AHIC Successor Meeting

Wednesday, September 5, 2007

**[\>\> Judy Sparrow:]{.underline}**

Welcome everyone to the technical session on the AHIC successor. Just a
few logistical points. We\'ll have three points during this meeting
where you can ask clarifying questions and you can do that in three
ways. Those of you in the audience can go to the mic here in the middle
of the room. Those of you online, please click on the question and
answer button and then submit your question which will come to us via
e-mail. And third, on the phone, if you\'ve dialed in on the phone, just
click \-- or dial star 1 and that will open up a line for you to ask a
question. Again the first three public comment periods will be for short
clarifying questions only and please hold your longer questions for a
question and answer session at the end. Thank you. Rob?

**[\>\> Rob Kolodner:]{.underline}**

Good morning to all of you, all of you here in the room as well as those
of you who are joining us on the Web. And welcome to this AHIC 2.0 or
AHIC successor grant technical session, or technical assistance session
today.

In addition to the participants who are here in the room, as I mentioned
we\'re joined by many who have signed up to join us on the Internet
Webinar, and the purpose of the meeting today is to provide a more
detailed view into the vision of the AHIC successor, describe several
considerations for designing the new entity so that those of you who are
planning on responding to the grant notice will have a better
understanding of the nuances of the envisioned successor, and finally to
provide more information and answer questions that you might have about
the grant application process and evaluation criteria. If I could have
the next slide, please.

The format of the meeting is that I\'m going to take about 30 minutes to
review the AHIC 2.0 vision, design concepts, and discuss potential
collaborations\-- excuse me. Then I\'ll step you through some of the
different design considerations stopping several times during the
session for any clarifying questions that you might have. After a short
break we will conclude the day by reviewing the grant process and
application evaluation criteria and answering any questions that you
might have. Next slide. Okay. Wait for the next slide to show up. Okay.
So let\'s get started. Next slide.

For anyone who is on the phone or on the Internet or here in the room
who is unfamiliar with the AHIC, and I hope or I expect there are
relatively few who are unfamiliar. It\'s a Federal advisory body that's
chaired by Secretary Leavitt of HHS and it's provided the focal point
since October of 2005 for public/private guidance and input regarding
steps and priorities that HHS should be taking to achieve nationwide
health information interoperability. As has been planned since its
inception, in late 2008 the AHIC will transition from being a Federal
advisory body to becoming a public/private entity or decision-making
body in the private sector with authority to act on its decisions,
consistent with public policies. Next.

Transforming the healthcare sector into a true healthcare system, a
challenge that Secretary Leavitt has noted on many occasions. One, a
system that has high quality care and that provides value is a long-term
commitment. As we noted on August 17th, its span is much greater than
that, than the span of a single HHS Secretary\'s tenure in office. To
sustain the necessary progress over the long-term, to achieve
interoperable nationwide health IT, we need strong leadership in both
public and private sectors. For reasons that we outlined at that August
17th meeting, we strongly believe that the best path to provide
sustained leadership and commitment for this time span across the many
transitions that occur regularly within our political process, that the
best process, the best plan is to transition from the current AHIC to a
AHIC 2.0, from an advisory committee into this public/private entity in
the private sector. We\'ve seen increasing progress over the past two
years in achieving our goal, and it\'s important that the momentum not
be lost. As we all know, there\'s a real risk of disruption and
disrupting our momentum during any change in government administrations.
Therefore, now is the time to transition the AHIC to the new entity that
will focus on interoperability and will maintain and accelerate the many
different efforts and keep them moving in harmony. I want to reiterate,
as we have stated on multiple occasions, that HHS and Federal government
will continue to be actively engaged and will have a significant role in
the AHIC successor. Next slide, please.

The guiding principles for governing AHIC 2.0 have been the following
\-- and we\'ve reviewed these actually with the AHIC since the April
meeting. This AHIC successor should engender trust among the many
different market sectors with a stake in the decisions made, who have a
stake in the decisions made. It must represent the stakeholders, the
consumers, the employers, insurers, clinicians and others. The AHIC 2.0
should act decisively and make progress towards interoperability but be
governed in a way that all interests of the stakeholders are addressed
by those decisions. The government, as I mentioned, will be a
responsible board member as well at the table in the design stage and in
the operations stage. Also this AHIC successor should be relatively
simple to establish but sophisticated and durable enough to adapt over
time to the changing industry needs that will evolve as we move forward
over the many years. Next slide.

In order to ensure these principles are part of the successor
organization, we identified six key attributes of AHIC 2.0, all of which
were detailed in the white paper that is published on the HHS AHIC
Website. In order to set the stage for our discussion about the AHIC,
the AHIC 2.0 design considerations, I\'m going to step you quickly
through each of the six attributes, providing highlights of each. Next
slide, please.

Starting with the high-level vision, from the 30,000 foot level, the
successor is envisioned as an independent membership organization with
members from both the public and the private sector, and with a focus on
the creation and use of an interoperable nationwide health information
system. But this is not technology for technology\'s sake. Its real goal
is to address, improve and sustain the health and well-being of
individuals and communities, communities of individuals, throughout the
United States. Next slide, please.

The functions within this organization could include continuation of
AHIC interoperability initiatives; setting nationwide priorities for the
sequence of getting to full interoperability; advancing certification,
harmonization and activities related to the Nationwide Health
Information Network, or NHIN; and it might even include new activities
such as the accreditation of health information exchanges that want to
connect into the NHIN. Next slide, please.

Clear language is really important at this stage. So I want to be very
clear about the term interoperability. As we use it here,
interoperability refers to initiatives that identify and remove
obstacles to health information exchange. These can be technology-based
obstacles, such as the lack of harmonized technology data exchange
standards, and it can also be removing obstacles associated with lack of
business rules and agreements necessary to allow the enabling
technologies to be used. There\'s a spectrum of interoperability that
runs from technology standards at the core, which are necessary but not
sufficient for interoperability; and then there are product-level
interoperability obstacles that can be addressed with the adoption of
standards, with product certification; and then there are even broader
more complex obstacles that might block adoption or block market
development of a nationwide trusted network of networks.

Now we have this diagram that you see on the slide there of the
concentric circles. And notice that when you move away from the
technology standards at the core, that the remaining interoperability
activities pertain more to business-level concerns than to pure
technology concerns. And we expect that the AHIC 2.0 will address these
multiple layers. For example, in the case of personal health records,
technology obstacles might include the lack of an accepted
interoperability specification for the exchange of information, while a
business obstacle might be the lack of model data sharing arrangements
among PHR vendors, hospitals, providers, laboratories, and health plans.
We have both the technical as well as business-level kinds of obstacles
that need to be addressed. Next slide, please.

As I mentioned earlier, we expect that AHIC 2.0 will be a
membership-based organization, where the stakeholders, that is, all of
the relevant and affected parties in the health community, would play
the role of stockholders in the new organization. Membership would be
open to all, and anyone who is eligible could not be excluded, except
under very limited circumstances which need to be defined ahead of time.
Members could be organized into sectors where the sectors are used to
support creation of a governance body and to inform decisions made by
that body. Sectors are attributes of governance used to mitigate the
risk that any one market interest would control or dominate the AHIC
2.0. The nature of membership itself can vary. For example, we created
an illustrative model of the successor that we\'ll be using today as one
example of how AHIC 2.0 might be organized, and in this model we
envisioned both direct and participating members, each with different
rights and responsibilities within AHIC, but all being members of AHIC.
Next slide, please.

In this prototypical or illustrative model we identified the nine
membership sectors that you see here. There\'s nothing magical about the
number of the sectors. But in thinking through the perspective of each
sector, we were able to do some what if analyses of different approaches
to constituting an equitable board that represents the whole. We
realized that the actual composition of the board, how many seats for
each sector, if sectors are the approach that\'s used, will need to be
determined during the detailed design process during the phase one of
the grant. I want to point out that one of the sectors we defined is
predominantly a geographically-based organization of all the other
sectors. That is, the one that\'s labeled there health information
exchange sector. And I point this out because we\'ll talk about it in a
little more detail later as one of the design considerations, whether
the sectors are geographically independent or may be
geographically-based. Next slide, please.

