TRANSCRIPT – 7/21 HIT Standards Mtg

I have posted the rough draft transcript of the HIT Standards Committee’s 7/21 meeting below the meeting materials.

Meeting Materials

Rough Draft Transcript:

Event Started: 7/21/2009 8:48:27 AM ET


Morning everybody.

We’ll come to the third meeting of the HIT Standards committee. We have members of the audience as a lawless people on the phone as well as listening over — as well as people on the phone and listening on the Internet. The meeting is being transcribed and we want to have proper attribution. Let me go round the room if you could introduce yourselves and I will begin with Doug.

This is Doug it and I am from Arizona St.

John Gina, Judy, [ Indiscernible ] from Blue Cross Blue shield.

Lloyd Isenberg from National Quality Forum.

Steve Finley.

David Blumenthal National coordinator.


Chris Shoot Mayo Clinic.

[ indiscernible ]

Kevin Hutchinson.

Liz Johnson.

David McCauley.

Stan from Intermountain Healtcare.

Jodie Daniels.

We should have a number of people on the telephone.

Martin Harris?

Janet Corrigen and Mark.

Hi, this is Mark.

I will turn it over to Dr. Blumenthal for comment.

Good morning, I want to welcome you all to the Holiday Inn in our neighborhood. We are having, as you know better than I, our third meeting of the standards committee. We are at this piece of monthly meetings. And I know it’s probably not what many of you are used to it you have served on comparable government committees in the past. But I want to assure you that you are providing an invaluable service to us at the office of the national coordinator, Department of Health and Human Services and I think to the American people. To say that I am and all of the quality and amount of work that our committees are doing is probably not overstated. You all have done an extraordinary amount of very high quality thinking, and formulating and writing. I am sure that many of you are thinking that you are asked to do to much and if you have more time you could be more thorough and you could design better plans, find more of the gaps, late a better foundation. I know you all are thinking that. But I’m sure that you hardpan seen our work enormously — You are advancing our work enormously. And we are all living with the deadlines that Congress created for us. Those deadlines are tough but also provide a kind of discipline that perhaps is beneficial in the end. We are working towards an initial, an interim final rule that will include standards and certification criteria to underlying the implementation of meaningful use in the 2011 time frame. And our goal is to make sure that we give physicians and hospitals and patients every chance to have the benefit and the use of electronic health records and other health information technologies that permanent improvement in their care by 2011 to the maximum extent possible. And knowing that this is just the beginning of the process, and not the end of that process. And that we will be continuing to design what we are doing, continuing to fill gaps, continuing to make things better over the next several years. So we appreciate your willingness to stay with this, and continue working at the piece that you were talking. We want to assure you that we are listening carefully, and that your work is helping us to do our work in a very material ways. I will not take more time. I want to apologize in advance that I have to step of the meeting at about 10:00 for a couple meetings that I cannot avoid. But I will be back later in the morning thank you, David. Good morning everybody. This is John. I share Dr. Blumenthal’s awe at the amount we have accomplished. We wondered if it was doable. And those individuals who have not been party to all of the subcommittee work, let me just assure you that daily there has been conference calls. One of the questions that arose with the subgroups was to coordinate with each other and to triangulate. And that has gone on very effectively with much of credit to the office of the national coordinator who helped us with some very complex concepts. We have a tremendous amount left to do, that we are to do in today’s discussion. We wanted in addition to express appreciation to go through our usual process. We have adopted the process of asking if anybody has anything that they know to be in conflict in terms of personal interest with any of the items on the agenda. Let me stop and pause and ask that. If we go on around the room are there any members of the committee would that have any conflicts of interest?



No Gina? John? Ann? Wes? Floyd? Dixie? John H.?

I belong to a provider organizations so I am sometimes biased towards doctors.

No conflicts.

F Linda, member of provider organization and a better representative on the board of HITSP.

No conflicts.

No conflicts.

I am a member of the port of HL7 and the cochair of the committee, I do not have any financial interest but I do have a bias.

I have the no conflicts.

Let me just say that Jim Walker has joined by telephone.

Jim, good morning.

Any conflicts to disclose?

And we have a some people on line.

Okay we will continue on.

I trust that you had a moment to review the minutes. Let me just ask if there are any corrections or modifications or Amendments that anybody would wish to offer were.

Let’s declare that we have agreement on those and move forward to the meeting. Let me introduce the first part of the agenda for today. We obviously are going to come together with a division on our insights and standards to support meaningful use. It has been provided to us through the meaningful use workgroup and office of the national coordinator. And our focus was on the 2011 activities, objectives that we would want to support. We appreciate what this group has offered in not only identifying standards, and also assessing the readiness of the standards for adoption. And a great deal of thought which has gone into that and we’ll see convergence of the standards to support what is teed up for meaningful use in 2011. And, of course, there are caps and there is work that will need to be charged. But between that that needs to be charged and that is ready for adoption are two levels of readiness. And those that are essentially in progress and incompletion and those that are, in fact, chartered. And you can see the logic between what is really available in the year term, and what that requires for down the road. We have had some reports from our three work groups, clinical quality and the criteria for quality. How do we represent the data that will provide insight into performance? And they have done tremendous work on criteria work quality. The clinical operations work group has an extraordinary work in terms of providing specifications of the molecular granular data elements that are necessary for the exchange of information that underlies not only meaningful use but real life use of information for the care patients and the care of populations. Privacy and security Workgroups has also had the philosophy that has been tremendously helpful. It has been framed from the outset into how to make meaningful use possible and how to achieve the aspirations of health information for improved health care. Beyond responding to the development of meaningful use they were charged by statute in the high-tech legislation to attend to what we have been referring to as ARRA eight and the privacy and security standards and a great sensitivity towards pursuer perceptive how to understand assurances are created with. And the use of information are protected and usable and accurate and I try to avoid technical terms because this is really at this juncture is a gray from those individuals — — a segue from those individuals to a broader understanding to understand how this is used to improve health care. Let me turn to my co-chair John Halamka and I want to thank you for work that your organization HITSP has provided in terms of mapping the standards in a functionally defined manner to the concepts of around this.

Good morning, John.

Good morning. And a point that you made, we really took Mark’s comments and ask ourselves, what is the deployed ability of the standards that we are doing and all of the elements, and so you will see as we have in Dixie’s matrix and the the pliability for this particular purpose and we actually got quite granular and the committee. Thinking through in what way is the standard used today? Is it used with in an organization? Between an organization? And this sets within an organization is probably ready for a prime time and that is a good way of taking the work that has been done by HITSP, standards development organization, and the industry and putting it into a framework that people are actually going to sit oh, we can do that on the time frame that you have outlined. And Jamie has done similar things and where we want semantic interoperability. Of course, we want that, the ability of computers to exchange information and have data that goes between organizations that is untreatable. Can we have it tomorrow? Me it may be slightly aggressive. But we should not lose sight of the need to do it and say, 2011, you should but there is an account and in 2013 the out goes away. You have to use those vocabulary’s. And there is this wonderful ramping up and I think you used the term escalator we have to set the speed of the escalator so that folks could get on and would not fall off because it was moving so fast. I think you will see that spread throughout Jamie’s work and similar the work that Janet and Floyd have done and the architecture for how one describes quality and I think we can all it meant that when you look at the measures there are some gaps and there are some gaps of around how the measure meaningful use? How do I electronically measure the e prescription I did not write or paper based educational materials being handed to a patient. So if they have fought very clearly about what do you want in 2011 in 2013 and what can be electronically recorded in what has to be at the station. And their work which will continue on over the next several months is to put some scores on each of these measures just as Jamie has done about the deployability. And it’s really remarkable in the coming together of these groups, there has very little dissension. There has been great discussion. I think it was rather amusing that so many stakeholders came together and had such unanimity. So look forward to the day.

Thank you, John.

Thank you for your terrific leadership.

I suspect as many members of the committee were asked, John Glasser will update the status of the recommendations did the health information committee and meaningful use that we have been responding to. And I will amplify one of John’s point that many of us are often asked about this. This does change things. But I think my sense of the direction of activity is that the office of the national coordinator and all of the people involved in and academia and providers are joining together to want to make this work. So I think that really has been really encouraging for me to see each of the work groups respond. Bring together consumer perspectives as patients, users, advocates from the technical perspective what are the necessary prerequisites to actually put this in place, and help to serve health care more effectively. So with that let me ask David if there are any other comments that we wish to offer before we get into meaningful use with Dr. John Glasser.

Thank you paid as you know, meaningful use is at the center. In the June policy committee meeting, Paul and Douglas presented the preliminary recommendations and I have an opportunity to happen over a few of that presentation. And there was a public comment period and approximately 800 comments were received. That went into the work group deliberations as well as the policy discussion itself. Last week Paul and George, the new co-chair who has joined ONC presented a revised definition and put in the wide range of thoughtful and terrific comments that were received and I will give you an overview of what Paul presented at the policy meeting last week. I will move relatively quickly because they want to make sure that there is enough time for the workgroup are in this meeting. Also I doubt I can do these presentations the same justice that Paul did so we will try to hide that fact by moving rapidly and I will not be using any verbs for the next 20 minutes so I challenge you to go along with this —

Okay. Let me grab something here. Okay. It might be my Catholic upbringing — sing along in your hymnals, psalm 43 and we will go from there will. So the core thing and we will look at slide number four is to remind us from the framework that is behind the meaningful use recommendations that the work group came up with. That is the evolution using the escalator analogy, moving an issue from data capturing and cheering from 2019 to infanta and the processes and then dashed into an enhancement of processes and there’s a shift as years go by. If you go over to slide by, you notice the term used internally the North Star and they have transformed the health-care system that is remarkably more safer and of higher quality than the one that we have today, and realizing that there are multiple threads. One of which is the work in the HITECH and the health care reform agenda. So this captures on slide number five the central city of the meaningful use comments by a year, 11, 13, 15. And as we deliberate, we go to slide six, the conclusions and recommendations we have to consider a variety of things. One is the reform agenda that is under way. The other is to remind us that we are looking for outcomes not necessarily for the Software installation, etc., and in the course of moving the industry aggressively we have to consider the adoption rates are not what they are to be in a lot of ways. There are a wide variety of communities that would like to move but they do not have the resources to move. So there’s a balance, a juggling act between aggressive movement and the practical realities it on how far we can move in the state of industry today. And last but not least the fact that the legislation’s particular type prints and we have to be mindful and conform. So all of those had to factor in and be considered in the course of the discussion. If you flip over to slide seven there is a screen shot of one of the pages of the meaningful use definition that was presented in the June policy committee meeting, and given the feedback the workgroup frame their responses according to the categories. So they categorize the comments, and they might have multiple points across these categories and we will walk through these next couple minutes. The first on slide nine on V meaningful use framer, it was a wide lead knowledge that the framework was terrific and the efficiencies that we all aspire to achieve free and that the measures provided a good way of stressing, in other words, if you were able to record a wide variety you had to be using the EHR and you would have been having electronic laboratory results and the problem list, and you would have prescribed medications etc., and they did a nice job of moving us toward that to express those outcomes. And they exercise the broad range of EHR capabilities. And as we evolve Purdy’s a framework represented before — for these framework represented here and how the target is expected to grow as the standards and delivery of care will increase. On slide number ten with specific feedback regarding timing, and that is in the number of cases a concern about the aggressiveness of the schedule. In other words, can we really do all of this or can a large portion of the industry do all of this in the timeframe for 2011 is only some months away and there is some concern on CTOE and some concerns elsewhere. And if you look at these payments schedules, the goals if you receive the maximum amount of incentive possible that the start date was not January 1st 2011 or even the fiscal year 2011. And that is the work it mentioned on the last bullet on slide ten, the adoption. And that is, in fact, that we will illustrate that on the subsequent slide on page 11 here. As you see in that schedule this is a schedule that is part of the legislation that went out if meaningful use begins in 2011 there is a stream of payments that go from 11, 12, all the way up to 15 until the penalties can. But if you start at 2012 and you can start at 2013 and receive less payments. So the suggestion was that meaningful use start on one of these calendar years. In other words, if 2011 is a meaningful use year. So you could start using the 2011 definition in your 2013 and that would be your Year one rather than your 30’s of giving provide for some time. Because if you go out to party began to surrender some incentive but giving them more time to pursue some of this. Because some people might say I’m not getting on the escalator because it is moving too fast or too quickly and things like that. So that was one of the recommendations with this notion of meaningful use here to fundamentally give the industry more time to respond. You also see continuing on that threat in spite of is rather than the initial definition, we have all orders by 2011. So he began to move your way through the House or the inpatient unit. That might be some pilots and a couple units and we would not expect that all be done at that period of time. In regards of decision support we would want that to be moved earlier where there is drug interactions and other decision support here. But also balancing that if we need to actually have a EHR in place and you want to have the implementation done. So with their recommendation was to start with one rule, a fairly wide open on what that might be but make sure it’s relevant to the clinical priority of that organization or group of providers. And flipping over to slide 13, the feedback on patient and family engagement, it was to provide access to electronic health records whether it is a PHR type approach which is distinct to an electronic copy or could be eight thumb drive so they actually moved up those recommendations from 2016 to 2013 From response to that feedback and on slide 13 there were comments and there were measures on efficiency and quality and safety and we are mindful of the Health Care cost and record ability for both governments, businesses, and individuals and we need to be more focused on that. And the National partnership remark that was adopted broadly for the new police also has an emphasis on efficiency. And as we proposed some additional metrics with and associated set of objectives with that and you can see them here, all medications entered as generic when generic options exist for that drug class. Also efforts to reduce the inappropriate use of expensive radiology procedures. Two areas that are not dead center did EHR but should be factored into this is more of the administrative and financial transactions for the termination of eligibility but also the electronic submission of claims. So they brought in those two criteria that are appropriate. Nonetheless the are good recommendations. And going to slide 15, some concern about from the specials community when they looked at these, the are largely primary care measures and some are relevant to was in the specialty practice but most are not paid and by the way the special the measures that we made in our society, we do not see those year. So what about me? That is really the tagline for that. And sort of the recommendation here is that they focus on a couple of exempla measures that would be broadly epochal across a range of providers may be not all but broadly applicable across a range of providers. The other for the specialist’s particularly in the efforts to create a registries which CMS is working on it and that they contribute to their special the registry in the data that those treaties registry is contained in that would be more relevant to their measures of quality and the specifics of having quality reporting as part of the meaningful use recommendation. On slides 16, some feedback that we need better measures for care coordination with. And they point out that NQF is working on that and they also propose a 2013 measure of the readmission that often happens because of the poor coordination of care. In the second bullet that you can see on slide 16 is the concern. On one hand we want to encourage and motivate the use of health information exchange recognize in 2011 we may not have broad capabilities across the country. Some of their recommendation is that in 2016 that we might require an exchange given the exchange time to come to be and grow. But also to require the ability for change and make some additional recommendations to the HIE workgroup. And I expect that we will hear more from them. Moving in on this, the major comment was under investigation and we will hear from Dixie and folks around these lines, that you could become paralyzed or something along those lines and you can see the revised wording that they recommend is that to the degree that there is a complete that there is effectively an option for them to put an something that would resolve or have resolved the particular issue. To both ensure that people conform to the privacy and security regulations but also not to inappropriately keep them strong during the course of the pursuit of a meeting to address something pecans be the maxi and slide 18, of future work, we will give them a break. you can see on-site team, of future work, we will give them a break. And then you can see their future work is to review and revisit the 2015 vision and to redefine the 2013, 2015 measures and criteria. There are other areas, the process used which we have been working at to arrive on this definition. We ought to make sure that in the years that we have a process that is more deliver tip and there will be coming back and how to do the meaningful use definition calibration process and then like all of the stuff that they put out we need to monitor the industry to say, how terrific are the? When the confront the reality and have some feedback mechanism from the field into the meaningful use objectives and measures and refine them as appropriate here. I think in summary you can read, I will not read this for you, and encapsulation of all the work that I just wanted to give you a brief update on both their work and the revisions that the proposed to the policy committee. The policy committee approved these recommendations and has ordered them to David and ONC. So we’re looking at those internally and the want to thank the workgroup and there may be a question or comment on what I decide so we will take it from there.

