American Health Information Community

EHR Workgroup Meeting

July 25, 2006

1 p.m. EDT

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\>\> Good afternoon, everybody, and good morning to everyone, I suppose,
on the West Coast, and welcome to today\'s AHIC Electronic Health Record
Workgroup conference call. Today is Tuesday, July 25, 2006. And we know
how busy everyone is so we greatly appreciate your participation to help
us advance this really crucial work.

Before we begin, Matt, perhaps the first order of business here is that
you might take a roll call for us.

\>\> Sure.

\>\> I\'d also like to acknowledge my Co-chair, Jonathan Perlin, who is
also with us as well.

\>\> Okay. Calling in on the phone, we have Howard Isenstein from the
Federation of American Hospitals; Jason DuBois from American Clinical
Lab Association; John Tooker from the College of Physicians. Judith
Yost, I believe, is here on behalf of Barry Straube from CMS. And we
have Daniel Morelli who is in for George Lynn today. And at the room at
ONC, I know Mr. John Houston is there. Is anybody else in the room there
with you?

\>\> Hi, this is Judy Yost, I\'m sorry to intervene but I wanted to
clarify that I\'m really just listening in. I\'m really not representing
CMS today.

\>\> Okay.

\>\> Thanks for the clarification.

It looks like that\'s it for the roll call. Just a quick review for all
the call-in procedure works for everyone else and then I\'ll turn it
back to the Co-chairs.

For the Workgroup members, you have an open line, when you need to speak
we ask that when you\'re not speaking you keep your line muted so we
don\'t get a lot of noise in the conference call. When you do speak,
please identify yourself so we know who is speaking. If you\'re
following along, looking at the slides on the Webcast, please don\'t
touch any of the controls to advance or reverse the slides because all
the changes get streamed out over the interpret.

And lastly for the members, you will have an opportunity to ask a
question or make a comment at the end of the meeting. Lillee?

\>\> Thank you, Matt, so much. Before proceeding, Dr. Perlin, would you
like to say a word or two?

\>\> Thanks. It\'s sort of an oblique introduction because some of you
may know, others perhaps this is news, that I recently announced that I
would be leaving the Veterans Health Administration. It\'s been a
wonderful honor and privilege to serve the Undersecretary for Health.
Prior to that as the Deputy Undersecretary. Prior to that as acting
Chief of Research and Development, as well as coming to Washington as
the Chief of Quality and Performance. Great deal of fun and I\'m really
very \-- remarkable to be able to build electronic health record with
colleagues here and implement performance measurement. But time to make
a change. I believe it\'s also public knowledge that I\'ll be joining
leadership team at HDA, as the Chief Medical Officer, Senior Vice
President for quality. And will get to join my private sector colleagues
in trying to make those things work in that environment to advance the
safety, the quality, the efficiency and the compassion of the health
care we provide. So did want to share that with all of you.

And would just note that I\'m not quite sure what the relationship to
either the AHIC or the Workgroup will be in the immediate future. I\'m
working with Secretary Leavitt to determine that. But to the staff at
the National Coordinator\'s office, I would simply say thank you very,
very much for the opportunity thus cigar if there\'s anything I can do
henceforth, look forward to working with you in whatever way the
Secretary deems appropriate.

I would also be remiss if I didn\'t acknowledge a great Co-chair who is
a tremendous leader among all of the 3600 hospitals of VHA. Karen Bell
who has done yeoman\'s work and David Brailer and the Secretary in terms
of putting this vision forward and turning it, I hope, into a reality
with the help of each of you on the committee.

So enough on me. Just do really consider it a great honor to have worked
with all of you thus far in this capacity. Look forward to continuing
work in whatever way again, the Secretary sees fit, to really help
achieve the vision of making electronic health records available to
Americans in the next 8 years. If not sooner.

\>\> Thank you. And I just want to personally say it has really been an
honor and a privilege to serve with you. You have been a tremendous
supporter of this work, and have also shown very clearly that the
leadership structure for this Workgroup has been able to work very
effectively between the government sector and the private sector,
something that we need to consider as we go forward.

So thank you on behalf of us all for your dedication, leadership, and I
think only perhaps Karen Bell and myself know the amount of time that is
going in behind the scenes in this effort. And I just want to
acknowledge that. So I think you went from a 80-hour workweek to a
100-hour workweek when you accepted the Co-chair appointment. Tear.

Dr. Bell is there any hello you\'d like to make? Or should we go in the
procedures and we were going to go over FAC, before proceeding.

\>\> We will, and again I would just like to echo again my thanks to
Jonathan for all of his leadership, not only here on this Workgroup and
on the AHIC, but all the work you\'ve done in Federal Government to push
forward the HIC agenda. We look to be getting a strong leader for all of
the efforts that will follow in the private sector as well. So again,
just thank you from the bottom of all of our hearts here over at ONC.
Jonathan, and we all wish you the best moving forward and hope to
continue to see you in various capacities in our neck of the woods
again.

I\'m actually going to defer the piece on the call-in procedure and the
guidelines to Judith Sparrow, who as you know is our new executive
director for the American Health Information Community. Judith, you can
assume the responsibility here.

\>\> Thank you, I\'m delighted to be working with you and the rest of
the Workgroup. I\'m not going to say too much about the FACA guidelines
because I do have about a four-page summary that I\'m going to be
e-mailing to all of you later. But I thought I would just remind you of
two of the most important points about serving on a Federal Advisory
Committee Act subcommittee. One, is the fact that we\'re sort of
operating in a fish bowl. Everything is transparent. Everything is open
and public, all of our documents, minutes, et cetera, are on the Web and
are available for the public, and the second point is that we are acting
in an advisory role to the parent committee, which is the AHIC. So
everything that we propose is a recommendation to the AHIC. And again, I
will be sending out in the next day or 2 a short three- or four-page
summary on FACA. If you have any concerns, my name and e-mail and
telephone will be attached and please don\'t hesitate to call me. Thank
you and I look forward to working with you.

\>\> Thank you, Judith, very much.

\>\> Lillee, could I interrupt for a moment to introduce the fact that
Dr. Clancy has joined us.

\>\> Great.

\>\> Hi.

\>\> Welcome, Carolyn.

\>\> Thank you.

\>\> We need you.

\>\> I thought I\'d come in person and try to make it especially
helpful.

\>\> Thank you so much.

Our next order of business is the review and acceptance of the minutes
from our June meeting, and I think the good news here is that most of
you on this call were in our June meeting. I am hoping you were able to
review the summary of our Web conference that was held June 27, 2006.
And that was the sixth Web conference of this Workgroup. And my
continuing compliments to the ONC staff because you\'re able to really
capture a lot of discussion into a document that\'s workable. But let me
just ask any member of the Workgroup, do you have any additions or
changes to the minutes? Hearing none, I will declare a consensus for the
minutes. Again, as a part of this call, if there\'s something that you
review that you would like to have changed, let us know. But it\'s my
understanding, Karen, that these get posted on the Web very quickly?

\>\> They do. If you choose, you could have a 24-hour or 48-hour waiting
period for further review or comment. And that would be acceptable, too.
Whichever you choose.

\>\> What\'s the pleasure of the committee?

\>\> I suggest we go ahead and accept them.

\>\> I agree.

\>\> I would move a consensus.

\>\> They\'ll get most posted within 24 hours.

\>\> Thank you very much.

The Workgroup leadership changes, Dr. Perlin did talk about very briefly
just a few moments ago, but I want to reiterate the commitment that he
has had, and I also want to reiterate that we will have our Co-chair
leadership appointment made as quickly as we can. I think it goes
without saying, I need a Co-chair. And we will certainly let you know as
soon as possible. We have our meeting next week, so perhaps we will have
some of those leadership changes made so that we can discuss those next
week, or is it two weeks? When is our next AHIC meeting?

\>\> August 1.

\>\> August 1. Have all of those behind the scenes, pieces in place.
John and Karen, is there anything else related to the first five items
before we really get into the meat of the meeting that we have forgotten
or need to once again review or are we good to go?

\>\> I think we\'re good to go.

\>\> Okay. Let me just emphasize that we have some very important work
to accomplish in this meeting, and for the members of the public that
are listening in, perhaps for first time, I just want to review that we
need to agree on a recommendation for the EHR first responder work. So
that can begin. This was a challenge and a charge that the Secretary
gave to us a couple months ago, and that is an extremely important
component of this meeting.

The second is we are going to talk about updates where we are in terms
of our current HIT deployment coordination slide, which we will review
at length, but this is a piece that Dr. Brailer put in front of us in
2005 as a way to check our work and look at our work and in very
specific areas. And we also want to begin our broader discussion of the
EHR adoption, and the critical components related to that.

So given the work of today\'s meeting, let\'s begin with a discussion
and hopefully acceptance of an EHR recommendation to AHIC, is \-- Karen,
we will formally present this to AHIC and need to make sure that we are
all clear and have consensus around what we\'re recommending by the 1st,
correct?

\>\> That\'s correct. And I would just suggest that John Loonsk actually
wanted to be involved in this part of the discussion. He \-- we just
heard he can\'t join us for about another half hour. So I\'m wondering
if the chairs would not mind moving into Item #7 first, and I do
apologize for the delay. John hoped to be here but can\'t be here for
another half hour. That being the case, would you folks mind very much
moving into the next item and perhaps starting with the HIT adoption
survey, because we have those presenters ready to go?