The members of AHIC 2.0, like any member-based organization, will be
governed by a board. In this case one that equitably represents the
sectors. The number of seats on the board and how they will be allocated
in the different sectors is a detail of the design that will require
collaborative work between HHS and the grant awardee. However, the
principle that will drive the design is the need to prevent decisions
that have broad impact, such as health IT priorities, from being
dominated or controlled by one or a small group of sectors or interests.
Similarly, eligibility for being elected or appointed to the board will
need to be clearly defined, again as a collaborative effort between
public and private interests. Next slide, please.

Moving to rights and obligations of members and the board. Membership
voting rights, if any, will need to be delineated by a set of bylaws.
Board member voting will likely be from a fiduciary perspective, with
each board member, regardless of the membership sector they originally
represented, voting based on the best interests of the successor
organization and its mission. And again I\'ll talk about that in a
little more detail later. Voting, decision making in general, will
specify the use of quorums and circumstances and issues where a double
majority or a super majority will be required. And in that sense we use
the term that this is like the Constitutional Convention, we talked
about that on August 17th, and if you look in the Constitution you\'ll
actually see examples of both double majority and super majorities that
we use to govern our country today. Next slide, please.

The general attributes of governance, as I\'ve just reviewed with you,
will be put into operation through incorporation and self organization.
The new entity will need to identify and address complex business and
legal issues related to corporate law, best jurisdictions for
incorporation or other legal formation, securities law, anti-trust law,
trademark and intellectual properties law, Federal and State law
regarding membership. All the more reason to conduct the detailed design
in collaboration with private sector entities and with individuals who
have current and relevant expertise. Next slide, please.

To conclude the review of the attributes of AHIC 2.0, I want to vet our
thinking about the management and staffing model. There\'s nothing
particularly extraordinary in the organizational structure. There will
need to be the necessary operational entities, a CEO, a CFO, counsel, a
secretariat, support for the board and so on. What I\'d like to point
out is there are four management attributes that are key to the success
of the new entity.

First and foremost, and you\'ll hear this again a little later, is the
overall organizational leadership. The entity requires a leader with
national recognition by a wide constituency of the health community,
someone with a reputation as an honest broker and who is respected and
lends credibility and prestige during formative stages of the entity.
This is for the entity itself starting next spring. Again, during the
August 17th briefing with Secretary Leavitt, we talked about this as the
George Washington, the person who is trusted to bring people together.
Second, there needs to be designated a senior position that is
responsible to build membership and to ensure that the entity is the
health interoperability organization for both public and private
stakeholders. Another senior position is needed to be responsible for
driving forward and resolving the technical issues while yet another
senior position is needed to drive resolution of the non-IT obstacles
for health IT interoperability. Next slide, please.

Designing and establishing an entity like the AHIC that we envision
hasn\'t been done before. This is a new type of thing. It is not
anything that we\'ve experienced within our current organizations. And
there\'s a certain risk when doing something that hasn\'t been done
before. So in looking at how we could decrease these risks so we can
increase the chance of having a higher chance of succeeding, we
identified a few success factors. First, we need continued strong
government participation. When AHIC 2.0 comes into existence, government
will still be a major participant. Federal as well as State government
is a major purchaser and provider of healthcare and will be at the
table. Other success factors for the AHIC successor include the need to
be led by an honest broker, I mentioned that earlier, and this leader
really needs to have exceptional leadership skills and as a result be
able to attract equally exceptional leaders and staff. And the leader
should be an esteemed individual who will act for the greater good.
There must also be a clearly articulated list of planned accomplishments
in the short-term. It has to establish the reputation that it gets
things done and it has to show that it can deliver it. Has to have
adequate financial backing and needs to have broad participation and
commitment from both public and private sector with the board made up of
the most esteemed and trusted individuals in each sector. Next slide,
please.

That is the first overview. And so with that overview of the AHIC vision
and its attributes fresh in your mind, I\'m going to move to a more
interactive part of our morning, the discussion of design
considerations. And the interaction at this point is going to be
stopping at certain points to get clarifying questions. So between now
and around 11:00, I\'m going to walk you through a series of questions
to consider when designing AHIC 2.0. We\'ll cover three broad areas:
membership, board of directors, and the relationship between members and
the board. And I\'ll stop between each of these areas to take questions
on anything that needs clarification. The more in-depth questions about
these design considerations will be held until the question-and-answer
period at the end of the session and after we finish talking about the
grant application process.

Before I go through the design considerations \-- next slide, please \--
I want to provide a quick illustration of the impact of each decision,
and this will be fast and might be a little challenging to follow the
first time through, but you can go back and listen to this or read the
text. And it will demonstrate the nuances of the design and how it can
impact the resulting AHIC. Next slide.

For each of these 14 aspects, I\'m going to articulate one option so
you\'ll see the example of the design considerations we\'re referring
to. So, for example, in consultation with our expert advisors, one model
that we came up with for the AHIC 2.0 design has the following
characteristics. Membership is organized by sector roles. The sectors
operate according to the board-prescribed membership agreements. Voting
by members is weighted to ensure consumers are balanced with large
corporate interests. The board members for each sector are elected by
members in that sector using eligibility criteria set by a planning
board. And as you see I\'m kind of ticking off solutions to each of
those different 14 areas. The number of seats on the board is determined
by the number of sectors. And as is usual with a nonprofit organization,
the board chair is a separate person from the CEO of the operating unit.
The board members rotate yearly into a three-member executive committee.
All members have a fiduciary duty to the full membership, not the sector
that voted them into the seat. And the board makes decisions by both
simple and super majority, and some decisions require a double majority,
that is, the board has to have a majority and a particular sector or
sectors also have to have the majority, as per the bylaws. And all
members have a prescribed and active role to stay informed and vote on a
set of reserved matters, again as defined in the bylaws. So this then is
what might result. Next slide.

Based on the choices that we made in that model, the organization might
be constructed as shown on this slide. Of course, this is just one
model, an illustration, that\'s intended to help clarify your
understanding of the attributes. The final organization might look
similar to this or might look different depending upon the choices made
regarding these 14 aspects as well as choices made about other
characteristics. We offer this model as a starting point that embodies
all of the core characteristics we think are necessary to create a
balanced, multi-stakeholder entity, open to all relevant and affected
parties, while keeping any one sector or subset of sectors from
dominating, an entity that can make rapid and substantive progress to
achieve interoperability while adhering to all appropriate public
policies promulgated by local and national governments, and while
protecting the interests of the most vulnerable sectors as it also meets
the needs of its corporate members.

This design is not necessarily the only one that could achieve this
result, and we recognize that we don\'t have a market on having all the
best answers. That\'s why we are going through this grant process. There
are many, numerous, bright, creative people and organizations who we
hope will choose to join together as a collaborative to apply for the
grant that we\'re talking about today, and who can then improve our
illustrative model wherever possible to design the best possible AHIC
2.0 which will start up in the spring.

As you\'ll see, each consideration has far-reaching implications and
each requires careful thought. For each of the considerations identified
on these last two slides, I\'ll point out the relevant design objectives
as described in the white paper and the Notice of Funding Availability.
And then I\'ll present two to four different alternatives for meeting
the objective, along with some pros and cons of each choice, neither of
which is illustrative. So the alternatives and pros and cons are being
shared with you to illustrate the nuances of each of the, of each of
these design considerations and to stimulate your thinking about how to
best meet the objectives. We\'re not recommending any of the
alternatives as the only one, except in one case where we will indicate
our strong belief that it will probably be in a certain direction, and
we\'re certainly not saying that we\'ve identified all the potential
alternatives or all of the pros and cons for each. So quickly I\'m going
to step through these 14 areas. Next slide, please.