Thank you, John. Thank you for all of the work that you have done in shepherding this work along with the ONC staff. They have been terrific as well. I want to put in perspective, this is something that Jodie usually does but she will Janet and how will I do on this. And that is too late, clique out the context of the Policy Committee and the workout that you all to — is to lay out the context for you are providing us in valuable recommendations under the law that created this policy committee. Those are recommendations to the office of the national coordinator. And they will be transmitted to the secretary. And they will inform the rulemaking process that will establish the definition of meaningful use. And that rulemaking process will result in a notice of proposed rulemaking. Under the current schedule it will be issued late this year. Probably around December, sometime in December. But that is not a certainty. The standard for Medicare Medicaid services will be part of the Department that issues that role because it will be governing compensation of providers under Medicare and Medicaid. So while they are extremely serious, they are not policy. They are not set in stone as policy. The same is true for your work. What you recommend to was will be taken extremely seriously, but will not be in policy by themselves. Your work will inform an interim final rule that will be issued by statute has to be issued by the end of this calendar year. And that will contain certification criteria and standards necessary to undergird meaningful use. And as you listened to John the talk and his comments on how we modified the meaningful use criteria and objectives as they go for word. I do not want you to misunderstand that there was our policy of the Department of Health and Human services. They are recommendations. And we cannot say for sure whether they will or won’t be in all other aspects adopted. Anything that you would like to add to that?

I think you did great. I think we can go home now [ laughter ]

Thank you, K one and thank you John — David and thank you John very much.

I know there may have been some questions or comments and you can put your name card up so let me see if there are any comments.

We will start with you John Halamka.

This has been a very aggressive process, one concern that we have as multiple iterations of meaningful use are issued, that somehow might not aligned with the work that we are doing. The good news is that you see across the multiple iterations that we have been working on the themes are similar. Pair may be slight adjustments, 10% for this and 30% for that. But there was not a substantial change of direction so there is a very good alignment in the parallel process.

Kevin Hutchinson?

Hey, John, the question on slide 16 that refers to where possible the information exchange which I think is very applicable knowing that not all lab results can be done to avert electronically these days. That is what I assume that is referring to pick where there might be pockets of transmissions that simply might not be able — we may not be able to have on the receiving end.

Yeah, listening to the work group conversation there is for imitations. Either the center is not able to send it ordered the provider might want to be able to send it to a recipient or they are not capable with.

I think the one thing that we should be careful of and what if we require certain functions, but the capability is not on the other end, it will make workload as you well know very difficult. They are still required to enter it in but I will have to print and fax it and send it but I’m still required to enter its even though the exchange is not available on the other end. There may be some workflow challenges with trying to make that functionality to fill the requirement even though the exchange of it is not a requirement.

And I think it’s to David’s point, we look these the route and in December you see similar or exact type of wording. There is a fair amount of work in the industry and how do we ease this transition because we will not have broad interoperability by 2011 and full EHR by 2011. So I think it will take collective, not only people on the committee but policy at large to sort through all of the approaches to minimize the workflow hassles and all of that. So I think we have our work cut out on the multi year transition and the minimizing.

Let’s go over to Stephen.

Of the 800 comments that you have gotten, have been categorized them in any way and are they posted on the Web? Is there any categorization that has been done that is posted on the Web? And if not is there any intention?

We did categories and by type of center, whether its a consumer group or IT industry or hospitals and there is categorization by concern or recommendation. For example, we are clear that a lot of the directors came up with [ Indiscernible ] recommendation that we did. And I am not sure of the posting of those for public review, etc.

They are available for public inspection and we have hard copies of all of them. We are still, I believe going through and redacting any proprietary information and things like that. Our intent is to make them electronically available as well but I don’t think that we have that up on the web site yet but it should be forthcoming.



Thanks did I have a question for John. % want to pick up on something that can and said — First I want to pick up on something that Kevin said. He said that requiring the physicians to enter an order was not worth the trouble if it was not being transmitted electronically. My own analysis of what Steve colter gets what value for what part of the e-prescribing process, the prescriptions get a very minimal amount of the value and there is an argument for the efficiency of the overall system. They get the value piscine the medication information and having the opportunity for clinical decision support engagement as opposed to however much money they save and callbacks from a drug store. The reason I mention is not to pick on Kevin, but I think that we continually battle with this distinction between the good of society and the good of the efficiency and the good to the position and a lot of us have concerns. There was an article in the major media yesterday about position resistance to EHRs and I think keeping that talent and mine will be critical as we go forward. John, in the meeting that you reported on there were other topics that were discussed that were not discussed here. I just want to know what is the status on to the vacation, if there will be a comment period associated with that. I am not sure whether that came a recommendation of the committee or not.

Decertification group did had some high level recommendations that were approved by the committee but there was a request that they come back in August regarding the specifics. So the high level recommendations are focusing on meaningful use. And this sort of stopped there have that meeting. And so we are planning to bring them back on August 21st, I believe, to be set for the recommendations regarding how they see the near-term and long-term carrying out the certification process. There was a public hearing that they held on the 14th and 15th of July that had a party of testimony from vendors and purchasers of that was open to the public. And there were summer in comments received here. We have some decision internally were the we open a public comment period. And I doubt that we will do that at this point. We may not have a fully, , and period. And there was the presentation at the policy committee meeting that we may not have the additional comments period.

Obviously waive the fact that public testimony before the recommendations does not constitute comment on the recommendation.

Correct. So there was a hearing of the issues and concerns, etc., but there were not recommendations put on the table on the 14th and 15th. There were at the policy committee but not on the 14th and 15th.

Let me say one thing. The Professional certification process, and the certification process that we develop that — there will be an opportunity for public comment. So there is opportunity for the public to make comments at the work group meetings when we have a public meeting and there will be a formal comment period at some point in time when we go through rulemaking as well.

Soever approaches, we will go through the rulemaking process.

That is our plan, yes.

And I know people asking when, but do you have a sense of when?

That is a good question. We are trying to put it up with the other regulations that we have been talking about. I do not have a specific timetable right now.


Next question?

I think this exchange [ Indiscernible ] and need for comments and have been much of my life in Washington the rulemaking process can introduce many opportunities for a commentary which I think the volume of responses to meaningful use Web are aware of and encouraged to take advantage of those opportunities. Any additional comments or questions for John Glasser?


Is this final version open for comments?

The public comment period on this as closed and we now have a recommendation that is going to Health and Human services. And as David mentioned this will be part of the CMS portion of the rule so when they came out with that in December there will be a subsequent comment period. Right now it’s close but once it comes out in December there will be a public comment period.

He reported that he would go back and look at June and look at 2015 for more?

I think the work group has been focused on 2011 because of the reg writing and they did not have as much time to look at 2013 and 2015 so after their break we will revisit with them with what they would like to do with that. But I think they will want to go back and whether the change anything, I don’t know. I don’t know if it results in making modifications to that.

My only concern that this is the last chance. The disclosure is in 2013, and the accesses in 2013 to consumers. So I don’t know if that would make consumers be concerned about knowing who is accessing their information.

One thing, when it comes how you all can collectively read it and expressed concerns along those lines would. And let’s look at the work group regarding what they want to do for 13 and 15 and whether they want to take a repine shot at that and when they present initial thinking. So I think there will be opportunities for people to come back and say, I have an issue with that.

Thank you.


Just to be clear, what is the timeframe of the CMS proposal and what is the length of the comment period?

The CMS, there are two sets of the deletions of focusing on meaningful use is due out mid December. So there will be a 60, 90 day —

I think that CMS will require to have at least a 60 day time period. That is my understanding. And our internal rule, we have at least 30 days and we have not made a decision about whether it’s 30, 60, 90 and CMS would be at least 60 and ours would be a minimum of 30 but it could be longer.

So after December, two to three months.

Okay. It — got it.

Okay one more question, the HIE debate on the policy committee was not finished. Will there be additional debate around some of the HIE recommendations before rulemaking starts?

I presume that they will be back in August with refinement of that kind of stuff. And obviously if there is a recommendation there we will have to factor that into the rulemaking process.



We appreciate that. I should also say that despite [ Indiscernible ] which processes are very — the balance of the opportunities to allow and encourage commentary on David part of this discussion. Jodie do you want to close out?

I want to make one point, in the policy committee as well as this meeting there has been questioned about the process and when there will not be a commentary in what is will making and what is not. And we have heard that loud and clear that there has been some confusion. So we are trying to put together a very high level outline of what our process is that we would pull Center Web site. I do not have a gap anybody who is on the list, we will let folks know — We do not have a gap anybody who is on the list, we will let folks know at a very high level to see what is going on and if we make any changes and we will make sure that that you have seen that data.

Traffic. And just to show that there is responses, and the idea of time lines and this is part of that. And your question about the things that are keyed up 4.11 those of the markers that are helping orient the field — keyed up for 2011 and thank you so much to the entire staff for your incredible work. Our appreciation and George and the meaningful use workgroup as was.

Now to our work and we will get really into the bulk of the efforts of this group. These are decisions all areas in terms of going forth with recommendations. And what we require for the work and Dr. Blumenthal has outlined to was with the time frame is for 2011 and what is deferred to 2013 and beyond. With that said, let’s switch to the first of the workgroup presentations. I am going to invite Dr. John Halamka to moderate this section.

So you see now a series of three presentations that build on each other. We will start with quality that gives us the framework to measure performance and you see from Jamie the standards that would be used to link hobos quality measures and then from Dixie and Steve on how you would ensure privacy in their transmission and other aspects of security. You will see that each of these presentations include two types of presentation material. The report of the committee in PowerPoint format and the matrix that gives you incredible detail on the exact nature of the standard selected. And as mentioned you will see from both Jamie and Dixie the measure of maturity or deployability. And in the case of Jamie he has shown you this. And they are both using the same sort of notions that John introduced us to pretend they are clearly ready to implement now, four is a glimmer in our eye and some between.

Will you be doing the presentation?

I will be doing the presentation.

Okay being thank you.

Thank you for the opportunity to present. If we go to the first slide, just a process to show our meeting. I can do that. I’m sorry. Thank you. That we have had two conference calls with the Workgroups on June 22nd and July 15th as well as consultation with the policy committee where we met with the meaningful use workgroup and presented our findings as to the operations group. And we received feedback from them and also presented to the policy committee on the 16th. So we do have a lot of interactions back and forth. We identified a potential set of existing standardize performance measures corresponding with the quality measures that currently have been approved by the policy committee. And from that sat there are some gaps where there were no measures. We have selected indorsed quality measures because endorsed measures have gone through the process of consensus and assured the of the evidence behind them and the value of the measures. We also identified specific data tapes and I apologize for the new acronym, and you see QDS, Quality data sets which are the key elements to use to calculate the measures of. And we have handed that off to the clinical operations work group to identify standards for use. And the National Quality Forum database has approximately 512 endorsed measures at this time and others are going through endorsement in the pipeline by the end of next week. Others are through 2009. It includes — we includes measures and used by a CMS for hospital and ambulatory reporting and the Alliance measures and position codes — physician consortium and also under AHRQ funding convened a health information technology panel for creating a framework for the types of elements required to measure quality. And this includes a quality data set that indemnifies codes and their related context with used to create the quality data element to identify its use with an electronic help records. And the HITECH draft report was out for public comment in the final is in progress. And it went out last night to the full HITECH panel and we expect publication by the 31st. Except for some minor editing that will occur after that will be out on our website for a full reading. The types of data necessary to calculate and report performance are present in the data said. We also identified data flow attributes. So that they can identify from Houma or what the Vice went in to — what device went into and what setting it occurs and and what health record field or location it would be expected from and there are currently over 56 data types identified and that will health us with the future framework. And we have identified four measures to hand over to operations. And on our hands out of the Grand there are 27 performance measures. Part of our additional work which we will be after this meeting will be to add scoring and thresholds to the measures that currently exists. There will be some additional work on that as well. The recommendations are provisional until we go through the threshold. You’ll see and I will give some explanation of some of the reasons why earlier portions of the — or some versions can be used in 2011 are more robust in 2013. Some of the retooling when we talk about these measures, they are geared for claims, submissions, or manual chart extraction. So there needs to be some retooling rather than creation of a new code that says that hemoglobin is less are greater than nine. It is looking for that there was a hemoglobin A1C for a diabetic and the term it was within a right threshold. So that requires some retooling. I will show for slides that are not in your slides said to explain what that means and we are seeking standards committee approval understanding that there may be some changes. So just to look at a single measure this is a measure published as A description out for public comment now if you go to the HITSP site. This is for stroke for inpatient care and the anti coagulation therapy. It focused on extractions’. So any patients that have a stroke who have this need to be prescribed anti: — anti coagulation therapy and they are identified using an algorithm and also had stayed and definitions and the data dictionary and also three or four of tendencies with all of the data elements. So in order to describe this more clearly knew what we have done in a process that I will put in my HITSP data — I’m sorry, my HITSP quality Tiger Team, what we have done is identified the data elements and definitions and logic. What is new for retooling is would be the organization. Where do I find it in the record? And the code set or values at that represent each of these elements. The measures already identified the logic based on evidence and it’s the code stop that is new. So in the grade in the report that you find on the HITSP site it talks about the elements common definition, and logic that exists. And where would we expect to find that in eight EHR or interoperability format. Where are some comments about buy and where we find the value sets. In that process for this particular measure, it has modified what might be an ICD9 to a Snowmed codeset so there are both for the specific measures. And the next step with the tooling is to put it in a computer readable format. We would not expect the average reader to read an exile document but a computer could so that is a process that is in development now. And five e-measure is coming forward in HL7 for public comments and goes and on the week of September 20 if that will incorporate the performance of this. The.

If we look at Gap’s there are some measures requested four additional resources. And using CPOE. For the current 2118 is likely for collection. There are some structural measures that we have endorsed that request at the time each patient is discharged from — or send home from the office, if the electronic prescribing it is not performed at an additional form and they felt that it was adding additional work for the conditions and they preferred that we do e-prescribing in office rather than adding a code. Although those measures to exist. We do have some clinically enriched measures. But they do not always taken an edge of the clinical data. And one example would be patient with high-risk for cardiac events on aspirin prophylactics and we will need to identify that aspirin is on the medication list. Some measure is required data types that will be challenging to capture. Even though we have endorsed measures as a look at this we have a pediatric measure and a adult measure that is greater. And there are two measures with slightly different criteria. So there is a challenge in trying to align those two instead of collecting one measure. We also would expect some specification differences. And you will hear that more run the operations group where everyone may not be able to use the SnowMed value sets for 2011, we would expect that for 2013. Some measures also required data when there is no standardized means, embolism asks for the use of eight anti for robotic device — of an anti phlambotic device or anti coagulation and there is no standard to identify devices, they are all local codes and to know that it was placed on the leg is another issue. And some may require data that is costly to collect. And the example in the profile is not that the profile is costly, but the measure actually asks for the theory of the profile. In our workgroup we identified that it’s only the LDL that is needed on follow up, and if we ask them to look at profile all the time we may be encouraging overuse so looking in some of those measures, those just came out. Significant harmonization, they should be patient centered and current measures to bury someone across said Deans whether it’s in the hospital, ambulatory — do vary across settings whether its hospital or ambulatory. So these are some of the challenges that we can address. This was part of the talent in selecting the measure on your credit. We are currently in a detailed review process of the detailed measures and a subgroup of the work group will be reviewing all of the details of them to provide guidance for retooling and identifying any changes. Also to identify thresholds’ for performance and also some scoring guidelines. So we will be classifying them for a degree of readiness and scoring and also the thresholds. That is our next step. That is the full report.