\>\> John, do you have a problem with that? I don\'t.

\>\> No, not at all.

\>\> And Carolyn, will you be here at least for a portion of that
discussion?

\>\> I\'ll try. I have to get to another meeting at 2:00, and they know
I\'ll be a few minutes late. We\'ll see how it goes.

\>\> At least if you have the document in hand and can give us some
feedback but I think your input would be valuable.

\>\> Thank you.

\>\> When we were preparing for today\'s Workgroup, we thought that it
would be important for us to get updates on the current status and time
frame for a number of parallel activity that are taking place. You may
have seen as a part of the materials for this call, the health
information technology deployment coordination slide that Dr. Brailer
put in front of us early in our work. And it brings together all of the
infrastructure changes that need to take place, the work of the
breakthroughs, the work of \-- thank you, Matt. We have the slide up now
on the Web. The work of the four workgroups, because at the end of the
day we are trying to achieve industry transformation as well as
increasing consumer value. It struck us that we at AHIC, get good
updates of the work of the four workgroups, but what we have not heard
from in a while is the infrastructure technology industry component
which, as you can see on slide, is comprised of four key aspects that
need to occur to speed the work.

Standard time certification and compliance certification. The NHIN work,
privacy and security HIT adoption. So we really felt that a way we could
chunk our work and make today\'s call most useful so that we could get
on with the recommendations that need to be had, is to really get
grounded in where we are in this infrastructure work. And we are
prepared today to give you updates on four of the five infrastructure
buckets, so to speak.

The HIT adoption piece is, where I understand we will begin and we\'re
excited to understand that because when you remember the Electronic
Health Record Workgroup\'s broad charge, is to make recommendations to
the AHIC on ways to achieve widespread adoption of certified EHRs,
minimizing gaps in adoption among providers. So this piece of the
presentation strikes right to the heart of our primary charge.

So let me turn it over to our HID adoption speaker. And Matt, thank you,
I think the first slide is up.

\>\> So I assume that\'s my cue to enter. This is David Blumenthal, I\'m
calling in from Boston. I\'m at the Mass General Hospital, here as
director of the Institute of Health Policy, and also a professor of
medicine and health policy Harvard Medical School. It\'s been a
privilege to be part of this activity, working with David Brailer and
Karen Bell and their staffs on the HIT adoption initiative, which is one
of the Office of the National Coordinator\'s major initiatives.

Just by way of perspective, our task has been to help the Office of the
National Coordinator measure the spread of HIT and especially the
electronic health record among individual physicians in small groups,
larger groups of physicians and hospitals. And we have produced five or
six reports on various aspects of that general charge.

What we\'re going to be covering today is materials that touch in depth
on one of the deliverables that we produced for the office of the
national coordinator, and that is the result of an environmental scan of
studies of EHR adoption. And we\'re also going to be touch somewhat more
briefly on another deliverable, which looked at how one might go about
measuring the barriers and incentives to adoption of electronic health
records among physicians, groups of physicians, and hospitals.

Just also by way of perspective, we developed, as part of that second
deliverable, that is the deliverable related to trying to understand the
policy influences on EHR adoption, a fairly simple but a useful
conceptual model of the factors that influence adoption, and therefore
general types of factors which we\'ll be talking a little bit more about
in the first part of this presentation.

The first general type of factor is financial incentive. And that\'s I
think pretty straightforward. I\'m sure everyone on this phone call or
listening in.

The second is the state of the technology itself. The ease of use and
standardization levels.

A third is legal and regulatory factors. And a fourth is organizational
factors.

As we will show you when we get into reporting what we\'ve learned from
looking at the literature on EHR adoption, the amount of empirical
information on the potency of barriers and incentives related to each of
these broad influences is very modest. But we are going to highlight
them for you and to begin that I\'m going to introduce Sarah Rosenthal
who is an instrumental part of our team, who will cover the legal and
regulatory issues that affect adoption. Sarah?

\>\> Thank you very much, David. And good afternoon, everybody. I\'m so
pleased to be part of this and to be on the call with you all today. I
teach law and policy at the George Washington University, and with David
Blumenthal, the Co-PI, the particular theories of studies. And you
should all have in front of you, I gather at this point, the slide, and
there is a slide that is specifically a slide on legal consideration.
And I just am going to take you through very quickly three different
types of legal considerations that we think play into decisions around
adoption. The first one is probably the consideration that you would be
most familiar with, and that is the legal questions that can arise in
the process of adoption itself. And specifically in this case around the
diffusion of technology. The best example, of course, and the one that
the federal government has devoted considerable resources to, and
absolutely crucial, is the extent to which the distribution of hardware
and software related to use of an EHR would in fact violate various laws
designed to curb the abuse in health care, one of which is known as the
stark law, which is aimed at curbing what is seen as self-dealing by
medical practices. There are series of related laws. The department has
been hard at work through various agencies on attempting to ameliorate
the effects of stark and related fraud laws in this context.

There are probably another set of concerns which do not come directly
under the department\'s purview, but which are worth thinking about, and
that is issues related to antitrust. The voluntary sharing among
organizations that are in antitrust parlance considered competitors in
the field. Of information and data that might help them as a group
compete better, raises antitrust questions for lawyers and we presume
that these are issues that the department may be at work on with the
Justice Department.

There is a second set of issues that are actually not quite so visible
to the naked eye, and but we think certainly come up for entities that
are considering adoption and certainly come up for the counsel to
entities, whether it\'s a physician practice or a hospital or other form
of health system. And that is the legal consequences that come from
greater information transparency and information use. Information is
pivotal to health care, it always has been, legal access to information
is a critical aspect of the legal system for health care, and to the
extent that potential liabilities that might not attach in a less
transparent system become more evident this is an issue.

And finally, and related to the second issue is the problem of \-- or
legal consideration related to the consequences of holding a lot of
information. There is a very rich body of law that deals with the
obligation of health care providers, of course, to protect health care
information, some of it is familiar, it\'s privacy and security matters.
But there are also very basic legal questions having to do with control
of medical records.

One of the interesting aspects of health information is that an
electronic medical record, of course, dramatically expands the amount of
information potentially in the control and custody of a health care
provider. And raises unique legal questions of its own.

So these kinds of issues, issues in adoption and issues once one is
beyond adoption, all are in the environment and I can say from simply
one on one discussions with colleagues in the field and certainly with
health care providers in the field, that it is \-- that these issues
weigh on providers more than I think we would realize from large
studies. Something that David will come back to.

\>\> Let me just talk very briefly about some of the other barriers, and
say to you that for every barrier there is of course a policy
intervention or incentive that might affect that barrier. And I\'m going
to touch on these at a very high level.

The first related to finances, and related to finances, and I don\'t
know, by the way, if someone is changing these slides, but this was a
slide on legal considerations. We should now be moving to the next slide
entitled additional barriers to EHR adoption.

\>\> That\'s what\'s up there.

\>\> Okay. First of all, there\'s obviously the lack of a business case
for performance generally, and that applies to every initiative that
might affect performance, including EHR adoption. If it\'s not
beneficial to improved performance in today\'s health care market, then
interventions to improve performance won\'t be attractive.

And then there are special issues related to lack of a business case for
EHR adoption, which I\'m sure you all have talked about.

The second issue which I\'m also sure you\'ve talked about, is the state
of the technology. Its dynamism is itself is a problem because people
don\'t know when to actually stick their foot in this river that\'s
moving so fast by them. That, together with worries that they won\'t be
able to connect one part of their organization to another, or that the
interoperability of their physician lazy not be present when they adopt,
for example, a hospital puts a system in place and that extends not just
to local interoperability, region interoperability but
interconnectedness within the organization, an organization itself.

Then there are a lot of organizational influences that can serve as
barriers. The lack of organizational accountability, for quality that
has been part of the lack of a business case or performance. The lack of
a trained workforce in many organizations to support the implementation
of a new HIT, or EHR system, which of course applies in spades to small
group practices and to solo physicians. Timidity among leaders. There\'s
ample evidence of leaders working to make these \-- to put these systems
in place and there\'s ample evidence of leaders who don\'t act to do
that.

Size, lack of size, lack of critical mass in organization seems to be an
important influence. We\'ll talk more about that. And that relates to
the fourth, which is the availability of surplus, or capital.

Moving on to the next slide about incentives, you can readily see how
the opposite side of the coin for each of these general types of
influences can be an incentive or a policy that could overcome them. For
example, paying for performance, public reporting and performance,
paying for use of electronic health records, grants or low interest
loans to encourage adoption. Inkind assistance like the Vista, VHA Vista
system. All kinds of interventions could affect the financial picture
associated with EHR adoption.

Legal and regulatory changes, I know some are under consideration right
now, and are about to be announced to stark law modifications, and so
on. And HIPAA clarifications.

The state of the technology, including some of the vital work that the
\-- off office of the national coordinator is doing, could be an
important clarifying factor for the field, and of course creating a
local infrastructure in communities that would promote interoperability
would be another potential influence of note.

Organizationally, it comes clear that factors that promote internal
reporting requirements, whether they\'re from CMS, or JCAHO, or local
markets, coalition of employers, whatever they may be, could be an
important spur to EHR adoption. Workforce training and certification,
training of health care leaders at every level, assistance to small
providers, and assistance especially to safety net providers because of
their lack of capital.