So the discussion then that I\'m going through is meant to be
illustrative of the design process that we expect the grantee will be
going through. And it also is an opportunity for us to share our current
thinking that\'s been formed over the last few months. I\'ll start with
considerations regarding membership, that\'s that first section here,
and specifically how to organize members. One of the precepts of AHIC
2.0 is that it will represent all elements of the healthcare community
and that no one part of the community should control or dominate.
Because we envision that AHIC 2.0 is an open membership organization,
there\'s need \-- there will need to be a way to ensure that the
membership is balanced. One way of doing this is to organize the
membership into sectors. But how do you define a sector? Is it by the
role or the stake one has in the system, or do you do it based on
geography? Or is it enough to have geography as just a sector, like
government, that doesn\'t cover just one specific area? And at what
level are the sectors defined? So, are all clinicians treated the same
or are sectors broken up by discipline or specialty? Next slide.

The stakeholder model brings together entities with similar interests
and supports representation of each stakeholder\'s interests \-- excuse
me, each stakeholder's concerns and interests. This lessens the risk
that any one group will feel disenfranchised from the health information
interoperability priority setting process. On the other hand, this model
could perpetuate silos, when collaboration and cooperation are the real
goals of the interoperability.

The geographic model could take advantage of the emerging health
information exchanges or RHIOs and leverage that momentum, a coalition
of the willing, so to speak. However, some geographies may end up being
over-represented relative to other geographies, resulting in limited
representation for some stakeholder groups. Next slide, please.

Regardless of how membership sectors are defined, if they are defined,
how do members align with a sector and how does the sector operate? One
way would be to allow for self-selection into a sector, and then have a
sector establish their operating rules. So do I say what sector I\'m in
or am I assigned? Or the AHIC could assign members to a sector and use
the board structure to prescribe how the sectors will address voting or
how sector members are notified of decisions. Next slide.

So looking at the pros and cons, again not meant to be exhaustive.
Self-organization is highly democratic and would encourage the broadest
participation. However, at inception of the AHIC 2.0 there will be a
lack of structure within which participants would be able to organize
themselves, and that\'s what we're referring to as the chicken-or-egg
problem. You might need an initial structure to allow self-organization
to flourish into more robust structures. A prescribed approach as to how
sectors will build members and how they will operate would avoid this
early confusion and minimize disputes. But the drawback to prescribing
which members are assigned to each sector is the potential for
misclassification. Next.

On this next attribute, the third and final question about membership
pertains to membership voting, and this is not a question about what
members vote on. We\'ll talk about that shortly. But we need to consider
the pros and cons of each, of having each member have one vote
regardless of that member\'s size and impact, or whether member votes
should be weighted based on some relevant factors. Suppose that sectors
are defined as different stakeholders, and that large insurers and very
small insurers are aligned with the payor sector. When the membership is
asked to vote on an issue within that payor sector, an issue such as
change in the AHIC 2.0 scope of responsibilities, does each sector
member get one vote or are large insurers allotted more votes based, for
example, on number of covered lives? So a Senate or a House type of
approach. Next slide.

Again, looking at the pros and cons, the per capita model is simple to
administer, but the weighted model is, of course, more likely to align
with incentives and participation, although, the weighted model is
complex to design and could effectively disenfranchise the small
entities. So again what are the choices, how do we choose among them,
what do we design into AHIC 2.0? Next attribute.

AHIC has to be self-sustaining and membership fees, if there are any,
cannot be a \-- cannot create a barrier to participation, or should not
create a barrier to participation. So if you assume that there will be
membership fees, are they the full source of the AHIC funding? Are they
used to partially fund AHIC? Or can the full funding be secured from
alternative non-membership fee sources? And in deciding the membership
fees how do you tier them or scale them across the different sectors so
that they don\'t create a barrier to that participation? Next slide.

So looking at these different alternatives, using membership fees and
the pros and cons of them, using membership fees to fund the operation
of the AHIC 2.0 relieves the operation from having to spend time
identifying other sources of funding. However, whether full- or
partial-funded \-- whether fully or partially funded by membership fees,
the operation will need to expend resources to build membership. So you
spend the time building membership, you spend the time raising money.
But there may be funding via gifts or grants or sales of products and
services that might allow the board to focus on interoperability and not
on funding. But there may be no reliable way to predict the likelihood
of gaining adequate grants and gifts, which would make planning for
future initiatives more risky. And there are probably no products or
services to offer in the first few years of the AHIC 2.0 operation. So
again, decisions to be made by the planning group that comes together
about how the initial AHIC, starting in the spring, should be
structured, should be funded. Next slide.

So we\'ve now completed that first broad area regarding membership
issues. Next slide, please.

I\'m going to stop here for a moment before moving on to the board
considerations about the AHIC 2.0 in order to take any questions either
from here in the room or from those of you on the Internet. Questions
that are meant to clarify any of the points I\'ve made. As I mentioned,
more substantive questions about this first section should be held until
the final question and answer period which will be following the
presentations of the grant process, and that last part will start about
11:00. We\'ll talk about the grant process and then have a general Q and
A time. Let me stop here and see if there are any questions. For those
in the room if you'll go to use the mic in the front, and then I\'ll
pause also to see if we get any questions from the Internet.

**[\>\> Carol Bickford:]{.underline}**

Carol Bickford from the American Nurses Association. In taking a look at
the stakeholder list, I did not see information system vendors as
partners in this initiative. Could you explain which category they might
fit?

**[\>\> Rob Kolodner:]{.underline}**

Excellent question, Carol. I think in the model that we designed we
actually consciously chose not to include the health IT vendors since
they actually would be beneficiaries of the activity that would be going
on. The planning board that comes together this fall and this winter may
choose otherwise. But it consciously was that it wouldn\'t be there as a
health IT vendor. On the other hand, they are employers, so they\'d be
part of the employers. They are each individually consumers, so they\'ll
be part of the consumers. And in fact one of the things about this is
that we expect that various entities will have membership of different
sorts in the different sectors. They may be participating in one sector,
they may be direct members in another sector. And this cross-link
actually is part of the weaving together so that there\'s a common
interest moving forward rather than a separate. But the decision at that
point for that particular model, the prototypic model was to actually
not have a separate sector for the health IT vendors.

**[\>\> Kelly Cronin:]{.underline}**

Let me add one more point to that. This is Kelly Cronin. If you notice
in the example that was given, there are two members at large that could
be elected or appointed. And as the planning board is convened, they
could be contemplating, if they choose to go in that direction, who
might be represented in those two slots. So there could be some thought
leaders from the informatics community, for example, or someone from
industry who is perceived to be influential and has the right
characteristics to represent the organization\'s interests.

**[\>\> Rob Kolodner:]{.underline}**

Okay. We have a question from the Internet from Joe Conn. And the
question is: what product or services are envisioned that the AHIC might
sell?

I think this is part of what the planning board would be looking at. For
example, one of the possibilities is that they actually would provide
the governance for the NHIN as it gets stood up. Not necessarily the
initial process, which right now ONC is working on and the Federal
government is working on, but once it becomes operational, it may be
that that NHIN \-- in fact we do think that NHIN will need a governance
structure and the AHIC 2.0 could serve as that governance. In that case,
the services of the NHIN may in fact charge a few cents per transmission
or for transaction over the Internet. And that could in fact be a source
of it. As we\'ve mentioned in the past, one of the inspirations for us
has been looking at what Visa was able to do in the banking market and
the credit market. And while we recognize that the complexity in
healthcare is very different and may be orders of magnitude more
complex, both in terms of having a different kind of entity be part of
the membership, as well as the complexity and volume of the data that is
moved, one of the things about Visa is that it is able to move the
messages, the transactions, the financial transactions, around the
world, translating language and currency, for less than a penny a
transaction. And so the idea is that the NHIN wouldn\'t be a source of
profit but would be a break-even, shared resource and that you cover the
costs of that and share it and that may in fact generate the necessary
funds for the governance structure, AHIC 2.0, to go forward. That would
be one example.

Another question from the audience here?

**[\>\> Ruth Perot]{.underline}**

Good morning. I'm Ruth Perot from Summit Health Institute for Research
and Education. In light of the goal, or one of the goals, of the AHIC,
to serve the health and well-being of all individuals in the United
States, was consideration given to a membership principle that the AHIC
should be diverse, reflecting the rich diversity of the population of
the United States racially, ethnically, and et cetera?

