American Health Information Community

EHR Workgroup Meeting

June 27, 2006

1 p.m. EDT

**Disclaimer**

*The views expressed in written conference materials or publications and
by speakers and moderators at DHHS-sponsored conferences do not
necessarily reflect the official policies of the DHHS; nor does mention
of trade names, commercial practices, or organizations imply endorsement
by the U.S. Government.*

**[\>\> MATT McCOY:]{.underline}**

Okay, Dr. Perlin, you can go ahead.

**[\>\> JONATHAN PERLIN:]{.underline}**

Good afternoon, everybody. Good morning to those in the West Coast, and
welcome to today\'s Electronic Health Records Workgroup conference call.
Thank you all very much for being here. Matt, perhaps the first order of
business is that we should take roll. This is Jonathan Perlin,
Undersecretary for Health. I\'m joined by my Co-Chair, Lillee. Do you
want to say hello?

**[\>\> LILLEE GELINAS:]{.underline}**

Hello everyone, welcome.

**[\>\> JONATHAN:]{.underline}**

Matt, if you would be so kind as to take roll call of membership.

**[\>\> MATT:]{.underline}**

Sure. Joining us on the phone we have Daniel Morreale from AtlantiCare,
Jason Dubois from American Clinical Laboratory Association, Howard
Isenstein from the Federation of American Hospitals. At the ONC building
I know we have Mr. John Houston, is there any others I\'ve missed?

**[\>\> KAREN BELL:]{.underline}**

Yes, Dr. Carolyn Clancy is here as well, yes.

**[\>\> MATT:]{.underline}**

I believe that\'s it, while I\'m speaking I\'ll do just a quick
explanation of the call-in procedures one more time. Since everybody
does have an open line, or all the Workgroup members have an open line
on the phone, please mute your line when you\'re not speaking. And when
you do make a comment, please identify yourself first so we all know who
is speaking. And if you\'re following along on the Webcast, please
don\'t touch any of the controls to advance the slides.

And lastly, if you\'re a member of the public listening in right now you
will be given an opportunity to ask a question, or make a comment, in
the last 5, 10 minutes of the meeting.

**[\>\> JONATHAN:]{.underline}**

Thank you very much, Matt, I appreciate that. Let\'s jump, then, to Item
4 on today\'s agenda, and that is the review and acceptance of the
minutes. I would just note that your Co-Chairs are tasked to volunteer
prepare a mockup of a paper based personal preparedness, personal health
record, for presentation to the Workgroup. I know this might be a first
step to the longer goal of developing a system that would ensure
critical health information being available to first responders, to have
what they need when attending to people in disaster or emergency
situation, and connects us electronically. However, I may ask Karen to
comment; this may have been overcome by events by the HHS request for
information, entitled voluntary storage of personal data in preparation
for emergencies. Perhaps you might comment on that, Karen.

**[\>\> KAREN:]{.underline}**

I will. As you know, there are nine initiatives that the Secretary is
focusing on for the duration of his stay in office. And one of those is
around emergency preparedness, in its full scope. Not just in terms of
clinical preparedness, but also what communities can do, what people can
do to prepare for any type of emergency or disaster situation.

And as part of that, a group was pulled together to inform the public
about what information that is important clinically that they may wish
to have stored someplace, in a secure, safe manner, that could be used
down the line or in the future, if they needed to get to it in a hurry.
And this could be kept with a relative, it could be kept electronically,
it could be kept on paper. And it\'s just a very basic set of
information that would be useful in any type of a situation.

So that has been essentially been the \-- been the basis for the RFIs
that have come out, as you know, in the National Register on May 23.

And so I think there will be, obviously, the responses that come through
that, and that will inform that discussion.

**[\>\> JONATHAN:]{.underline}**

Perfect, thank you very much for that comment. Let me open up to anyone
else who might have any comments, amendments, recommendations, for the
minutes?

Okay, if there are no objections, then, with the annotation that HHS has
put out a request for information, and synopsis of Karen Bell\'s
comments, if there is consensus, consider those minutes accepted.

Let\'s move on now to the real work of the day. Start with just a
refresher on the timetable. I know many of us are sort of going through
this kind of mixed sense of progress from where we are. First let me
acknowledge and thank everybody for the tremendous work and discussion
that led to the Electronic Health Record Workgroup being able to put
forward a slate of coherent goals. We also thank Karen Bell, the ONC
staff, for the help \-- helping that take form.

At the same time that many of us feel a sense of accomplishment in terms
of being able to articulate those goals, I think all of us feel a sense
of unease or anxiety that they have to be made tangible and move from
aspirations to a set of clear deliverables that are action-oriented that
really serve both the broad charge and the specific charge.

In terms of the actual timetable today, June, our goal is to develop a
work plan that lays out the critical components of the broad charge and
a process to address them.

