dispensed and the setting is ambulatory and the field is the medication list. Diabetes also involving laboratory results here, the lab device, recorders, the setting is ambulatory and the field is lab results. So really to identify in the data flow over all source recorder setting. Now of what the quality work group has been doing is to start to construct what we call the meaningful used evaluation matrix. And here what you see in the first three columns of are what comes from the policy matrix, 2011 objectives and brief measure descriptions. So we look to see where there are existing NQF endorsed performance measures and many of those are listed here as an example in this particular case. And those measures in great detail with the numerator, denominator, exclusionary list. And then to translate that over into the HITEP Quality data set, data types that will be needed in order to support this. And last but not least the HITSP as well.

Let me take you through a measure, and here we have the percentage of hypertensive patients with blood pressure under control. This is a performance measure that has been used extensively, controlling high blood pressure and the% of patient — percentage of patients and this is owned by the National Committee for Quality assurance. And you see the description of the new leader, adequately controlled, less than 140 and diastolic less than 180 during the measurement year. And all patients greater than 18 years of age with a diagnosis of hypertension within the first six months of the measurement year or any time prior. And this in turn, in order to be able to support this measure, what is needed in the quality data set, data type, we have to have age, hypertension diagnosis, ambulatory encounter, systolic blood pressure results, and the HITSP capability is the Communications document using CDA. And the second would be the prescriptions transmitted to electronically. This particular measure is the adoption of medication and e-prescribing is the title and whether they have adopted a qualified system and the extent of use in the study. The particular steward or owner and is CMS and its base structure measure for whom this is written. In order for this to be retooled and use with electronic help records, essentially the EHRs need to capture and the e-prescribing system needs to be used and reasons for not using e-prescribing and the HITSP capability would be the document using CDA and issue hospital prescriptions. So that is essentially to examples of measures that you’re going to be going through dozens and dozens of measures of the next week or two. The next that would be to identify a complete step of measures and which can be retooled to me time frames and we will have to map them over to the HITEP data types and the HITSP capabilities. And as Jamie indicated there is a lot of collaborative work that needs to be done here and a clear handoff. And the firkins of the group — the focus of the work group will to be where they are at in the retooling process because that needs to take place in parallel. And there are some set of measures that have been retooled and others under development and we are attempting to coronate that work. And probably will have a joint meeting of the two work groups to make sure that we coordinate extensively especially when it comes to the HITSP and the certification criteria and component of this work. I want to acknowledge the contributions of all work group members and in particular Floyd Eisenberg is leading the HITEP work and he did a space share of the work on some of our initial evaluation matrix — he did the lion’s share to up rationalize these concepts so thank you for your contribution.

Thank you for that and we appreciate that. We will start with questions over there.

That was actually a very illuminating overview and I am actually impressed with the degree of organization and thought that has gone into this specification. That being said, it does raise from where I sit — how do I raise this, technical standards perspective — the obvious dissidence for what you are characterizing as data tapes and what you characterize as these quality identified units. With what in my simple head I see EDS data types coming out of state, the template world or the HL7 data type world and perhaps this could be the basis, Jamie, of our interaction with quality. It is all right, how do these HITEP data types as you are calling them really map and correspond with what I think of as the nuts and bolts of EMR specifications like value sets in units of measures and a detailed specifications of how does that data type on bold. Because if you treat them as these large aggregates and these in my mind are very complex entities. That have within them specified data types and components. But I cannot see my way clear from this level of specificity to what I’ve considered to be a clinically interoperable specificity. And I am aware of your connections with HITSP and I have been out of it for in the wild but I may be — for a little while so I may be dated. But it seems regrettable, given that opportunity, I think to give much more detail and much more specific elements that could be perhaps found in a CDA bucket per ton at Copley would be much deeper than that — but hopefully it would be much deeper than that.

There are two types of standards, messaging standards and a persistent document. When you look at the data type you map to both kinds. So when you look at medication, and order would be a transit message and an administration may be a document. The fact that there are multiple constructs within HITSP and Floyd and Jamie and others have worked together over the past year and that our specifications of these mappings. And I think the work that has to be done between these two folks over the course of the next month is that given the nine specific quality measures and the work that you do from HITEP that it does map to both the CDA documents and the mortgage — more granular messages.

Another comment, in response when we get to looking at the detailed work that supports what Janet has just presented in the measures I think you will be impressed with the level of detail and specificity that is in there. And I think it will be some of the work of art work group from a EHR perspective to make a recommendation on what can be, for example, in 2011 versus 2013 and delineate where we see gaps.

And a comment, we have been talking about readiness and we agree that lab transactions today are probably ready, e-prescribing, probably ready. And they use up widespread clinical architecture may be pushing the envelope. So how many of these can be achievable with the lab and typical e-prescribing and the things that are already flowing

Thank you, and the implementation of the matrix is to go from the emerging contact and that concept from a to granular level.

A quick response to Chris and then a question for Janet. I think this dissidents between what a researcher calls a data element and what a computer nerd like me calls a data element is about as profound as what you see when you go to a football game in Dallas or London. And I know a lot of great work is going on systematically, a bridging that gap — bridging that gap. And we looked at the measures that Jamie describes and in the early years we will be looking for at half methods rather than systematic methods which means a lot of detailed specifications. Janet, in your presentation, there was a measure of all of the patients who have had a diagnosis of hypertension at least six months into the year or anytime in the past. And I think as we look at meaningful use criteria for EMRs as opposed to foreign organizations or regions, and what is the issue here with all? And if you look at the stuff in California, the paper defines the population and a patient is in the population for the provider because the payer assigned them to that provider, presumably at the patient’s request and then you have access to patients who are not going to the doctor. And that is what you want with hypertension with a lot of measures. But if you’re measuring me to use of EMR Bi practice is to the patients they have seen or were assigned? And how do we put that definition under their control?

It’s a great question and a bit of the hot button in the quality world as well. And we call it the issue of attribution. Who decides what population they are responsible for? And it goes further as the debate in the quality community because even though that patient may have come in there is a debate about whether or not the provider can and should be held accountable for whether or not there but pressure is under control because some of that is under the control of the individual patient and the treatment program. Soy whole set of issues around attribution and it’s done differently and down for different purposes and objectives. You might have rules in your public be reporting the data or in and getting it in paper performance programs and the need for use in incentives that are associated with it. So I think that has to be an issue that is thought through in terms of how the measures are defined specifically for ARRA. It’s a very important issue and can be done in different ways.

Jim, I know you wanted to comment.

Suggestion/question. Some of the feedback that we have already received is to fold and one is that they should be centered on primary care which is a fair discussion and there has been a couple friends about are there a set of measures that are in. So whether you are primary care or ophthalmologist or research and these are measures that you would have across the board. He could have a class devoted to primary care, surgery, etc. and also you should be mindful of the Medicaid incentives. And whether or not there are measures there is a part of it is and I don’t know how far we can get in the course of the conversations that you are having in addition to the response of the sets that is there is whether there is a subset, that is provider period including the range of Medicare eligible folks and whether — or how far along we are in the specific measures and that may be boiling too much to take on at once but sort of the initial reactions to that stratification.