**[\>\> Rob Kolodner:]{.underline}**

Yes, excellent question, Ruth. I appreciate you raising that explicitly.
That was something that we have been concerned about. We want to make
sure that all interests, particularly those of the vulnerable
populations and those that tend to be under-represented in other times,
also be considered as part of that design. And so part of our
negotiation, part of our work in the cooperative agreement will be to
make sure that the design is one that includes the interests of all
stakeholders, particularly those of minority or under-served
populations.

And seeing nobody else moving to the mic, and hearing nothing more from
the Internet, we\'ll proceed. The next slide, please.

So I\'m going to be returning to the presentation material and cover
some issues regarding design of the board. I\'ll move quickly through
the eight topics that you see here. And then again, stop for clarifying
questions. Next slide, please.

The assumption we have is that the AHIC 2.0 will be governed by a board
of directors that has an executive committee. To be clear, the grantee
is being asked to set up a planning board. This board, the planning
board, is the group of collaborators who will be designing AHIC 2.0, and
is not presumed to be the same individuals who will assume the role of
the board of directors of the AHIC 2.0. There are two separate
processes. So we\'re wanting to get a collaborative that has trusted
members of its board to help in the design and planning. And then the
establishment of the AHIC board itself will be a separate process that
will be part of what we work together on during that planning process
and recruiting board members and staff for the set-up. So this board for
the AHIC 2.0 will come into being in the spring of 2008. Given the
assumptions, we need to consider how AHIC 2.0 board members will be
selected in an ongoing basis, and ensure that the process results in a
board that has balanced representation of all the members. And we ask
that you consider whether appointment to a board is a better option than
an election, or, depending on the sector, would a hybrid of the two
work, where some members are elected and some are appointed? Next slide.

Looking then at the pros and cons, appointment assures that specific
voices are heard, such as under-served populations and government
leaders, but appointing members can make changes to the board difficult.
Election ensures each sector's members have an active role in filling
the board seat, but requires that you design voting eligibility
requirements and procedures and how you\'re going to deal with making
sure that various sectors in fact have some representation. Next slide.

To avoid disputes and maximize collaboration, eligibility must be
clearly articulated. Eligibility must be designed so that it supports
the mission of AHIC 2.0 but does not disenfranchise any member sector.
So the design issues here are whether each sector \-- or, if sectors are
established, and again I\'m talking about sectors, but you\'ll have the
same kinds of things if you go with a different type of design that does
not use sectors \-- so whether each sector should determine the board
eligibility within its own sector, or whether the board itself should
determine the board eligibility across the sectors. Again, this is the
eligibility to serve on the board on behalf of that sector. Next slide,
please.

Looking at these pros and cons, when sectors determine eligibility
they\'re most likely to define them in a way that fits their needs. But
this could result in parochial criteria that are not necessarily in the
best interests of advancing the nationwide vision for interoperability.
And this sector-based method will most likely result in different
eligibility criteria per sector, which may or may not be a bad thing,
but at least we expect that it would be different. When the board
determines eligibility, there will be efficiency and consistency, but
sectors may feel that the criteria are imposed upon them. And we also
would have the chicken-and-egg situation where you need a board to
define a board. In this case it might be the planning board that defines
the first starter board for AHIC, which has a limited time span and
needs to evolve to the ultimate board over a short period of time. So
how does the initial board get created in a manner that engenders trust
among all of the members and allows for an evolution over an appropriate
amount of time to both provide continuity so you don\'t have a rapid
change-over of all the board members and have a discontinuity there, but
also allows for rapid enough change to minimize a transition from that
initial board to the ongoing operational process. Getting on with it
rather than taking years and years to make that transition. Next slide,
please.

In addition to considering eligibility for election or appointment,
there\'s also the need to understand the optimum number of board
members. We examined both the senatorial model and corporate model. The
corporate model included both for-profit and non-profit board
compensation. Next slide.

Looking at the pros and cons of those two models, the size of the board
under the senatorial model would be driven by the number of sectors, and
could result in a large number of seats. While this provides broad
representation, it also increases the likelihood for extended
deliberations and presents a greater risk for deadlock. A more
streamlined corporate model supports efficient decision-making but also
creates the opportunity for the board to act more independently of the
members and this is only a con if the composition of the board is not
genuinely balanced and representative of the whole. Next slide.

Another consideration, this is the fourth of those eight for the board,
is the chairperson. In the for-profit model the CEO is the chair of the
board, while in the not-for-profit model the chair is typically a
volunteer position, while the CEO is a separate, salaried position.
Whether the chair is the CEO or a separate person, the chairperson and
the board should not have fundamentally opposing philosophies. And the
selection process should result in the strongest possible leadership.
Next slide.

We looked at the pros and cons relative to that. When the board chair
and the CEO are one and the same person there\'s consistent and strong
leadership for the board and the staff. However, this consolidates the
power in the hands of one person. With separate leaders for board and
the staff you have a rational balance in leadership, but you also have
the potential to select leaders with strong competencies and in the two
different disciplines leading, those leading staff and those leading the
leaders. And again this is not exhaustive of the pros and cons, but you
get a flavor for the kinds of things that you're going to need to look
at as you\'re doing this planning phase that is planning for the design
of AHIC 2.0. Next.

Regardless of whether the CEO and chair are the same or different
individuals, the chairperson must be selected. And in the corporate
model where the CEO and chair are the same person, the board elects the
chair by majority vote. In the popular vote model, the membership votes
for the chairperson. Next slide.

Looking at the pros and cons for selecting that board chair, the
corporate model empowers the board and possibly results in the selection
of the most capable person, not the most popular person. But this model
distances the chair from the membership. The popular method for
selecting the chair will result in the greatest level of buy-in from the
members, but will require that voting requirements and procedures be
designed. More complex. Next slide.

Efficient operation of the board, efficient operation of the board will
depend on a well-functioning executive committee that will be available
to exercise the power of the board between board sessions which are
typically held on a quarterly basis. This committee is responsible for
effective management of the organization including organizing board
agenda, evaluating management performance and compensation, and
encouraging frank and collegial conversations between board and
management. An executive committee is essential to good decision-making
for larger-sized boards. The security council model would provide for
three members in one year, adifferent three in the next, and so on.
Board members would automatically rotate in and then out of the
executive committee over a three-year period. In the corporate model,
the chair chooses the executive committee members. Next slide.

Looking at the pros and cons, forming the executive committee using the
security council model avoids institutionalization of the functions but
could result in less qualified members serving on the executive
committee. While the corporate model promotes efficiency but creates
greater risk of decision-making that does not have wide support. Which
one do you want to choose or is there another alternative? Next slide.

A key consideration when designing the board governance is the specific
scope of the members' responsibility or duty. We envision that the AHIC
2.0 board is one where members have the duty to AHIC 2.0 goals and
objectives. But we explored the opposing model, or alternative, where
the board members have a duty to the sector they represent. Next slide.

A duty to AHIC supports the collaborative nature of the AHIC objectives,
although it may restrict some from serving. A duty that\'s limited to
the scope of the person\'s industry interests is consistent with
industry norms but is not likely to foster the trust across the sectors
and move the interoperability ball forward as we need to do so. We\'ve
seen the extent of progress over the past two decades under this
turf-specific type of model. Next slide.

Okay. That\'s the one \-- and I expected to see one other thing pop up
there. This is the one \-- if we go back a slide, please \-- this is the
one where we actually believe that the duty to the AHIC successor, the
fiduciary responsibility to the whole, in fact is the one that we think
is the right answer. We\'ll consider others, if you can make a good
argument for how we\'re going to accomplish the achieving the goal by
having the duty to sector. But we believe that the board members need to
operate with regard to a duty to the whole rather than that of the
sector. Next slide, please.

Once the board is populated and has selected a chairperson and an
executive committee, the final design consideration is about how
decisions will be made by the board. Potential models here include
making all decisions by majority vote or making some by super majority
vote and even sometimes using a double majority as I described earlier.
Next slide.

The benefit of using the simple majority model is that it enables
efficient decision-making and supports the concept of collaboration. But
it runs the risk of resulting in decisions without adequate support and
adoption, or the domination of a particular sector. Super majority or
double majority voting requirements for specific circumstances, when
used in conjunction with simple majority, helps to build broader buy-in
but if used too often could slow progress, and so we'd need to define
very carefully what are the circumstances under which we would use the
super majority or double majority. Next slide.