Now, you may recall that when the Secretary spoke or charged us to move
forward following our presentation and at the subsequent meeting of the
Community, he asked that we, in the time ahead, in July even, which is
coming up quickly, begin to pull together the background research
necessary, including testimony of experts, to realizing these
objectives, including analysis of barriers, enablers of critical
components.

So we\'ve got some heavy lifting to do, and I think this heavy lifting
is what may help us resolve that sense of unease, both about where we
are, and how we make real the goals that we set forward, and the
aspirations that were put before us in the broad and specific charge.

Let me at this time, then, turn to Dr. Karen Bell for her discussion,
consideration of movement from \-- the broad charge, but let me change
that to really the \-- progress that we would make, in terms of meeting
our objective of transplanting these goals into a number of clear-cut
steps, critical components, for achieving the objectives that we\'ve
identified, and in turn, supporting the charges given to us. Dr. Bell?

**[\>\> KAREN:]{.underline}**

Thank you so much, Dr. Perlin. And I\'m jumping into this discussion,
because I think it will help inform your discussion, in terms of what is
it that can be done today, next month, and subsequently over the course
of the next year. And I will basically start by describing a little bit
the documents that you\'ve received to inform the discussion.

You have received something entitled draft, goals, objectives, and
strategies. Basically, this is a new framework that has been updated
from the original framework, so that we can truly move forward with some
very specific strategies, tactics and actions that will support not only
your work, but the work of the other workgroups, as well.

And I think you will see i if you read this document that there are a
number of objectives that we intend to develop measures for, so that we
can truly assess our effectiveness in moving forward with these
strategies and tactics.

In addition, this becomes a coordination tool, where not only our
activity, but the activity of other members of the Federal Government,
AHRQ, DoD, DEA, are highlighted and showcased as examples of what can be
done in these particular areas, and also, what the private sector can
do. It\'s a very comprehensive document, and the piece I think I\'d like
to call your attention to is actually the first set of goals and
objectives, and that is the goal to inform health care professionals.
Because clearly, this is the driver and the goal behind the need for
widespread adoption of electronic health records.

And as you review the documents, you will see that there\'s already a
tremendous amount of work that has been done in these areas. But there
is also need to do more.

As an example, when we talk about Strategy 1.11, to simplify health
information access and communication among clinicians, clearly all of
the work that this Workgroup has done to date to support the access to
historical lab information is a very significant tactic. And all of the
actions, the recommendations, that you\'ve made will be translated into
actions to make that happen.

There are, however, other types of information that would make
electronic health records particularly valuable to clinicians. And so I
would ask you to think through, as you go along, what those other
actions might be. Whether that is access to x-ray reports, or discharge
summaries from hospitals, or any one of a number of things, could be
important ways that we could make EHRs more valuable.

So that would be, again, a way to describe how an objective goes to a
strategy, and then we can move forward with tactics and actions.

There are a number of strategies here that we\'ve not yet done a lot of
work on, and I think the real question becomes are these strategies that
you as a workgroup would feel are important, and that you would identify
as critical to addressing your broad charge? And if so, then we would
again need to look at what tactics could be applied, and subsequently
what actions, and those ultimately can read lead to recommendations.

Just as an example, now, I\'ll jump into Strategy 1.12, increase
incentives for clinicians to use EHRs. And while there is a lot of
discussion about incentives through use for pay for performance, there
are multiple other ways that incentives could also be applied for
clinicians to use EHRs.

Rather than go through and read the entire document to you, because I
don\'t think that that is perhaps the best use of your time, since you
have it in front out of and you all had it previously, I simply would
like to essentially point out that literally everything in this entire
set of goals \-- all of the strategies under the goal of informing
clinicians, could be considered as components that you might choose to
work on moving forward.

I don\'t necessarily believe that it is absolutely inclusive. We may
have left something out, and if someone can identify some of the gaps,
we clearly would want to add that to the picture, as well. But this is
at least a fairly robust starting point, to think through what
directions you may choose to take to identify the next steps of work to
really make EHR adoption much more widespread.

Before I turn this back over to Jon and Lillee I also just want to state
that there are a few objectives and strategies in some of the other
goals that would be important as well, and that is particularly to
ensure that information can interconnect clinicians. So that there are
several strategies there that you might find important, so as not to
leave that out. And anything related to the personal health or the
public health arena could be important, as well.

But the main meat of what I think you would want to be looking at is
under that very first goal, and not every single one of them is highest
priority. So your job will be to identify those that you think are going
to be the most important to move forward, and then we can collectively
develop the tactics and the recommendations, i.e., that we\'ll need to
take to effectuate them and bring them about.

Does anyone have any questions about the document?

**[\>\> LILLEE:]{.underline}**

It\'s Lillee. It\'s not that I have a question, I have a question for
Jon and his colleagues, because as \-- and I\'m so sorry that I missed
our last Community meeting, but it struck me, as I was reading the
strategies and goals, that they seem to apply more to the private sector
than the VA or DoD sector. Because we can certainly resonate well with
them.