One of the things that obviously would be very helpful to know is which
of these barriers and incentives at any given time or over time, are
likely to be most important. That is, have the most influence. If you
could focus your attention on eliminating one of these barriers, which
would it? And I don\'t think that at this point the information
available supports any conclusions about that general issue. And for
reasons that become apparent as we go through the available data on EHR
adoption, and the influences upon it.

So I\'m going to move now to the next slide. And talk about measuring
the rate of EHR adoption. This material now comes from another
deliverable of ours, environmental scan, which has actually resulted in
a paper that we\'ve recently submitted for publication.

And what we\'ve \-- a little bit of background information. Despite the
enormous amount of concern, interest, attention that electronic health
records have received, the amount of reliable data on its rate of
adoption, the prevalence and change in prevalence over time are limited
and of varying qualities. And there are a number of problems with past
efforts to measure it.

First of all, there hasn\'t been a clear definition of electronic health
records. So it\'s very hard to compare or place reliance upon individual
studies. Sampling frames and nature of response differs widely from one
study to another. There\'s an absence of information relating to
adoption rates that are \-- that could be related in turn to specific
barriers and incentives. We did, however, look carefully at the existing
information, with the intent of developing the best possible current
rates, information on rates of adoption, and levels of adoption. We were
assisted in that, by the way, with an expert consensus panel which was
very important to this work. But we went ahead and we identified all of
the surveys on EHR adoption and assessed their quality and then went
from that quality assessment to trying to understand what the world
looked like out there.

The next slide goes over, we searched for published and unpublished
data. Confining ourselves to studies done since 1995. We compiled a
list, as you\'ll see, of about 35 surveys. We attempted to collect all
those instruments, we were successful in 21. We\'ve since \-- since this
slide was put together, we\'ve gotten a couple more in. We examined
those surveys and examined reports of the results of the surveys, the
methodology, in every detail we could identify. We then went ahead and
developed a rating scheme from the published survey quality literature
and advice from our expert consensus panel. And having developed those
standards, we rate four reviewers, independently rated the methods and
their content.

So the next slide looks at the features that we used in grading the
quality of the surveys. On the left-hand column you\'ll see all the as
expects of the methodology that we took into account. I\'m not going to
comment on each of them. And on the right you\'ll see the content issues
that we looked at. We first looked at simply whether the survey even
touched upon an issue of importance, like whether an EHR was present or
absent. What functionalities it has, what barriers it affected and
incentives had affected its adoption, and were also very interested
because of the interest of the Office of the National Coordinator and
Robert Wood Johnson Foundation, which is funding complementary work in
disparities from region to region and population to population.

We then developed \-- did an assessment of our confidence that the
specific items that were used and the respondents that were asked those
items, would be likely to yield reliable and bias results related to
each of those areas of content.

The next slide looks at what some summary information might \-- some
summary information about the results of that exercise. At the top line
you\'ll see that we were able to actually assess the quality of only 21,
because those are the 21 on which we had an instrument. And a thorough
report of the methodology.

And if you go down to the bottom two lines, you\'ll see a summary of
what we found. One line says high rating in methodology, and EHR content
of the what that means is these were surveys, this is the number of
surveys that we rated high in methodology and also high in the content
components that would enable us to assess whether an EHR had been
adopted or not. This is one of the dimensions of content that we looked
at.

If you expand that to surveys of high or medium rating in EHR, in
methodology and EHR content, we found eight surveys. And since we\'re
interested in physicians and groups, physicians and also hospitals, we
divided these, as you can see, into those that \-- we rated them in
terms of how they reflected on physicians or hospitals, and you can see
there\'s a much larger number of high-quality or medium-quality surveys
that relate to physicians or groups of physicians, than there are to
hospitals.

As a matter of fact, there\'s very little information right now that we
thought was of high quality related to hospitals adoption of electronic
health records.

I\'m going to go through the next two slides. The only thing that I\'d
like \--

\>\> This is Sarah, you have about 5 more minutes.

\>\> Okay. So just one point I\'d like to make about the \-- if you look
at barriers to adoption on this next slide, very few surveys even touch
on the issue of barriers to adoption. That\'s been one of the problems
that we\'ve had in bringing back to you any information on that
specifically.

So I\'m going to move now to the 13th slide. Which gives us \-- gives
you sort of \-- our bottom line based on the data that\'s been reported
in the published literature. And I\'m going to focus you here on the
right-hand column of the 13th slide, which says \-- which is entitled
best estimates based on high quality survey. High quality surveys. And
these are the best point estimates, obviously there\'s error around
these point estimates. But these are the best point estimates that we
can provide related to the proportion of physicians in offices in
general, solo practitioners, groups of physicians, and hospitals. And
that have adopted as of 2004--2005, electronic health records.

The last line is for CPOE. There\'s better data on CPOE than there is on
the electronic health record and our best estimate at that time was 5
percent of hospitals had adopted CPOE.

I\'m now going to go to slide in the interest of time, slide 15. The
national ambulatory medical care survey, NAMCI, is a very important
resource for measuring adoption rates. And in 2005, they included on
their survey of physicians participating in their annual data
collection, a series of questions on what they called electronic medical
records, not electronic health records. And what I\'d like you to do is
look at the top line, and this by the way is a survey of physicians, not
of hospitals. Look at the top line that says all physicians. And look at
those numbers. The first is 23.9. And the second is 9.3. 23.9 is the
proportion of physicians respondents who said that they have full or
partial use of a electronic medical record.

On the right-hand side, 9.3 percent, is the proportion of physicians who
report using an electronic record that has what our ECP thought was a
minimum set of required features, or some of the minimum set of required
features that were necessary to call something an electronic health
record.

In that sense, the 9.3 percent figure is probably a better figure than
the 23.9 percent figure, because it gives you a defined set of
parameters on what constitutes an electronic health record.

Moving to the next slide, I\'m sorry, beyond that to slide now 17. I
want to just point out something that I think is becoming increasingly
clear in the literature, which is that if you look at the right-hand
column, the percent of physicians reporting a minimum set of required
features are using an electronic medical record with the minimum set of
required features ranges from about 4 percent among solo practitioners
to 21 percent among physicians in groups of 11 or more. That, I think,
is an enduring feature of the current rate of adoption or pattern of
adoption among physicians in the United States. That is groupness is a
very strong predictor. And that\'s also true in multivariant analysis.

I\'m going to move now, in the interest of time, to slide 19. We did
some very, very crude projections based on current numbers, and
projecting forward potential rates of increase from 2005 in the
proportion of physicians, office-based physicians in had the United
States, who might have an electronic health record. What this shows is
that if a 3 percent annual increase were to occur by 2014, about 50
percent of office-based physicians, assuming this is linear, by the way,
and not part of a sigmoid curve, that about 50 percent would have an
electronic record. Double that rate of annual increase would give you
about, close to 80 percent by 2014. That gives you some sense of what
kinds of rates are necessary based on the data we have to achieve the
goals that the President has set forth.

So the last couple of slides, conclusions, understanding the current
levels of adoption is critical. We all, I think you all know that. I
don\'t have to say that. Our ability to make reliable estimates is
limited by the quality of the available survey data. And the lack of
special studies on adoption, on key adoption barriers and incentives.
And keeping policymakers, you and others in the Office of the National
Coordinator and department, informed, I think is going to require
improved efforts to track EHR adoption as we go forward.

And, to the strength of surveys involved.

So I\'m going to stop there and take any questions that may \-- that you
may all have.

\>\> Any questions?

\>\> This is John Tooker. Can you hear me?

\>\> Yes.

\>\> Two questions. The criteria that you touched on, but I don\'t think
we saw completely on the slide for electronic health records, are those
the IOM high-level criteria?

\>\> Yeah, they\'re actually a subset of the IOM criteria. We took the 8
IOM functionalities that \-- and asked our ECP to rank them in a Delphi
process in terms of their kind of essentialness. Which had to be present
for people to say yes, that\'s an electronic health record. And they
picked four of them. There\'s actually a slide on this that I slipped by
in the interest of time. Slide 16. But it\'s a subset, four of the
eight. Which actually in itself actually still constitutes a high
threshold, a high fence to overcome.

\>\> Thank you. And the quick followup is, in relationship to \-- in
relation to adoption, do you also have related data on initial adoption
failure to sustain or failure to adopt?

\>\> No. Kate, do you recall any information on that in the surveys?

\>\> No, that was one area that we noted that, you know, initially we
had adoption broken out by acquisition installation and use, and we were
looking for questions on those sub domains and that was an area we
didn\'t find any data.

\>\> That\'s Katherine DeRoach, the project coordinator for the adoption
issue.

\>\> Thank you.

\>\> David, this is Lillee. I have maybe a comment not question. But I
was \-- now I\'m starting to put some points together. I was just
reading on the CDC Web site the CDC\'s national center for health
statistics put out that health e-stat, electronic medical use by
office-based physicians.

\>\> Yes.

\>\> The state of the State in 2005.

\>\> Right.

\>\> So I\'m going to assume that the data that you presented that came
out of your work is what fueled the CDC publication. Is that correct?

\>\> What we did is we asked them to do an accelerated analysis of their
data. From 2005. And they very kindly helped us out. And the data I
presented to you was the data they generated for us and have now
reported on their Web site.

\>\> Yes, so all the Workgroup members know, the full E-stat can be
accessed at the CDC Web site. So thank you rapid dissemination of
information.

\>\> This is John Houston. Can I ask a question?