So I\'ve now run through the eight considerations of that of the board.
Next slide.

And I\'m going to stop again, briefly, to see if you have questions of a
clarifying nature regarding the material that I\'ve presented in this
second section before moving on to the final design considerations.
Again, I think we have one question from the Internet. And if anybody
here has questions, if you\'ll move to the microphone.

From the Internet a question from Miguel Berry: Good morning. I\'m
representing a community college in south Texas. We are interested in
organizing a non-profit regional health information exchange entity.
I\'ve researched some of the AHIC background materials. Is there a
process for recognition or linking to the State and national health
information community entities?

I think this is part of that, of the evolution that we are talking
about. You saw that we had one that said a sector would be health
information exchange. If there is, then that sector would need to come
up with the rules or the board would have to come up with how that
sector is going to be organizing and becoming members of the AHIC. In
fact, one of the many things that might come out is that the AHIC will
be the national member organization for the health information exchanges
that organize fractally, that is the local connect to the region, the
region will connect to the State, the State connect to the national.
That might be one part of the structure and their relationship with the
AHIC 2.0, or it might not. So right now there isn\'t a specific way for
how the local \-- the nonprofit regional health information exchange
entities organize on the national level but that will be emerging as the
AHIC itself comes into being, AHIC 2.0.

Any other questions here in the room? If not, if I could have the next
slide, please?

So the two remaining design considerations pertain to the
membership-to-board connection. So we\'ve talked about the membership.
We\'ve talked about the board. Now we\'re talking about the connection
between the membership and board. Next slide, please.

As a membership organization that\'s open and inclusive, it will be
critical for all members to remain informed about the decisions of the
board. So we ask that you consider how communications occurs between the
membership and the board so that that communication will be assured. A
few models we considered were the passive and the active models. And we
realized that there are any number of ways to implement either the
passive or active solutions. Next slide.

Again, some pros and cons. And as you can imagine, the passive model is
not as effective as the active model. But engaging sectors does come at
a cost. And the question is how do you do it, how do you engage the
members, and how do you make sure everybody is informed about what\'s
going on, so that when they get to vote, and there will be some of those
decisions that may, by the bylaws, be made by the whole, it\'s an
informed choice that\'s being made. You may even require that they meet
in an organized fashion in some way, if it\'s geographic or if it\'s by
organization, and that those decisions roll up in a structured fashion.
And actually that\'s the next part, next, please.

The first was communication. This next part is the greater challenge,
determining the circumstances under which the membership vote is called
for, as contrasted to the vote of the board. And here we have four
models that we considered. One where members vote on all material
decisions and the board makes recommendations to the membership. Another
model, at the other end of the spectrum, where the board has governance
over all material decisions and keeps its members informed but they
don\'t actually get to vote directly. And then there are two models at
the center where members vote on matters reserved in advance, as defined
by the bylaws, or members vote by initiating a referendum. There\'s
nothing per se that they get to vote on except when they have a concern
and they initiate the referendum. Next slide.

As you can imagine, the member-centered model supports adoption of
decisions better than the other three models, but it's cumbersome,
costly, and time-consuming to implement. Now, it may be worth going
through that. That\'s part of the decision that the planning group needs
to look at, that it may be worth that cost and time. The central board
authority model is the most efficient and allows the greatest degree of
flexibility to respond to changes in the industry and in the healthcare,
changes in the healthcare system that we are going to be fostering, but
it reduces accountability of the board to the membership. The models
that reserve a set of predetermined matters for membership voting or
have membership vote by referendum provide more balance between the
membership and the board but each has their own drawbacks to be
addressed. Next slide.

This concludes those questions in that last two areas that is the
membership-to-board considerations. Next slide.

And again, I\'m going to stop here and take any additional questions
that you may have. Kelly, given we\'re a little bit ahead of time, I
think at this point we\'ll open up and take questions that you might
have not only of a clarifying nature but more substantive questions that
you might have regarding these design considerations.

And I\'ll start with a question from the Internet. This is from **Rex
Brooks**. If no duty to sector is allowed how will consumers be
adequately represented vis-à-vis insurers?

The duty to sector, it says if no duty to sector is allowed, the duty to
sector alternative is actually the one where insurers would be
accountable only to insurers, and where consumers would be accountable
only to consumers, and providers only to providers, and employers only
to employers. So when we talk about consumers being adequately
represented vis-à-vis insurers, each sector would be represented but
you\'d have more fragmentation as they come together at the board.

The duty to the whole is one where the insurers are responsible also for
what\'s best not only for the insurance community but for AHIC, which
includes the individuals, the consumers as well. And the consumers also
are responsive for what would make sure that those who were delivering
care also have their needs met. So there\'s a sharing of that back and
forth. So the representation of insurers for the consumers would
actually be better achieved with the duty to the whole, and if you did
have the duty to sector, you\'d basically have the voting and the
governance balancing out the interests as they come together with
probably very different viewpoints.

**[\>\> Jennifer Macellaro:]{.underline}**

This is Jennifer. I just wanted to let everybody on the phone know that
even if they\'re already dialed in they still need to press star one if
they want to ask a question.

**[\>\> Rob Kolodner:]{.underline}**

Thank you Jennifer. Other questions here in the audience?

**[\>\> LeRoy Jones:]{.underline}**

Lee Jones, for GSI Health, and program manager for HITSP. To the extent
that the, in your concentric circle diagram, there are these attendant
things, like HITSP or CCHIT, how are those entities, which I think have
some, CCHIT certainly is a legal entity unto itself, HITSP has a goal of
being self-sustaining. I think that the NHIN contractors are likely
going to propose in a context of things that they\'re already doing in
whatever region, or at least in some cases, how do those, the fate of
those various initiatives get wound into this? Is it going to be
prescribed by the groups that put things forward or is it going to be
collaboration of some sort? How do you envision that happening?

**[\>\> Rob Kolodner:]{.underline}**

Excellent question, Lee. And we\'ve also been talking to Mark Leavitt
about this, relative to CCHIT. We don\'t see this as being something
that will be defined coming out of the box. We see this actually as a
negotiation between the AHIC 2.0 and those entities. We\'ve said that in
order to achieve interoperability, they will need to have
responsibilities to drive forward on the standards; that is, they\'ll be
setting the priorities and be needing to function in this area much as
the current AHIC is doing. It sets priority, it looks at the standards
coming back. So it will have to have a relationship with HITSP. What
that relationship might be is between HITSP and AHIC to work out. Same
with CCHIT. And so I see those as something that will evolve once AHIC
comes into existence. One of the things that we\'re looking at from
ONC\'s point of view is taking the funds that we use to, for HITSP for
development of standards, or CCHIT for the development of certification
criteria, and possibly starting in 2009 working those funds to the AHIC
2.0 so that we still have management control of that, but that the AHIC
2.0 would then be serving that AHIC-like function of setting the
priority and receiving the standards back. And then the tie-in, and
we've talked about this on some of the others, there\'s needs for some
of those standards to be recognized, accepted, and recognized by the
Secretary of HHS because it has certain implications for the
government's use of those standards in its systems, in its contracts,
and for Stark and anti-kickbacks. So there will be a process, and
there's a couple of things that we\'ve been looking at having to do, for
example, with voluntary standards, consensus boards, or by bringing
those back to another FACA that would allow the government to take
action that it needs to in addition to what the AHIC 2.0 takes. Do you
have a follow-up question?

**[\>\> LeRoy Jones:]{.underline}**

Yes. So then is it truly when the AHIC comes into being, or is it
premature to participate in that planning committee reference?

**[\>\> Rob Kolodner:]{.underline}**

Actually, I did misspeak. We expect that we will have HITSP and CCHIT be
part of this planning, so that the discussion can start then. Although
it may \-- unless it gets resolved there, which may or may not occur, it
can continue when the AHIC comes up. But we expect that we will bring
both HITSP and CCHIT to the table as part of that planning process.