I had \-- I\'ve just had the privilege of being able to ask many of our
chief information officers across VHA hospitals what\'s the number one
thing that this Workgroup can do to advance the agenda, and it always
came back to standards harmonization and alignment. Because everybody is
off doing their own thing.

But to the point where you read these, can I just get some sense that
these apply across health care in the United States? And they apply, as
well, to the VA and DoD sector?

**[\>\> KAREN:]{.underline}**

Lillee, I\'ll jump into that if I might for a moment.

**[\>\> LILLEE:]{.underline}**

Sure.

**[\>\> KAREN:]{.underline}**

This is a public private partnership, and while the major issue is
getting adoption in the private sector, because as we know VA and DOR
are truly leading the country on adoption right now, clearly, lessons
learned and shared on all of these strategies and tactics will be
absolutely critical. And particularly in terms of interoperability, and
sharing information between the public and private sectors, we certainly
need to have the Federal Government on board.

Would you agree, Jon, Jonathan?

**[\>\> JONATHAN:]{.underline}**

Yes, Lillee, I would generally agree in the sense that we have a little
bit of early adoption experience, but the incentives and the concerns
about the need to reconciling or harmonizing standards are as germane, I
believe, in our context, as well. But thank you for taking that up.

Let me then segue from Karen\'s lead, I\'ll turn it back to Lillee in
one moment. But we then have a task then of really prioritizing those
things that get us downfield the most that are listed as strategies in
this document that is dated June 6, 2006, off the National Coordinator,
goals and objectives and strategies.

I tell people just as orientation materials, in case you haven\'t had a
chance to totally cost reference everything, there is a slide set that
summarizes some of the highlights of this material, and I\'d also offer
just as a personal bias, that there is in the slide set maybe four
slides that have perhaps some of the greater leverage, and those are
slide four, and priorities in the one set that particularly 1.1.1, the
simplification of health information access and communication among
clinicians, and also the context of lowering the risk of EHR adoption.
This gets very logistically \-- with the CIOs, you know, 3,000-plus
health organizations that VHA represents, one of the very front and
center challenges, which is people don\'t want to feel that they\'re
betting on the wrong horse.

Slide 7 has the 1.2 set, and you would quickly see that it tells the
same vein, lower cost and lower risk, EHR, 1.2.1, foster economic
collaboration for EHR adoption. And we\'ll come back in far more detail,
but just to sort of tee up the set, Slide 8, 1.2.2, again, is elaborated
further in terms of lowering cost of purchase and adoption.

And then Slide 13 really summarizes this increase in support for
clinician use, investment, knowledge, et cetera. But these are really
the sort of future trajectories. But \-- starts to draw themes, since we
are the Electronic Health Record Workgroup, and while the initial
business case has been the laboratory, our theme or trajectory are, as I
see it, and I\'m happy to engage in any sort of discussion on that, is
obviously the adoption, the understanding, reduction of risk, alignment
of incentives, and ultimately the adoption and advancement of electronic
health records.

So I think there are some threads, whether we operate from the slides or
from the overall document, there\'s a thread or a theme that I think,
regardless of some of the other priorities that we need to hold on to,
in terms of meeting the broader or specific charge. And I am going to
stop at this moment and turn it back to both the combination of Lillee
and Karen to walk through one or both simultaneously of these documents.
But before we do that, we just open for discussion on any comments on
that sort of thematic alignment, and trajectory.

There\'s either violent agreement or violent disagreement.

**[\>\> KAREN:]{.underline}**

I know, I was getting ready to say, "Wow."

**[\>\> KEN WALLBILLICH:]{.underline}**

My name is Ken Wallbillich, I\'m representing Mark Lewis from EMC
Corporation, and I am in agreement with the trajectory.

**[\>\> JONATHAN:]{.underline}**

Thanks. Okay, well, let\'s \-- got a theme to work at, let me turn to
Lillee and Karen, and maybe we can sort of take this thread trajectory
and flesh it out and begin to segue from a perspective, and aspiration,
to the either sorts of tools that we need to achieve these aspirations
or the information resources, including the opportunity to get the
expert testimony of others to resolve what the right question is for
what the information needs are, also, to realize this. Lillee?

**[\>\> LILLEE:]{.underline}**

And Karen, you know, you could help a lot because you and I were just
talking about what were the most important things to achieve today. And
I am really proud of this Workgroup for being able to ask the tough
questions and not shy away from issues. But as you know, when the
Secretary gave us this additional responsibility of the rapid response
EHR, and the need for first responder info to be interoperable, can you
help me with where that fits in here?