Thanks. Just a couple of comments. You highlighted how HITECH looked at the workflow, where do you capture these measures? Because if something is an observation with the time the stamp at the moment that the nurse pushes the fluid versus a diagnosis created three weeks later, that is clearly an important distinction with that level of granting a rarity. Who is the actor, what is the event, and Wendy capture it in the workflow? And understand the types. There are both nouns and verbs. A noun meaning medication or a verb may be administered and they may happen after be like date/time so we will declare an measure that based on the fact that it was Please stand by whilecaptioners are transitioning.

Jamie’s group, said, how would you actually represent the particular event that will transfer to – – metric gathering organization. A quick comment about some of the gaps. We chatted in one of our meetings about that it is challenging the measure some of the methods. How do you figure what you’d – – are you prescribing what you did not E prescribe. It may very well be 2011 which is the best but there could be proxies. This may be controversial and not accurate, but if you imagine that I got the number of E prescriptions that I wrote and a number of encounters with patience that I had and not certainly perfect and normalized across specialist and PCP, those that are young and old and sick and well, but if you throw it 100 prescriptions with 100 encounters versus 4000 patients and 100,000 encounters, it give you a qualitative sense that E is being used. This call was every time an encounter is close, have the physician check the box. Wrote a prescription or did not? That would clearly be a burden for the workflow and require modification of the existing HR system so did not seem a rational approach. Lastly, one of the things that you saw in the presentation, those vocabulary – clear coordination between quality and operations had occurred because we know this is a big moving target. I seen nine very commonly used today, Snowmed being introduced in clinical the day but maybe not ubiquitous by 11 maybe by 13, so it has been in their quality data type work a recognition that multiple a cappelletti might be used and may be passed over time to use the various to vocabulary’s. Let me open it up for questions based on the presentation and the matrix of the 27 items that you see.

Always the same hands. First of all, I want to say that this is a wonderful piece of work. The business of going from the high level concept to the thing that looks wonderful when you first talked about it to what really makes it work. It is such a slogging through the mud and the work that has been done seems to be very positive and potentially doable. I have a couple of the questions that may have been answered and other context. I would be happy to take a reference instead of an answer. The first question is in determining the denominator, these measures to look like queries from a database, all patients were over all patients – there seems to be some conditions missing in the queries. For those environments where patients are not an arbitrary Administrator Lee assign to whoever you are measuring, were there are patients who come in and come out in the community health center, it seems like determining what other patients that have to have a measurement in order to do the denominator is difficult problem. The bigger question and confusion I have had in this process is what we believe is the scope of the EHR? in most organizations that I’m familiar with, if you want to answer these questions, you do not go to the computerized system, you go to the warehouse. There are a lot of reasons for that. Some good some not good, but all real. If in fact we are in a meaningful use measure, determining the eligibility of a hospital or a practice to receive incentive payments for its EHR, can we ask it to do more than the EHR does or not? I hope that we do because this is what it is all about. I just want to understand how we do it.

I will start briefly and turn it over to Floyd. Denominators are challenging. You can imagine that Floyd said in a slight four that diabetes can be defined as an icy nine code. It could be defined as a non – you are on insulin and maybe that people on insulin had never had an diagnosis and 250 URLDOT exe. You want to look at multiple possibility in the fighting that denominator I am sure Floyd can describe the thinking. Regarding the date of house question, they have a query capability built in. I have an abstraction on a nightly basis, the EHR vendor itself provides a duplicate copy of technical data that could be queried. It is becoming more commonplace for his products to allow identification of who in your panel has set a particular condition our issue, that is part of many employee use. What we are spacing the next sitting is if you have a capacity and / or your environment that has a and EHR warehouse of generating some of the numbers. Floyd please comment on those.

For the two questions, the first was pretty much attribution. How do I know who is in my denominator? Most measure developers have determined that perhaps in the ambulatory area asking have you had to this is within one year? Very likely that if you are looking at a specialist and primary-care physician, each of whom have to visits with the patient, you can say that the they each have attribution. That is a master developer decision of how that attribution is determined. The data element becomes an encounter. The date and time and you need to of them. Each element is you need to of the data elements or presentations. In hospitals, it is admitted so that is a little bit easier. On the question about use of the HR, when I mentioned the data flow attributes of IT expert panel looked at, they identified health record fields and it was not down to the exact field, but it’s is suggesting that I finder conditions on a problem list and so if a problem list is used, in the EHR, that makes it more meaningful because the problem list gives you the condition that are going on with the patient at any one time and adds value. The fact that Your medication come from the Midwest, and the fact that you are on over-the-counter aspirin for profit taxes, because you are over 50 and are preventing coronary artery with the system or you have an MRI and presenting and occurrence, since it is over-the-counter there is no prescription for it. The fact that it is in your medication list, it beat it allows you to see all the medication together and potentially do medical interaction checking. To find the allergy, it is not just in the note, but we expect to find it in the allergy less. That is how we suggest that it is applied to EHR. What that means is if it is in the data warehouse, they have to identify where it came from. So the allergy had to come from the allergy list to make it meaningful. Or and intolerance can come from the allergy list or and tolerance less. That is where we see the connection.

Usually there are two reasons to have a data warehouse. One for additional functionality and determining things and the other because my enterprise is badly fractured in terms of how it serves individual conditions. – – clinicians. If I understand, it is a good challenge. You are expecting that enterprise to solve that problem in order to get payments for a EHR. Many of the visits for a patient may not be in that EHR.

I think what we are expecting is the EHR is certified for use of and containing a problem list and allergy list, way Med List. And have the function to manage that. If that function is obtained, a service from the warehouse and that organization, I think that is potentially acceptable as long as it is in use.

For example if we use here at traditionalist, two it encounters a car with a doctor, they’re required pitch – – whether you access it by clearing the HR directly or querying a data warehouse, would be fine?

I think your question would be what if they visited somebody and did not have a medication list? Or allergy list?

I cannot count the fingers and hand in this room that the numbers of medical centers have a difference record for inpatient and outpatient and the metal or third record, they’re reporting for quality measures, there are – – it does not imply that anyone of the users of those three systems have a consolidated problem list or medical West and so forth. I am happy for us to do anything that actually measures quality and that is fine. I am having a hard time connecting it to paying for one of those three EHRs in that setting.

I get the challenge and interesting question for the group is let’s imagine that the hospital has out information system with CPT and EHR and prescribing software and has a warehouse and it turns out that you did get a medication list, but it actually came from one of the data sources and used for reporting qualitative measure the they still get credit, because the quality measure came from the Organization, that is an interesting question.

The only thing I would say differently about the question is they have EHRs. Our assumption is that they have en EHR for the entire organization. That is how we are organism ourselves conceptually so the different products they are putting together have to be [ INDISCERNIBLE ]. They have to be really clear on that because it is not the state of mind that people have when they buy brand X for ambulatory even though they have brand wife for inpatient.

Take my own organization, I have a single jay-10 across my own physicians except for the transplant team. They have a very peculiar need for doing specific reporting so they use a different EHR and then I have a different a chart for my none known physician in my community. For me to do declare meaningful use, I have to report to three different system capability reporting the measures.

For you to report quality, you would have to do that. Okay. [ LAUGHTER ] we are clear on the confusion.

The take home point in all this, that final bill comes out, there is a notion of linking the EHR to the capacity report quality, we really have to make sure that the data that came prom EHR and ended up in the warehouse versus some other system and in the organization reported it. Or we have to knowingly accept that we made a compromise that we will move forward.

I think you are next.

It occurred to me that the readiness if any of these measures seem to be a function of both how easy it is to capture the numerator and denominator, as well as the maturity of the vocabulary that is used to code it. I was curious to know how you plan to assign a read it as a value to these measures?

Actually, part of the redness, it you will hear more from Jamie in the operation side, but it is the maturity of capture and the maturity and availability in use. The terminologies. Snowmen is there, but how often it is used, – – Snowmed. You will see that it can be used in 2011, but it will be expected to be used in 2013 and 15. So hopefully that helps to answer the question, but that is what we would look at, that ease of capture and the maturity of terminology.

You would take what ever comes Jimmy comes up with and factor that in their assessment to how easy it is to capture the value and then assign the intersection.

In some cases like the eight sample of every time I send a person home from the office, I have to enter another code, there is a measure technically, technically can said it is mature, there is a G code RC P2 code that will do that, but that is considered by our team to be contrary to workflow and adds an extra step so that was not felt to be what the team wanted to use.

This is work that will go on over the next month because the books were writing that will really want this information available so our next work-group call.

Regarding WESs, an area, we have not said the work certification in terms of getting the source data consistent to any kind of mechanism, is that another group of people working on certification decide us? Of that EHR? In meaningful use – – the ability to exchange quality measure, should there be an entity that can receive them. Just a capability to do this. Comments that you would make? I do know that CCH IT has an advance Quality certification workgroup that is working in the very near term to have advance Quality certification criteria for EHR, but I believe that is 42013. There are currently certification criteria for EHR to use the problem less. TSA Med List and reconciliation. I believe, one of my additional responses to Wes’ comments, in order to achieve if I remember the wording correctly, to achieve meaningful use, you have to use a certified EHR and you have to use it meaningfully. So the assumption was you are using when we look at these measures, you are using the certified EHR and using the certified components, you are meaningfully obtaining the data needed for the measures. That was the direction we talk.

2011, looking at the metrics, requires the reporting of this quality measure to CMS been one thing that is not specifically discussed is CMS capacity to receive them at this point.

That is correct. I agree.

I think next we have Chris and then Kevin and then dug and then Wes.

Not clear to me that this is a fully question, but I will ask it to the room. It is picking up to what Wes had said. In the context of the earlier presentation, John, when he was presenting, what happened at policy particularly with H. IT, it begs within the enterprise communication, and the Fargo is the whole notion of patient safety, if it is the whole notion of meaningful use within the context of the enterprise, then multi vendor environment, effectively might require if we think this through, the moral equivalent of a HIE with an enterprise. Be that manifests as the warehouse, the benefits of some other kind of communication between systems because in our own environment, the May 0 clinic, we have the campuses and we struggled fiercely to make sure that what happens in Arizona is known to Minnesota for those patients that move back and forth and in a smaller scale, what happens to the transplant surgery might be useful to other care providers and vice versa. It gets at the scope of, you can have meaningful use of in and instituted and an instance of an EMR, but it is not really from the perspective of patient safety and perspective of meaningful use across the enterprise. Where we want to be, but how we reconcile that does not seem to have been addressed.

The H IT work-group is looking at enterprise the Enterprise Communications and we recognize in the interest of coordinating care, making our own organization talk to themselves can be a challenge. Although we have not in our particular deliberations talked about our architecture issues inside the organization, mandating specific code sets within the organization, we have always said border of organization. We may use proprietary cards, but if you transmit to the outside world, they must be translated into these industry standards and the man cultures. Your issue of encouraging people to get their own houses in order if they’re going to commit to the outside world is a very good one.


I have two comments. When the Apollo with what Wes is saying. We have to accept the fact that we will have multivendor environment. By multi vendor, not necessarily a multi more bender, you will have some vendors that built the airport tools and have left capabilities and E prescribing and longitudinal records for patients, and so there is going to be the classification of meaningful use should be down to the level, are they providing an ability to pull this reporting and capability of storing the information sources are my using System A, B or C? Because there is the best of breed approach in the technology world and then the single vendor approach and I don’t think it is who is this committee to describe which of those is the better path to take, single or multi vendor. Especially large enterprises, it will have multivendor environment. And you will have partnerships that created between the technology companies to fill the gaps to help meet the meaningful use criteria. My real question is maybe this is for Jody. A lot of the measurement, because of the funding and the incentives are Medicare based, are the percentages that we are talking about just around Medicare patients since it is tied to Medicare incentives or are the percentages is tied to all patients? Data physician sees. I’m not sure that – – I heard there will be a CMS regulations. Is it specifically around a percentage of populations from Medicare?

Certainly Medicare and Medicaid, but I would think all patient is the goal.

I did say we would be looking for your advice on that and then figure out legally what we can and cannot do I would defer to David and John. We would go on within HHS and your point Kevin, is important. It is not without precedent that CMS has taken the perspective that [ INDISCERNIBLE ] has relationship with the fast – that is of course the relationship that was established with the aid to cap patient experience survey. That is very well taken because [ INDISCERNIBLE ] architecture in his internment different system related to set of patience and there is a broader sense to – – will take a moment to recognize that we have been joined by Dr. QI proc, the chief technology officer for the White house – – Dr. Chopra.

Kevin’s point is a very good one. Let us reflect for a moment on the three possibility of the certification market recently outlined that the comprehensive EHR and the EHR composed of modules and the [ INDISCERNIBLE ] a chart. If you have an IPhone App for laboratory – – resulting and another asked for E-prescibing and they are completely different bet vendors and system and capable of – – from a clinicians office, should that be – – rather than a single comprehensive test EHR? And you would think that would make a complete sense.

I think we have dug next. One of the things that strikes me when we are thinking of the quality measures, but we are trying to do is measure things like evidence based practice and what is the best care and ways of both quantifying where we are and if you take a look at the gold that 2015, we want to be driving to with continuous improvement. One of the things that strikes me, do we need to consider as we think about the quality measures to build into the process, the ability to support clinical research or be able to do comparative effectiveness as part of gathering this particular information because if we think about it now, it may be much easier for us when we get to 2015 to continue this process. So that it is not just that we have 90% of the diabetics that are under good control, but in fact, we start driving further because we have a instrumented our system in a way that would support ongoing clinical research and clinical quality improvement.

[ INDISCERNIBLE ] has been working with H. H. S. and ANC and Working Group, clinical research and Data Standards and your point is a good one. Many of the data elements we’re seeing are not gathered as a byproduct. The actually require at putting the form putting to – – that are related to the clinical trial and go into a repository. It would be reasonable I think to have our body of work reported to this committee at some future date. And I know Floyd have a comment.

As I look at many of the measures in our database, many require additional data elements which we would call quality data set elements to look at risk adjustment and identify other issues are around a population that is being measured to add to research. Many of them already do that. The measure is self may include five or six elements or 15 elements but there is another set that gets reported with that for the purpose of risk adjustment and analysis. I would see that as an additional quality data set element to do the same. As John was saying for a clinical trial, there were elements that were not normally be in the record and many instances should not be in the record because not part of routine care. Many of the elements can be. One of the efforts of that clinical Research Group is to take what ever can be from the record and have that mapped into to pre filled the form and allow manual entry of everything else. A number of the measures already have risk assessment analysis – – to do that and I think will add to research. So [ INDISCERNIBLE ] continued to work on the – – like clinical research and trial. We will make sure this is coordinated with OSC and brought back to this committee.


I want to comment that there was a breakthrough. I am not sure whether the breakthrough for a group or I finally caught up with the group but either way it is a breakthrough. That is that meaningful use that stimulus money, incentive money goes to either a hospital or a physician. And it is not directly tied to whether they have one product or many that the breakthrough is our criteria has to be specific enough for meaningful use. If they had many there, they are using them over their population as opposed to only some subset of the panel of patient or something like that. If we think about it, it is the responsibility of the organization to do meaningful things. Whether the organization maybe a practice or a hospital then I think that helps clarify many of my questions.

Based on these comments, I want to clarify the policy committee that they feel that interpretation that is the physician that needs to demonstrate the quality measures, reporting that these are being done. Regardless of the infrastructure it could be a self built in MSDOS as long as they can do the stuff. It is not the system is an malpractice. The doctor or the hospital.

John we have comments or thoughts?