Other questions? Why don\'t we take a ten minute break and we\'ll resume
and talk about the grant process following the break. Thank you very
much.

\[break\]

**[\>\> Judy Sparrow:]{.underline}**

Everybody, could you please take your seats? We\'re beginning again.
Jennifer, is everybody\'s line open?

**[\>\> Jennifer Macellaro:]{.underline}**

Yes. They were never closed.

**[\>\> Judy Sparrow:]{.underline}**

I can\'t hear that.

**[\>\> Jennifer Macellaro:]{.underline}**

Yes, Judy, they are.

**[\>\> Judy Sparrow:]{.underline}**

Okay. Just a reminder for those of you on the Internet, please, if you
want to call in and ask a question in person, you need to dial into the
number which was on the screen earlier and then push star 1 to ask a
question directly, or push the Q and A button and new and then type in
your question and hit send and it will come directly to us. So I think
without further ado \-- Rob, are you taking over with this section or
Marc? Kelly?

**[\>\> Rob Kolodner:]{.underline}**

Actually Kelly will.

**[\>\> Judy Sparrow:]{.underline}**

Sorry. Third guess.

**[\>\> Kelly Cronin:]{.underline}**

Thank you all for staying for the next session where we really wanted to
get a little bit more into the details of the grant process and what
we\'re expecting or hoping to see in applicants that are going to come
forward to apply for the cooperative agreement. I think \-- if you could
change the next slide?

As has already been articulated in previous meetings and earlier today,
this is going to be a two-stage process that will be funded through a
grant or more specifically a cooperative agreement. The first stage will
be to actually design and establish AHIC 2.0, as we\'ve been calling it.
And the details of this have been published and the Notification of
Funding Availability which is available on the grants.gov Website. So
it\'s fairly easy to query for the NOFA and there\'s also a hyperlink on
our Website for the AHIC successor.

So the grant is for a 24-month project period, and we\'re funding the
first 12 months with our available funds now. But it\'s intended to last
at least, well, starting 24 months and then there\'s also the
possibility moving forward for continued government involvement. And
the, as I mentioned, the first stage is really the design and
establishment phase that will be done by a planning board that Rob has
been referring to, and then once the new legal entity is established it
will then be considered operational and go into stage two, so that the
funds and the cooperative agreement would actually then be with this new
legal entity and funds would be transferred to that new legal entity.

HHS does plan to play a substantive role in the entire 24-month
cooperative agreement period. First, as a collaborator with the grantee
in the design phase, and then really as a very active participant and a
member of the new legal entity, and it will really be up to the
decisions that are made in the design phase in terms of who from
government will be on the board, perhaps, or who will be potentially
members. And ONC will be facilitating that. Next slide, please.

I just wanted to give you a brief overview of the facts of the grant. As
I already mentioned, the type of grant that we\'ll be awarding is a
cooperative agreement which is set up actually in statute to allow for
substantial government involvement, which is why we chose this vehicle.
We obviously decided not to go with a contract. But we wanted this to
really be a collaborative effort with government, which a cooperative
agreement enables.

It is for a period of two years, as I already mentioned, and the grant
will be up to 5 million dollars for the first 12 month budget period
with a potential for an additional 8 million dollars for the rest of the
grant period, the second year. There\'s no restriction on eligibility to
apply. We truly are seeking a multi-stakeholder collaborative that will
step up, that would ideally coalesce into one single collaborative
through the grant process, but we understand that this is a competitive
process, and that there is a likely situation that many different
organizations will be interested and perhaps more than one applicant
will be advancing an application.

The ideal collaborative is one that includes these individuals who
really can look beyond any specific special interest. We really want, as
Rob articulated before, people to take on a fiduciary role, to be
looking at the greater good, the interests of the whole, and not be
overly concerned about commercial or special interests. And we know that
this is more or less how Washington operates often, but we are hoping
and planning to work with whoever the grantee is to ensure that this
intent is realized. Next slide, please.

So just to reiterate, stage one, again, is for the design period, and it
is to really facilitate collaboration among public and private entities
to come up with a new, stable entity over time that will survive and be
sustainable, that is focused on nationwide health IT interoperability.
We expect the first stage to take approximately four months with the new
legal entity being designed and then fully functional after that. And
then the remaining grant period would be stage two. So stage two would
allow the AHIC successor to operate according to bylaws and it will be
probably commencing in March or April of 2008 and will allow for
adequate overlap of the current AHIC. We plan to work closely with the
awardee or the grantee in the design period to do some transition
planning given there\'s a lot of ongoing activities that AHIC has
responsibility for now, not only for prioritization, but across seven
Workgroups, there\'s an enormous of activity and over 130 experts and
stakeholders involved in a lot of complex issues. So part of the
planning process is figuring out this smooth transition and how, as the
Secretary has been referring to, we\'re going to pass the baton over
time. Next slide.

So what exactly do we mean by design and establish? There\'s obviously a
long list of tasks that are going to have to have to happen in stage
one, but it is going to be only a four-month period, a lot of the work
we\'ve already done that you heard Rob articulate earlier is an attempt
to give the grantee a starting point where they can think from. So
obviously we\'re not prescribing a lot of the answers, but we have at
least outlined a lot of the considerations that will have to be
contemplated and addressed in the design phase. So it does in some ways
provide a framework to think from. But some of the specific work that
needs to get done is to develop the membership rules, the operational
structure, define the roles and responsibilities of officers of this new
organization, as well as the members. The governing documents need to be
drafted and finalized, such as the bylaws, initial policies and
procedures need to be established, and a certificate of incorporation
must be filed to actually get the new legal entity established.

So we expect that the planning board is really going to have to cover
all these details, such as how to compose a balanced board, the rules
around voting, quorums, super majorities and double majorities, and
these all are going to require considerable time and efforts and
expertise. People who have already been through designing not-for-profit
organizations or who have been participants on boards and have dealt
with some of these issues, or legal counsel who has considerable
expertise in these issues. All of that needs to be contemplated by any
potential applicants that you can think through the combination of
resources that you can bring to the table or try to get access to to be
able to successfully complete stage one. So toward the end of stage one,
there needs to be a common and clear understanding of how the entity
plans to pursue the focus of interoperability through its initial
activities. It would also have to contemplate its communication strategy
and a plan for transitioning the appropriate responsibilities from the
current AHIC to itself, of course in collaboration with ONC and all
those who are involved with AHIC right now. Next slide please.

And by the spring of 2008, as we mentioned before, probably March or
April, there will be this stage two starting under the, or as the new
legal entity is established. And this initial operational period between
the spring of 2008 and the late fall of 2008 will really be the critical
time for establishing the operational entity and providing direction to
the nationwide health IT agenda. Just to recap what we have articulated
as some of the potential operational activities, but this, again, will
be confirmed and really debated by the planning board as it\'s convened,
but it includes prioritize stakeholder requirements for the nationwide
health IT interoperability. Accelerating and coordinating current AHIC
interoperability initiatives, including standards harmonization and
certification of health IT. The exact role and relationship between AHIC
2.0 and HITSP and CCHIT will be determined, as Rob and Lee Jones were
discussing earlier, during the design phase, hopefully with a clear
division of roles and responsibilities, but perhaps also maybe some of
the operational aspects of that would be determined in stage two. And
then of course, as we\'ve already articulated, the goal, one of the
goals or one of the functions of the organization could be to advance
the certification of products, network providers, and/or operations.
Again, this is a function that CCHIT is currently serving. Next slide,
please

I wanted to say a few words about some of the responsibilities, not only
what we\'re expecting from the grantee side, but also ONC\'s
responsibilities in this. With the cooperative agreement, there are
responsibilities that are specific to the grantee, the collaborators
collectively that come together to apply. They collectively will play a
convening and managing role that requires at a minimum strong
facilitation of the planning board; executive oversight of the design
process, staff, and deliverables; and thought leadership of stature that
will bring people together and encourage them to coalesce around a
common cause. So there\'s an expectation that there\'s a lot of
different roles that this group of individuals or group of organizations
is going to have to play and it may not be one individual as a CEO or a
chair playing all these roles, but collectively there has to be some
kind of executive management function to make sure that everything is
done within a four-month period. But there also has to be very strong
facilitation of the board meetings. And obviously we need to have the
right organizers and thought leaders of stature to really have people
come together and take on a fiduciary role. There\'s also a need for
domain expertise and a deep understanding of the national health IT
agenda, including what\'s going on with HITSP and CCHIT. We want people
to be based in reality and understand the competitive and commercial
interests, but also have some expertise around organizational design
related to public/private partnerships since this is not an expertise a
lot of people have, yet it is out there and can be brought into this
process. And finally there needs to be some \-- people, and obviously
many who would logically be involved, would have a strong business
acumen and have the ability to think strategically about where is the
future direction going and how can this organization best meet the
needs, including perhaps developing a governance function for the
emerging NHIN. Next slide, please.