**[\>\> KAREN:]{.underline}**

I think to be very honest there, is as I said before, a number of other
places other than goal one that could be applicable to this work. And we
have a strategy, 4.4.3, support and management of health emergencies.
And clearly, within that, the scope of a first responder EHR is \-- an
interoperable first responder EHR, would be an important strategy
tactic.

So I think that we certainly have this, we can include this in our work,
and can prioritize it at a very high level. What it will entail is
having this group agree on a set of information, or data points, that
ultimately will be referred to HITSP for standardization so it can be
operable among multiple electronic health records. Not just the one that
is available at the first response setting, but to EHRs that accept
patients, literally all over the country, from any type of disaster
situation.

So I would definitely include that as part of our work. And it will have
to be considered along with all of the other critical steps and critical
components to support the broad charge, and would be, I assume, a very
high priority, given the amount of tension that we all recognize is
necessary to meet the challenge of another hurricane season.

**[\>\> LILLEE:]{.underline}**

Okay.

**[\>\> KAREN:]{.underline}**

And I think one of the things we could do, because we do have another
workgroup coming up next month, is after we have the discussion today,
in terms of the critical components, and the priorities, we here at ONC
will put together, with some health \-- with other staff, as well, the
results of this discussion, which we will share with all members of the
Workgroup for their input it comes back to a next meeting. So that there
will be enough information for everyone to I think comfortably go
through a prioritization process at the next meeting. What do you think,
Lillee, should we start going through these various strategies and see
if there\'s some fertile ground here in terms of developing the critical
components?

**[\>\> LILLEE:]{.underline}**

Yes, and I\'m going to assume that didn\'t occur in the last Community
meeting?

**[\>\> KAREN:]{.underline}**

It did not. The last Community meeting actually we were only able to
present in the last 5 minutes just the overall concept. It will be
presented in greater detail at the next Community meeting, because we
didn\'t have any opportunities for discussion, for validations, for
anything else at that point. So this is really the opportunity to really
discuss the value of these various strategies and what can be done, and
particularly, what critical components or next steps we need to take in
order to move forward with your charge.

**[\>\> LILLEE:]{.underline}**

And I think you did a great job on those goals, objectives and
strategies document, I guess it\'s a Word document and a PowerPoint
document?

**[\>\> KAREN:]{.underline}**

It\'s primarily the Word document. The PowerPoint document was what we
showed to the AHIC, with respect to some of the work that was already
underway, under these strategies.

As I said before, all of the recommendations that have come out of this
Workgroup regarding electronic health records and laboratory data
constitute \-\-- one of the tactics and all the of the recommendations
constitute the actions that fall under Strategy 1.1.1. But there are
other \-- there are other decisions that we would need to make about
what other information would be high priority to bring in an operable
way to an electronic health record that would further increase the
value.

**[\>\> LILLEE:]{.underline}**

Is your vision we would go through this goals, objectives, and
strategies document and get it to the next step so we that can finally
present it in August to the Community?

**[\>\> KAREN:]{.underline}**

I don\'t know that this goes to the Community, but we certainly need to
go through it in order to identify the critical components that are
necessary to help get us to the next step on that broad charge. And we
will also then need to go through the prioritization process. I don\'t
think we\'ll get through prioritization today, but I think we can go
through the strategies and identify any critical components that are in
them that we can then lay out for everyone, and we can go through the
prioritization process at the next Workgroup meeting.

**[\>\> LILLEE:]{.underline}**

Okay. So we want to take Goal #1 here, the informing health care
professionals piece?

**[\>\> KAREN:]{.underline}**

That would be the first one, and all of the objectives and strategies
under it could support EHR adoption. Some are more critical than others,
and I think that\'s really the \--

**[\>\> LILLEE:]{.underline}**

Meat of the discussion?

**[\>\> KAREN:]{.underline}**

Right.

**[\>\> LILLEE:]{.underline}**

What I wanted to ask the Workgroup is just thinking two words as we go
through each of these goals, what do we need to clarify, and what do we
need to amplify. You know, is there anything missing, anything needs
clarification, what do we need to amplify to make sure we\'re able to
meet our charge.

**[\>\> KAREN:]{.underline}**

And what are we missing, too.

**[\>\> LILLEE:]{.underline}**

That\'s right, what are we missing. So if we look at this first one of
informing health care professionals. Are we just taking it piece by
piece?

**[\>\> KAREN:]{.underline}**

I think it might be helpful, unless someone has \-- I think it would be
helpful to have comments from the Workgroup members on the objective
itself. The high-value EHRs.

Is the language that describes that objective something everyone is
comfortable with, or when you first got this document were you finding
yourself underlining all sorts of things and red lining? Is this an
objective that makes sense, is it complete enough, is it specific
enough? Is this something you\'re comfortable with?