I think it has been a terrific discussion. I am trying to InVision the real-life setting of 80 – – to suggest that – – all the answers and queries will come out of one ideally certified system is probably wrong. The juxtaposition of multiple system, front and, Data repository, logic engines, the query, et cetera. I think that you are right, Wes, there is a breakthrough, it is not monolithic, it is not one-to-one relationship with one of the systems. That implies a recommendation, I don’t think it implies that we can set policy, but it is – it strikes us. If I am hearing a consensus, there is an interpretation that is likely that the data element that are sought have to relate to the system that is meaningful that we use and certified. But the elements are probably captured by some relationship of multiple settings in many if not most seventh. I think we need to feed that back to the Office of National Coordinator and as John suggest, to juxtaposed with the policy group. That really is a clarification that is important to point out an exhibition that we also waste that is useful in terms of the relationship to the five elements that you described it. Is that helpful to the group in terms of setting that?


The follow up on that very theme, I think it would be as we work on the recommendation to zero Wednesday, we also need to clarified that that particular issue that the provider organization we need to be able to pull this data across several either several platform system platform or whatever so that they can report on their population of our panel. That very strongly talks about the vendors. The need to be able to have standards between themselves. There should not be – absolutely any to have commonality in that information exchange. Particularly, what I hear coming out is that clinician is going to need to see how the decision support is coming into play. So they can answer the question. Not it’s strictly a EHR to capture the data, they have to answer the question that how many patients that I will need to find out on aspirin, or insulin, or my immunization profile for my kids. In my family practice, very quickly, and I need to have good querying capability within the EHR. In my organization, I absolutely – I have different packages and the inpatient environment for critical care versus what I am using and part of the ambulatory and in heartier, when are part of entry occurs. That is a very critical across the continuum of care. We can never want to rely on one single product, but we want to be able to create a single view for that patient or population. I guess – I think in 2011 or 13, I think we should be able to say that as we talk to this and put this out in the vendor criteria population that they more than anybody will need to see the need for standardizing the information interchanges to support this.

Certainly the ideal world, the vendor systems themselves will in price of a controlled vocabulary. We know in the interim there need to be a proprietary card that are now between the system and some vendors may refuse to change. Might be an interesting challenge internally.

I love reading the materials and I am excited about the project made and I had a quality question. South of clinical trial and north of just running the practice and running measure, are we starting to see some consistency and in the business analysis six of activities that are people running – my perception ties that there is a team of smart people querying the data that decide whether A or B intervention makes sense. They may not be treating has a traditional clinical trial but looking at mechanism for quality improvement, are we starting to see some consistency on how people of a running back analytics and what can we do to help the major that is incorporated?

Good question. I think it varies with an institution from place to place. In small ambulatory practices, I don’t know we are seeing consistency. There are products that are geared to collecting data for the purpose of the specific measures, pre identified and when something changes or new one comes out the update the system. I think in most large organizations, there starts to be some consistency. I know there is talk that standards organization like HL7 about how to combine the terminology and the data from using for research and clinical care. I know some of that work is still in progress. Not done. I think some of Barry’s by in this institution and how we encourage that I think through – semantic inoperability tomorrow. It is not the EC solution.

I think there is an amendment when answer as well.

I am a researcher for the May a clinic. It is not clear to me that the analytic infrastructure is the critical piece. But part of it, Floyd was saying, it was the information inoperability. I want to point to the clinical research tiger team within its be that is starting to recognize that clinical Research Information Standards really must align with clinical information’s and the because if we have differences in those world, at the end of the day, quality improvement is really a kind of research at quality people do not see it that way, but it is. To the extent that we have comparability and consistency between the way they conceptualize information and the way clinical trial folks can sexualize information and clinicians conceptualize information and commonality across the mains, and if you – in first – best becomes frosting on top, becomes arbitrary because what is an important is to – – the underlying information is compatible.

Last week, I was in an integrating that enterprise meeting, in Chicago. It has been two years since there was a domain develop coal quality research and public health trying to see how to coordinate the data among all 34 you use, research Quality Measurement and clinical use. It was very interesting conversation that occurred when for the first two years, there was discussion of clinical research the state that that’s how I mapped and because of the research tiger team, the comments went through and we need to get research looking at data as a clinical use and not map it. There is a strong movement now to court denied that and I think it’s be tiger team itself.

We should move on to Jamie’s presentation.

I want to go back to your point about communication of the policy committee. The discussion emphasizes that need for information exchange and what I know very well is that hospitals and physician practices using EHRs are not necessarily capable and probably will not be capable and a time soon of sending Snowmed transactions. I am very concerned about the environment where it stands today and the likelihood of a small thing moving to 2011 pennant implementation and it is really important that we communicate that to the policy committee and the world that the health information exchange can play in that is standardizing of that did that and being able to report back and the Standard as format.

One of the important roles of the health information exchange is data information that you will get in format – – or they can provide a unified view.

I know that administratively, Judy, you want us to take action on this presentation and that is will there be any objections to accepting this report as – – work in progress and there is additional work going forward?

Okay. Very good. We will accept the consensus, thank you very much, Floyd and let us move on to Jamie and clinical operation.

This is Liz Johnson. We talked about in years – and this committee last week, Thursday, we heard adoption. Are we going to do any correlation between 2011 and adoption of your one?


This is a discussion we had in the clinical operation meeting and that is John, you have been the case of HIT policy committee and meaningful use has the sliding multiple years, do standards slide as well or do we really want to say Snowmed is is a statutory requirement by used in 2013, you cannot release slide that.

You may want to use the microphone.

You have to consider the fast movers and hence the requirement that front. The fast movers will be start early in 11 and in place in 13. If you want to put requirements out in 13, fast – that is my suspicion. But you ought to debate. Does that make sense.

If we go through in some detail in Jim’s presentation, our Kendal years rather than meaningful use ears.

You are going to guide product development and some years the met some people will be 13 in meaningful use three and they have to be – I don’t know – my sense is this is the guidance that you will all the side. You know more about calendar years, mean pull years is payment related mechanism than it is when the vendor products or self development or whatever the strategy, when do day – if you are in meaningful use year three and you ought to move to proprietary from standard then you will do – – if you are a vendor you better be ready in calendar 13 even if the customers are in meaningful years one. If that makes sense at all [ LAUGHTER ]

To summarize, we as you’ll see in Jamie’s presentation, ICD nine is acceptable for 2011 and Snowmed would be great if you can do it, but by 2013, you will be doing ICD 10 and Snowmed so we build calendar year progression based on the statutory agreements going on in regard to changes like ICD 10.

I understand you are saying that the interpretation and the rest of the world was when we talked about adoption year, if you chose to make 2013 your adoption here then what we’re now calling 2011 standard would apply to 2013. If you look at the slide as a meaningful use presentation, that is the way it showed. I am confused.

What I heard the policy committee say was – there are two requirements for getting your incentive payment. One is that entity adopted a certified product and the other is they are meaningful use of that product. What I heard is the second half, the meaningful use part. Recommending that if somebody enters and begins to adopt in 2013 that they should meet the criteria for meaningful use year one. That does not necessarily – I did not hear them say that the certification requirements should be different. For the product. So let’s assume that ICD 10 is a standard for 2013. Somebody who starts adopting in 282011 will have to move and ICD tend to 2013 and somebody without in 2013 would have to have a product that utilize ICD 10.

What [ INDISCERNIBLE ] was given? What I heard was if you are in the first year of adopting, you might not be able to report the quality measures because it you are for starting to get your system up and running and capturing data. Perhaps if there was a requirement to have the capability of reporting on a particular measure but not reporting in 2011, there would be released in 2013 from having two up the reporting requirement the activity that they’re doing.

If they have CBOT for 20% of order and C POA for 50%, somebody who stars adoption at 2013 will have – will be held for the 10% Hispanic so that is really is. What I hear is there is no relief on the standard side. Is that correct? What we are saying is you may get a relief on the CP 0E adoption by fourth here getting to 70%, for example. In a standards perspective, the way you report the data, it will step up whether you start in 11 or 13.

The measures will be by Ed captioner, but the standards will be by calendar year.

Let’s see your presentation then I’m sure we will have a lively discussion.

Thank you . I am Jimmy Ferguson from Kaiser Permanente eight. First I will – I have a slide listing the workgroup members and most of whom participated in a series of calls. We did have similar to the quality workgroup, we had additional cost, we had some joined with them and we have had quite a number of hours on the phone in the last few weeks. Coming up with the recommendations. I want to thank everyone for their participation. First I will summarize what the whole presentation says. We have it used to a two phase process, the first to identify applicable EHR standard and then to assess the feasibility of implementation of those standards for widespread implementation according to 2011 versus 22013 versus 2015. We addressed almost all the measures. INT the very end there are a couple measure we missed and I will ask for permission to go back and look at the same and information as it applies to. We started as we were instructed looking at the applicable department adopted recognize or accepted standards. So that is what we are recommending for 2013 and 2011 as they apply to the measures. We did identify some gaps in the standards that might affect the use of the scope and measures for 2011. And lab results, there are no adopted standards for every four blood bank and surgical pathology or genetic test results. How those kinds of results can be reported in a standard, no currently adopt the standard that is something that we will work through. In general, while we are setting a level of standard that is the current adopted standard for the 2011 measure, I think we should be required for 2013, for 2011 we are allowing a degree of flexibility in our recommendation in terms of the use of unstructured documents including PDF and text instead of structured continuity of care documents and also allowing local and proprietary coding systems to be used instead of ICD Snowmed. There is some flexibility and I will go through the reasoning so that is my summary. In terms of the process that we used, first we did go through in reviewed the meaningful use objectives and measures. We focused initially on the quality measures and came later to the coordination of care measures. We identified dies existing DHI standard that could apply to the meaningful measures. We looked at that existing adopted recognize and accepted standards first and also looked at and listed other widely accepted and widely deployed standards. That could potentially be alternative. And look at and listed those as they may apply and also identified caps and the standard for the measure. And we did this process looking at standards for the measure both in relationship to the text of the way the measure was written but also looking at quality data sets the regard from our joint work with the quality team. In identifying what is in the measure the way it is calculated by the basher stored. We also identified the feasibility whites. Implementation of the EHR standard by 2011 or 2013 or beyond. We followed the same taxonomy which is also referenced here earlier. Finally and throughout the process, we took a formal step of saying what is our reality check on what we are recommending and we made some additional notes and wanted to make sure that this was a realistic set of recommendations.

That is the process that we followed and go through a particular example in some detail. As Floyd said, the existing standard for quality reporting are not geared to EHRs so the measure will now need to be calculated in terms of EHR standard in the future. So deeply here, we are we using standards that were adopted for different purpose. Some standards that were chosen for clinical interoperability are now being recommended for quality reporting. In particular exception to that, as Snowmed CT is recommended for the same purpose, but adopted for the consolidated informatics standard adoption which predate Hitsbee using Snowmed clinical documentation. When you look at the matrix of recommendations, you will see and you look later, you will see the same thing that are here and the visibility column and having been translated to the current the command of Hitsbee. That is the transmission between the process and actual recommendation. In this particular measure at we are looking at a position that is high risk for card it events for has been and identified that in terms of the adopted and recognized standards, we could use the standards that are referenced in the Hitsbee continuity document for E-prescibing and medication management. We did not see that there were any other widely accepted standards that were needed are applicable to this particular one of. We identified a couple of gaps. So back to the quality workgroup, we need a way to identify high-risk patients but also we did not bash the measure itself included a calculation that in part was based on patient self reporting of medications and there was not a specific standard adopted for that purpose. We thought the standards and that are the recognized standards were widely feasible for implementation by 2013. That is what we have in our 2013, but for 2011, we thought that a local proprietary code may have to be used. ICD nine may have to be used in 2011 and at the same time we do not want to penalize those who are able to get to the standards earlier than 2013 so you will see in the recommendation for each of the measure, we have in the 2011 column, the 2013 standard selection or recommendation and what we recommend as the allowable variation in terms of the local and proprietary closed, that appear in almost all of them. As acceptable alternative port for 2011 because we thought it was not feasible for 20 widespread implementation for everyone to get here for the 2013 recommendation. You can see in the reality check that we saw for the particular standards, they adopted standards are not currently widely deployed for this use. We have this discussion about that. As Floyd described, after these adopted standards approved for this purpose, and it gets back to the quality work group to oversee the detailed definition of the actual code ballets for calculating each measure and the particular recommendedstandards. We had a number of discussion during the process, I want to reprise some of them. We had a lot of concerns raised regarding the ability of those who have not yet implemented EHRs to get here. As well as a lot of discussion about those who have already implemented legacy to alternative and how they are going to get to this level. One of the main concerns for new implement terse, that was a ICD 10 and doing the same work all the work at the same time, but the greater proportion of discussion was really about the legacy system implementation that was already in place and what it takes to get to standards. As a sidebar, and Kaiser Permanente day, when we brought the different region two migrate to, system standards ourselves, we found that the loudest objections came from organizations that had already made that clear to commitment and investment in local proprietary system and alternative standards and I would not expect anything different. We had discussions on that. What we talked about was the longer the legacy systems are in place, the longer the proprietary and alt are in place, the more it gets built up around them and the greater the cost of upgraded to the standards. That is part of our discussion and making the recommendation. We believe we consider that fully. That is part of why we are allowing the degree of variation especially for 2011 and 2012 reporting. To summarize the recommendation. We’re saying that meaningful use based on the standards that are in the recognize and accept that accepted Hitsbee capabilities detailed in the attachment, it is recommended for 2013 and 2011 implementation of the 2011 measures. If you look at the detail that is in the attachment, and an actual Hitsbee documentation, there are many uses of the continuity care document as a summary record and specifications that are in there, the use of labs, are ex norm, drugs, and other standard, Snowmed is one of them and I want to point out that in some of the conversations and earlier part of the meeting, some folks recommend Snowmed will be required for 2013, that is not correct. We are saying that Snowmed or ICD 942011 or snow mad and I see the 10 is recommended for 2013. We anticipate the criteria should match the recommended standard and we did not have any length a discussion on certification criteria or process in particular. We are going to go through a single example, detailed example of the recommendations with this the percent of diabetics with under control [ INDISCERNIBLE ] that Hitsbee capability, you have to look at the attachment and the list of numbers to get the full context. The capabilities when 17 and 18 are inpatient and ambulatory prescribing. When 19 and 120 are structured and unstructured documents. 126 and 127 our lab results. You can see that this is a translation of what we have. When we went through the process we document things like CCD and labs. And actual recommendation, we translated that into the current document numbers that are used and accepted and recognized standards. When we say that ICD 94 Snowmed have to be used we are not specifying how BSI is stored or manage internally, but we are saying that you must be able to represent your data in ICD nine or Snowmed for this purpose. That principle was a subject of a lot of discussion and it applies to all the recommendations. Another thing that I will point out on this detailed example, you can see that we have local and proprietary cause and unstructured documents, they are recommended as allowable for this meaningful use measure in 2011 as alternative to basically what we’re calling 2013 standards. Those are removed from the 2013 recommendation for the 2011 measure. Also in 2013, we are recommending that ICD nine replaces ICD 10 and that is consistent with the CM’s timeframe four ICD 10 implementation and the current final roll from CMS. Instead of having 2015 column for say, we have what we call directional statement of intent. The direction that we think 2015 should go in and it is the recommendation of that direction, but we did not want to be prescriptive that fared far out. Remote device monitoring, there are is a lot of sender’s work and the way for home health device monitoring and so forth and it may be possible that those standards and specification for measure in 2013 but almost certainly in 2015 should be added to this particular measure. Snowmed CT so for clinical documentation, we believe is the target and should be used by 2015, but we did not want to be completely prescriptive about that so we are calling the directional statement of content is critical documentation is really the problems for this purpose should be done in Snowmed CT and now no longer ICD in 2013, but – – so we had long discussion about the feasibility. Of changing the documentation. Ozal this is about EHR implementation where ICD is really a classification system for administrative purposes and if you read it the CMS – that describes that – – ICD is for administrative and billing purposes. We wanted to maintain that split and we are really talking about clinical documentation of problems in health record use by physicians and hospitals. That is why Snowmed is then adopted standards for that purpose. To summarize the recommendation, we are requesting – the detailed recommendations are attached and a matrix so we can go through those to the extent that folks want to. We are requesting committee approval of the recommendations for the 2011 measures to be forwarded to zero Wednesday. We also missed a couple. These are in the second bullet here. Percent of encounters where it med rec reconciliation is performed, – – submitted a – – and that 30 day admission rates. The 30 day admission rate we deliberately delayed that one because we thought it would take too much time and we wanted to get our vote recommendation on the table. They’re the ones, we’re sorry we missed them. We are asking for permission to go back to see if the body of standards that were recommending or suitable for the purposes and we could ask for approval of an end to go ahead and recommend those but not to go outside of those and great new stuff. We also realize that the caps had to be filled somehow so we wanted ask Wednesday to determine what the process is for giving these gaps. A couple of comments, you have received electronically that document that identifies all the capabilities so if you see Jamie use those numbers, you will see them referred to the index. This is available in and an electronic form. As a PDF. As of this morning, all the Hitsbee work are available in indexed x HTML, you can find it in Wiki that – –

Makes it AZ to navigate because it is HTML-based.