\>\> Of course.

\>\> This goes back to one of your earlier slides where you talked about
the state of technology, and one of the things I have a question about
is, other than the fact that you talk about standards for
interoperability and product certification, are there viable products
otherwise out in the market that physicians are willing to adopt? Or
didn\'t that come up as being an issue?

\>\> Well, we can\'t really comment on that, because I don\'t think
there\'s any reliable data about it. I think there\'s enormous amount of
anecdotal data. We, did by the way, a lot of focus groups and
interviews, case studies, and there\'s no question that if physicians
knew, in my mind, I can\'t prove it quantitatively, but my strong
impression is if the average physician knew that this was a certified
high quality electronic health record that was going to be supported
over time and have some durability and sustainability and not have to be
replaced in one or two years, that that would facilitate adoption.

\>\> I can tell you \-- this is Sarah. I can tell that you the effects
of the announcement last week were immediate. I advised a large group of
safety net providers, and as soon as the certification list came out,
they\'ve been involved in a very lengthy process of trying to figure out
what to adopt. And as soon as the list came out, I said to them, stop,
stop, stop, look at the list. And you need to choose from among this
list.

So I think that that contribution, having standards like that available
for people, will help immensely.

\>\> The soft issue of usability, though, is one that I think is still
playing in the industry, and you know, I hear it from physicians all the
time of, you know, implementing technologies that end up costing them
time. And it\'s great to have EHRs within their practices but its \--
and it\'s great to have standards and certifications with functionality
and the like, but there has to be \-- I know this is a soft issue that
is going to \-- is going to give barrier to adoption, I would think. And
I\'m not sure how you quantify it and you try to do some type of study
on it. But I think it\'s going to be there and I think it\'s going to be
a major one.

\>\> I think one could get a better hold on this than we currently have,
using survey-based methods and focus groups and case studies. It will
never be ironclad, but you could get some sense of the priority that
should be associated with this particular barrier, compared to other
potential barriers.

\>\> David, it\'s Blackford Middleton, hi.

\>\> Hi.

\>\> Following up on the prior question, do you have any sense of any of
the survey data or other data that would characterize extent of use of
the cardinal functionality as defined by the IOM, but depth of use
within a particular future or function?

\>\> There are some surveys that talk about extent of use. There\'s one
in particular, well, two of them that come to mind. First of all,
[NAMSI]{.mark}, and the commonwealth survey. And you know, the larger
the \-- the higher the barrier or the higher the threshold that you need
to overcome to say you\'re using something, the lower the rate of
adoption. And from, just off the top of my head I\'m trying to remember
the survey. I would say that as you ask for frequent use or intensive
use, the rate of apparent adoption might drop for about 27 percent to
about 10 percent.

\>\> This might be one thing that would get at the usability question in
a somewhat indirect fashion, asking about the depth and breadth because
if features and functions are used, one might imagine the depth of use
and frequency would go up and perhaps not part of the HIT, adoption
charge but part of the ONC charge.

\<Q\>: I think the IOM came out with what they report about medical
errors and it\'s pretty profound. Is there any correlation in this work
around HIT adoption and cost in error in because in this previous report
I didn\'t see that jump out.

\>\> We were actually, for this first set of deliverables, we were asked
explicitly not to concern ourselves with the effects of EHR adoption but
to focus on how to measure the rates. And that\'s occupied us for the
first year.

There are \-- we do have ideas, it\'s not easy, but we do have ideas on
how you might begin to measure impact. But that\'s, I think, in the
future.

\>\> Okay, thank you.

\>\> Karen, should we move on? Thank David and his team? It sounds like
there are no questions from the Workgroup.

\>\> Yes, and Dr. John Loonsk (ONC) is here to address the rapid
response EHR issue, and again thank you, David and Sara for joining us
on relatively short notice and putting together such a complete
presentation. We look forward to talking with you.

\>\> Great job, thank you.

\>\> Thank you. Bye-bye.

\>\> Okay, Matt, if we could go back up to Item #6, on our agenda. And I
thank the Workgroup for their flexibility here. We are going to move
back on our agenda to the Agenda Item 6, discussion, acceptance of an
EHR recommendation to AHIC. And we will come back to Agenda Item #7 with
the other three components when we complete this piece. And I want to
point out that we\'re about 50 minutes into this meeting thus far. So
Karen, if you would introduce our speaker, please and get us centered on
this task.

\>\> Absolutely. John Loonsk is the Director of the Office of
Interoperability and Standards and overseer of several of our major
contacts, particularly those related to NHIN, and standards as well as a
few others. I\'d like to just ask him to comment a bit on the emergency
response to EHR recommendation.

\>\> Thanks, Karen. There are a number of activities going on in
response to the impact of Katrina and some of the lessons learned from
the value and need for electronic health information and a followup to
that. Some of those activities are identified in draft document that has
been shared with you. There are other activities going on, including a
request for information that have relationship to this, and a number of
different tangible products, projects to try to move toward practical
response capabilities. But one of the things that is striking in an
ongoing to need, is that to coordinate these different activities, and
to help move along the axis and take advantage of the fact that private
and public activity are going to be critical in a next response, and the
ability to interchange data is going to a core component of that. Is
that we need to queue up really the advancement of the standardization
activities around some of these core data so that they can \-- those
standards can be the focus for the way in which some of these systems
will interact. And there are a good number of systems here. There are a
good number of capabilities and Federal agencies that have
responsibilities in certain areas, Health and Human Services has
activities. It is working on through the Office of Public Health
Preparedness, potentially having an electronic health record for Federal
medical stations, and so Health and Human Services we\'re seeing a real
need to move forward with this capability. I know that others see this
need as well. We are very interested in trying to make sure that we can
get this larger appear apparatus of the national agenda to consider some
of the needs for this next step response. Because \-- or next step
activity. Because it is really going to be a public-private effort.

So the draft that was shared is \-- suggests a potential recommendation
that would focus on the development of a use case in this area. We have
some interest in developing this in some resources that the Federal
health architecture can potentially apply. But the concept would be to
have a broad process where input for that use case could come from
several different quarters, including some of the activities that I have
already named. But to try to then move forward with the use case in a
time frame where there could be standardization products and other
products from architecture potentially in terms of a nationwide health
information activities, next step activities, to allow for a number of
these activities to coalesce around interoperability and advancement of
standards. It seems to get pretty clearly to the concept of a patient\'s
summary record as a critical cog in moving that activity forward. And I
think that that summary record could actually have significant value in
a number of different domains, not just the activities. But this is a
clear need, there\'s \-- there are pressing time frames for a number of
groups in moving this forward. The hope here is to coalesce a number of
those activities in helping to develop a use case, but then also to help
develop, through the Health Information Technology Standards Panel
process, the standards for which these groups could then focus their
work.

So there\'s a little bit of that background in the cover document, and
then a potential recommendation that just tries to suggest that the AHIC
prioritize that activity in the development of a use case to feed the
broader process.

And that is what is in front of you.

\>\> John, this is Lillee, and thank you for that. It would seem to me
that we need to have a little bit more around the use case
recommendation, however. Understanding the questions that the Secretary
asks. Has the team thought more about that? When we say it should be
developed and prioritized. Can you expand on that?

\>\> Sure.

\>\> Because we\'ve said all along that it needs to be developed.

\>\> Sure. In the circumstance of the breakthroughs, the \-- each of the
different ONC contracts had speaks tied that they would pursue three
specific use cases, and we associated the use cases with the
breakthrough working groups, this being one of them, as a method of
advancing that through, you know, coalescing people\'s focus, making
sure that people were talking about the same thing, as they move
forward. The use case is a tool that is used to coalesce attention
around a particular need. And to articulate that. And the process that
was used before was a fairly inclusive process of getting input from a
variety of different groups as to what that use case would be. We would
anticipate that similar type of process would occur in terms of getting
broad input, but that then a written use case would be developed, we
would \-- when that was developed there would be an opportunity for
comment and input on it. That would allow for this group, for example,
to have an opportunity to contribute to that process. But the goal is to
have an output that then can be used to focus the attention of the
Health Information Technology Standards Panel on harmonizing the
standards necessary to accomplish that. And that\'s the use cases,
develops and describes the context for them so they can pursue that. The
prioritization reference here is to indicate that we have to start
thinking about the next step prioritizations and all the AHIC working
groups are thinking about what are the next most important activities to
focus this apparatus on from their working group. Thing one, because of
its emergent nature is a natural one in that regard, and there are
frankly a number of related processes that will be dependent upon having
this before that they can actually move to concrete implementation. So
it\'s a natural one to think about. But the prioritization is really to
then ask that the AHIC recognize the fact that this is a pressing need
and that it should be at the top of the list of next steps for HITSP to
consider in the next steps of the Nationwide Health Information Network,
consideration potentially in the next steps of the certification
commission as well. And so it\'s really queuing up those activities and
others that relate to all sort of rallying around a focused activity to
move it forward.

\>\> Can I test one or two premises here. One premise is that what will
be recommended, what the AHIC is going to be asked here is one in a
series of network activities, for lack of a better term, that all focus
around enhancing emergency preparedness, if you will, in the IT space.
You know, there\'s the RFI, and so on and so forth. We\'re specifically
focusing on standards that need to be developed.