So in terms of ONC responsibilities, they include consultation and
technical assistance in the planning, operation, and evaluation of the
design activities. We\'ll be providing information about AHIC and ONC
programs, not just the contracts and funds that are going to HITSP and
CCHIT and other related initiatives, but we'll clearly have sort of the
latest and greatest information about what\'s happening within AHIC and
within ONC that we can incorporate into the process. We\'ll be assisting
in collaborating with the appropriate Federal, State, and local
government officials in the formation of the membership and the board.
This will be a critical role in the early stages given that there will
be a lot of concern and appropriate interest in ensuring a significant
government role, and ONC will be doing its part to ensure
representation. And obviously, as I\'ve said before, coordination of
AHIC activities will be an important part, and particularly developing
the transition plan. Next slide.

So there are some joint responsibilities, including the identification
of a planning board for stage one. Now we don\'t anticipate that we\'ll
be working collaboratively with applicants who are now contemplating
applying, in convening or identifying a planning board, but after
applications have been submitted to HHS, there will be a phase where we
will have some exchange and there will be the ability to talk through
and decide on an appropriate planning board. So that will be a joint
responsibility. If the collaborative consists of a large number of
collaborators, ideally this planning board would be a subset of a large
number of organizations because we\'ve contemplated the difficulties of
having a board that would be as large as 25 individuals. So ideally this
would be more of a organization of about 12 nationally or regionally
recognized leaders, including government representatives. Next slide,
please.

So we do plan to conduct a criteria-based review of all applications
that are received. The ONC will be convening a review panel that will
assess the quality of the proposed approach and the likelihood that the
approach will be successful. So the criteria, organized into four
different categories and weighted, as you can see. The approach and work
plan is 25 points; collaboration 20 points; convening and dissemination
10 points; and staffing and organizational arrangements are 25 points.
So we are really thinking that collectively these four different
categories need to be well addressed in the application, a lot of the
details around this are in the Notice of Funding Availability, so I\'d
encourage any potential applicants to read that carefully, since we did
put a fair amount of thought into how we would specifically evaluate
these. Next slide, please.

Who is likely to receive this grant? In an ideal world we might only get
one application for the grant if all stakeholders were self-organized
and everyone could agree on one single approach. But I think it\'s
likely that there will be more than one set of organizations coming
forward. We don\'t know for sure. But we would like to, you know, have
folks keep in mind that this is a competitive process, and that they
should be looking carefully at the Notice of Funding Availability and
trying to do their best to meet the requirements that are articulated
within that.

In order to select among potentially multiple applicants for the grant
we will evaluate the proposals based on several criteria, as I
previously mentioned. So for example, the applicant will need to
demonstrate a strong understanding of the national health IT agenda as
it\'s unfolded over the past few years. They should be describing an
approach for designing the governance that is fair and balanced and
allows for cooperation of ONC and our experts in the design phase or
design process. The same process should also support and encourage
participation from many different industry sectors. The application
should demonstrate that in addition to the grant money they will be able
to secure additional funds if needed, and that if they have the staff
and resources needed to convene and disseminate the information. The
proposed staff to work on the design will be reviewed to identify the
best fit for this unique and unprecedented responsibility. The proposed
leaders for this effort will be a key discriminator among proposals for
the grant.

Lastly, we do want folks to know that we intend to try to combine
forces, so if there are going to be multiple applicants, that people,
applicants should be open to collaborating potentially with other
applicants that come forward with the concept that they would, we would
ideally like to end up with one unified approach that really does seek
to comply with the principles that Rob outlined and really make this in
keeping with the spirit of true collaboration.

So I\'m going to turn it over to Marc Weisman now to go over some of the
specifics about the grant process.

**[\>\> Marc Weisman:]{.underline}**

Thank you, Kelly, but before we do, you had mentioned joint
responsibility and Rob has one more slide to present about the
responsibility of government in the process.

**[\>\> Rob Kolodner:]{.underline}**

So if on the slides we can go back to slide 58, there was one slide
before the break that I didn\'t cover and got some questions at the
break about that.

And so in addition to the AHIC design considerations that the grantee
must consider, there are also several government-specific questions. The
National Technology Transfer and Advancement Act of 1995 provides that
Federal agencies will use data and technical standards that are adopted
by voluntary consensus standards bodies. An OMB circular defines the
voluntary consensus bodies as organizations that plan, develop,
establish, or coordinate voluntary consensus standards and that are
characterized by openness, balance of interest, due process, an appeals
process, and a consensus process. There are a number of existing
public/private partnerships that feature the participation of Federal
government as a member or as board members and in some cases government
employees play a formal role in governance as representatives of a
government agency. In other cases they serve as board members on a more
informal basis. So we have things like the National Quality Forum, ANSI,
and the National American Energy Standards Board as examples of such
organizations.

Federal employees participating in the AHIC 2.0 would remain subject to
the applicable Federal ethics laws, including those pertaining to
conflict of interest and appearance of partiality as they would taking
such actions in their officially capacity as federal employees, while
serving on the board. And Federal employees who participate in AHIC as
board members may have certain fiduciary responsibilities or obligations
to the AHIC successor and that might give rise to certain conflict of
interest issues with respect to their actions as Federal officials so
we\'d be having them consult with their agency ethics officials prior to
accepting such positions. But we are looking at ways that Federal
entities or Federal employees can in fact be active parts of the board
and I had received a question about that and had skipped over that slide
so I wanted to cover it.

If we can go back now to slide 72, and Marc Weisman will take it from
here.

**[\>\> Marc Weisman:]{.underline}**

Thank you, Rob. And this is the first time that the Office of the
National Coordinator is using its grant-making authority, so I want to
start by thanking both National Library of Medicine and the Assistant
Secretary for Planning and Evaluation for assisting us in this process.
If you look at our announcement you may see NLM and ASPE mentioned in
those announcements, and they\'ve been giving us specific help in
designing the notice and in making sure that we have all the proper
application processes and attachments included in the application.

The Notice of Funding Availability, I\'m sure all of you have seen, it's
on grants.gov. If you need to reach it, you can just type in the number
of the grant and it will come up and you can access it that way. And on
our previous slide it had the particulars of the grant, that application
number, the HHS ONC number, will link you directly to the grant.

We\'ve also asked that if you are going to submit an application, that
you submit a letter of intent. It\'s not mandatory to submit the
application, but it helps us in designing the size and structure of the
review panel and knowing how much time we might need to process the
applications and have some feeling for the type of entities that may be
proposing.

The grants are due on October 5th, and you have your election in
submitting the grant, whether it be in paper or through grants.gov. We
will accept either process, as I say, this is our first go-round and the
grant is open to all entities, and so entities not familiar with the
grant process, if a paper submission is easier, then that is perfectly
acceptable to us. We will begin the application process as shortly after
receipt of applications as possible, and our target date for award is
sometime on or before the 13th of November. So there\'s a slide that we
can put up there that shows you those dates. They are all in the
application notice, and those are the controlling dates. Also, you
should be aware that in grants as in contracts, there is a late receipt
prohibition that we can\'t accept things after the time and due date,
and grants.gov sets forth its rules in that case and our announcement
gives you the place and time that would be submitted would be here in
Washington at the Office of the National Coordinator on the due date.
And that\'s all articulated in the announcement.