Gaps. I think you heard Jamie highlight the yes. Important that coming out of today’s meeting because there are a series of gaps identified that we will work with ONC and that ONC will want to make sure that these caps are addressed by Hitsbee or organization as a prepared because we want to make sure that we fill those. It is important to see the division of labor between clinical operation and clinical quality. You saw will it come up with the measures. Jimmy came up with the mechanism by which the data is gathered, but floored once again came up with a specific code of values. When we say ICD nine will be used, you tell us that is to 50 that XX, and snowmen concept and that. That would be good coordination and interplay. It also purging make up about structured and unstructured data. This is the escalator over all over again. Would it not be plugged tablets if they have a – – a completely structured allergy list with you and II clinical designation on every substance the higher allergic to, food, medication a component and every encounter broken down into a Nye’s History of Present illness and chief complaint. We are not there today and in 2011 it will be a stretch. We will see in the recommendation is they have said 2011, structured great. Unstructured, okay. If you can take a PDF of the encounter that happens to have a human readable problem list medication list and note, that is okay. By 2013, we really want to have atomic and granular. It is a road map of getting us there. With that, we would like to open up for questions. Mark might have the floor.

We have a fundamental question that I must admit somewhere along the story here. We talked a lot about what standards and what Hitsbee constructs might be adopted. It is not clear to me because in one hand a little bit earlier we talked about we’re not worried about what codes and structures are used within an organization. But only when it hits the barrier. Are these the standards for transmitting because in some ways the measures described, with is the percentage of patients that have adequately controlled hemoglobin based on some criteria, and we are talking about CCDs and things like that which does not really – I don’t understand that.

Mark, this is Jamie. We are talking about a list of standards for example within CCD, Hitsbee made specifications within each template and same thing if we look at Labs, the number of different specifications within that and what we’re saying is the standards that are referenced in the specifications should be the one in this case the quality workgroup, specifies the core values for the calculation of the measure. We are not saying that this is the way that the data have to be represented and an internal database or anything, we are saying that it does have to be able to be whether through translation or mapping or other means, it does have to be reliably used for population of the measure it and in a specified code set.

The CCD is the part that throws me.

From my perspective, Mark, the transmission of data between two organizations, whether provider to provider or provider to buy surveillance or quality matrix organization, these are the standards that the work group has proposed for those transmission between organizations, not for use within organizations.

In terms of our use of CCD and recommendations, many of the recommendations have to do with coordination of care. Both providing summary records for example, encounter summaries, longitudinal summaries both to providers and patients. For that purpose we are saying CCD is essentially the format for transmission, but we are not – in other cases, we are using the terminologies that are referenced within the Hitsbee standards that should be used for the calculation.

To be clear, when we are talking about transmitting the quality of measures, we’re talking about sending for example a percentage of diabetic that are controlled. There is no accepted standard for doing that. There is ongoing work. There is discussion, clearly level two or three standard or category three, whatever. For that purpose.

Floyd ORG Jamie, you want to talk about KU RDA? KU RDA is work in progress.

KU RDA is address the standard for HL7. The patient level report which is all the data it is a level one. That is not calculated, what is your performance. It is for each patient. What are all the data elements. Level two is more for aggregate and three is higher-level aggregate. Level two and three is in May Testing – – is in a testing and level one is still is work in progress but addressed standard. And uses CDA format.

What is in our recommendation is not the actual transmission of the measure with patient level data, but what we’re talking about is the calculation of dent numerator and denominator by a meaningful user.

I do not understand what that has to do with CDA or CPD.

To summarize, and Jamie and Floyd, jump in. We wanted to do a couple things. There is clinical care coordination which requires a summary problem list medication list and laboratory information between organizations and that is the CCD. There is the measurement of the individuals performance process, outcome with regard to quality measure and you have specified the vocabulary is needed to do that. There is the transmission of numerous and denominators which is very much a work in process. What you said, Mark, QRDA, very early in standard creation process.

Those are the three levels of standards that we are looking met in the committee. My point is I think it is premature and inappropriate to include CD a, CCD under the bullet items that are quality reported items. Certainly appropriate for sharing information between organizations that CCD is still fairly early in terms of abilities to deploy. In the real world.

Right. Certainly CDA is widely used, CCD is emerging and the question I guess, coming back to the committee is we have specified the vocabulary that would be used and you will come up with the code sets and values, but the transmission of actual patient identified data to a quality registry, that is getting to the heart of Mark’s question. You see that the CCD document per patient or the see that as a different type of message board does that – – is that work to be done? We have not considered and specify that question and we have not specified in that consideration. It’s

In that case, for example, the Hitsbee 62 Guide for CCD includes some terminology, vocabulary standards in the relevant sections and those are the ones that are relevant to the calculation of some of the measures, not talking about a man’s of transmitting patient level data to a quality data recipient.

I would suggest to clarify that to avoid confusion by others by removing that reference. I do have another comment.

The work for the committed to clarify it once the measured at the patient level has been done and once observation has been made, how is that transmitted to a quality registry? David. David Macaulay. At risk of piling on, I want to agree with Mark’s point. The use of CCD in this context was extremely confusing because CCD is a data standard for transmission of a snapshot in time. There is no specification of what the snapshot has to be. Could be a single encounter, could be last year. It is for moving data from place to place. Does not represent internal state about the patient. CDA, describing clinical document about a critical does it may have a included the that that has specific instance. A CCD will not work in that context. Clarification is really important. Otherwise, vendors may assume that you are trying to imply that the CCD is a data structure which is

As chair of the revision process, I am painfully aware of the provisions of ICD. That being said, I have asked about snowmen. Specifically, while there is, in the Hitsbee documentation, a clinical numeration that is the list. It is not actively maintained, the best I can tell. It is widely acknowledged to by its developers to have specific gaps. It does not have pediatrics information at all. How do we sprays this politely, it has other shortcomings. Furthermore, the National Library of Medicine yesterday released a clinical problem subset of [ indiscernible ]. They are the National League designated Center for snow implementation. While I personally have not examined it, Bob has suggested to me that they are different. So, we are — since the clinical problem enumeration is such a core component of these recommendations set and very few clinical organizations have implemented this and even the men’s of what constitutes clinical problems, how do we for is this a tad fuzzy in United States? How do you see the reconciliation of the reconciliation of this moving forward as bearing upon Snowmed?

Obviously, there has got to be in maintenance process for the specification of not just Snowmed, but also the last summit list of labs and drugs and so forth. I really thought that was out of scope for our particular work group. If the current list that is an adopted standard is the list that is used by the Kaiser is VA my understanding is that NLM will be maintaining a problem list and that whether it is there a Hitsbee or another mechanism, there will be an adopted standard for problem lists. That is what we should be using. In terms of the maintenance of it and the degree to which if it does not meet the needs of the code values that are identified by the quality work for these particular measures, then it will have to be updated for that purpose. So — There is a broader question. Starting CHI work where Snowmed was first adopted and through the Hitsbee and FDA use of the problem was so upset, that is what we are keying off of. I am not disagreeing that has to be maintained, but we have selected what is there now.

So the question is, given that we have this rather long will these year ramp up, will we be able to achieve the clarity that you ask in these multi years? I have just received the above NLMs problem list subset. We are going to be implementing a tester over the next year. Certainly, I would be able to report back in 2010 how that is going and how to limit actually reflect on the 2013 application for Linda, I think you’re card foul. I imagine that you have a comment.

Just a recommendation to the subgroup to go ahead and invite the [ indiscernible ] to come and talk to you. You are referencing a number of things taking place in the federal space. I have done standards for a long time. Nobody has paid any attention. Now all of the sudden it is getting quite a bit of attention. There should be some fixes coming to the federal activities that are taking place. The more verbal you are, the more we have provider’s doing that feedback loop with places like the National Library of medicine. There will be able to advance quite quickly. Keep those communication lines open.


This is a bit of a subject change, but as part of the deliberations on the subcommittee, there is the column there that is sort of, what is the feasibility and the timing appropriate for these? In that deliberation, the question comes to my mind is sort of, what is the target we are shooting for, feasible for what percent of the population or for what percent of people implementing systems? This is really not a question as much as is — a question, I guess, not in a sense for the subcommittee, but a question for policy or even maybe some insight into those who passed the legislation. Is the intent that we should set feasibility in that sense at a level that we think 90% of the institutions would be able to benefit or 75%? We are shooting for sort of an unknown target when we say whether this is feasible. But now, there is such a step, except from of skip — such a standard. Leading institutions would be able to meet almost any standard and others that are, basically, not automated of all, you are setting the standard. I am asking, I guess, if there is any direction that could be offered about whether we are trying to shoot for 90% of people being able to achieve this if they work hard or 7/8% or 100% or 50%. Is there any direction that you could give about how hard we are trying to make this?

And I think our last meeting, there was the question to David, are you go into place a number? It has been discussed previously that 70 set of all hospitals and 90 percent of all doctors will have a electronic record by 2014. Should we shoot for 20% or 80%?

I think the better part would be to repeat David’s response. There is no number on the table. We are just shooting for this. I think there is a judgment call both here and in the policy community about what represents terrific progress. There is this judgment call. Ideally, there would be a number. Legislatively, there is not. I think it is a hard one to pick, even if you picked it to justify. I think the other thing I was thinking goes back to one of West’s comments on the certification. When I am listening to you, there are Standard directors. [ indiscernible ] versus Standards more for the exchange. There are really three categories that place simultaneously. Part of the question is, if we are going to certify EHR, what exactly are we certify in here? We have three categories going on. Do them — do you roll them all into the EHR? I suspect the reason that is sort of irrelevant in this particular percentage conversation is that organizations made in a modular cents could be larger ones from EHR from the quality reporting apparatus and from the exchange apparatus, I can meet the standards even though I am extending — I think it probably still have to think about having the EHR pass all of these things for those organizations. That is what they have got. They will not have the larger apparatus. They will rely on a vendor. Nonetheless, I don’t think we have a percentage. We are not like to have a percentage. Use your judgment credit I think we have to rely on industry about how best to go after that in fighting ways that are clever. We do not have a number for you.

And what we can up with in our [ indiscernible ] was 20% of the industry has deployed it. Ready for introduction was a two, well-developed was a three. In a sense, we said 20% of the industry has already deployed it. It is at the Gardner threshold where the hockey stick will likely occur. So, we have not come to this point, come up with that we think it is 80% achievable. We just think it is mature enough for introduction. We have several others. Let’s go ahead with Doug.

One of the things that sort of a person is that there are seven capabilities, and structured documents, ICD nine, and [ indiscernible ] one of the charges of the Quality group is that we have to come up with a value sets that will help define those quality metrics. So, there are five or six different kind of standards that might feed into a this quality metric. A variety of different lawyers have been associated with them. Some people might have X norm or they might have Snowmed or they might have ICD nine. There is a whole number of different permutations that this specific standard that the quality group needs to take a look at. When I look at that, and I am not even sure exactly how to interpret local and proprietary codes. I don’t know if that is something we define as what that would be or that would come from the local systems. I personally, as I am looking at this and trying to figure out the impact that has on the clinical quality group, it would seem to me that at least we need to identify a couple of these measures, and we need to kind of go and flush them out in detail, not all of them necessarily right away, but at least one or two. Just to see what the impact of the operations group is in terms of defining those data elements, how that is going to impact the quality metrics come and the number of possible equations that we have to define both in terms of numerator and denominator to support those standards.

Let me just ask Floyd, do you want to make a comment on that?

I know you are on the work group. When I saw the local codes and the free text, pretty much my assumption was that a value sets that we come up with for those measures will be — we would expect that someone locally is going to use some analysis to take the free text or two of the local codes to the value sets provided rather than expecting that we would be able to provide some value set based on all local codes as an example. And I also — I think I discussed with Jamie earlier that we would not necessarily, if we came up with the Snowmed by use that, we would expect locally that that could be mapped to ICD in nine and use their local codes in order to do the appropriate reporting. Is that an agreement with where you are in the operations group, Jamie?

Our thinking was that where we specified as an example, Jamie as an alternative to Snowmed, we weren’t working, coping that the quality work group would define a specific code values that would be used for calculation of the measure and not leave it up for local limitation.

I will add to that. For retooling, we would expect to do that. The caveat is for those that have been retooled under the Hitsbee work effort. Like the stroke three, they have been retooled with Snowmed. That would take extra effort to add the Jamie ICD-9 list.

Just to reflect on this, I think what is being said, for certain kinds of data exchanges, I think we understand the structure and unstructured makes complete sense recognizing that support will be better if it is structured, but it is human readable. For quality supporting maybe we cannot be quite as close as saying, any local codes set could be used, because then there is not a code set that can clean the map to it. We may need to get a little more restrictive sang, in 2011, we recognize if it is a problem, well, diagnosis is a proxy for a problem and [ indiscernible ] is accepted. If it is a medication, we know the [ indiscernible ] is not widely applauded, – deployed.

I just want to emphasize that I think there is a lot of value in actually taking these and looking at one or two examples. In the process, we are going to learn a lot. It could be the combination of ICD-9 and NDC is better than Snowmed — and I am making this up. We are able to better identify certain aspects because of the way in which those systems work in terms of identifying raider and denominator. I really think that we need to do that. We will learn a lot in the process about informing the rest of the work that goes forward.

Right. The next call of the clinical quality group and clinical operations may want to consider a joint call.

One more comment on that. In the process of doing that, we need to do it with the developer of the original measure, because often there are concepts that are not necessarily written in the specification that led to the choice of the set of values that they are using. That is the experience we have had. We can show some examples from what has been done in the Hitsbee effort. You can read a paragraph of what they are looking for, but there are some nuances to it that only the developer and the measure and those in order to come out with that result. We would have them at the table as well.

Very good.

Nancy from the zero d. In this discussion — as this committee starts to mature in its meetings, I would like to ask if we could clarify what role this committee has in identifying standard is that need to be evergreen or that need to be fleshed out in more detail as soon as possible to meet 2013 or whatever. What do we do about where we see gaps did we know that Hitsbee has some roles in there, but there are some Brodericks — broader perspectives that we are dealing with. I would also say as an example, four organizations as we try to implement ICD-10, [ indiscernible ], which is probably the right direction because there is specific context to use it. How do you maps that up to a coarser categorization of ICD,s. It has been a big problem. It is very difficult. We proved that in the demonstrations. Our organization had to call and a group of people and said, what do you think this problem is? Many organizations use extender codes for the ICD-9 today, like unique extender code. I think many organizations are trying to grapple with, are we going to have to do the same thing with ICD-10? Is there a better granular the in those, or should we use Snowmed? I think if these quality measures in these issues — if we could give some guidance in that area, that would help quite a few people. I know my clinical staff is struggling right now. How are we going to collect these data for the quality measures? We probably have to add more extender codes to ICD-10 credit I think we could very well help organizations say, we recommend that you do this in the Snowmed context or do this in here. It is very expensive to think of continuing organizational unique extender codes in the ICD environment. If you have tried to buy a product and you want to continue that and you know every year you have to do continued organizational reviews, you are looking at a grim process from experience. My two questions are, what role do we have in helping identifying gaps and where there should be rapidly will agreements? Second, what we do about making helping, should organizations look at the ICD and Snowmed relationships?