**[\>\> LILLEE:]{.underline}**

I can just start real quick and maybe get the conversation going. When I
first read it, it seemed to be very financially driven, and the clinical
quality components aren\'t jumping right out. And Carolyn Clancy may be
able to comment on that. But there is a dual-pronged value that comes
from the financial benefit or the financial penalties that would occur,
but the huge impact on patients now from duplication of care, misuse,
overuse, or underuse of care, mortality and morbidity related to lack of
interconnected EHRs in the private sector, for sure. But that didn\'t
seem to be teased out as much as the financial piece.

**[\>\> HOWARD:]{.underline}**

This is Howard Isenstein.

**[\>\> LILLEE:]{.underline}**

Yes, Howard.

**[\>\> HOWARD:]{.underline}**

I would totally agree with that comment. You know, it would be critical
to just come up with a little bit more nuance language about that issue,
including the whole issue of \-- med providers will have their
compensation based on both private and public payers which will be
generated by these EHRs.

**[\>\> KAREN:]{.underline}**

One of the things that I would just ask you about, is as you \-- we will
certainly welcome all your comments and make changes as necessary, but
as you go through, there may be other \-- other objectives where your
comments are highlighted a little bit, in a little bit more specificity.
So if there turns out to be one \-- an objective where that\'s captured
elsewhere, I\'ll cross-reference it as we go through the document \-- as
we go through the documents, or as I make the changes in the document
down the line. Okay?

**[\>\> JASON:]{.underline}**

This is Jason Dubois. I just want to make sure I\'m following along,
here. This is the six strategies for active consideration, page 7,
correct?

**[\>\> KAREN:]{.underline}**

No, we are on page four of the goals, objectives and strategies
document.

**[\>\> JASON:]{.underline}**

Okay I\'m a little ahead of myself, all right.

**[\>\> KEN:]{.underline}**

This is Ken Wallbillich. I\'d like to reiterate the quality metric,
although the second sentence does you know deal with higher quality
care, and I hesitate to bring a lightning rod to this particular topic,
but the identification, right, the accurate identification of who the
patient is should likely be addressed in some part and parcel of this
draft document.

**[\>\> KAREN:]{.underline}**

Okay. Thank you.

I have one question. This is \-- you know, kind of apropos one of
Lillee\'s earlier comments about the focus. This clearly looks like
it\'s very much focused towards ambulatory EHR. I\'d particularly turn
to the colleagues from the hospital world, and ask if they feel that
there needs to be more emphasis on hospital EHR adoption.

**[\>\> KEN:]{.underline}**

I hadn\'t \-- when I read it through I didn\'t get that impression.

**[\>\> LILLEE:]{.underline}**

I didn\'t either, Karen.

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

Kind of a universal assumption that it\'s physicians.

**[\>\> KAREN:]{.underline}**

Should we put more emphasis on hospital EHRs?

**[\>\> HOWARD:]{.underline}**

Well \-- this is Howard. I would say, you know, that\'s a hard question.
I mean, this whole EHR thing, I mean, for the last 2 years, the mantra
is the small doc, the small doc, the one- to five-practitioner office
where most of the care is rendered. That\'s been my operating assumption
since the beginning, is that wrong?

**[\>\> KAREN:]{.underline}**

I don\'t think that\'s wrong, I think that is addressing the adoption
gap. But as we look at this, as a strategic document going forward \--
and again, this is a draft document, and you are the folks that we are
looking to to give us strong feedback. If you feel it\'s important to
include more emphasis on hospital EHRs we will certainly go back and do
that, and that\'s a question I have on the table for you.

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

Rather than trying to shoehorn it in, why don\'t we describe it as a
scope document, we could describe the fact that there are \--
(Inaudible) adoption, and \-- as well as, you know, small providers and
the like, but that this document is intended to act globally to discuss
adoption of the EHRs across a spectrum of providers.

**[\>\> LILLEE:]{.underline}**

No group is excused from the conversation.

**[\>\> KAREN:]{.underline}**

We try to be inclusive.

**[\>\> LILLEE:]{.underline}**

Yes.

**[\>\> KAREN:]{.underline}**

Okay, well this is very helpful, thank you.

I\'ll then just jump into Strategy 1.1.1, if I may, Lillee.

**[\>\> LILLEE:]{.underline}**

Please.

**[\>\> KAREN:]{.underline}**

Which is simplify the health information access and communication among
clinicians. And here\'s where we would like to, I think, begin to think
about what other types of information are likely to be critical to make
EHR, interoperable EHRs, particularly valuable to clinicians.

Laboratory data we know is one of the top three that physicians clearly
wanted. There are others. I think people talk about discharge summaries
from hospitals, they talk about x-ray reports, there is other
information.

So what is it that \-- what else can we do here?