\>\> Well, I think that\'s the obvious, most direct first step. And
there are needs from a lot of these activities to have those standards
in place for them to move forward concretely. There are still a lot of
questions, too, in terms of how to move forward in some of the areas,
and roles and responsibilities, for example. But unless you have the
standards, that forward movement is difficult to achieve.

\>\> Right. I have to run in a moment and I apologize for that. I also
have one comment in the last sentence of this use case recommendation.
It says patient summary record. I\'m wondering if you shouldn\'t say
component. Because after all, the phrase patient summary record conveys
to many folks, a discharge summary or some kind of PDF, which I think is
exactly what we don\'t want. So it may be a bit redundant for those who
live in that space \--

\>\> And Carolyn, you\'re absolutely right, we talked about we as a
Workgroup had consensus around the central components of what should be
in the emergency document.

\>\> And the other point is just, I believe that your office actually
commissioned a review of what worked and what would need to be improved
upon next time from Katrina, which I think would be a pretty critical
input to some part of this spectrum of activities. Probably not to the
very specific focus on standards.

\>\> I understand you need to run. I was trying to drill down on your
first point. I think you said components in the context?

\>\> Yes.

\>\> And you then mentioned a PDF, for example; not a desired outcome
here and this is about \--

\>\> If I\'m wrong, tell me.

\>\> No, and I\'m not arguing that point. I\'m just trying to \-- this
is a relatively contentious area in the standards community. And I think
that it is something that is going to have to be dealt with sooner
rather than later from a standard harmonization standpoint. And I think
this is on that target, so to speak.

\>\> You mean what is the content of a patient summary record?

\>\> Uh-huh.

\>\> The critical information?

\>\> And it wasn\'t intended to necessarily indicate a discharge
summary.

\>\> No.

\>\> But most of the language in this regard is denominational in
regard. Another suggestion for language would be very helpful, and the
intent is to describe something that would meet the needs of this, and I
think some of that gets fleshed out better as these start to write a use
case, and describe it.

\>\> I mean, I guess the only sense I have is that it should be
something about the most important component, useful component, some of
which are already \-- I mean, obviously pharmacy standards are, you
know, in place and the additional standards will be ready presumably in
early \'07. Some of that is already rolling. I guess what I\'m hoping is
to get, in the interest of aerodynamics \-- I always remember that word
from Jonathan \-- this recommendation can skirt that line of not
avoiding contentious area, but not necessarily diving head first into
it. Because I think the various health professionals could debate
what\'s an efficient summary record probably for the next several
hurricane seasons.

\>\> Perhaps. I mean, I think that there maybe is a fair amount of
agreement on what a summary might be in this context, at least. But \--

\>\> Well, I\'ll take that up. Thank you.

\>\> Thank you very much Carolyn.

\>\> You know, Carolyn, I would like to tee up once again for this
group, but we had an outstanding presentation from, from the American
College of Emergency Physicians about the EHR, and what components,
discrete data needs from a communications standard would need to be in
place. We talked at length about prehospital EMS, and routine data needs
and then from a disaster standpoint what those data needs would become.
So perhaps we should reflect on that, it or perhaps we would want to, as
a part of some public testimony and further research, drill down into
that a bit. But I am struck, if we were to have a hurricane tomorrow and
we have another Katrina fast works that help move the ball any further?
Because it just feels like here we are a year after Katrina and we\'ve
had the action report, we\'re no further along with the first responder
EHR, than we were last October.

\>\> I think you\'re right. And I think that\'s why the Secretary has
made a concerted effort to move forward within the Federal Government on
a number of venues, to address that issue. And I think that in this
particular situation, and clearly very desirous of moving forward with a
rapid response EHR, that has elements in it that can be
interoperability, with other parts of the delivery system, this is a
first draft attempt to make a recommendation to this Community, to begin
that process. And we do have within our own office here, particularly
through the FHA, folks and staff ready to go to begin this work. If we
can agree on how a recommendation should be articulated. John has some
comments, too.

\>\> A question. I think the way to make things more slowly is to make
decision through a democracy. It sounds like we\'re trying to make these
decisions regarding the form and the content sort of as a democracy and
with a lot of process. I\'m assuming that is a requirement, me not being
part of the government, I\'m going to ask that question naively, rather
than AHIC simply saying this is what we need to do.

\>\> Somebody asked the question. This is Ken. I completely agree. We
can ask the questions to ultimately get to the tougher issues, and my
opinion here, the questions are how do you identify the patient. Are the
elements that we\'re capturing discrete or more PDF like and ultimately
how do you secure it? Core pieces of it.

\>\> I guess what we\'re describing here is a process that we\'ve gone
through once in terms of the use case process, where we did still reach
out, but were able to drive toward a deliverable that was relatively \--
in terms of the use case, was relatively \-- gave the specificity
necessary to carry on the task but didn\'t get hung up in some of the
more controversial issues around a particular software system or a
particular approach. And I think that\'s doable here, too. So I do think
it\'s appropriate to get input, I think it\'s appropriate to get a
variety of groups. This will only work if it\'s a public-private
process. It won\'t work if it\'s just a government process. Or
otherwise. So \-- but that by passing a recommendation like, this it
really gives us a opportunity to drive toward the deliverable. And to
say to \-- and get blessing from the AHIC that says this is important,
we need to (indiscernible) the resources to move forward in this
direction.

\>\> My recommendation would be to make sure there\'s specific
milestones, and I don\'t think they really were called out in here as to
when we have to have certain things done. Force the decision be made and
in a time frame, because I think you can really \--

\>\> That\'s fair enough.

\>\> I think you can get caught up \--

\>\> To add to the recommendation, specific time frame for deliverable
when that would be available.

\>\> And also, if somebody comes back and there\'s another Katrina, God
hope there isn\'t, somebody will say why didn\'t you have this, spinning
your wheels much at least there\'s a process defined. Here\'s what we
were going through and the time frame to develop it. So it meets a
couple of different timelines. But I think it\'s important if we\'re
going to have this process to say here\'s the time frames.

\>\> In the private sector, there\'s a lot going on now with \-- and
maybe this leads into the Consumer Empowerment Workgroup that I\'m not
aware of. But just personal accountability. And a lot of organizations
saying, you know, have in your wallet, your primary medical condition,
your medications and your allergies, and that\'s it. And some are \--
you know, I\'m sure you\'ve seen some of about even having it posted in
your \-- whatever way you can, no matter what your situation is. So that
if you\'re unconscious, someone can find it. I want to make sure \-- I
couldn\'t quite hear who said before, but I want to make sure that
we\'re not getting caught up in process and at the end of the day don\'t
have an outcome that we can execute on. This is an iterative process.
The first responder EHR we have in 5 years will be light years better
than what we have today. But to quote the Secretary, we don\'t want
perfection to trump progress and we need some progress. And where are we
now, what progress do we have a year after Katrina? And at least 6
months after the Secretary gave us the charge, I just have to call the
question that I don\'t see where we are. If the group feels that this
recommendation that we make the recommendation to AHIC that the
emergency responder use case should be developed and prioritized, if
that\'s the recommendation, I think we ought to move on it and move
forward because we\'ve only got about 45 minutes left in this call.

\>\> This is Karen. What I\'d like to also offer is that I think we do
need to make a few changes to how this was ordered. It was a draft, the
first go-around and perhaps we could use the same process we did for our
other Workgroup recommendations. We will recraft this, redraft it, send
to everyone for their comment and sign offs, and at the next AHIC, which
is August 1, then perhaps you could then thee up as a recommendation to
them, after everyone vetted the final version.

\>\> As long, Karen it comes out in a timely fashion.

\>\> Tomorrow morning.

\>\> Yeah.

\>\> At least it\'s not in our head yet.

\>\> Thank you.

\>\> Okay.

\>\> So is there clear consensus around we\'re going to revise this, get
this out to everyone, and the expectation is the Workgroup will weigh in
so that the staff can craft the final draft that will go in everyone\'s
materials for the August 1 meeting.

\>\> And we will include particularly timelines and also a greater
emphasis on the elements, the specific elements that were talked about
in these Workgroup meetings previously as the critical factors to
concentrate on.

\>\> Absolutely.

\>\> This is John Perlin, I would endorse the timeline and the elements.
I think just to recapitulate what seems to be a consensus is that we\'ve
had good input and testimony on the critical elements and in fact you
just enumerated the top three there. And indeed our experience in
Katrina as well, you know, primary diagnose circumstances drugs,
allergies, as the de minimus, were the most essential and one could
build out from there.

I think this is a particularly important potentially very powerful area,
not only in terms of the immediate need, in terms of emergency
preparedness, but in a sense one could almost think of this as a
prearchitecture in terms of something that is even more personal that
interfaces with the consumer empowerment/personal record approach, and
that begins to truly build infrastructure as well as serving a very,
very pressing and urgent need.

\>\> And John, didn\'t we talk about the VA\'s process as a way to
inform this one, that maybe the staff could dive into that a little bit
further?

\>\> I think actually we might have initially, but I think what was so
compelling is exactly what we might have said, was articulated by the
representatives of the American College of Emergency Physicians.

\>\> Yeah, yeah.

\>\> Great, thank you.

\>\> Okay.

\>\> Okay to proceed?

\>\> Yes, thank you very much. We could probably move on to the because
John is still here and he could talk\' it because he\'s the project
officer for this contract.

\>\> Great. Please proceed.