In the chart that we were given that shows the relationship of all of these various groups, a the HIT standard committee can consult with Hitsbee and others as is necessary to gain implementation Guide and harmonize standards. Presumably, we will report directly backed with ONC. The could Commission standards to be harmonized or create them as necessary.

Or create these thought you said. You are going to be testing the 6,000 problems. I think that is a very big problem.

I think the answer is up to us to identify gaps and work closely with ONC in together figure out how best to apportion them.

Also, to reflect back on your questions about gaps and Evergreen Standards, part of our recommendations are in fact to ask ONC for guidance on how to deal with gaps. What is the process for dealing with gaps, and how should that be addressed? What I have heard in a couple different comments here so far, Chris’ and others, we’re about Hall do standards get maintained? How do specifications get expanded for additional measures? I think that relates directly to this and should be coming in my view, a recommendation that we make as a committee. Again, probably to ONC to request guidance on how to deal with the need for standards maintenance, which I would call that all different aspects of standard maintenance.

It is a multi tear effort. Not only do you have to add to the content of the standard, you then have to continue to maintain the specifications and the update specifications for the use of that content.


Thank you. I cannot emphasize enough the slippery slope of proprietary coding to be involved in any of what we are doing. Because of the fact that we are relying on this to grow in the future, we need standard — sorry. And we need standard coding officially recognize coating with an official maintenance process with a regularly expected release schedule, so that we did not end up having every implementation of our EMRs take eight months because of the proprietary coating that has to be installed. I cannot emphasize enough. Strongly enough to where I would not approve with a the wording of the proprietary coding in the clinical operations. We have really got to stay with standard coding. Whatever standard ones exist and then work with whatever entity maintains them.

So what you’re suggesting is that the ICD-9, [ indiscernible ]?


Into the recommendations that they all — I think that is a recognition based on our discussions. It is not feasible for a widespread implementation all of these standards by 2011 in that timeframe. Those who can get there, we certainly want to encourage and not penalize, but at the same time, for calculation of the measures, not everyone can get to all of the standards in that timeframe.

I respectfully totally disagree. It is a slippery slope that will not recover after the 2011 if we cannot meet the requirement, then we should back off on the quality standard that we are trying to measure. If we did not have a coding structure to support it. I have a question on the side. I think I have made that point. I can move on. I need to understand the incentive process there are two different incentives, as I know of. One is for you to give financial support to install EHR, and the other is in Medicare payments being less or more, depending on if you have one. Is the meaningful use tied to both of them? Do you have to have EHR that is certified for meaningful use in order to day in the payment — day in the payment incentives on the road? I ask this because of a comment made earlier. That was that hospitals can have anything out their credit there are providers or doctors a who will not participate in a certified EHR. If they were able to somehow pull the data together by whatever means they could, do they then qualify without a certified EHR for the incentive payments?


That helps me understand how the two are tied.

There is Medicare and Medicaid incentives. The Medicare incentives do not fund you to go out and buy EHR Credit they are paying you a in 2011 for the meaningful use of EHR.

It is a set of functional criteria, but the definition of what a certified EHR is is evolving. We could say, certainly, we have seen in the waiting — latest meaningful use integration that you must have 10% of your transactions in a hospital entered through an electronic ordering system, whether that is itself a bill ordering system or whether it is a commercial product I do not think has been specified. Just to clarify, to my knowledge, there are not any incentives to acquire EHR other then the Medicaid I believe does allow some early acceleration of some of the funds if you love greater than 30% that might assist with the systems.

We want to be sure that we do not overstep. I think your questions are good. I am going to take your questions in the spirit of trying to understand the relationship to the specifications.

That is where I am coming from.

It is clear from the comments that there is still ambiguity hovering over the last discussion. From the last discussion, I think we recognize that there is no singular system that I am aware of that would answer all the different utilities. It also appears to be that there is an invasion in the certification process that is evolving that will define certain components that are going to be fundamental. I think the final policy in rulemaking through HHS will define that relationship between the cert peace and a meaningful use piece. I think we would be overstepping before any elaboration. Is that a fair working approach?


Let me step of my role and say, how am I approaching this? My interpretation is that a certified EHR would be a very Corps piece. There’d be certain actions like provider entry that is a component of that. However wonderful function they are in terms of that utility, many of the quality measures are derivative data that are entered for a variety of sources. Order entry plus the pharmacy system, for example prodded the conjunction of data to some sort of derivative calculation may live in a data repository. Just as an individual and thinking about this relationship and looking forward to that policy.

That was helpful. Thanks.

I also want to be a little bit cognizant of time. I want to make sure that there is some extraordinary work done on privacy and security. I think these conversations are also incredibly helpful. If we are not clear on these points — I really appreciate bringing it out, but I don’t think anyone else likely is either. I appreciate that. Let me turn it back to you.

As far as standard codes, I want to [ indiscernible ], who I think said clinical standards is as clinical standards does. What I mean by that is that the whole issue of standard coding has come a long way over the last few years. We have gone from being a for the we could not afford the cold sets we had in some cases, having cold sets that were so big it was hard to say how to use them, to applications where people are not talking about identifying standards subsets. We figured out how to pay for Snowmed there is no doubt in my mind that somebody is starting a new and would prefer to go with standard code sets rather than try to make all that stuff up again. Even though it is not trivial, you still have a lot of work. It was not there before. We have almost astute use of IT being done by places that had to improvise along the way. I have been thinking about, how you deal with that, and how you deal with all the other stuff? The thing that strikes me is that we are really talking about three kinds of interoperable Libby and one kind of in probability here. We are talking about the inner upper ability that is conveying to hospitals and physicians what we mean by a clinical standard. It is the reverse direction. There has been a lot of work done both in Hitsbee and other communities and in this work group to nail down what we mean by that. Some of the research in this work group was to look at what other standards were all in use in order to inform what could be used to respect quality standards. Just to give the unambiguous or possible [ indiscernible ] creditor there is the interoperability about sending it out. There we have more work to do. There are measures for meaningful use that are more about just getting the information from one physician to another to support a transition in care regardless of how well a computer can deal with it. We did not actually have all lot of studies, I think, that show that that is useful. Certainly, we know that it is useful in respect to the environment. We know it is the lack of information for people going in the nursing homes and all kinds of things. I would not want to do anything toward measuring quality that got in the way of enabling that easy stuff as a step on the escalator, as a physician. If that means I am anti code, I will go fight it. I was interested in capability 120 in your document, which in effect says, for now at least, the way it is used — for now you can at least send as text for PDF. What it doesn’t say, which I would like to get feedback and is should be considered is if you can send it as an image of a document. There are a number of EHRs and now that have some structure data in them it seems like. Being able to access that information at least for awhile makes a lot of sense.

And that is also in capability 120. I did not see it said in the document.

I think you have to go to the next level of detail, which is the thicker document.

Oh, there is a thicker document.

Let me summarize all of this very good discussion. I think there are some elements of confusion between those standards used for the continuity and coordination of care, those that are used for the transmission of quality measures at eight denominator and moderator level. There is some concern. At least state [ indiscernible ] and something basic. The other is, innovation has happened with proprietary codes that have worked in the past. How do we actually figure out how to leverage that bucks maybe it is good for care coordination, but it is hard for quality. It seems to me that, and I want to get the consensus of the group that based on all the comments we have heard, there needs to be some revision done to this work so that it is a little bit more clear to all of our stakeholders. Again, I would ask a point of order from the ONC folks. If we want an end to I just — wanted to digest all of this and revise it and bring it back at the next meeting incorporating all of these comments, how might we do that? Do we do an inch from acceptance pending the revisions? Do we say, we will table it until the next meeting and we will bring the revisions back? What has been done in the past?

That is a good question what the policy committee did when they wanted to go back, they tabled and came back. Our timing is such that it is going to be challenging, because in order to get regulations written and published by December, we are trying to get our heads around this or we will not make our deadline. I would say if there is anything that you are comfortable with four working on in the interim that would be helpful. Obviously, if you want to think more about it, that is your decision. We would be happy to hear your thoughts on these recommendations.

Just thinking about the work that has been done.

I wonder if there is a way to porch this into two pieces turn a one is to ratify the standards, but also an agenda item on the ongoing discussion and on the in this novel. One thing out there, the performance level for any of the metrics, which will not be set by us, may ultimately resolve the issue of the one thing this are ready for adoption. Again, I believe the entire trust of this effort is to help make people succeed. I start with the frame of that all this coming together is in the interest of propelling the help. Whatever their performance levels, but ever the difference pieces, they are not meant to be barriers. I think this is for the privacy and security is such an incredible contribution credit is all friend as elements of support. Here is my suggestion. If the group feels ready to adopt the granular elements in a general sense, come back to the use of the data centers for the director of functions and recognize that whatever the outcome of that second piece is ultimately going to be calibrated to the performance levels that are identified elsewhere. Does that some like a proposition given — you know, essentially what we set out to do in the timetable?

And try to make very specific recommendations to say that we agree as the group that the continuity of care document is an appropriate means of sending a summary from place to place for care coordination. We have a goal to use all or X norm and Snowmed as the vocabulary’s, and we do have some additional work to describe the path to get there. Is that what you are suggesting?

If I can just point out, I think that is actually what we have in our recommendations. That is exactly what you are saying. I think what you are suggesting is, in fact, the recommendations would be adopted as they stand, but we would have to come back and review the application of the recommended standards to quality reporting and the transmission of quality data.

The chair accepts that as an motion.

[ laughter ]

Is there anyone who has strong concerns? I see a lot of head nodding positively.

This is Mark. I have a strong concern. I do not think the CCD reaches the category one Standards requirements.

Your concern is that the notion of using CCD for care coordination data exchange in 2011 would be a concern?

Yes, to the extent that category one standards are those that are at adoptable levels. I think it is pretty hard to make the argument that is there.

I just want to point out, our recommendation is that that would be a 2013 requirement. In 2011, unstructured documents, including free text and PDF also could be images used.

Mark, with the understanding that this capability 120, which offers the unstructured option, which could be taxed, PDS, image, could also be HL 72. and setup. Mark, would that meet your criteria?

I think it is our least conceivable.

Okay. What we have is a motion on the table that has been seconded with adopting these standards and recognizing that as they articulate with the quality measures, there will be clarification made.

And that I have a question — a consensus with [ inaudible ] I am falling. Are we in agreement?

I still have my issue with proprietary coating, because I do not know how it relates to?

Let’s make sure that that is noted. Stena right, and I understand the majority.

Any others?

Can I just asked? Just for clarification purposes. Does what you are saying mean that the table we have where its as recommendations for 20 of an implementation is, basically, those are the recommendations —

2011 and 2013.

Okay. Thanks.

That are in the attached table?

That are in the attached table.

Thank you for that.

We will work diligently over the next month to clean up language to incorporate —

At a guess a friendly amendment to the motion is that we are also recommending that we continue to clean up the last couple of measures that we did not get to and see if these standards can also be used for that purpose in the same way. We are also recommending that ONC determine the process for filling the gaps.


I look at — the question was, are we are proving the power point or the matrix? If we are approving the matrix, I see a line here that says — It is hard to tell, because you have to read the page before. Percentage of all this is page 73% of all medications entered into EHR is generic when the chair — generic options exist in a relevant drug class. I see recommended for [ indiscernible ]. Care document and a number of other things. It does not say or. I cannot even know what this column means. Does that mean that the EHR has to do all of these things? I just don’t know how this applies to that measure? I mean, if I understood, if it was informing the discussion on whether the measure was feasible, I understood that. If it is implying that there is a requirement to either certified or use these standards to achieve meaningful use, one, it seems to contradict. Two, I am having a hard time. I do not know that [ indiscernible ] is available in 2011.

Let me clarify this. It is the and that is confusing you. It is saying that and the unstructured documents may be used in a local and proprietary code set may be used. Structured documents are not required to 2013. It is the fact that the exceptions are added to the end of this list.

The way the wording is also developed is that and says in the specification of the measure that will be done or overseen by the quality work group, they will use the standards that are referenced here in the and statements. Perhaps it would be clearer, and we did go back and forth and it has been suggested that these should all be or. If we want to consider these all as or, that is —

I wonder if the original mover who did not always make a motion at the time would accept it as a motion and they would consider a friendly amendment that the substance of the documents that are available for ONC staff to use, but that there would be a revised publication that clarifies these issues. I think it is easy enough to explain it to staff. It is really hard to explain it to people who are not here today.

I just want to be clear that I do not think we are going to see the quality work group come out with a [ indiscernible ] or how to determine something out of a PDS. When we developed any of our value sets, they might be ICD-9 and Snowmed, but they are not going to be using local codes. That is not feasible. The way that was worded makes it seems that could happen. In the spirit of what we are getting at is contained in the power point, the wording is confusing the added to the understanding that seat 32 would be used to coordinate care, and in 2011, a PTL for on textured format might be used. Recognizing you are coming up with value sets, structured values will be used and we will continue to work on the mapping of the standards to the quality transmission.

Very good. I know we are behind time. We want to give time to Dixie, but I also realize that there are some biology breaks that need to take place.

How about a five minute break, but let’s convene at five minutes. Understanding — I appreciate the very good discussions. I just want to recap. The general matrix, the concept. The work to come back with the uses for quality. This discussion will be captured. ONC staff will work with John and Jamie to capture that in an iterative, kind of revised document. I appreciate that.

Basically, as I understand it, the recommendations are approved, but we have to go and revise our documentation to clarify the points that Wes and others have made here.

Okay. We stand adjourned for five minutes. We will reconvene shortly.

[ HIT Policy Committee Meeting on break until approximatley 12:23 EST. ]

[ Captioner is unable to make Brian Ahier’s comments due to being on a listen-only line. There will be a new captioner on at 12:30 EST, so please repost your comment so that it can be made during the public comments. Thank you. ]

We will be starting shortly.

We are ready to resume the meeting. Can you please take your seats? Can you please take your seats so we can resume the meeting?

Thank you all for sticking to a tight schedule on the break. I appreciate the dialogue. It’s an interesting discussion and obviously a lot of issues that require continuing work. Please understand the commitment is that critical operations work group will be addressing all of those issues that were identified for further, work. Obviously, and have an interface with the clinical quality group. I think the sense of the group about the uses of the standards was clearly expressed. I appreciate that discussion. Someone let me and note and honestly I cannot read it.

The Microsoft Web has requested that she make a public comment. I’m a doctor, I can read this.

I am sorry to whosever hand writing that was. We will move to public comment after the next session. Let me go back to you John to moderate this final piece of work.