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

Well, I think, you know, that the question, looking at it from my
institution, at least, I think physicians find great value,
unfortunately in some of the high-end stuff, you know, images, and
things of that sort. And I guess the question is, is that is not rather
a matter as much when, and sort of trying to bifurcate EHR adoption and
deciding sort of when do you decide, okay, you know, as you said
discharge summaries, when does that layer in, at what point do you
have \-- you know, radiology images rather than just simply the reports
themselves.

And I think that\'s, in my mind, the context of the way we should have
these discussions. Because at the end of the day, again, I see
physicians often wanting to see image data, and other types of things
for (Inaudible) simply the \--

**[\>\> KEN:]{.underline}**

This is Ken Wallbillich. I\'d like to support that premise that the
consent itself is going to be different based on the constituent.

There are specialties that absolutely will demand the clinical imaging,
where others wouldn\'t know it when they saw it. So you have to be
ubiquitous to the content. And one way to increase adoption between \--
if we just take a laboratory result for a moment and understand that\'s
kind of the entry point to the rest of the tsunami of data that\'s going
to be available, the ability to communicate that information with
patients is going to require some level of content-specific
authentication, that is, to create a circle of trust between the
physician and the patient.

**[\>\> JONATHAN:]{.underline}**

This is Jon Perlin, again. Let me just throw in an idea, which is that
first, there are a couple of dimensions we\'re talking about, here.

First, we\'re trying as a group now to assess what are the priority
information elements, and this may be one of the areas where we seek in
our next call or meeting to get that expert testimony of individuals who
prioritize what information is generally of most value, most usable to
the most clinicians.

The second dimension is okay, given what people would identify as what
they want, what is the practicability, what is the \-- to use the term
we use for the lab data, how aerodynamic is the type of data. So some of
these might be again things that we might surmise, for example, today
much imaging is borne digitally, and because there is already commerce
going on in imaging, that may be an area, along with medications, where
there is greater sort of lift, if you will, in terms of getting those
data.

But we may sort of want to flag this area as one of the areas, whether
it\'s a member of our own Workgroup like Blackford Middleton or others
like Don Dettmer that we identify as individuals for testimony to
provide not only their own insight, but a summary of literature and
insight into what is both priority data area, and what data areas are
most feasible in the short term.

**[\>\> JOHN:]{.underline}**

This is John Houston. I think we have to be mindful of the rapid
evolution of technology, and that \-- you know, if we say something is 5
years down the road, in terms \-- in terms or the priority order puts it
5 years down the road, and even if there\'s a lot of bandwidth, say,
related to making image data available, in 5 years it may seem trivial
what with technology provided, so I think there\'s probably going to
be \-- you know, if you get to the basic stuff now, by the time you even
prioritize getting to the more complex stuff, I suspect the costs and
the efforts associated will be much simpler than we think it is, because
we\'re basing on today\'s facts.

So I think it\'s important to take that into consideration, even now,
because I think it is going to be much easier to do even a few years
down the road.

**[\>\> JONATHAN:]{.underline}**

I think \-- Jon Perlin again. I think that\'s a great point in terms of
not being able to necessarily predict. Which again may be one of the
reasons to recommend certain individuals with certain insight into these
particular areas, with their sort of near term and mid-and longer term
scan.

**[\>\> CAROLYN:]{.underline}**

I guess I\'m having a little trouble with a couple of the questions
which may be a reflection of getting in late, but Jon, you mentioned a
point earlier in terms of layering on things, and I wasn\'t sure if you
were referring to a trajectory for a group of doctors, in terms of which
information they consider valuable, or trying to get to what \--
there\'s a normative statement here that basically says if you have
access to information, you do better things.

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

Absolutely.

**[\>\> CAROLYN:]{.underline}**

Empirically that\'s actually a little tricky to demonstrate. In fact,
from folks setting up Community networks, health information exchanges,
they struggle with actually identifying where are those decisions where
it\'s unambiguous, that if you had information you would do something
different. Because that way they could show that their investment \--
that there was a return, and so forth. So I\'m having a little bit of
trouble getting my head around what question we\'re trying to ask, here.

The comment that it would be helpful to hear from folks who have got
experience as opposed to our opinions is highly informed and as erudite
as they may be about what information physicians value, I think would be
very, very helpful.

And it might also help us \-- how would I say this, dissect or partition
the historical results issue, because I can\'t think of an example as a
clinician where you need 10 years of data.

**[\>\> JOHN:]{.underline}**

Not necessarily the age of the data that\'s necessarily important, but
you could have a test \-- a family experience from last week, where a
family member was at one hospital, had a test done, ended up in another
hospital from another provider system, and the doctor said boy, I\'d
really like to see that. Now. And it was image data. So that is a case
where, you know, you don\'t necessarily know what information is
necessary, but, you know, I think in these types of cases that the
doctor obviously saw it as being relevant, and unfortunately, it was not
available until some time later.