The last two slides in our deck are some of the application attachments,
and then a final slide on grants.gov. We don\'t have a formal
presentation on those two slides, but myself and Dr. Corn from NLM are
happy to answer questions that you may have about the particular
attachment that needs to be filled in and submitted or about how to
apply through grants.gov. So at this time I\'ll ask for questions both
on this part of the application and on Rob\'s final statement.

**[\>\> Jennifer Macellaro:]{.underline}**

This is Jennifer. I\'d just like remind everyone on the phone to press
star 1 if they have a comment.

**[\>\> Rob Kolodner:]{.underline}**

Okay, while someone is coming up to the microphone , there was one
question, anonymous, from the Internet, that said how do I apply to
become a board member?

I think there\'s two boards that we\'ve been talking about. The planning
board, be part of the coalition that applies. And then within that
coalition and in conjunction with working with us, we\'ll be working
together to select the board members. With regard to becoming a board
member on the AHIC 2.0 itself, I think those are the processes that are
yet to be determined and after the planning process it will be clearer
how one becomes a member of AHIC and therefore what the rules of
engagement are for becoming a board member.

**[\>\> Meryl Bloomrosen:]{.underline}**

Hi. Meryl Bloomrosen with the American Medical Informatics Association.
Directed I think at you, Kelly, because you made a comment that I was
interested in following up. You talked about potentially having multiple
applications from two or three or numbers of groups of organizations,
and after review by your review panel possibly requesting that more than
one group collaborate together. Would that involve direction from ONC in
terms of making only one award, or potentially might you make more than
one award to two separate entities in that process of asking for
collaboration?

**[\>\> Kelly Cronin:]{.underline}**

That\'s a good question, and I don\'t know that I have answers
precisely. I think that clearly we do want to see one single
collaborative result at the end of the grant process or at the time of
the award. And I think we will be making an internal judgment as to
whether or not that\'s best achieved through the merging of more than
one applicant or the collaboratives that are brought to the table
through the application process. And the Secretary certainly has
mentioned in previous meetings the value he\'s seen in multiple awards
with the design-build process he used for highways. Whether or not that
would be applicable in our situation I think we'll have to wait to see.
But there\'s been probably more consideration at this point given to
just one single award and having one single collaborative of the right
individuals that meet a lot of the goals that we\'ve already
articulated.

**[\>\> Asif Dhar:]{.underline}**

Asif Dhar with Deloitte Consulting. Just to follow up on that point,
would it be useful for the government for individuals that respond to
the grant to create a set of options in terms of things that could be
excluded or included based on the government\'s preference, in order to
facilitate that exercise? For example, if there are particular options
that the organization felt would be prudent to execute or not execute,
that could create a vehicle for the government to essentially merge
different responses into consolidated group that \-- or grantee, if you
will.

**[\>\> Marc Weisman:]{.underline}**

Let me answer the question at this time by saying the grants will be
graded on the criteria expressed in the announcement. If you wanted to
propose some alternative solution, you should clearly mark it as an
alternative. But you should have something that addresses the criteria
and works with the criteria as established.

**[\>\> Rob Kolodner:]{.underline}**

In part, the process, the real planning process isn\'t what the
application is about. The application is really a series of things
including we\'re capable, here\'s what we\'re bringing, we\'re able to
deliver in the time period. The kinds of things that address those 14
attributes, for example, will be part of what\'s wrestled with as part
of that planning process in that short period of time. So the idea of
\-- we wouldn\'t expect different applicants necessarily to lay those on
the table immediately. And we\'d have to look, if we award more than
one, we\'d have to look as to whether we\'re actually wanting two
parallel processes or whether we would say we're awarding it but you
have to work together. And that will be part of what comes out.

**[\>\> Asif Dhar:]{.underline}**

Thank you.

**[\>\> Rob Kolodner:]{.underline}**

There is a comment rather than a question that came in from the
Internet, and I want to read it and acknowledge it\'s from **Henry
Beitz**. And this is a comment: it\'s apparent the thinking is that the
technology will be forthcoming and this is a trivial part of the
concept. With over 40 years of experience in the area of medical systems
technology I can attest to the fact there are no technological solutions
currently in use that come close to meeting AHIC\'s needs. The emphasis
on the design of the legal entity may be important, but there\'s a
design problem that is orders of magnitude larger. That\'s the actual
design of the interoperable IT environment.

Having also been working in this field for a few years, and also with
the experience that we\'ve had with ONC and with moving the health IT
agenda forward, I absolutely acknowledge that the solutions are not
trivial. What we do believe is that having the governance right allows
us to then work through the very difficult challenges and the
development of the standards and the adoption of the standards, and the
evolution of that and how they work together within networks and how
different networks since the NHIN is a network of networks, how those
work together, the protocols, the issues of privacy and confidentiality
that we know are so fundamental, need to be included in there. So there
is not in any way an attempt to trivialize the difficulty, but the idea
is that the governance is also something that we have not had before,
and we need to have that. And that will also then need to engage all of
us who have been part of it, who have expertise in the area, in order to
move forward. So I certainly didn\'t mean to give the impression that
we\'re saying that the technology challenges are trivial. Marc?

**[\>\> Marc Weisman:]{.underline}**

We have a question from the Internet from **Arthur Hamerschlag**:
Letters of intent are encouraged. Will the entities that file letters of
intent be made public? It\'s not our process to make the letters of
intent public. So those are for our planning purposes, and so the answer
would be no in that case.

**[\>\> Rob Kolodner:]{.underline}**

Although, there\'s nothing to prevent collaboratives that are forming
from putting out the fact that they are forming, and recruiting members
in any way that they might want. But we won\'t be the ones who will be
advertising that or putting it out. Question?

**[\>\> Don Egan:]{.underline}**

Don Egan, LMI. Along those lines, though, will you, can you publish the
list of attendees, Internet and live, to this meeting for the purpose of
collaboration?

**[\>\> Kelly Cronin:]{.underline}**

Yes, I don\'t see any problem with that.

**[\>\> Marc Weisman:]{.underline}**

(inaudible) consensus, yeah.

**[\>\> Rob Kolodner:]{.underline}**

Decide and without violating one\'s \-- right, the issue of the privacy
\-- if you don\'t want your name published, please let us know. The
other issue is the degree of contact. I think the name and organization
would be what we would put out. We wouldn\'t put out other information.

**[\>\> Marc Weisman:]{.underline}**

That\'s correct.

**[\>\> Rob Kolodner:]{.underline}**

And then if you want to reach them and you aren\'t able to reach them,
what you could do is to notify us and we could notify that individual
and see if they want to join, but we won\'t be putting out people\'s
e-mails and phone numbers and other kinds of things.

Another question that came in from the Internet from **K.J. Lee**,
saying, or asking, explain how you envision to maintain continuity if
the selection committee has to be different from the board.

There are two different types of continuity here. There\'s the process,
the grant, which has a planning group, and then setting up the entity
itself which goes forward. That continuity is actually less of the
continuity challenge than the continuity between the current AHIC and
the AHIC 2.0, because that\'s really the functional continuity that has
to occur. So I don\'t think that the planning board, AHIC 2.0 board
discontinuity is really the issue. What you\'re wanting to do is bring
in the best individuals to be part of AHIC 2.0. What we will be working
very closely with, both with the planning board, for what the steps are,
and with the AHIC 2.0 when it's set up, is how to do that incremental
but fairly rapid handoff of activities between the current AHIC and the
AHIC 2.0.

One of the points to make is we don\'t expect that there is a total
separation. In fact there are, as Kelly mentioned, hundreds of people
who have been part of various processes and Workgroups and other things
on the AHIC, current AHIC. I expect that many of them may be engaged in
the work of the AHIC 2.0. And that would certainly allow some of that
transition. But the exact details of how we do it, how the decisions are
made as to who serves on the AHIC 2.0 who might have served on AHIC,
those are details to be worked through as we get into the planning and
as we negotiate the details in the future.

Are there other questions from the audience right now, or from the
Internet? If not, thank you very, very much for coming. We appreciate
your interest and look forward to hearing about good things and about
collaboratives that are starting to self-organization among all of you
who are here and those who are on the Internet. With that, the meeting
is concluded.