Dixie and Steve will present the standards for security and privacy as well as get inside to their impact on the consumer. Why will all of this make lives better for us as patients? Dixie? Next will be the brief warm-up act to Dixie. In the interest of time, I will take less time than we planned on the consumer part. We wanted to put a little bit of this in context. First I want to thank the members of the work group, the active members who were on two or three or four or five calls over the last couple of weeks and especially thank Dixie who was fearless and tireless and did an enormous amount of this work on her own late-night and on airplanes and that sort of things and she was shuffling around the country. We owe her a deep debt of gratitude. We wanted to establish a little bit of context before Dixie dives into the technicalities. What is we are obviously seeing lots of polling in surveys during the last month on health care reform, some of them in response to the proposals in Congress. Some negativity is appearing in some of those. This was a survey released last week which reminds us of the dissatisfaction with our health care system and move to the next one. On the subject that we are addressing today in the context of the discussions, this was part of the same survey again released last week. The very sobering for all of us, the basic finding here consistent with other surveys we have seen, 68% in 2009 were not at all confident that there EHR would be protected. Only 12% were confident they would be secured and particularly note the jump. It is sobering from office from 2008 to 2009 from 38% to 51% of 1000 people responded saying they’re not at all confident that their electronic health records would be secure. Just a reminder really as we died then that we are living in a world that is unacceptable both in terms of our health system and in terms of the paper based and faxed based system we have. We need to move to a system that is going to solve that problem. I think I feel confident that the work that Dixie has done in this committee has done in the work group, it is going to move as a better place in terms of security and privacy. I would make an addition to the points made here, I won’t read them in the interest of time, I think it we will be better in able to, the electronic records protected when enable consumers to participate in decisions that improve their care in the doctor patient relationship. Whether we all know, the use of computer networks introduces new risks to personal privacy. I will be labour the point again. The main reason for the consumer and patient perspective we need to do this are listed there. Again, I will not read them. On a personal law, I learned a lot participating on this group there have been discussions much like the one we have half and hour or so ago. I still won’t claim to know the difference between the. [Speaker Faint/Unclear] But others on the committee, I am getting there. My big play and I made this to our group is that we have to pay attention to communicating this stuff to folks be on our realm. I make a commitment to do that as best I can. Turning to Dixie for the technicalities. Thanks.

To encourage the broad adoption of EHR, the stimulus bill offers reimbursement to eligible providers to meet two different, but complementary requirements. First of all, the have to acquire a certified EHR product for service and second lady had to demonstrate a he or she is using that product or service meaningfully. The standards committee, all of this here me to recommend both criteria for certifying products and criteria for demonstrating that an applicant is using that product meaningfully. I think we too often get those confused and think we’re simultaneously certifying both the product and its use and they really are two separate steps and, in fact, two separate steps of criteria. For privacy and security in particular, certification that it defined function our service metes a certification criteria is not sufficient to demonstrate that it is being used meaningfully or that it is being used at all. In particular, for example let me give you an example, I am certain that the certification criteria for EHR products Fidelity will include a requirement for an audit capability. The capability record audit of actions. As anybody who’s worked on the system knows, you can turn off audit team. A second example is the encryption. I am sure that these products will be capable of encrypting information but if the EHR is used within a hospital that is physically protected, in all likelihood you probably won’t need to use the encryption. If you post that system on a laptop that you carry around the community, you probably will. It is important that the security and privacy workgroup specify both of these types of criteria. We have adopted an approach that addresses both the certification of products and the demonstration that the user is using, the certified product meaningfully. In these two citation read the approach that we used. We started with a eight priority areas of focus identified in the long and we extract it does and identify those that are particularly relevant to security and privacy and that security and privacy can speak to. Then we looked at being standards reference in the HITS P it we identified standards and will identify gaps. Ultimately out of this, we will have service is required, certification criteria standards required and then if they product meets all of the certification criteria, it is certified. Moving on to the meaningful use, we anticipate identifying a subset of those requirements for product that would be absolutely required for use or may be required for use in the following set of circumstances. That will become part of the meeting for use criteria along with security IT infrastructure and required and secure operations. For example, we want to make sure the risk assessment required by the hip of law and the security standards, its current and up-to-date and that the risk management approach is current and up-to-date as well as the current contingency plan. As we pointed out in the introductory remarks, security does more than protect confidential information. It is equally important to protecting the integrity of data and the availability of services and critical information at the point of care. We want to make sure the contingency plan that specifies the backup and recovery of information, the continuity of operations plan and emergency operations plan are all current. All of these are important to ensuring that that product can be used in a meaningful way.

Using this approach, the seven following two slides, identified the eight ARRA prior is a focus. First of the technologies that protect the privacy of health affirmation and promote security and qualified electronic health record including the segmentation and protection from disclosure of specific and sensitive individually identifiable health information. This one particular area of focus is specifically security. Some of the later ones that are very relevant to security is not as straightforward. This area of focus requires just about every privacy and security service out there. It requires identity management which is issuing that a person, when they are given an account, is to the claim to be. That is a process as well as technology. User identity authentication, once you know the identity of the individual they have provide proof they are who they claim they are. Identity and role based access control, access control is a Service determines what resources an entity or user can access as well as what actions they can perform with that resources. There are basically three types of access control. One is identity based which says that Dixie Baker can access this resource, while based says the administrative system can perform the following operations. Identity and role based access control, one or both are present in most systems today. Even on your desktop system. The label based access control is a type of access control of access is based not on the identity at the user but on a clearance that user has been given. They are clear to see top-secret information and matching the clearance of that that user has with the sensitivity label that is associated with the resources they are attempting to access. That label based access control came out of the Department of Defense and the intelligence community, but it is also being used and other industries that. That is a third kind of access control. Consent management has to do a consumer’s consent. Consent is a loaded word. That includes both my authorizations to use or look at my private information, but it also has to do with informed consent on what actions I have given my consent to happen. What procedures can be performed, what research databases my name can be in and even what clinical trials I might participate in. Managing all of those types of consent is another requirement here. Transmission integrity, integrity is really important to safety. A good example is if you look at me and somebody modifies my weight in my health record and makes it 180 instead of 80, I could die from that modification in my health record. The integrity of data is important. Finally the transmission of confidentiality protection. The protection of confidential information when it is transmitted. On the right-hand column, whether the EHR standards with security and privacy standards, they do not address label based access control. I do with the caveat that. The priority area of focus mentions the segmentation of information. To me segmentation means label based access control. It means segmenting the highly sensitive information, information traditionally known that is deniable such as HIV. Actually it is up to the policy committee to set forth that definition which they have not done yet. Consent management, I will talk a bit more about label. It is partially addressed because consent management is a complex challenge. And there are standards in. [Speaker Faint/Unclear] That address part of the problem, but we don’t think it is addressed control the second area of focus is a nationwide information technology information structure for the electronic health record. This requires secure communications channels that protect the integrity of data as well as the sensitivity of information and secure e-mail. Both of those are addressed. That era of HI eat in 80 years, we will identify more security services associated with that. The third one is the HR certification. All of these security services address certification. Technologies as a part of a qualified electronic health record allow for accounting of disclosures made by a covered entity. This requires auditing of actions on an individual system, but auditing is certainly not the total picture. To capture an audit record, and you have to have a consistent times ours especially if you’re auditing across multiple systems are between systems as an enterprise Theresa ability. Enter price trends ability is our turn for what ARRA requires which is accounting of all disclosures. As information passes from entity to entity, we need to maintain a Theresa ability of what happens to it. Finally, non repudiation. Non repudiation prevents someone from denying having taken some action. The most common mused technology in this agreement is the digital signature, but there others as well the fifth priority area – let me go over that. Three of the four of those are addressed under the HITSBY standards. Enterprise traceability is not beyond auditing. The use of certified electronic health records to improve the quality of health care is number five. Security is often equated as a privacy mechanism but in truth it is absolutely essential for assuring the quality of health care in that a protect the integrity of information and provide this assurances that information and services will be available when they are needed. The HITSBY standards address integrity protection transmission and non repudiation. Service availability, the HIPPA standards address Service availability, but it is not clear how will ultimately defined that one. The sixth one is technologies that out individually identifiable health information to be rendered unusable, unreadable are undecipherable to an authorized individual. This requires that transmissions be protected or encrypted. It also requires the identification, anonymous Asian and or pseudomonas Asian. These three approaches in particular the the last two in public health, the identification is clearly defined in the privacy rules exactly what 18 elements one needs to remove to Ranger to identify. Anonymous Asian and pseudonymous Asia are methods used, they don’t fully Dee identify information and nomination takes them out, pseudonymous stations inserts a link said that the data can be re identified at a later time if necessary. Finally the limited data set which is an itemized which of also the minimal data set as well. The identification and anonymous station. And pseudonymousation, is partially is really not in HITSBY. The privacy income security work group made and number of general recommendations. The first of which is that certification criteria should not dictate policy beyond what is specified in ARRA and the HIPPA saw security role. We need to specify standards such that a doctor can configure the products to its individual policy based on its own risk profile. We don’t want to tell everybody exactly what the need to implement, but we need to tell them what standards they should use and give them the flexibility to configure it according to their own needs. Second, product certification should address both functional requirements which are the service providers – services provided and the insurance levels. Assurance levels are orthogonal. It is important to assess the strength of a mechanism be used to implement the standard. Secondly, the implementation itself, the strength of the implementation itself. For example, you might have a standard that requires authentication. Two factors is a strong mechanism to meet authentication then it single factor authentication. How the authentication is integrated with the products is a measure of the insurance level. Assurance level is also measured by penetration testing, conscience efforts to break security mechanisms. It is really important. The strength of the projection is equally as important as the functions that the protection provides. We are recommending that the common criteria, the international standard, criteria for Information Technology, Security evaluations, the, criteria specifies a number of evaluation assurance levels and we are recommending that being zero and C look at the criteria and recommend evaluation insurance levels for cases. Third, for greater openness and brought inoperability, we recommend that the ONC prefer standards developed by international standards. There are plenty of them. HL7 is an international standard. We think this is really important. The next recommendation is that certification criteria and standards should enable design possibilities that leverage fundamental principles and standards. Once again, we don’t want to lock anyone into solutions. We want to recommend open standards that allow them to apply fundamental and generally accepted design principles to develop their own solutions. Product certification criteria should build full inoperability with Healthcare Partners and consumers. This is what people have been referring to all day as the escalator approach. We believe it makes sense for 2011 for securing the enterprises themselves in accordance with HIPPA and privacy standards which is what the policy committee recommended, plus some simple shared and sharing with Healthcare Partners and consumers. We think secure health exchanges with Healthcare Partners and HIE is better to look toward 2013. In 2015, we think full integration with consumer preferences with enterprise and Exchange access controls is a good target.

I would add that the 2011 recommendation is consistent with what the meaningful use working group recommended that John went over earlier. We believe the meaningful use criteria should be rules based and to specify what certified teachers must be used and how within the context of the plant operational use cases. As I said earlier, if you are a hospital and physically secured, you will have a different use case and if you are a doctor traveling between hospitals and homes and carrying your laptop with you. We think meaningful use should include the criteria for meaningful use and should include at least required certified teachers and their configuration within the applicable use cases. She cure IT infrastructure, the current HIPPA risk-management and current HIPPA contingency plan as I mentioned earlier.

The widest and perhaps most urgent gap that we identified maybe consent management. Consent management involves several functions. As I mentioned before, it is a complex technical as well as operational problem or challenge. First in a false recording patient elections, the privacy operations and their informed consent in a consistent way such that both humans and computers can interpret the elections consistently across systems and across organizations. It requires transferring the selections among entities that handle their PHI so that basically elections should consist of the data elements they referred to. Third, it involves transmitting these elections into access control rules. It is not sufficient to have the elections on a piece of paper and filed in a filing cabinet when the information itself is being sent from provider to provider or two labs and to payers. Finally, it involves managing the continually changing elections. The law allows that for someone to change their mind. I might say that anybody can see my information but the next week, I may be diagnosed with the condition I don’t want people to know and I may go back and change that election. This is an evolving consent. There is work underway and work that has been done, some good work that has been done in this area. I think what is needed more than anything is some clue to bring these efforts together. HL7 is developing a consent, at the referenced information model for version three includes the sensitivity label and HL7 is developing in the process a hierarchy set of consent vocabulary that can be used.

John has done some work and postulated a consent assertion markup language. These be 15 tepee 30 includes the HIE privacy consent profile, the BP PC captures patient consent and to find a method to enforce it. The one I didn’t put up here is. [Speaker Faint/Unclear] Which is a standard being developed by oasis which as a great deal of potential. XACML and able to capture of both up enterprise policy and access rules as well as access rules. We believe these pieces need to be brought together. In particular, none of these efforts to address a standard way. BPPC talks about a method to enforce but there is no real standard for transmitting access control rules from consumers into access control rules enforced by the system.

I see this as bringing the away says, the HL7 and the BPPC together. Consumers are beginning to play a much greater role in defining how their information is used and shared. It is important we take the initiative and the ONC stepped up. We are encouraging the ONC to encourage and support the rapid well-informed diplomat of consent management standards that comprehensively address all four of the points I went over.

As John mentioned, we have assigned these readiness ratings to the standards we have identified. They range from 124. They put forth these four definitions at our last meeting and they thought they were good and applicable. A rating of one is a mature standard, why they are used in using the guard our measure of at least 20% of industry. Not just health care, but industry in general. A rating of two is that it is ready for introduction, but is probably not probably on our 2011. A rating of three is well developed and that work is in progress. It might get it 2013 or 2015. Four is a loose guide. We think this is needed, somebody started it, but it is not real as of yet.

I’m certainly not going to go over all of these listings, but you do have three pages in your slides of standards that we are recommending. As I mentioned before, the oasis extensible access control – it’s an approved standard but it’s not widely used in any industry. It is very powerful because it does provide a means of capturing both enterprise rolls as well as individual consents. We believe it has a lot of potential. Oasis’ security assertion markup language is one that is widely used within the enterprises, but it is not widely used between enterprises. We gave it a rating of run because it is used extensively within enterprises, but it is with that caveat. Some others I wanted to mention, a tea and a, audit trail and note authentication and and note IT Praia, it defines basic security between modes and the uses the TLS by direction all. One know the authenticate itself to the other and the set in node authenticates it back before the transmissions can occur.

The. [Speaker Faint/Unclear] Was developed by MIT. This is been around a long time. A decade or more. It is authentication between to identities and uses a trusted third-party. Synchronous encryption and symmetric encryption. The important part of it, the reason I am pointing that that it is exactly Inc., that is really what the you an uses. There is some sort of quasi duplication because EUA uses Perot’s. I think that is all I wanted to point out there.

I talked about the HL7 data consent which is vocabulary that needs more work. I talked about BPPC. All of these are very standard for cat four and establishing a standard time element. There are several here, SDX was on a previous slide. These standards are not exactly security, but they’re not clinical operations either. Jamie and I got together and decided we would put them on the Security and privacy list. There really fundamental infrastructure standards. I don’t want to keep you here forever. Transport layer security, this is what is used every time you go to Amazon and buy a book. This is beyond one. It is also known as asset FL. I think that is it.

Very good presentation. Thanks so much. Comments or questions from the group? In the interest of time, I am just going to ask, I have a number of questions some I which I think are pretty important like the VAL certification, for example,. Is this document going to be moved for approval today or is it a chance to go off line and get questions answered?

I think given the time frame that ONC is under that this document would be moved for approval. The floor is open if their particular concerns your head. Just a question then, maybe there is an easy answer. The EAL approval, as far as I know that requires an auditor who has been approved to do, criteria certification. We know that CC HIT took a lot of gaps because it cost a lot of vendors on all of the functionality security and the inoperability. What is the cost to a vendor of that enterprise system to be certified for EAL?

There are six levels of assurance EAL levels. The first level is strictly performance testing. The first level is exactly what see CHIT has been doing all along. The common criteria does not specify who does the evaluation. That is specified to ever develops the protection profile or specifies the EAL level. ISO does not specify. Level one has to be an independent tester.

ISO 9000, to be an ISO 9000 you have to be authorized as a certified, that is not the case. [Overlapping Speakers]

Not, but I know of. In the case of the common criteria evaluations that are done with in the U.S., they are all done by entities that certified by a missed. What I understand is in endorsing the use of the common criteria, we’re not buying in or endorsing a specific level and there is plenty of time to work out the issues.

That is what I recommended that the ONC recognized the specific label based on the use cases. I think there are probably cases in which a Level one would be perfectly fine. There are other use cases that it wouldn’t be. I think we have gone so far, there hasn’t been any flexibility to do that.