I think it will take us to the next level in analysis and selection of measures. There are measures clearly that are more neutral and not specific to specific area. Like a patient in Cajuns and understanding their treatment plant and care creation measures or whether you are in a specialty area. And we have also made considerable progress in the last year and a half or two. With measures that are specialty and sub specialty measures and there are two or three that are applicable and to use by CMS and others. So we will have to take a look at it through that lens and there are many measures that are applicable to the full care team. And, indeed, we try very hard for measures to be specified and applied that way especially if you are in a setting where there is a well-defined care team and not just a clinician so some of these are neutral to the specific provider but I think it’s a great point, John. We did not look to it in that alliance. We will have to go through, there are about 500 about 200 in the pipeline so this is a growing area that will evolves. If we cannot give a complete set of measures for 2011, there will be gaps for many specialty and some specialty areas. We clearly can begin to achieve that, though, in the subsequent years.

Terrific dialogue there and I see a couple more columns in the matrix. And I know, I want to stress for all listening today that this is really a set of examples, not definitive. But when you think of quality and measures, think of process measures and things that affect blood pressure or immunization and your point is so well taken and there are measures and the care between environments that in each and the provider types and get other aspects of quality and better court needed health care more broadly. Let’s take a class, and hear from David Macaulay and then we will get to the privacy and security discussion before we get to the second half of the meeting.

Thank you. In the distinction between the message and the document in either case something has to triggered the capture of the event that gets measured. I wonder if you’re leaning toward suppositions on word that occurs and what those truckers — what those triggers would be, would it require transmission to an external system or a HIE for example as the point of capture? It’s important to define what you are capturing first but are you moving towards assumptions on when, where, and how the data will be accumulated?

Certainly there is, yes, quite a bit of work in HITEP to try to think through from who the source, the recorder of the setting in the Pacific field that you signed it in. So if you go back to the earlier example that was given here, you will see as the work progresses taking for example, the medication dispensed a does begin to identify the source — it does begin to identify the source and the actual field so that does address some of their questions.

As a member of HITEP and to your point, it’s not only the metric but the work flow. So at the point is there a trigger and who is the recorder? If you might imagine three different architectures Pee-wee were architectural neutral in HITEP and what would be the EHR or saw for itself has a registry that is capable of reporting on some of the metrics and there is an external registry there is some night the extract that takes place it may not be HIE, it may be local to the organization. And then Number three it could be a registry sitting at a HIE level where there is an export of data elements that goes to a more community oriented registry. But I don’t think we have made any assumptions on which of those three will be used for it and the answer is, why not all? It depends on your circumstance.

Let me thank everyone for a terrific discussion on this and many insights that will be useful to the next iteration of activities and thank you very much, Janet and Floyd Eisenberg and all members of the work group. Dixie and [ Indiscernible ] will present the initial reactions and let me begin by thanking them and has been instructed to me to follow along but it has been reinforced of the point that Jody Daniels has made so effectively that beyond privacy and security, this is also a fuel to ensure the capabilities of everything else that is intended. And I think in that regard, you have made tremendous contributions in the framing. So let me turn to Dixie Baker for your report.

Okay. Thank you. We have had two meetings, to teleconferences. And in the first one, John said your work is different from the other two. And I think here in this today it has reinforced that fact. It is very different but, in fact, security in particular is essential to people actually using these systems in a meaningful way as you guys Arlene out rinceau, thank you, I will give you an update on where we are. We have five steps and right have that we could see some need for improvements in the Policy definition for privacy and security measures for me full use. So we set forth on revealing that matrix itself and I will present some recommendations to you today. Our second step is to map those 2001 measures into specific features and functions in three categories. And this is really where the divergence between our workgroup and the other to begins to become obvious that in some of the security features and functions will be implemented in products that will be certified. And those certified products if they are on going and going to CMS to ask for a reimbursement, I would say, I thought this certified product and that category of features and functions will have been taking care of. But in addition to the securities that is inherent in the products themselves there are also IT infrastructure features and functions that will need to be implemented that the product will assume are in place so we will need to specify that category as well in the category of requirements for the product itself and for the IT infrastructure and the third is the operational environment in which the system will operate. And the third step, once we have set forth those requirements we will map those two standards and certification criteria that will be used to determine whether it’s used meaningfully. And then finally we will recommend the standards and certification criteria. The next several slides, as I am not — oh, okay.

Thank you. I will discuss briefly the recommendations that were made briefly to the matrix itself. This is the matrix that has been handed over to us and on the left-hand column you see the clothes that are set forth in the matrix as it stands were to insure privacy and security protection for confidential if the nation and policies, procedures, and technologies in compliance with applicable law. We thought that specifically directing this goal at confidential information is ignoring the enormous contribution that security makes to the quality of care and to patient safety. Security measures to not just protect confidential information they also protect the integrity of data and the essential services and information. And I will Kirin to you that if we point EHR technology out there — I will guarantee you that if we put the EHR technology out there and they cannot trust that technology to protect the integrity of their data and to be available when they needed, it will fail no matter what we do here in the mean — meaningful use activities so we want to protect care quality and patient safety and population health. And then we want to suggest edit team the second bullet, to make it protect confidential information and EHR services. And also one of our members brought up the fact that transparency of data sharing is important to providers as well. Entities, insurance companies, for example provide information. And they need to know what they do with that information. So our recommendation is to change it to provide transparency of the Data sharing. And the next slide sets forth the objective and they came up with two objectives, compliance with security rules and state laws and the fare data sharing practices and the nationwide privacy and security framework. And we wanted to add to the ARRA provisions and we feel this is essential in order to meet one of the objectives of the personal health — I can remember what it was called — cannot remember what it was called the consumers access to information objective that this earlier in the matrix.

Aniks disclosure.

Yes. We want to make sure that the ARRA provision that electronic health records be made to consumers be incorporated in we would do that by adding ARRA privacy and security provisions. And we want to add for the availability concern, patient safety to insure that EHR and information are available at the point of care. The next slide is a continuation of the objectives. And we recommended two more bullets. One is to enable EHR the above data to be used to minimize privacy risks. And remember the overall goal of the policy committee is to protect the population Health through the implementation of the electronic help record so it’s essential that that element being there. And to insure that that measure is attainable by small practices as well as large hospitals. This will ultimately translate into the standards that we prescribe. Because some of them can be implemented by small practices and others really are more appropriate for large, integrated delivery networks or large hospitals. The next slide is the measures and all of these are for 2011. The policy committee recommended full compliance as the measure, but compliance with HIPAA and if they are under investigation for HIPAA they cannot achieve meaningful use. And First about it was not clear as you know, with ARRA the states can bring the action so we wanted to make it clear who the investigation was under. So we want to insert that its by the HHS Office of Civil rights. And to keep it on hold until they are cleared by the investigating authority and we know that that could take forever. So our recommendation is to put, until a plan has been put in place. Okay. The next page is the security risk assessment. We wanted to make this clear that this is a risk assessment appropriate to the size of the organization and it will vary. And we wanted to add two measures, one to ensure the timely availability of services and information required for safe care proved again addressing the idea of the care unless the services and information are available, this whole undertaking will not be successful. And then finally on the next slide is to provide a non allies and — anonimized data. And HIPAA enables the protective health information with public health but is limited to a limited data set and has to be audited. But public health organizations generally try to anonimize it and take the names out and when they’ve sudonimize it got, and if it’s with an outbreak of disease the hospital is able to relink it. And we felt that they should be included in there, at in the 2011 timeframe so those are our recommendations. And our next step is to specify features and functions required. And I wanted to give you a couple of examples and I think the first one is familiar to you. Products that can be purchased, they say that they bought a certified EHR so I am entitled to the reimbursement. The second is the IT infrastructure. For example, they have to provide identity management to provide the identity to the EHR so that they can control access within it. And secure e-mail might be something else. These are just examples that the environment provides outside the product. And finally we all know that HIPAA requires an enormous numbers number of administrative safeguards as well as physical security safeguards. In order to show their HIPAA, they need to be Standards and Best practices and criteria in that category. And the last slide I provide an example of where you might have the full compliance with HIPAA privacy and security rules and we break it out into features and functions in these three areas and we specify standards starting with the HITSP standards as well as the HIPAA technical notes 900 which is a comprehensive document on security. And this has a lot of standards in the area of security as well as ISO and OASIS. And then translate those into the certification criteria. Any questions?