\>\> Hey, this is Pam. Just before we move off that topic, I don\'t
think we can disconnect the two conversations about the EHR and the
emergency response system. If we encourage broad scale adoption of an
EHR and then the patient response system as something separate, and not
connected to that, I think we\'ll drive the whole health care system
crazy. So you know, I think one of the things that should happen
naturally is if there is an EHR, there is some interactivity that helps
build and maintain that system. So just listening to that conversation,
we\'ve moved as if they are two separate topics, but I think one of the
issues with adoption is people don\'t know what to do first and they
don\'t see these efforts as connected. So maybe we should think about
putting that in the recommendation as well.

\>\> Pam, let me be very clear that I thought that\'s what I said, is
that I view these as connected. In fact, this is a very nice sort of de
minimus version what have might be prelude to a later architecture, and
I think it would be distracting and counterproductive to have.

\>\> Maybe I misunderstood. I think there has to be consistency and
definition in here between EHR and emergency response systems, and
phases and things, so we get a little bit more synchronized. And PHRs. I
mean, it\'s amazing how many e-mails I get from customers asking us to
define what the difference is between an EMR, and EHR, and PHR, and tell
them what\'s the top priority. So I think there\'s just a lot of
confusion about what we expect people to do out there in this new
emergency response system is clearly something I support, but rolling it
out as another initiative and top priority to a large audience, I think
right now would just be like the next thing. As opposed to just
finishing with some of these initiatives. So I think we have to be very
careful of how we put all this stuff together so somebody who has to do
it can digest it and sequence it.

\>\> And this is John Loonsk, and if I wasn\'t clear on what I was
saying, I don\'t think this is one system. This is an effort that we
were talking about to try to ensure that a variety of different
processes, systems and projects actually have some core data that can
support interoperability and standard for interoperability between them.
I think we\'re all saying the same thing, and it sounds like on the same
track in terms of this as a core need for moving forward.

\>\> Thank you, Pam. Karen, back to you.

\>\> Back to John.

\>\> Okay, so in terms of the NHIN, we are now into the process for the
Nationwide Health Information Network effort and it really involves
just, to be clear, a few different things going on at the same time. One
of them is the drive to having software prototypes that implement
potential architect tours for what a NHIN can look like and we have four
consortia working on those prototype architect tours and we\'ll have a
deliverable in a January time frame of demonstrating those prototypes
much but at the same time throughout this year we\'re working on
architecture deliverables and we had we had the first public nationwide
network conference in D.C. at the end of last month. And that conference
reviewed whether we would call functional requirements. And these are
simple statements that express what the NHIN needs to do to accomplish
its goals. And we have each of the four consortia developed and advanced
functional requirements that they saw. We accumulated these functional
requirements into a list of somewhere over 1,100, that were then put on
display for the public, and discussed in the context of this public
forum.

The forum was I think very well received. There was a lot of really rich
discussion. I was very pleased with the sort of maturity of the
discussion. There were a lot of people who in a public setting, in a
public meeting, were actually focused on the same kinds of deliverables.
The same kinds of need, and having a conversation at a relatively high
level.

The products of the forum, in terms of the comments that were made the
suggestions for additional requirements, and the discussion in the
breakouts, as well as the requirements I previously mentioned, have been
handed over to a special working group of the national committee on
vital and health statistics, which is going to produce in the September
time frame a harmonized list of those functional requirements which will
show what are common, and also show what different architecture
variations exist in those. So we\'re not asking them to determine
architecture by virtue of this, but to help us by naming the
architecture variations in some detail so that we can have subsequent
discussions and follow up on them.

The other aspects of the forum that I should mention, in the context of
the conversation that we had there, was that we were not trying to make
policy determinations in that setting. We were talking about functional
requirements for systems, and we noted and recorded policy implications
and have committed to advancing those to the appropriate group, whether
that be the AHIC proper, a particular Community working group, or one of
the other processes that\'s in place for looking at policy issues
related to some of the specific activities that are going on. We also
described this as an iterative process. This year is about prototype and
prototype architect tours within the nationwide health information
network and we anticipate that things like the HITSP standards being
developed this year, the products of these harmonized functional
requirements, the discussion in related working groups and committees on
policy suggestions and activities should feedback around into the next
steps of the NHIN architecture as we move in a step fashion to get to,
driving toward implementation.

So we have had a very successful first forum. The response to it that we
got was very positive. We have identified a likely next public forum for
the NHIN, in mid October. That would focus on security and systems
issues. Again, it might not be the exact same format as this one in
terms of the number of breakouts, this was a really open setting with a
lot of breakout opportunities. I think the next step forum might have a
little more of a technical nature and there might need to be more
presentation to get to that level and a third NHIN forum tentatively
scheduled for mid-January, wherein there would be a presentation of the
prototypes that the NHIN, and consortia have developed in terms of a
business models and conceptualization of how roll-out next step
activities can occur. So that in a thumbnail is an update on the status.
I\'d be happy to answer any questions if people have them.

\>\> Questions?

\>\> Nope.

\>\> Okay. Thank you.

\>\> Thank you.

\>\> Karen, are you next with the press release announcing certified
vendors, or this piece of the agenda?

\>\> I am and I\'m going to be very fast in the interest of time. As
many of you already know, the Secretary and Dr. Mark Leavitt, who is
head of the CCHIT announced at George Washington University last
Wednesday that the first batch of electronic health records have been
certified to over 280 different criteria for functionality,
interoperability and security. These basically offer purchases of EHRs,
a degree of comfort that a certain baseline of critical features are
available in these electronic health records. It is not the be all and
end all on several fronts. There will be more products that will be
named at the end of July, and there will be an ongoing iterative process
as more interoperability standards become available. And will be
incorporated in future certifications.

And as my colleague here, John Houston, pointed out, and a very verbal
and loquacious group of physicians yesterday pointed out to me, it\'s
very good to have a certification process for this type of structure,
but ease of usability and implementation are issues that still need to
be addressed and so again, this is an iterative process.

But bottom line, this was a huge first step for our office, for
physicians in general, for the industry. And for the Secretary. It was
our first big deliverable that is very visible in the world, again, not
just to physicians and vendors, but also to patients. So we were very
excited about it and thank you for sharing my passion.

\>\> Where would we get the list or find out who ended up being
certified?

\>\> It is on the certification commission\'s Web site.

\>\> It\'s already out there.

\>\> Yeah, so one only needs to go to www.CCHIT.org.

\>\> Great. I think perhaps that\'s important enough that it should be
in your AHIC notebook for the August 1 meeting.

\>\> I suspect that the Secretary will make a big announcement of this
at the AHIC meeting on August 1. He\'s very excited about it.

\>\> Great.

\>\> Thank you.

\>\> Look forward to announcements like that.

\>\> We do, too.

\>\> Judith Sparrow going to help us in briefing on the Confidentiality
& Security Workgroup...

\>\> I\'m here but Kelly Cronin has stepped into the room and she\'s
sort of one of our organizing people around that, so maybe Kelly will
give you a better update than I could.

\>\> Great. Hi, Kelly.

\>\> How are you?

\>\> Good.

\>\> We\'re in the process now of confirming new Co-chairs for this
group, and we\'ve been meeting with them in the last week or so. We have
a tentative list of Workgroup members, many of which are come from the
existing workgroups. And we\'ve tried to pay attention to those who have
previously volunteered or who have particular expertise in privacy and
security that could represent a lot of the public discussions that have
already gone over the last six months or month. Related to the specific
charges that there\'s good continuity when this privacy and security \--
actually we\'re calling it the Confidentiality and Security Workgroup
gets established. It will be a full subcommittee under the AHIC, or you
know, as we all call them, workgroups. But it will have this
cross-cutting perspective where it will take into account the
breakthroughs that the workgroups have been focused on over the last 6
months.

We are going to try to work closely with the Co-chairs in trying to
flesh out specifically what are the issues we\'re going to tackle first,
second and third. We recognize that many of them are contentious and
complicated. We\'re going to have to get very comprehensive public
input. We are anticipating having full-day public meetings with a lot of
hearings \-- a lot of testimony from all the key stakeholders, and
hopefully we\'ll have balanced discussions with the clinical perspective
being represented, along with the consumer or privacy perspective, in
parallel with the technology real world implementation expertise. So
that with every issue we take on, we get not only comprehensive
testimony, but that we have a balanced discussion with those three or
more stakeholders represented in those discussions.

So I expect that over the next week and a half we\'ll have everything
finalized in terms of membership and the Co-chairs. We\'ll be able to
share that with the rest of the Community, and I think you could expect
to see our first public meeting in the next month or so. So we\'ll
definitely keep you updated when we have more of a substantive matters
worked out. And I think of the issues that will be important moving
forward is making sure there\'s good communication among the workgroups,
because now that we are going to have a cross-cutting workgroup that\'s
going to have to sort of continuously stay up to speed with what the
other workgroups are considering, there might be need to have occasional
Co-chair discussions to make sure that everyone an exchanging any
concerns or issues that are brought up that might be more appropriately
addressed by this cross-cutting Confidentiality and Security Workgroup.
For example, with our Consumer Empowerment Workgroup, we know that
we\'re getting into the concept of certification of personal health
record, trying to consider not \-- whether or not it would be
appropriate given the status of the market. And there\'s privacy and
security requirements that would obviously go into a certification
process, or could be part of a certification process.