So I don\'t know where that puts it on the trajectory, but I just think,
you know, as we look at trying to grossly prioritize what data we make
available when, in this type of an environment, we need to look I think
at least look at the complexity of the data and how much effort it would
take to make it available and the portability of the data.

But I think grossly we need to decide \-- we\'re not going to get
everything right now, but what are the strata of when we would want to
try to make different times of data available, based either on priority
or complexity of making it available.

**[\>\> KEN:]{.underline}**

I think if you take a prioritized approach you\'re going to be
hamstrung, because of the demands of individual constituents. You know,
every different clinical discipline is going to believe that theirs
should be first. And I think that would be supported by \-- by the
clinical members of the Workgroup.

I\'m just suggesting it might be important for us to take a look at how
does one create a platform by which those decisions can be made.
Essentially, a platform that removes, you know, the friction in the flow
of information, such that it\'s not defining what the content is, but
simply how that decision could be made. As to what is important. And
make that more dynamic, in the context of this document.

**[\>\> KAREN:]{.underline}**

And I\'d like to \-- this is Karen Bell \-- I\'d just like to clarify a
little bit about some why this is an important process to decide and put
into place. And that has to do with two of our other processes. One is
the HITSP standardization process, getting back to the earlier comment
about how important standards are. And then secondly, the EHR
certification process, which was also mentioned earlier.

We recognize, for instance, that we are not going to get standards for
10,000 different laboratories results overnight. And we will not be able
to have standards for all of the information that clinicians may
choose \-- may want overnight. So we do have to have a prioritization
process for it. Because as the HITSP standards become endorsed or
ratified, they will then be included into the certification process, and
they will become an important part of EHR certification.

So it truly is an important process that needs to be addressed, and
that\'s why this conversation is very critical.

**[\>\> JOHN:]{.underline}**

But I think the flip side of that too is there is going to be other
things, such as image data where you have a DICOM standard today but you
may not necessarily have the infrastructure to push the images around.
So you have both things you have to balance when you look at when
something becomes available, so \--

**[\>\> KAREN:]{.underline}**

Again as far as HITSP is concerned, it\'s not just having like the DICOM
standards, HITSP is dealing with the full range of what it takes to make
those standards interoperable. So it is a very involved process, and
there is, you know, a limit to what they can produce. So that the
prioritization I think will be critical here, and if we could at least
agree or begin to develop how we might go about developing that process,
I think we can go a long way to meeting this very first piece today. And
I would just ask if Connie Laubenthal is on the call from ACP? Has
anything been done in this arena in your area, Connie?

**[\>\> CONNIE LAUBENTHAL:]{.underline}**

Not that I\'m aware of.

**[\>\> KAREN:]{.underline}**

Okay, does anyone know of anything that\'s been done to prioritize needs
like this? Or are we the seminal group to do that?

**[\>\> LILLEE:]{.underline}**

I think there\'s a lot \-- I\'ve seen a lot of white papers, Karen, on
prioritizing needs, but it depends on who wrote it.

**[\>\> CAROLYN:]{.underline}**

Didn\'t the NHS do a strategy like this to create the spine where
basically the IT guys went around \-- I\'m greatly oversimplifying, but
spoke to every specialty to try to say okay, what\'s the must have, got
to have got to have?

**[\>\> KEN:]{.underline}**

Right, I\'ve got some experience at the NHS find and they did in fact go
around and survey the different silos of information, and the outcome
was \-- the one that screamed the loudest appeared to have the highest
priority. So it is clinically difficult \--

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

Democracy rules.

**[\>\> KEN:]{.underline}**

 \-- to pull it together.

**[\>\> KAREN:]{.underline}**

I think that\'s where \-- like I said, I don\'t think there\'s really a
process to prioritize this.

**[\>\> JONATHAN:]{.underline}**

This is Jon Perlin again. Let me come back and amplify Carolyn Clancy\'s
point, because it was right on target. Carolyn, if I heard you
correctly, you drew together two parallels. First, we put out a
normative statement in the document that says quality is better, and the
business case is still somewhat elusive, but there are pieces of data
that suggest we can do better. Like hospitalization that unnecessarily
occur because data weren\'t available, and PETAC data provides some
support for that as an example.

In a similar vein there\'s an evidence-based approach to the
prioritization of data, and I think none of us \-- I think we joked
about it as a group, but none of us want to see those that scream the
loudest were determining priority. And the point was very well made that
even if we try to project a priority chronologically, we may be very
wrong.

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

Absolutely.

**[\>\> JONATHAN:]{.underline}**

Which is why I come back to the point you made, Carolyn, which is right
on target, that there I believe are individual evidence on what are the
most \-- to use the term someone just used a moment ago, what are the
"gotta-haves," and what evidence base is there to support those
gotta-haves. And my own personal parenthesis on that is perhaps some of
those are presently \-- and in the future, presently more aerodynamic,
which allow us a little bit of a lever, given that our goal is
adoptions. Let me just throw that out as a bit of a synthesis for where
we are, recognizing that we\'re on 1.1.1 out of a very long document.