Let me propose that we have three activities to accomplish and with the transition between the section and the next section. So the first is and I want to outline them and then we will put them into the context of discussion. And thank you for the terrific work. First you proposed a number of amended objectives. Are there any objections to proceed with those as amended by the work group?


More of a question really to the public health one. And in particular, the very specific anomization and the FDA as a public health entity. How does that —

How do we want?

I guess that strikes me as an overly strong recommendation given the exemptions that are provided in HIPAA for the Public Health organization’s.

We are recommending that we include the anomization and sudonimization?


We are not recommending that they use those as operational approaches, we recommend that these environments are capable of doing anomization and sudonimization.

If you are not going to deliver data pathway why require somebody to have the capability to do that?

Use say, if you are required to deliver it in that way?

Let me put that in the form of a question, if that were cabby acted — caveated as required.

Specific entities may want less than the both demographic and in the interests of data being at risk and not having your Social Security number and the sorts of things. But your comment is fair. Depending on the nature of the Organization it may not require sudonimization or anomization.

[ Indiscernible ] in this area.

Two questions on this, one in the same topic, the matrix that the policy committee discussed last week had something similar for measures, objectives and measures in 2013. Are you suggesting that that be moved up to 2011 or are you suggesting that this is a different standard than was put forth in that matrix?

I don’t know what was brought up last week.

All of the materials that we have here, provide summarized data when sufficient to quantify it requests population help services which is similar.

No, that addresses the minimal use but it does not address the capability to sudonimization data. But I would agree, this really points up an example of how the same objective is not equally applicable to small providers for example in they should not be expected to do that but large hospitals probably will.

So then I am wondering if perhaps hearing what Mark is saying if, when necessary, some similar language that when sufficient to satisfying a data request if that could be mimicked in your recommendation to the address that issue.

Yeah, that’s good.

And while I have the floor, one other comment that I want to make on this, in the 2011 measures in this sense the investigation by HHS officers and I understand that your point was to not bring on all of the potential state enforcement actions. My one, and would be striking the Office for Civil Rights centers because they have the authority to enforce HIPAA so you might want to leave it to HHS.

That’s right.

Just legally they do not have the authority.

Good point.

So our perfume is to take the recommendations for meaningful use — our perview is to take the recommendations for the meaningful use and the objectives so that they can be offered in of rationalized — so they can operationalized be and ultimately measured. And this is a good way to transition into the work of the second half today in the privacy and Security Group is a little further ahead in putting together some more specific measures on the table. So if we can accept General concurrence and ask Jody Daniels that it confirms with regulations and taxonomy of all parts. Can we assume consensus around this modification to make them operable and second we will come back after the break and the measures as we say great into the work — as they go into the work and then leave the stage or clarify for that discussion after probably a much needed bio break.

Let’s start with Kevin.

This is in reference to make these operable. I know be have added some different language in here and small practice.

Large hospital and we need to define what is the definition of small practice and where is the cutoff for small. And then in the section about under investigation, we said that the entity is clear by the investigating authority. Who proves that it’s an adequate plan to basically allow them to now be meaningful use? I am trying to work through, to an operable standpoint, we have to be careful in how we implement those and measure them.

Let me speak to your first comment, I meant to mention this when I first brought it up. Because they just mentioned yesterday a bet that, you know, making these objectives appropriate for the size of the organization is not specific to security and privacy, it’s one that we should consider across the board because we don’t want to overburden the small practices. The second comment was, let me see — I live on the west coast.

The plan.

Oh, the plan. I think the Office of Civil Rights or the CMS would be the organization to say that. I don’t think that it would be the meaningful use people, you know, it would be the same entities that are responsible for enforcing security, the security rules and the Office of Civil Rights, it would still belong to them to make that determination.

The point is well taken, the term to employ the specification of size or processed need to be defined in operational terms down to all who outlined when, where, etc. and break points, yes.


This is along the same lines. But more of a question. If it does not say a big group versus small or what is an appropriate level of diligence for the appropriate size organization. All it really does is says that an auditor or someone’s finding has the ability to take the size into account. Do we expect to actually creates — I’m envisioning that a one or two doctors practice probably by is a form at the medical supply store and checks off things. Do we in addition an entity that is responsible for creating that form? How do we get from the general notion of scale ability in HIPAA and to say that this qualifies as meaningful use.

That is one of my pick topics that I would like to discuss. Especially with respect to HIPAA. In many cases they will have been HIPAA compliant. But suppose there’s an organization were the first electronic system they had, do we want to take on the whole of HIPAA compliance under this umbrella of meaningful use? I think that is worthy of discussion.

That is something we can engineer before the break and something we will have to comment on and I don’t know, Judy Daniels, do you want to offer any guidance how the work group can best address that in a way that is constructive.

Yeah, we have had a couple of these conversations and I think it will have to be something as we discussed more as we get into the specifics. I agree with the point that trying to take, or outline all of the requirements for HIPAA requirements in a meaningful use context would be challenging. And perhaps to put a tip from our other enforcement activities and abilities — and perhaps repetitive from our other enforcement activities and abilities. I think this was helpful, there are two steps for the incentive payments. Bursts’ that we have certified products that meet specific criteria and then second that the doctor is the meaningful user of that product so I see this group focusing primarily although — focusing on the standards and certification criteria that we need to make sure that are built into the product so that they have the capabilities that folks believe are necessary for these products. In privacy and security its if little bit muddier, as HITSP has articulated, having a standard does not mean somebody is implementing that and that it secure. You could have the technical capability but if you are giving everybody the same user name and password in the organization, you don’t have appropriate security in place. So when we have spoken it seems to me in this area there may be some standards for the environment and operations that need to also be identified to make sure that, in fact, we have meaningful users of secure products.

There are ways to do that, there are standards in plenty of them out there. But when my three physician practices walks in the door and say, I bought a EHR and am using its meaningfully, what will we require them to provide to show not only did they provide this product but they using it meaningfully in a secure environment. How much are we going to demand of them, I you know?

That is where we could use your input. Clearly we will not walk through every single part of the HIPAA rule and document that for purposes of meaningful use. We still have HIPAA and that approach. What would be helpful to know is what are the key areas that a health-care provider adopt a certified product should be doing to demonstrate meaningful use and that it’s a secure system that they are meaningfully using. And sort of the top five things that we should be looking at with respect to tying it to the incentive payments. That would be helpful to know. And a PC with the policy committee did, they struggled with this — And if you see what the policy committee did they struggled with this. So any input from your expertise into that would be helpful at this point. I think it has to be something short of all of the specific elements and we have a regulation that does that. And whether the things that a physician in a small practice would need to show that they are using an electronic health record in a safe way.