The next question is, it is your recommendation say yes, no or is it silent on the issue of consent be on the consent levels they are associated with HIPPA?

It doesn’t say. The only thing I am saying about – I take that back. I am recommending that when we capture consent, the approach used to capture consent be able to capture not only the privacy authorizations which are HIPPA, but other informed consent that are required in the delivery of care and in clinical trials.

Consent for release of information, I don’t want this information to go to anyone who is related to any of my doctors. I am talking about the granular parity of consent for information release.

I have personal opinions about that, but my working group hasn’t discussed it.

We’re not buying into a specific level.

[Audio Faint/Low Speaker]

Role based is different.

He is talking about how much discretion a consumer can have to limit the use and disclosure of their health information?

Potentially to other Pratt tittered shutters in the course of giving them care.

We have not gone be on HIPPA.

This is where the standard gaps exist, I give consent to certain conditions and are given institutional provider, we are not quite there yet.

I think if the ONC takes our recommendation, I think what’s your question is really getting to is will be the most difficult part of the whole thing. I think it is also essential that if we’re going to be exchanging health information across the National Health Information Network that everybody has to understand the consent they receive means and that they be able to interpret it in an uniform way. Developing would be an uniform data model that could be implemented across an HIN.

My main concern was by the fall buying into something I didn’t think we are ready to implement. Lastly, there are specific topics in here such as encrypted e-mail that I called highly used, that in effect are used in environments where there is a public infrastructure and available. I am questioning whether it is reasonable to assume there is a net stoke public infrastructure available any die waiting standards for use.

I think it is unreasonable to assume that. Particularly for 2011.

There are used to use PKI. You can have portal to portal secure e-mail. I agree completely. It was e-mail I was concerned about.

Secure e-mail can mean many things. It can mean. [Speaker Faint/Unclear] Or web based portals, but they don’t exchange using TLS. We do not assume there would be and national PKI.

That exactly what we were assuming for 2011.

My question is is exactly this topic up PKI but also digital signature. I know this cheapening category three. What was the thinking behind putting, I think those are widely used and I am wondering what the thinking was putting those a category three purses perhaps category two. Is there a question of certainty, we definitely want to go there, but it will take more time or is it?

We really want to get there, but it will take more time. We at a digital standard signatures in HIPPA if you recall. I don’t see a health and PKI growing up in the next two years.

You think it is still on reasonable for 2013? To have PKI infrastructure? I was just wondering, but the work group discussions were.

I think is possible for 2013. I don’t think it is a done deal. That is why we gave it a three.

Any other questions?

We are evaluating slight 13 through 21 which includes recommendations to ONC on how certifications should deal with privacy and security, particular standards as well as how standards should be selected and consent, is that true? Is that the scope of what we’re recommending?

The scope of the recommendations today are the matrix which includes all of this selected standards plus in their level of maturity and there are specific recommendations for the feeling of gaps that we would want to work with ONC anything else to add to that I read through all of these standards yesterday on the plane yesterday. There is some slight duplication and editorial type of thing we would like to fix. The hand out that has the complete citations of the standards.

Primarily, 19, 20 and 21 is what we’re looking at today?


There were some issues within the recommendation slide, but I guess we’re not actually accepting those today in terms of looking primarily at international standards organizations, international use standards will help what we’re trying to do here. We probably don’t want to limit ourselves to just that and also using the constraint language with an intent to leave by about IHE. We have had a lot of work with IHE that has been provided by the organization. I don’t believe they aren’t actually.

That is why I use the work preferred.

So we want to probably used internationally used standards. Why call it out if we were going to constrain it with a preferred in front of it. This is not part of what we are accepting today.

What traceability says, when we can. [Speaker Faint/Unclear] If we have to go to an U.S. realm, fine. When we think a SDO, what is the definition of a SDO. There is also the implementation guide writers etc. I think report was suggesting we would want to use the internationally accepted standards and then possible as a preference.

You’re getting to the other questions of HITSP. HITSP has been a wonderful success in a short amount of time. I appreciate, Jamie’s presentation looks familiar and comfortable. It is very much following with the. [Speaker Faint/Unclear] Model. I don’t see that in this presentation here and what to get that assurance.

They had all been lifted from the HITSP capability.

I would point out HITSP and its latest teams did not identify capability for privacy and security. They seem to privacy and security cut across the capabilities. Every bit of this work is based on traceability. Just so folks understand, sometimes you can say capability and it exhumes a whole variety of privacy and security. This is all completely consistent. With that, today, we’re looking forward to an acceptance of this report and the security and privacy workgroup and those standards as named in the last three slide and in your matrix. Of course, their recommendations on gaps will like to go forward with. Many of Jackson’s to moving forward with accepting the work as a bid by Dixie and Steve? Okay, we will then move forward. A wonderful array of presentations, we do have refinements to do, but I think we have got some clear marching orders. At this point I think we would like to open it up to public comment.

Let me think all of the committee members of our group. I think everyone present appreciates the matter before. I just want to reiterate, there are terns and areas for confinement that the process will go forward. I appreciate the latitude to allow the national coordinator to do the work they need to do. I think for a comfort zone is for the work is appreciated and understood. I thank everyone for working out that. I apologize to the public members that this part of the session is delayed. It is in my estimation the most important part that I have received feedback on a logger. Next time and a better calendar. I think I appreciate all these complex issues. If you please identify your name and organization and limit your comment to questions to no more than # two minutes.

Thank you. I am Mike with the McKesson Corporation. I would like to commend to all the work groups. I think clearly the work product showed a thorough and disciplined approach. I would like to go back to a comment that Ms. Baker made in her presentation that she believes is occasionally this committee is confusing standards’ for meaningful use with certification standards. I appreciate the analysis of the profs Security and privacy to separate this to, I would really like to see the work product from both the clinical quality group and the clinical operations group clarified as to what is designed for meaningful use versus what is suggested as the certification criteria. I am not sure that ONC can move forward with clear guidance and I would just like to say that I believe that any state colder weather is patience or positions are hospitals or any technology vendor can move forward until we get this clarity. Thank you very much.

Thanks for your comments.

I am Kathleen Connors and an analyst and I have been of all but the standard settings organization that has been involved and with HITSP. The technical committee’s products and I am not an anti-Semite did not write that note. On behalf of the Microsoft Corporation I wanted to think HHS, ONC and the committees for the rapid progress for the high-tech requirements in such a short time line. We remain committed to promoting a future that liberates and leverages health data in ways that will empower both of the consumers and providers to improve health outcomes. For these reasons we support the policy committee’s position on the following, a limited and flexible certification process focused on validating the v h Technologies and get appropriate security privacy and data interchange capabilities and our able to report meaningful use measures. A definition of meaningful use that is focused on outcomes rather than peaches and functions and proposals for the health information exchanges that recognized that timely adoption must leverage the inoperability infrastructure already in place. To ensure the goals are accomplished. [Speaker Faint/Unclear] Both current and emerging, it is imperative from our a few that the meeting for use standard is the Technology neutral, platform independent and architecturally agnostic. Our concern is much of the progress could be avoided if the HITSP Standards Committee narrows the standard selection process to those that support only comprehensive v h are and help information exchange. Such an approach would not recognize any affected standards that would be critical to ensure effective safe and widespread it data interchange. HITSP standards have been selected to address the limitations of legacy EHR and for the most part inappropriate for alternatives EHR and. [Speaker Faint/Unclear] These non legacy HIT solutions which are used by providers and consumers include modular components for medical devices and quality measure reporting. Alternative to documents 8IE for the majority of the health information exchange organization which kept up adopted the IHE architecture. [Speaker Faint/Unclear] And laboratory orders and results and clearinghouses which might also be able to support the health information exchanges and helped platform such as Mike yourself Health wealth and Microsoft. [Speaker Faint/Unclear] For providers, dossier, Google health and other health applications on mobile devices. These alternative EHR and HIV technologies can conform with non traceability standards such as messaging standards. [Speaker Faint/Unclear] In the last reporting networks. HL7 matches thing. [Speaker Faint/Unclear] These can convey the same data that is being put the CD a profile. A widely used alternate to document standard is easier to implement then ACC beat and didn’t is in use to coordinate care. Computer before soap privacy standards that protect health standards far better than what is possible with standards being proposed for use with legacy VRH and more robust security standards that has been proposed by HITSP for secure note of that vacation. [Speaker Faint/Unclear] For data in motion as specified for safe harbor under the H. H. as notification guidance which has not been adopted yet, but we know it is likely to go forward. Microsoft supports the selection of technology appropriate standards for meaningful use certification to promote availability for affordable and easily to adopt VRH Technologies for low-tech and non tech providers in the Greenfield market and want to augment the installed systems with innovative the modules that will enable meaningful use. We see the reverse HIT technology ecosystem’s leveraging is the staying 8IE infrastructures, enabling privacy protection in data liquidity for systems and providing inoperable on ramps so that meaningful use objectives can be met while promoting market innovation. In closing, Microsoft thinks the HIT Standards Committee for considering our perspective and asked to consider recommending standards for products and services. Lighter weight and more agile and possible affected meaningful use technologies. We look forward to working with the closely on this and to sum it up, we see the boundaries you’re talking about, allowing enterprises to maintains the standards that they use. We must also use as and resupply to ecosystems such as the networks we are considering for HIE. Thank you.

Thank you for your comments.

I am here to represent our objective to director, Dr. Robert Bass, and the National EMS officials. What they would like you to hear is that of the. Hospital care data set has a wonderful standard out there in the form of the National AMS Information System Data Dictionary nexus. It we would want you to consider reducing that as the standard for many, many reasons. It represents a consensus pick it is well on the way of being implemented. Our state is going over to that standard, and I am in that process as the Project Manager.

Thank you very much for your comments.

We want to remind the phone audience that if you wish to make a public comment, you need to press star one of your phone to indicate that he would like to make a comment. We have a comment from Debra appeal. Would open her line please?

Thanks so much. I am sorry that my voice is so bad. I got this on a plane. I hope you can understand me. Patient privacy rights would like to suggest that even though this group just accepted the report from Dixie and Steve that their recommendations are so critical that there be a formal public comment. The work group address and include recommendations for the public for this incredibly important part of health information technology and health information exchange, because the health privacy advocacy community and the privacy advocacy community — fourth level, our coalition, which represents 10 million Americans, has not seen this before. But there are many peculiarities about it that require some study and some comments. Even though you all have a very tight deadlines, part of the purpose of the committee was to ensure that there really is adequate public input. I think, simply, passing on the recommendations from the privacy and security work group does not give us adequate time for public comment. We would recommend that you set this aside or develop a process to take in public comments and require that they be addressed and incorporated into the matrix and into the recommendations from the privacy and security work groups. That is, essentially, my first comment. The second comment or question that I would like to address to the committee is, you know, Dixie and Steve put up eight key areas of focus for privacy and security that came from ARRA. The most significant and historic and consumer privacy protection in ARRA is the ban on sales of protective health information without consent. We do not see that particular requirement of the ARRA on the timetable for of the health IT Standards Committee, so that is my, essentially, my second question. When is that going to be addressed? That is a central protection. How can the privacy community privacy advocates and the public interface more effectively with this committee in the development of key privacy and security standards?

Thank you very much for your comments. I do not know if you would like to offer any comments.

I just want to respond to the question about the provisions in ARRA about the data. That is something that we are in conversations with the Office of Civil Rights on. If is something that would be incorporated into any modifications they did on the HIPPA regulations, so that is something that will absolutely be addressed as required by ARRA. I am not sure that is something necessarily that the standards committee would be looking at. It is something that would end up being a legal requirement as opposed to being a standard for any electronic health record.

Is there a process for the public to be involved with 0CR and the development as that moves forward?

I cannot read event — represent the Office of Civil rights. There will be making public comments and incorporation and consideration of those comments before coming up with final regulation.

Thank you, Jody. I hope someone could react to my question or concerns about the recommendations from the privacy and security work group.

I hope you were with us for the whole conference, because there has been some discussion about the next phase of Commons and activity.

I was.

I just wanted to make a couple brief notes about the the some of the questions. Let me first ask if there are any other persons online or in the audience who would like to offer any comments.

We have no more comments on the phone at this time.

Just one really quick. I am Robin. My comment comes from [ indiscernible ] top health panel. That futuristic for 2013 or 2015 when you get into a consent, I just want to know that the examples were like human beings in charge of their own consent. Don’t forget that when you get into kids and you don’t know where they came from, you are not sure the data is, though not forget the layers of consents — Do not forget the layers. But forget that group, since that is one of the ARRA eight.

Thank you for your comments.

Any other comments? Okay. Well, let me start with the theme. That is the public commentary throughout the process. Of course, all of the meetings have been open as required. I really encourage the Federal Advisory Committee Act and its process. Jodie, maybe it seems that there still is a great deal of interest — could you describe once more the different threads for cover public comment? I will just press is that anything that is recommended to C M S and C MS takes up, they will have their own public comments. Let me turn to you for that, Jody.

Sure. All of our activities in the area of standards and certification, all of C M S activities and developing incentives and defining meaningful use, all of provisions regarding modifications to the HIPPA privacy rules that were in statute, which we have not talked about until just the last comment. All of that will go through our normal rule making process. The rulemaking process is designed to be a two phase process where the agency comes out with their best proposal on a set of rules. We look for comment. We are, in fact, to — all of the activity that this committee and the policy committee are advising ONC and CMS and also some comments that might be directed. Folks can be part and hear the deliberations as well as be able to make comments on the record as folks just did at the end of this meeting for the committee to hear. I think in some ways we have sort of confused the process a little bit by having a separate comment just on the policy committee hearing on meaningful you started that is not something necessarily required or frequently done, but it was something that was optional that the committee thought was important to do. We support the committee in doing that and received quite a lot of interest and send that information back to the committee. I am not, you know, at this point I do not really think there was any intention to do other informal comments. If at some point in time the committees are interested in doing that, we can discuss our ability to support that, but I have not heard an outpouring from the committee chairs on doing that at this point. Basically, just in some, all the things we are talking about will go through formal rulemaking. There will be public, a process used for that. Comments will be posted on the web, very prance — transparent as we will explain how we address all of the comments. Again, we encourage folks to participate in these meetings to make public comments to give your voice to the committee members in their deliberations, etcetera.

Terrific. Thank you for that. I think the themes that we have heard — I appreciate in the privacy and security, given that there is such work to do in and around a meaningful use, they chose a process, which is already codified. I hope that addresses one the set of issues, because it is already dealt with with far more stringent set of criteria. I think the comments that were also made are very helpful in reminding us about the importance of making sure that our work continues to facilitate innovation and that it is work that addresses this as well, of all honorable populations and addresses the needs of care delivery, a better environment other than the hospital and doctors’ offices. I think we heard that as well. I think the point about certification and meaningful use, there is a bit of a sequencing problem. This is now the time for some of that work to come together all of those points are points that we as community have felt the obligation to reflect upon and incorporate into our next set of activities. We certainly have marching orders in and around the next novel of the standards and their use and writing measures of quality. Let me turn to the committee and ask, are there any other issues or items you would like to put on the agenda? Anything for the good of the order before we break today, reconvening on August 20th, I believe is the date?

Just recognizing that standards are always a journey. I know that sounds a bit Zen or something like that, but what we will do with each successive meeting is continually constrain the variability. I think we have learned to today at the comfort levels we all have and the next meeting there will be more and the next meeting there will be more. I hope you all take this particular day as a step in that journey, and I’ll look forward to working with you.

Well said. Let me, again, thank you all of you. The numbers of hours is incalculable. Today we know there is more work. [ indiscernible ] and to realize the aspirations of improved health-care safety we’re not affected and more efficient by virtue of moving the data. Thanks so much, everybody. Thanks for your great work and leadership.


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