So should that discussion take place in the Consumer Empowerment
Workgroup or be part of the deliberations with the Privacy and Security
Workgroup. Those we\'ll be working out over time but I think we\'re
getting together a very good group and we\'re excited to get it
convened, particularly since we need to make sure it\'s going to feed
into the implementation of the breakthroughs, and we also want to make
sure any recommendations that get advanced to the Community and
Secretary are timely and relevant to the other processes we have going
on outside the office, like across the 34 \-- the 33 States and the one
Territory that received contracts from HIT, the part of the privacy and
security solutions contract we\'re comanaging with AHRQ. There is a lot
of interdependency with most of the things we\'re doing and we\'ll keep
you updated as we go along.

\>\> A quick question with regards to the privacy. Is there going to be
an attempt to try to look at some of the issues teed up there?

\>\> I think so. I mean, I think that in some ways, the Co-chairs have
read up on that and are trying to think about how we\'re going to be
looking at the next level of detail. So if you\'re talking about \--

\>\> There were some open vetting recommendations, there were things
that we had thought that HHS should do in terms of \-- sort of leaving
open issues rather than making recommendations.

\>\> Exactly, yeah.

\>\> I was wondering whether those are things we\'re going to try to tee
up.

\>\> I think some of them will be related to what was already described
in the recommendation to form this group. And I think it will probably
serve as one more input and background that everyone should be building
off of. I think it will definitely be a part of the contacts, we know to
be the issues, where do we take it from here. How do we think about in
the context of patient-centric lab data, what needs to get done.

\>\> Right.

\>\> Okay. Please keep us posted because I would say in the private
sector, if there\'s any issue that has more conversation, it\'s privacy
and security.

\>\> Uh-huh.

\>\> John and Karen, let\'s move on now to the next agenda item. And
Matt, if we could bring that up on the screen here. The discussion of
critical components. Identified at our last meeting. And prioritizing
them so that we can look at our tactics, actions and so forth.

So Karen, please tee up what we need to accomplish. I would say that we
don\'t have a lot of time for. This I want to make sure that we save
minutes at the end for public comment and questions, as well as
preparation for the next Workgroup meeting, what we need to make sure we
have accomplished.

\>\> All right, thank you very much. I think I\'ll start off a little
bit by jumping ahead to December. Because I think there are really two
big pieces of work we need to do between now and then. I just want to
keep us focused on what that December deliverable is. One of those
deliverables is to have a list of prioritized elements that are
important for use case development. We had a lot of discussion about the
rapid response EHR and the critical elements of a rapid response EHR, as
being very high priority, that really can\'t wait until December.

So we\'ll have a little bit more go-around around the recommendation
around that before the August 1 meeting.

But as we all are aware, there are multiple elements and multiple types
of information available in the electronic health record and we\'re not
in the position to essentially make every single element
interoperability overnight and it will probably take us close to 10
years to get there completely. But the real important piece of work of
this Workgroup is to prioritize those elements so that clinicians will
find the most value in interoperability in EHRs early on. Whether that
is immunization, information and immunizations available or the problem
list or some of these other things we have talked about before, we
really do need to set up a prioritized list of the element that the
standards panel, all of our other contractors need to focus on. That\'s
Element #1.

And Element #2, basically takes off on the discussion that we had last
time where we talked about the various objectives and tactics and
strategies that we could put in place to slings remove barriers to
(indiscernible) adoption or to enable in other ways EHR adoption. And I
think the presentation that Sarah and David started us off on today,
actually helps in had a discussion as well, in terms of articulating
from the studies that they have been doing, some of the work in that
particular area.

So what I guess I would ask of us now is to have some discussion on how
to move a little bit closer to December, in both of those tracks. We can
do that through doing some work on what we think are key priorities now.
We can do that by determining what type of public testimony you might
like on the next Workgroup meeting from various physicians, for
instance, or from other members, from vendors. There are different ways
that we can move forward in this agenda. And would very much like to
hear people\'s comments on how best to do that.

\>\> Identity silence?

\>\> This is usually not such a quiet group.

\>\> No.

\>\> I probably put everybody to sleep. I apologize.

\>\> Let me go back to objective one.

\>\> Let\'s do one at a time. That\'s probably best.

\>\> Yeah.

\>\> High value EHRs. And this essentially again is determining what are
the key elements in an electronic health record that are most important
to clinicians so that they will find a lot more value in obtaining
interoperability information on their patients. And so that really fits
with the first of the two pieces that I talked a little bit about.

\>\> Well, it\'s Blackford Middleton here. I guess first of all crossing
my mind might be to parse out the value question a little bit. Based on
the evidence and some of the work done, there obviously is the
clinician\'s perspective on value, and then there is perhaps a broader
societal perspective on value resulting from interoperability. As a
clinician, I guess I would just tick off the common things, the problem
list, med list, allergies, advanced directives, immunization status, and
the last note from an ambulatory encounter of my own with a patient or
perhaps someone else. Those are pretty easy and pretty standard. But
there are a lot of details obviously beneath that.

On the value side from a societal perspective as we\'ve talked about
before, having laboratory results from the patient even if they\'ve been
done elsewhere, have extraordinary value and may help reduce redundant
tests and procedures.

\>\> I think I\'ll jump in here again. This is Karen. To suggest that I
think in this particular situation, where we\'re really looking at
bringing value with respect to adoption, because I think that really is
the overall broad charge of our group to foster, enable EHR adoption
among providers. That perhaps in terms of priorities we might focus on
the needs of the clinician.

Would that make sense to you, Blackford?

\>\> I think for adoption, yes.

\>\> Okay.

\>\> Blackford, this is Lillee, I want to concur because focusing on the
impact of the clinician is vital. We can talk about financial
implication and we have an excellent presentation earlier that \-- but I
know in the private sector where the rubber hits the road we can have
the financial resources, we can do everything, overcoming stark, doing
all, that but at the end of the day, the people issues, how to use it,
how to make it intuitive, and you know, I remember making rounds
yesterday at one of our hospitals and seeing how it doesn\'t work or it
does work. So I just concur with that focus.

\>\> This is Don. At the end of the day for somebody who is adopting an
electronic health record and is relatively naive to the use of them, we
have to demonstrate that within reason that their life is going to be
down the road than it was before.

\>\> Absolutely.

\>\> Did this make your practice easier or not.

\>\> Agreed.

\>\> Okay. Keep going, Karen.

\>\> The other question, we were just having a little bit of a sidebar
conversation here, is in addition to the elements that are important for
adoption, clearly, if we \-- particularly if we move into low-cost,
low-risk EHR, what is the business case for adoption, and how do we
create a use case, if we choose to call it that, around a business model
that would lead to improved adoption.

And again, I think that may address a little bit Objective 1.2,
low-cost, low-risk EHRs. I said before because this was one of the
critical components we agreed on. It was a first wave. So I would wonder
if the group would consider that a high priority as well.

\>\> This is John Perlin, and I think this is a particularly important
one in terms of creating the momentum or the interest incentive to
actually adopt electronic health records and I think Dave Blumenthal\'s
helps to make a business case.

I think the risk is not only attributable to what is the initial
capitalization required for a health record but a series of derivative.
Is the health record one purchases going to be interoperable or is it
standards-based and I think the future work of the certifying commission
is particularly important and applaud the great work that\'s been done.
The next is particularly powerful in term of interoperability toward an
end. And here I\'m very being sort of parochial with respect to the
provider side. It\'s not just interoperability is good in and of itself,
but in a world that is increasingly requiring greater accountability,
which is in a sense mixed \-- you know, but incentives positive in being
able to compete effectively under pay for performance. It\'s also one
that is going to be increasingly required in terms of reporting. And so
the ability to have a system that will be interoperability, not just for
the social good but having contiguous health information, but for the
very pragmatic of being able to compete effectively for pay for fee, as
well as for report as is required \-- or reimbursement. By the way,
whether or not it\'s a public or private payer. So I think there are a
number of factors that really influence the risk and are directly, as I
think you quite accurately lay out, are related to business case. And so
I think this is an area that we can identify these things, and also
potentially identify to the Secretary as things that HHS might do in
terms of creating an environment that is more conducive or actually
inducive; that is, pull in interest of adoption of electronic health
records.

\>\> Thank you, Jonathan, that was very well said. And I think it really
does support this second area that we need to address. One thing I would
also like to throw on the table. As one goes back to Sara\'s and
David\'s presentation, spent quite a bit of time talking about the legal
considerations, but actually doesn\'t \-- except for stark, doesn\'t
actually appear on our objectives for moving forward. And so I was
wondering if we might not also want to have some public testimony or
some current concerns about some of these legal issues so we can get a
better sense about these as well.

\>\> We need to also make sure that those aren\'t already being teed up
otherwise because I think there\'s a lot of effort or maybe I\'m wrong
but I think there\'s a lot of effort with trying to address some of the
stark issues. I know the first attempt didn\'t necessarily go as far as
it needed to.

\>\> Right.

\>\> Might want to make sure we\'re not getting into a territory that
somebody isn\'t already being addressed.

\>\> Thinking \-- good point, but I wasn\'t thinking so much about the
stark issue but the legal consequences of transparency, the broader
information use, perhaps related to custodial control of large volumes
of data. That is a concern to a lot of physicians.

\>\> Maybe not so much as a legal issue as a liability issue, but the
question is how will different providers make use of information from
other providers and how will they depend upon it and what are the
consequences or what are the different concerns over that? And I know
that a provider typically gives more merit to information that it stores
itself versus information that it might get from a third party, and
concerns over completeness and accuracy and interpretation. So I guess
those are other considerations, probably more liability-based than
legal-based issues.