This is a useful dialogue with the measures themselves into drive purpose at the same time not to be so encumbered by replicating every other aspect of policy and law that exists. We will come back to that. Steve Finley —

I know you want to take a break, but very briefly, I know this is a critical issue. I take your challenge that we have to do some thinking around it very concrete week and working with you in the iterative process. And get a better sense of best practices and worst practices out there. So that we are fully informed and the work groups so we can bring that to the committee. Because I think it’s probably a very feeble environment of there with what is actually going on and Kaiser and others do it well and others who bought EHRs and it’s terrible practices. So we need some incentive on that. Thanks.

Great. Great comment.

Terrific first half and I see that it will be a very interesting second half of the meeting. For a meaningful information, there are two ladies room to the left and the men’s room is up the stairs, to the elevator, and to your right. Its 11:45 — let’s come back at 10:45 a.m.. Thanks. Good work.

Event on break until 11:45 a.m. Eastern time.

Let’s go ahead and take our seats again and get started.

If we could encourage our colleagues to come back in and take our seats.

Okay. Before we get on to the discussion, very practical order, I hope everyone has had the opportunity to read you the minutes and I want to thank the National Corporation Naders office for a terrific capturing of the minutes and if anybody has any corrections, amendment or implications for the minutes.

Jody Daniels we will declare consensus on that and thank you — hearing none, we will declare consensus on that and John will be coming back momentarily and lead to the next part of the discussion. I think this morning’s discussion was terrific. The work done by the work group was incredible and we have greater clarity with the delivery of the document on the meaningful use. And I think this morning’s discussion has been helpful in creating new synergies between the work groups. It reminds me of another one from Yogi Berra, in theory, theory and practice of the same and in practice they are not and I think Kevin’s point about what is adequate and what is adequate practically for creating the intractability that I think all of us are passionate about in terms of the meaningful use and the consequences of EHR. So that is a safe way to this next section. We will extend to this morning’s conversation to identify gaps and for their works and some measures in a general sense. And I feel incredibly privileged to sit with a subject matter expert, John, and ask him to be best to that discussion I want to offer one note in the agenda. We are scheduled to go until 1:00, and at 1245 are want to make sure that there is adequate time for comment. And we have a work plan for milestones for deliverables that is scheduled for 30 minutes and we will be to for ten minutes and I think it’s pretty evident that our next meeting is July 21st and in the interim they will go together to work on the consequences of this discussion in continuing activities in light of the ample use. So much will be predicate did on that time table in the interim. So I don’t think they need to protract on that part of the discussion. So just doing a time check that takes us to about 12:35 p.m. and it looks like that with the discussion.

I want to make sure that the work groups are on the right the trajectory and you saw some of the threads of work and our task is to identify those standards from HITSP and implementation guide writers that described meaningful use and some of those gaps and we will great deploy ability to the extent that we can discuss what readiness deployability and hopefully in the next couple days have the matrix for what clinical quality will to solve their marching orders are clear. If that is the nature of the trajectory of the work, taking the individual standards in making sure that it’s divided between all of the groups to make sure it’s done by July 21st. Were there some comments on that? I am seeing some shaking heads. So Jamie, Avenue have begun work and has involved many people, not just Jamie — as you have begun work and try to pick those standards that have been accepted, recognized, harmonized or generally in use what has been your impression? Where have you seen some serious issues or caps that we as the committee should think through?

I think from my own part in the clinical operations work group is to start looking at the list of available standards from HITSP from that clinical operations perspective. And where there are measures for computerized position Order entry there are a lot of standards that HITSP has not specified. So those are obviously some key gaps that we will have to deal with. And then also dealing with some of the measures around specific education and also around HITSP that has not dealt with those and there are some standards in that area that we have started discussing that we may start to consider so there are other sources and standards that have not been in HITSP but those are some of the key areas where we are seeing gaps so far.

A couple comments and let’s open it up to your comments, what HITSP is charged with is transactions between organization, not within side and organization. So to the point of what are the standards that you would use for CPOE, it’s a set of functions and might that be a certification criteria question instead of a standard question. And there are a lot of activities stated both on objectives and measures that are in a little bit challenging to standardize. So if every patient should be and given an electronic copy of their record this that required it is it a PDF, a thumb drive, on a PHR? Is it up to us or is it up to us to define what that means or any of the above are fine. And I think there may be some other gaps and all e-prescribing, and lab ordering has a standard. Is that will harmonized? Is that a gap that you see?

I put that in the orders, the category of orders there are certain clinical lab orders and that is one of the key areas that we will have to look at as a potential gap.

One final comment, and if you look at the meeting please use my checks it would be such things as what is the percentage of orders that are in electronic — that are ordered electronically and how does one know the ones that were not ordered electronically? And as John and David both said in 2011 this may be self report instead of an electronic measure of not electronic performance.

I think a couple potential thoughts on guidance here. I would not feel the need to take each objective and map it to a standard. I think the standards are fundamentally oriented to the exchange of data between organizations to capture and report quality measures and it’s important. But it’s not oriented that way to the effect that there is no standard like to it — Link to wait and I think every objective has to have a standard. So what can we find on this and that and the other word that might not be the intent of the legislation or health care agenda. And it is involving an exchange of some form here and we don’t have a standard and we are not so sure about our ability to have a category two if the industry goes without so to speak between now and 2013, how problematic is that? And that may not give you a standard. And we might be in the position to think, what is a compensating setup approaches here? So not necessarily all bullets but where there is an exchange of reporting quality data and those that are consequential and we agree that the there are still gaps and this would not be done anyway even if you declare it would be to think through some approaches. And what should I do? What are some options? And regarding the measures there is a priority with the new rate for an denominator are challenged — new reader and denominator are challenged and identifying a diabetic as the denominator is a problem. And there are issues that we do not have solved yet and may not be solved in 2013. Nonetheless one can say that, I realize that there are issues here but one of the Court points particularly in 2011 that the organization reports would solve this kind of data. Because the challenge to CMS will be to receive all of this and it may not be able to. So the fact that you’re looking at them and engaging in discussions on how to improve that. So there will be lots of imperfections and rather than try to fix all of the imperfections between now and 2011 with to identify that which we can and cannot. And maybe some guidance that we can give to the industry while we sort through for greater clarity on some of these.

One comment in relation to the caps that I have mentioned, we start with the selection of the standards that have already been recognized by the Secretary and then looking for the gaps that are related to that the. And when talking about the lack ordered Standard for example there is a lab result standard that has been resolved by the secretary. There are plenty of lab orders standards that are out there but not one that’s exactly matches the recognized result standards.

Mark, you have a comment?

Unfortunately, I too. And I wish David were here for this part of the discussion because this is the meaty part of things and, of course, HITSP does not write standards and I hear a lot of HITSP standard statements and we know that is not correct. They do a lot of good work but they do not develop standards. I am surprised about the observation — I think I heard it suggested that the HITSP recommended standards are deplorable. And I don’t think I agree with that. I think they are at best category two and three. I think there are some things that could be category one things buried in there but they are not a very well-developed. And whenever you want to pick, the transport mechanisms that are discussed, for better or worse, the HIN prototype work and very difficult at best to deploy it among organizations. And probably not, with the criteria that we talked about before, be used and in the plant and so on. That to me does not meet those criteria to be a category one. So I do not agree that there are very many. I think there are a few but not terribly well developed category one things. The second observation related to this and I am having, frankly, trouble getting my head around the overall process and I shared some of my personal progress with John is today and I think part of my challenge and maybe you can health me, and on the principle that there is no questions, but maybe this is a dumb question and I don’t get it but it’s easier to think about it the focus is on the data and the patients that that represents and I heard Jody Daniels talk about standards for the EHR. And I have trouble thinking through it when I think about it but this is a system environment in care and some of the things that Jim talked about with labs and radiology centers they are not subject and do not benefit from ARRA incentives. But yet we are counting on them to do that. And I am not sure that David’s argument that this is a new world and we have incentives, but they do not. Maybe because their customers will demand it and that will be a helpful thing. But at least for me when we think about some of these discussions in the form of what has to happen to the data, the clinical workflow group and the key capture and the other key part if you look at ending the kerb curve diagram that Paul Tang had in the first set about capturing data. And it’s not just about picking the standards and implementing the standards. You have to do some of that heavy lifting and it does not matter what standards are on the right-hand side whether its its or something else but to take us from where we are today and something that we can do to receive it and frankly some of the stuff that Jim was talking about, the pharmacy system that receives that, it’s not in the workflow of the pharmacy so that it gets stuck somewhere. And the polls and the things that David talked about and trying to achieve simply don’t happen in the last thing, this is a long winded comments but I have to leave early. One of the things that we have to be sensitive it is the in elasticity of our system. We can polecat it in various ways. But there are tremendous forces — we can poke at it in various ways. And I think we have to be careful not to fool ourselves as we’re having these discussions just because there’s something that could work and have been demonstrated to work, I think that brings me back to say I would rather be narrower and I don’t want to set the bar to go and John use the faced — phase, making the industry sweat and I am worried that we have such a broad agenda. We can dream all we want but this is not easy stuff to move forward. And like any other good leader, I hope that our secretary and national coordinator will focus their efforts on these fundamental things and I think the policy group had it right, capturing the data and health us move down the road but we are way beyond that. So other than that I have nothing to say.

Hey, great comment.

John, did you want to respond?

Well, I am leaving —

Truthfully, I have seen as you are speaking the cards blossom on the table. But let’s agree that there is a sense of the magnitude of this challenge. It’s extraordinary and that is resident from the vendor and provider community and patients and privacy and security. So here is what I will ask, let’s agree and stipulate that general concept. And with the flourish of cards that went up, let’s stipulate to your point, let’s be practical, it will involve incredible change and there may be elements that are not incentivized and there is a certain degree of inelasticity, and let’s stipulate to all of happen and what I would ask is that we frame this these next questions and what can we do to this purview of the community and remember David said to not try to boil the ocean, and what ways we can make this practical. To attach reasonable standards to objectives that are prepared for the time and in a general sense met with effort. With an appropriate effort to achieving certain markers of achieving health care in 2011, 2013, 2015. So I could just ask that we stipulate that these things are real but lets channel it into how we surmount those challenges in the context and comments.

And I think all of Mark’s comments are well taken and what will we stipulate when? And as we know in a perfect world with any standard and enough money and enough time we can get it done but what can we get done by 2011 and what is the person many of standards. Here’s the lab and the e-prescribing and based on clinical summary. And this is the kind of thinking, what can we achieve given the state of our industry as we know it today.

Let me start with the forest. Yes, go ahead.

This question was for David but I will ask it for their group that the means. It gets back to the point that he was trying to meet and stretching the goal. I think the great team and taxonomy that was presented earlier round standards is good and he was leaning toward to get us to stretch out and we need to be clear on what we’re doing at the base period and be clear about what we can accomplish if we start stretching grade one or whatever taxonomy you use into something that is more theoretical or not achievable, clearly in 2011I would be concerned that we are going to end up with the concerns that Mark had and promoting those kind of standards. So for the time off for the time being so we’re not dealing with David’s questions about how fast we can do it but clearly what is the grade first and a second step that focuses in on time that would make a specific process.

Rather than just bearing in, pushing it into grade one and having the second conversation so that is one and the second gets to Mark’s other point and I don’t want to focus on the gross challenges but I want to come back to what is not coming explicitly of the standards. So I believe we will get something that says we should be looking for a standard system to implement that we are doing meaningful use. And I think we will get a clear description of what clinical operations really means. But these comments about what is now on the list, I think should also be captured. So just the experience of having implemented laboratory interoperability in the state of Florida, Ohio, and Nevada. Three totally different experiences and the vendor on the other side was exactly the same. So as to start to think about what is deployable vs. deployed means that is an important part of achieving the goal we want in terms of interoperability and True meaningful use adoptions. So although we cannot certify those offenders and getting those issues on a sheet of paper where people can see them will be important because small practitioners, two or three physician office practices do not have the technical wherewithal to understand those issues. And if we don’t help guide them, they should be making a different decision than the one they might make.

Very good comment. So the idea of actually separating the grade and taxonomy and come to the committee and saying, what do you think? And you may want to advance a grade 228-2011 deadline if we think that is a reasonable going — to a 2011 deadline and the various players, even that might be a stretch, Wall said.

Kevin? Not — my comments will be very short. It really is going to be short. One of the major standards gaps and when you go back to e-prescribing. I think we as an industry and they are on version ten of the implementation Guide that has been deployed so far. And as we consider and think through with the major gaps in standards — is one thing to identify the standards. And if we do not come up with a way to create that implementation guide on how to implement that standard, there is that major gap of making that standards deployable is a very large.

Don’t worry, my comments will not be that long and take HIPAA for example, coal implement HIPAA and here is 4010 and that is great but unfortunately they implemented differently, and they got us to connectivity quite rapidly. And it’s very true that we need the constraints to achieve as much plug and play interoperability as we can.

So when there base standard, that would be better.

I will try to minimize my piling on, on the negative here, but should note my — bottom and left, but — [laughing] it’s not focusing on the positive, so much as really taking the recognized challenges and thinking how to work through them, to something practice cable for —

As a comment, I thought, I think Jamie is one of the most hard working and brilliant, not about him, but category one was really two categories. The difficulty of the presentation, that portion of category one which is broadly implemented, I think you will find it’s limited, the reason is that there has been a multi-year effort that provided enough value that people went to the trouble to get certified by a certifying operator of the interoperability mechanism. You can look at pockets in the United States, generally anything being done in Massachusetts is a good example of what you might be able to do in California 10 years later. I think you can look at Indianapolis, wonderful town for interoperability. But when we look at meaningful use criteria, we are being asked to say what will either get a physician in every county in the country, paid or not paid this incentive money, or a hospital, for meaningful use, and pockets of implementation then are, in my mind, sort of the second of the categories in second sub-parts of category 1. It’s not a very hopeful statement.

I think that we very much need to consider this issue I raised earlier of are we just incenting people to get EMRs, using interoperability as a way to measure indirectly a proxy for going in seeing how many times they reduced orders, or really trying to create an incentive that incents people to beat up their vendors, get interoperability to heat up labs, do the things it takes in the ecosystem to actually get interoperability. How we come down on that issue will be a strong point. I suspect that even if we take a very proactive effort, using the incentive as an incentive to work through the ecosystem problems around interoperability, we will still find that a very good strategy would be self — what’s the right term? Self-certification essentially. Yes, I am getting [indiscernible] results from somebody, in 2011. Maybe in 2013 I am doing it by this standard, but I really don’t care, but I think if we just focus on of it’s working somewhere in 2011, and then — attacking the eco issues up front.