\>\> Karen, I\'m looking at time. We have about 10 minutes, 15 minutes
left. And I don\'t think we could go each strategy and prioritize it
with that amount of time.

\>\> No, I agree. That\'s why I\'m wondering whether this might be an
opportunity to basically say let\'s look at these three areas. Some of
these liability issues I think are probably \-- I think you\'re right,
John, more liability than legal issues. And some of the issues around
the business case, use case development. And then the prioritization
process by essentially having at our next Workgroup meeting a series of
public testimonies from various groups of physicians about their
concerns and how they see all of this. And that might help our process
moving forward.

\>\> I was going to suggest, because we don\'t have, or at least I
didn\'t have in my materials the first couple of slides that David
Blumenthal used, but those areas that were initially up on the screen, I
think in terms of adoption, there was financial, legal \-- regulatory,
some of those four major chunks. Here\'s the recommendation.

\>\> Financial, legal, regulatory, state of technology, and
organizational.

\>\> Thank you.

\>\> That if in some way we could structure our testimony in those four
areas that also further the work of that group, and helps us stay
centered on other work that\'s also occurring. That might be beneficial
as well. I\'ll let the staff decide because remember we\'re only an
advisory group, and we can make recommendations until the cows come
home. But at the end of the day they\'re not final.

The only other piece that I would highly recommend is as a part of that
testimony is down to the fourth recommendation, under improved
population health. And recommends, or Objective 4.4, health information
support and disasters and crisis, and there are some excellent
objectives there. Around fostering the availability of field EHRs,
improving coordination of health information flows during disasters and
support of health emergencies.

Since that has risen to the top of the priority and we are going to ask
AHIC to make the first responder EHR use case a high priority, we should
at least have that as a priority on our public testimony list.

\>\> Absolutely. We\'ll definitely do that.

\>\> Karen, is the thinking that this public testimony will take place
in our August 15 EHR Workgroup meeting?

\>\> Yes.

\>\> Okay, and is that going to move to a day-long meeting?

\>\> I don\'t know that we need a full day-long meeting. Do you have
strong feelings about that one way or the other?

\>\> Well, I know early on we blocked on all the Workgroup members\'
calendars, 4 hours for each of these meetings.

\>\> Okay.

\>\> And they have been streamlined from there.

I don\'t know but I think for everyone\'s calendars, if the meetings are
going to be extended beyond two hours, for instance, we need to declare
that fairly quickly.

\>\> My sense is I don\'t think that we really need a full-day meeting.

\>\> Okay.

\>\> Unless someone thinks to the contrary.

\>\> Just says on the agenda, lay out agenda for future all-day public
meeting.

\>\> Personally speaking, I think it\'s height of vacation season and I
think we need to try to encourage the committee members here to
participate rather than their representatives, and I think that that
sort of changes the tenor of things when you get a meeting like that.

\>\> I agree.

\>\> So August, it just to me is bad time to try to do. This I think
you\'re going \-- you\'re going to be more successful getting people
lined up in September.

\>\> You\'re absolutely right. Since I\'m one of those people who won\'t
be on vacation, I completely forgot about it. You\'re right, especially
in the middle of August.

\>\> I guess the question I would have, we have the option of completely
canceling August.

\>\> Yeah, I just would caution that we are trying to figure out sort of
our own internal deadlines as to when we\'ll have to have final
harmonized use cases to the standards panel and certification
commission. And to the extent those deadlines are approaching and
putting more pressure on the Workgroup's to set the priorities.

\>\> Karen, I\'m not one for canceling August. I think in health care we
have to keep going. People have to go on vacation, they have to have
their mental health break. Vitality is an important component of the
work. But all that said and done, those that are on the watch need to
get the job done, and I\'m struck that we haven\'t had enough time to
really thoughtfully and planfully review the goals, objectives and
objectives here for you that we could get some useful work done for the
August 15 Workgroup meeting.

\>\> I absolutely agree. I wasn\'t advocating necessarily canceling as
well as trying to put together public testimony in an extended session
is probably not something that\'s going to work well for August. I think
you\'re absolutely correct that we could get a lot of useful work done
at another one of these sessions.

\>\> This is John Toker. I agree with that, and might even suggest that
we put this item earlier on the agenda so there\'s more time for it.

\>\> I agree.

\>\> One of the things we might consider doing, is essentially dividing
up some of the public testimony, have more of a discussion around
barriers and enablers, in general, and around some of our strategies and
objectives in general. But we may also be able to pull in some
testimony, for instance, around the prioritization, begin the discussion
around the business case. So we wouldn\'t necessarily do everything, but
we might be able to do at least some of these \-- one or two of these
four chunks. In a 2-hour period.

\>\> We can talk about the calendars issues, I suppose off line. We need
to wrap up this segment.

\>\> Karen?

\>\> Yes?

\>\> This is Bart Harmon with the DoD. Sorry if this is off subject.
With the notion of prioritizing elements. Across the DoD, and VA, we
brought in users who actually work closely related and asked them to
prioritize which pieces of information would help them the most with
patients moving back and forth between the DoD, and VA in one geographic
location. I\'d be happy to kick that in as maybe a departure point for
discussion if that helps with the prioritized element.

\>\> That would be fabulous. I think that would be a great way to start
that. So thank you.

\>\> With the VA\'s permission?

\>\> Great.

\>\> Yes?

\>\> Thank you, John.

\>\> Okay. So let gee in that direction, then. We\'ll certainly continue
with the August 15 meeting. We will keep it at its planned time slot,
and we will continue this \-- we will basically just have two items on
agenda. Continued discussion about the goals, objectives and strategies,
and some public testimony about prioritization of elements. That will
hopefully allow to us move fairly quickly down that road to making
recommendations on where the HITSP, et cetera, and these need to go in
terms of use case development.

\>\> Okay. And as we have had, while it\'s on everyone\'s mind because I
know that the staff is looking for identification of potential speakers
and some of the high leverage speakers that we would want to hear from,
have very busy calendars, I would think that we need to be submitting
names more quickly than not.

\>\> Agree.

\>\> So in terms of our next Workgroup meeting, Karen, we need to, I
guess, emergency EHR recommendation to AHIC.

What else do we formally need to prepare for that meeting? I think
we\'ll actually probably have in the next hour or, so another version
that we will send to everyone on e-mail.

\>\> Okay.

\>\> So we may be able to work this through consensus, sign off.

\>\> And is there any other piece, other than that, that\'s \-- we\'re
going to have to have ready for August 1?

\>\> No, that\'s the only thing.

\>\> Okay.

\>\> And is there any update to the Secretary that he need to know what
the Workgroup is doing, or we just proceed?

\>\> No, at this point in time, with the exception of the rapid response
EHR, we will not be having any Workgroup updates. We have a pretty full
schedule otherwise.

\>\> Other than, that the Workgroup leadership changes for the full
group?

\>\> Possibly.

\>\> Yeah.

\>\> Okay, so can we move to opening the lines to the public?

\>\> Matt, can you take care of that for us?

\>\> Arkansas the instructions have actually been up on Web for a couple
minutes now, so it doesn\'t look like anyone is calling in yet. I think
probably if we wait another minute and nobody calls, in we can assume
nobody is trying to do so.

\>\> Okay, great.

\>\> John, do you have any final thoughts?

\>\> No, just that to add the thanks to everybody, and I do think there
is a sense that awful us would like to move forward, translating from
the philosophical approach to a set of extreme I can recommendation that
is allow this to be actualized. And I think in the context of our
recommendations there are a number of things that we may be able to
provide to the Secretary for his consideration as potential levers for
creating the impetus for adoption beyond the social good of simply
improving the safety and quality.

\>\> Well said.

\>\> Well, Jonathan, and Lillee, I\'d like to thank you both for leading
this, and particularly Jonathan, not only for today but for all of your
support. We really have done a huge amount of work. The Secretary is
very impressed, very pleased with what this group has accomplished. And
look forward to what it will accomplish over the next few months. You
have certainly been a very significant driving force, and we really
appreciate all your efforts. Thank you again, Jonathan, and best of luck
to you.

\>\> Well, thank you, and many thanks to all for a great collaboration,
and look forward to doing what I can from wherever, to help move this
agenda forward.

\>\> Our paths will cross again.

\>\> Yes, they will.

\>\> Congratulations, Jonathan.

\>\> Thank you.

\>\> Great opportunity. Matt, no one from the public dialing in?

\>\> No, no one calling in.

\>\> With that, ladies and gentlemen, I want to thank you for your
participation today. We did get through three critical elements, perhaps
not to the depth that we would like to have, but I fully respect
everyone\'s very busy schedules. Judith Sparrow, thank you once again
for getting our FACA guidelines out to us. Many thanks around the EHR
emergency responder recommendation, because that is an important
component of our work to AHIC. Thanks to our four key speakers on our
HIT deployment coordination, and the work that has to occur there, at
least we are making good progress. And then our beginning discussion
around these critical components of our work plan and we will dive
continuously into that during our August 15 session.

With that, thank you, everyone. Jon, once again best of luck in your new
venture in the private sector. Hoping everyone to stay cool. It\'s very
hot here in Dallas, TX, as you know, but looking forward to seeing
everyone on August 1. Thanks, everyone. Have a great afternoon. Bye-bye.