This is exactly the [indiscernible] of the committee. How, based on your experience, are you genetic going to evaluate if somebody is ready for primetime.

Thank you, Jim Walker. I think we have a mental model where this is a linear process in 2011, and 2013, 2015, a linear progression. It occurred to me there’s probably a lot of people in this room who have actually never seen an implementation go, and the fact is that what you see is the beginning is very hard. Having tried it a number of ways, we found that if we give people very, very simple things to learn that fit their existing mental models, fit their existing work patterns, sense of who they are, what they do, providing people back when this mattered, e-mail, and providing them labs they can look at, don’t have to do anything, available to look at, much faster than finding somewhere in some pile of paper, it starts slow, but once people start to get the first sense of the benefits they can achieve, getting lab results, knowing you have seen all of them, fast, radiology images which before were lost, you spend an hour every day you round on patients trying to find films to look at. When people get the small wins, then what happens fairly rapidly is they start to say, well, you know, you could be giving me this in a better format, and why can’t we communicate with those other people across town, and why can’t I send a message to my patient, they tell me what their is, and we don’t have to drag them back in here every time. Increase what’s available, change processes and really transform healthcare. Thinking about this, and I love Martin’s idea, categorize it first, then talk about dates. But we want to remember if we can get people hooked, give them a positive and productive experience at the get-go, the sky really is the limit, and we will be able to move faster and faster with more and more functionality, more and more quality, more and more interoperability, partly because they will be driving it.

Very good point. Some have said, for example, if you create a simple standard for exchange of data, from place to place securely with authorization, authentication, transferring the stuff is the easy part. It will accelerate —

Good point.


It occurred to me that the easiest way to get individual providers, small providers, to adopt EHR quickly is to get them to sign for service. Software as a service instead of going buying, putting it in. I had Doug bring up the [indiscernible] adoption of EHI doesn’t say reimbursing for purchase of EHR. I was wondering maybe whether entry is to target a lot of software as service solutions instead of strictly buying, purchasing EHRs.

I think our challenge is that at least the way David defines [indiscernible] meaningful use, we have to be agnostic, service, package, home-built, et cetera. I agree with you, software as a service is good, it’s what I do, but it will be highly heterogenous throughout the country. Some people may have iPhones, with apps, clinical quality reporting, data exchange. Some people may have $50 million full-blown — others use web-based.

Can’t you certify the service?

Not to pile on, standards, we want to theoretically support not only adoption, obvious; but we don’t want to suppress innovation. I am hopeful there are things we can’t conceive of today that will simplify, provide the service, and may be application service provider model or things we have not in the envisioned to support the concept. That’s where the policy committee that’s giving guidance of the intent, standards have to support what’s do-able, the reference of what’s known, anticipating, and not suppressing for what may be possible. Your point is very well taken in that regard.

One is, we ought to be agnostic on how, realizing there are models that might be much more effective for the small provider, because there’s less hassle, variety of other things. To go back to the core, and I have my own form of dealing with this back in Boston. Say 2011 in the industry, the lab transaction, everybody ought to be using these standards regarding lab, et cetera. You say jeez, you could take a bunch of providers, expect large providers to be at 100% in labs, Martin, you are — that isn’t real because of the lack of implementation guides, other stuff out there. What isn’t acceptable either, where we are today, two years from now. If you had to phrase the standards in light of AKA, equivalent of 30%, how would you phrase or express the standard realizing 100% may not be real but there’s intermediate ground causing the sweat to occur, not force people into untenable situations, across work groups, the same on Jamie’s terrain as the other terrains we are talking about. Focusing on those, but having a sense of movement that isn’t complete in 2011.

Actually, I want to say two things, come back to Wes’ comment, and other comments made about the taxonomy, what’s deployed versus what’s deployable. The taxonomy proposed does not mention what has been deployed, only what’s deployable, following the direction Dr. Blumen that will gave earlier, setting stretch goals, moving things forward, so — that could be categorized as deployable. If we want to add a category 0, that could be done, would be the slam-dunk [indiscernible], could certainly add that kind of category. Switching gears now, and John, to your point just now about what percentage should the threshold be set at for declaration of success, one of the concepts I have heard is one whereby there wouldn’t necessarily be a single definition of success on an individual measure basis, but aggregated across multiple measures of different kinds, so if you happened to implement whether it was prescription orders, if you have a limited capability to implement in a particular time frame you might implement one capability first, another sequentially, so aggregated over multiple kinds of measures you achieve an average score of 50%, 70%, whatever it is, might be zero in something you hadn’t done yet.

Another way we have done standardization, sometimes you can’t get a single, instead of 20, you get to two, ideally we will get to one. Do it this way or that way, but three years from now it’s one way, that way you get people sweating and on the trajectory.

We have only a couple minutes left for this part of the discussion.

If you think about 38%, we need a performance standard saying lab — shall provide lab results in accordance with this implementation guide. Then we would be in business.

Right on that?



I wanted to make sure we covered clinical quality, as well as comments on private as, security. The group is going to first make sure we divide the work between clinical operation and clinical quality, and Chris and I were chatting at the break about, I can tell you, working on [indiscernible] it is not the notion of the NQF to invent standards, code sets, they are going to point to other clinical operational activities. That is absolutely the intent. That’s a body of work we’re going to do.

Then there’s going to be the how do we take all the issues specified, in meaningful use, put nomenclature, qualified, data types, then pointing back to other existent standards. If that’s a trajectory, did that seem reasonable to folks?

Comments on that?

Okay. No comments, but Janet, from your work thus far did you see major gaps? I know you and Floyd together have worked together to identify where you feel there may be gaps in data types.

I know some Florida identified were structural measures, have to be personal [indiscernible] don’t have measures currently de developed. One concern I will look into more deeply after this meeting, the pace at which the measures we saw can actually be re-tooled, the measures can be respecified using the high tap data types, so we have those ready as well. That needs to be moving in parallel with this other, need to be ready for implementation in 2011 too, that’s a sizable piece of work that has to be done.

Clearly, some of those metrics stated in non-EHR terms, have to be recast.


Yes, as you’ve said. Clearly, what will be done by that work group is identify whether objectives, measures, where there are gaps to be filled. There’s been a lot of work done over the last two years, talked about earlier, on capturing what data when, by whom. That kind of detail can also be leverage leveraged.

Privacy and security, we will look at IT infrastructure, best practices, the privacy and security elements necessary to support the product, and operational best practices. Based on those three constructs, was there any comment, seem like three reasonable constructs to approach?

Okay. So well, Dixie based on your work thus far, based on gaps, issues you have seen —

Haven’t really gotten into discussing the standards that are available, but in terms of security standards, the HIPAA requirements for security are what most companies who cared about security did 15 years ago. There are plenty of standards in security. In terms of the certification, C PH IT certification, my personal opinion is there are short falls in assurances, but not functionality. In my experience, the most — fuferghtest out on consent categories is privacy authorization as well as consent, just starting to get standards.

To the point of the deployability, you look at are there good encryption — absolutely Reasonable authentication standards, some with regard to role access base rolled? Some, but patient consent, they are just emerging. That may be something that is —

Even the policy is just emerging.

Right. We can have a unified national policy for the way consent is done, much easier. Okay — supportive today, this is great.

[indiscernible] so it’s an interesting problem, and lots of — the research community is interested in it, as well as the provider community, public health, so it’s a good topic.

We have broad agreement then, on the three work groups charged. We will turn in a moment to the actual getting to the deliverable by August 12. ONC, Aura, provided us with an interesting function. We have to take Mark’s comments seriously. That is, it’s a challenging industry, the standards aren’t perfect, we don’t have enough resources, the ecosystem is complicated, yet we are being forced to say something by August 1. You guys should say, it’s just too complicated, let’s send faxes for another five years, meaningful use, good luck. Our charge is to really take this careful look, and look at the fact that, yes, E-prescribing in ubiquitous, lab, may not be perfect but there’s a pretty clear trajectory on how we can get beyond where we are today. Other issues, like clinical summaries, very much a work in process, but as folks have heard before, even if it is not semantically interoperability, but a piece of text from a provider to a specialist to understand why the patient was there that would be better than we have today. I encourage us over the next month, take all of Mark’s comments seriously, your experience in implementation and then ask what really can we achieve, but let’s be a little aggressive, let’s cause a little sweat, into the best job we can for the small provider, large provider, recognizing it’s a journey.

Notice Now, the work ahead.

Back to you for the woo —

I sound Pollyanna-ish, but the irony is, from individuals who are parts of large systems, implemented these technologies, understanding some of the pratfalls, complexity, philosophy necessary, our work today, we try to be value neutral in doing this. Somewhat scientifically and reductionistically, map standards to — realize, the value of today’s discussion. Frankly, we cannot, in the context of this large a group, go through all the standards each of the work groups have been identified, and in a sense, you can telegraph the next section of that calendaring, will be each group will have to triangulate with each other, based largely on the most granular are items in clinical operations, can they be aggregated or quality concepts be friends in a technically reductionist manner to create a viable — and on top of that, change measure specification over time, as measures evolve, and similar in the privacy community, I think the discussion was extraordinarily helpful, and robust. We have to drive the intended consequence, which is secure and authenticate and private communication of information, but not constrain it by trying to replicate everything other, as mentioned earlier, statute and regulation and good practice has already specified.

I see an issue, you have a comment you want — you are welcome, your comment at this juncture.

I wanted to say briefly to applaud the work of the committee co-chairs, getting pretty far along the path here. Also want to do a firm that the White House wants to be supportive as possible in items that are practicable and — Linda and Nancy are here, clinical transformation, new methodologist, life on the ground, I don’t think they would be — to say how these ideas we work on over the next weeks start gel with live on the ground — we have resources, ARA, other aspects of the federal government all available will, willing to be supportive to this group as possible to achieve the goals in a very short period of time.

I appreciate that. And certainly I appreciate they have already proven to be great resources. That will definitely be taken note of during the accelerated work of the next month before we reconvene for a meeting.

So, having established that our goal is — sorry, go ahead.

I want to add the National Institute of standard and technology is in line with the others and willing to help where we can.

Absolutely. I introduced three new members before you were able to join, terrific resources that are pretty well-known to the group. Okay, so we established — let’s go back to the first principles. Someone phrased it at the beginning, they feel like we are on — bit of a metaphor, on the verge of a climate change, from a world that has been paper based to a world that will ultimately be electronic. Jim Walker’s points were well-taken. It’s not entirely — the hardest work is at the out set. We are not trying to come up with a framing that is rational, think about our colleagues in LNC. They are there, there’s a very clear governmental intent to drive improvement in healthcare. If we operate too slowly, we will never make the mandate, get to things I am frankly growing tired of, we want health information that is transportable. If we are too am ambitious, aspirational. However life — it’s not achievable, you have lost traction with all the elements that have to be specified. Tremendous work has been done introducing taxonomy shared, then today there have been some terrific discussion that said there are super veining characters, employability, achievability, and the implications for ecosystem. They are elements directly insented, others that are not, business rationale, or not, may be simply emergent from the incentives applied in certain quarters.

So, we have to now go back to our work groups, triangulate amongst the three. The clinical congratulations, John, Jamie, I will ask a series of three questions. Do you feel from today’s discussion you have a sense of the group, in operational terms, to provide another cut into the taxonomy that helps to define a trajectory that starts in a manner that is realistic, yet ambitious? Not demoralizing, but purposely ambitious, against the map to 2011, much more concrete or practical terms.

We will have two work group calls, thousands of e-mails in the next 30 days, I feel we can take the matrix, fill out with capabilities, standards, the notion of deployability, have that by the 21st of July for the full committee to review.

Great. Okay.

Let’s go to Janet. We had discussion, appreciate all the terrific work, you showed the concept of the matrix. There was the concept we have two different sets of standards, for the measures, much more emergent, and we have ri reductionistic data elements, super imposition of different communities, providers, physician specific, as well as other providers, and ambitious that aren’t just a measure of how much got done, but how something was communicated. Speaking for Floyd, so you have connectivity to clinical operations to provide that next iteration, working with Paul, [indiscernible] et cetera,

We certainly in the next week can go back in, take a look at the available measures to address the issues around whether we have adequate measures for specialty areas, ones that across all types of providers and settings, and also think about whether we can have a classification, definition of the levels of analysis, the issue came up in the context of Dixie’s presentation about the definition of hospital versus clinician versus small practice setting. Should be the same set of issues where the quality measures apply. We will go back, take a look at available measures to address different types of provider settings, and levels and units of analysis. I think what then we have to do quickly is to meet jointly with Jamie’s group, because there’s clearly, once we get the measures laid out, we bleed right over into the area of [indiscernible] standards.

Terrific. This is a perfect time to take note of an issue offered, there’s a great deal of technical expertise among the committee, certainly, welcome in terms of [indiscernible]

Okay. Let’s go to Dixie next. I appreciate you and [indiscernible] terrific report, we are fortunate to have Jodie Daniel’s expertise. Do you have [indiscernible] from the discussion today that, to come back, map to the objectives, measures, again, that sort of ascending slope, 2011 and on, that encourages adoption, but also assures the responsibilities that facilitate adoption.

Yeah, I think getting some clarity on how we really interpret this requirement of comply with HIPAA, and our freedom to really constrain the applicability to meaningful use is, in my mind that’s the next thing we need to do, how we want to break that out, what really should be part of our certification criteria and standards.


Yeah, I am going to rewrite HIPAA and give you a new version, I think we will all be thrilled with that. [Laughing]

To the point, do we get to the level of authorization authentication, role based access control, consent auditing, standards necessary insured for those, this will be some of the work of the group. We will have two phone calls for each group, most are scheduled, still some scheduling to do. Some cross-work group calls that will be held and to the extent we can have early deliverables to circulate for comment, get them all back by the 21st, we will make you guys, at least by July 21, give you a set of deliverables that are reasonably grounded.

That adjective reasonably, I look forward to that.

Clearly grounded.

We are not allowed to use the word meaningfully anymore.

The task ahead, I know feels very overwhelming. When meaningful use hasn’t be specified, some trajectories, we triangulated, some refinement, philosophy, fill matrix, but we can come up with — accelerating —

Let me invite John [indiscernible] to move to public comments —

First, thank you, you and your teams for the work you have done. You had a week at this, given what was done in the last seven days. I I great expectation of the next 28 days. A lot of progress in an exceptionally short time, due to hard work, focus and expertise. Nicely done.

My guidance to you would be on focus for 2011 standards and criteria, one ought to reasonable expect to be broad, set the industry well on its way. We can get stuck on the how far does it actually have to be, 100%? Won’t be at 100% in aggregate or specifics. That will be that far along, but separate the threshold from where the broad statement we have reason to believe the standards are well-defined, happen to be, that we should expect broad adoption of, or substantive, or meaningful use by the year 2011, work, implementation guides, further product development, et cetera, if we hold out, it has to 100% on this, we will back away, to something safe to do, too likely, won’t cause the sweating we have to do. There needs to be, obviously in this area and in the feedback from meaningful use, a calibration of what will cause the sweat, at the same time will cause the industry — because this is a volunteer program at the end of the day. Nobody has to take the money, can decide it’s not worth it. Walk away. That’s not the reaction we want. Put aside the measurement, percentages, focus on — pushing it. We ought to be able to get this done, it’s also the reality, it’s hard to push forward, broad place, standards not agreed on if the products are not there, variety of other things, real limits to what the industry can get done. I want to set to the side the threshold conversation so it doesn’t cause United us to inappropriately back down — aggregate and specifics, and still accomplish the — again, really nice work, looking forward to the conversations.

John H?

I think the next 28 days will be a marathon, but emphasize good communication among all of us. I am convinced — the process put in place is really quite sound and that’s the most important thing for today.

As we go — thank you both for those comments. As we go to the public comments, let me add my thanks to each of you. The work, effectiveness, extraordinary as I have ever seen from any group. I think the work ahead is ambitious, but I also am optimistic on the basis of what you have already done and the members of your work groups. Then we can come back with that. John G gives good council in terms of think being about what’s deploy believe, the conversation of percentages of achievement is for someone else, will divert — the standards, in support of — drive meaningful use implies.

With that, let us close this portion, come to our public comment, and we will ask each individual to please state your name, limit comment to two minutes

We will try to cut back and forth for anyone who — we will start in the room.

What the committee is doing, I wanted to make a comment about something pretty obvious to you, that if you are talking about a standard not only deployable, has been deployed worldwide, as the Dicom standard, that is accepted by thousands of hospitals, 100% of the big hospitals in this country, the adoption rate in the smaller hospitals is increasing all the time.

Your name and organization?

Richard eaton from the medical imaging and technology alliance. I would urge you to give that very strong consideration, as one of the deployable, deployed standards, our members can certainly be of great aid to you in the next month as you talk about implementation guidances, I think we can be of a lot of help to you, if you need our input.

One observation I want to make, I am a little confused about, get a clarification, that in looking at the materials today, those from the clinical operation to work group seem to state that radiology functionality reports are fairly much pushed into the foreground as far as when they will be implemented. I may have that wrong, so anybody can clarify that, I would appreciate. There seems to be a disconnect between that and the first draft recommendations of the hit policy committee in which it appears that implementation of radiology information is pushed back to 2015.

So there seems to be a conflict between those two. Given that Dicom is a deployable standard, is deployed, is adopted and medical imaging is a key part of the medical record, it would seem to me not logical to push this off into 2015 meaningful use is certainly not a complete concept without imaging information. If anybody can clarify that for me, I would appreciate it. Thank you.

One response to that is, looking at the meaningful use matrix, multimed ra, IE, x-rays are listed as a 2015 exchange criteria. We will certainly take guidance from policy committee —

The best way to do that, move forward or later, be sure the comment process for meaningful use, not really in the purview of this group to move stuff around, it’s the policy committee. There’s a comment process, you can know what that is if you are not aware, the best way to get in comments about moving stuff between — laid out.



Dan Road, American healthcare management association. Your conversation is extremely exciting, those of you who are members, my colleagues know how excited we are to see the standards, quality measurement, privacy and security. The one thing I would ask you to keep in mind that came up in the last meeting, we also have the implementation of the HIPAA standards, and ICD 10 changes in 2011, and 2013. If those can be integrated as you look at the changes and suggestions we are going to be making it would be greatly appreciated. Too often we look at one set, oh, and forget the other pieces. I think it will be extremely important as we look at the value of data, how we will use the data by 2015, that all are incorporated so users and providers and payers can recognize all these things are moving forward at the same time, not in isolated silos.

To the point Jim has made, Marty, John and I live in every day, life as a CIO is fraught with far more demand than supply. To say we will implement — and, and lab and E-prescribing, and clinical summary exchange, all has to be done simultaneously, would be a challenge. We should certainly think about that as we think about deployability questions. Gary?

Gary E. Dickersoner son, consultant representing [indiscernible] health. In terms of standards gaps, the biggest gap I perceive is the whole issue of electronic health records. The standards coming forward, majority of standards, interchange standards are focused on point to point interface or interchange with transient — talking about electronic lelgt health records we need to talk about persistence, audittability, doesn’t seem to be a topic coming forward, if we expect people will trust what we produce, use it in a trusted way, patients, providers, those subject to records, recipients, able to trust what we get so we can use it beneficially, practice have to have this end-to-end trust, record that is trace able. If we don’t get on top of this soon we will have done a lot of work that will ultimately collapse simply because we can’t trust it.

Certainly a comment that Dixie has made multiple times in her work groups, this idea of not only looking at security, but the data integrity. How do we ensure, to Gary’s point, the data incorporated is not only legitimate from a known source, but is it lost or modified along the way. Gary has been a valuable contributor, and [indiscernible] a lot of dialogues on thinking through how we get to as a whole industry this idea of making sure more good data integrity.

Good point.


Hello, my name is Dr. [indiscernible] practicing primary care physician in Florida and [indiscernible] a lot of interest in the issues you are talk today. I have been to — especially Germany — addressing these issues you are talking about today. For example, having to amalgamate — in healthcare systems, dealing with challenges with respect to portability and healthcare data. Has the committee studied this systems, extracted guidance, [indiscernible] I know in those two countries they, again, have the same issues, have overcome to a great degree.

Certainly in the standards harmonization activity through hitsBE, asking questions, where can we learn lessons from Canada, the U.K., folks who have done this. Certainly, look being internationally, work on [indiscernible] the adoption of common vocabularies, code sets. We have tried to take those lessons learned to drive to common semantically interoperability code sets. You will see coming up as next round of hitsbe, we do in the [indiscernible] tool, HRQ publish more code sets as have been used in Europe to ensure registries are more interoperable.

Other questions?

National coordinator looked —

Union experience in terms of their challenges, experiences, bring that’s knowledge to a number of colleagues, also served as resources, brought quads back.

Please know how much we appreciate the support, to all members of the, thank you for what you have done.

2 Responses to “Transcript – HIT Standards Mtg”

  1. james Says:

    “This is David Bromenthal, national coordinator.”

    Is this supposed to be David Blumenthal?

  2. ahier Says:

    Thanks for pointing that out James 🙂
    This is a very rough draft and although most real-time captioning is more than 98 percent accurate, you will see occasional errors. The captioner may mishear a word, hear an unfamiliar word, or there could be an error in the software dictionary. This is why the draft transcripts I post are very rough in form.

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