And I think the two rules that we\'re giving back is that the opinion is
great, but evidence rules, and that may be a data point that we need to
get for this in order to change that from an aspirational strategy into
a set of strategies that are backed by some operational tactics.

**[\>\> LILLEE:]{.underline}**

And in the private sector, Jon, I would add that there\'s general
consensus that we don\'t have a failure of evidence, we have a failure
of execution. And maybe there is a lack of understanding of the
evidence. But you\'re absolutely correct.

**[\>\> KEN:]{.underline}**

I think we\'ve got a knowledge management issue at hand. And I think as
Blackford Middleton said a few times, the evidence is available, as long
as we can manage the variety of content components that are available,
and prioritize them. Essentially, classify the information according to
its value. And if in fact that classification is flexible based on who
is classifying it, that is to say you have a platform in place that
allows for the classification to be varied. It\'s difficult for us at
the committee level to make those kinds of stratifications, but I think
that we could probably generally say that we need an environment that
allows that classification to take place.

**[\>\> KAREN:]{.underline}**

This is Karen Bell. I\'m wondering if the Workgroup would go so far as
to consider prioritizing certain specialties, and we certainly \-- and
the reason I say this is we certainly know that primary care lags far
behind specialty care in terms of EHR adoption. And from that
perspective, would it be useful to at least perhaps prioritize primary
care as a first \-- on the first go-around, and then we can look at that
find and find out what are the must haves for primary care. Would that
be of value to the group?

**[\>\> JOHN:]{.underline}**

Can I just chime in? I cannot imagine this not having been done in its
entirety. I know in many regards it is done, and I think we should be
trying to leverage that whatever is possible. I think the first thing we
need to do is find out what exists, because I suspect we are much
further along than we \--

**[\>\> CAROLYN:]{.underline}**

I think we should do that without question. Having said that, some
emphasis on primary care, and based on our careful analysis and
gathering of information, we can decide whether that\'s some, a lot or
whatever, made some sense. Only because the funny way that primary care
ends up being information poor, because that\'s where the revenue is
not. Whereas more highly reimbursed specialist can pay others to go find
the data. May not be as rewarding or satisfying as having it in front of
you, but nonetheless it\'s there.

**[\>\> JOHN:]{.underline}**

I agree with you. I think the first step is see what we can leverage,
because this will be a daunting task.

**[\>\> CAROLYN:]{.underline}**

Yeah, and I guess the other issue is \-- this may sound like weakening
of faith, I hope not, I think my theology remains strong about the value
of electronic health records. But I have moments when I actually imagine
there are some specialists that will never adopt, because they don\'t
need to. They\'ll have a nurse filling in this, or some assistant, the
way thoracic surgeons do at the registry.

**[\>\> JOHN:]{.underline}**

That doesn\'t necessarily mean, though, because they have someone
filling in, that ultimately in the back there isn\'t an EHR.

**[\>\> CAROLYN:]{.underline}**

I agree. But in interpretation of adoption, if you look for clinicians
\--

**[\>\> JOHN:]{.underline}**

Difference between them directly using it, versus whether the EHR is
adopted in the practice itself.

**[\>\> CAROLYN:]{.underline}**

Yes.

**[\>\> LILLEE:]{.underline}**

Jon, I will tell you this, just in this whole first objective, 1.1.1,
1.1.2, there\'s been robust discussion here, and if I could summarize
for the staff, there was three things I think I heard that the Workgroup
would like to see added. More of the quality business case, not just the
financial business case, around high value EHRs; distinguishing the \--
the second would be distinguishing that all providers are in this
conversation, not just ambulatory EHR. I was very interested to hear how
some took a take on that, and I had not. So part of our charge is to
make sure we are clear, and that\'s a great clarity point.

And third is this notion of what else is the \-- should we focus on
certainly specialties and prioritize them as targeted first.

Those are the three things I had. I know, Jon you\'ve got great staff
there too taking notes, what did we miss?

**[\>\> CAROLYN:]{.underline}**

Lillee and Jon, can I just add one point?

**[\>\> LILLEE:]{.underline}**

Of course.

**[\>\> CAROLYN:]{.underline}**

Early on someone said the value statement here in the overall objective
was somewhat financially based. And I think that\'s very appropriate,
that certainly has lots of clinicians paying very clear attention right
now. But when I talk to docs who cross the hurdle of the thresholds,
right? I mean, what I hear about is a lot of nonfinancial statements. So
to some extent, some part of value in meeting patients\' needs and/or
reduce frustration and greater satisfaction in work, I think would help
me require \-- you know, have a more comprehensive or holistic sense of
what value means.

**[\>\> LILLEE:]{.underline}**

Exactly.

**[\>\> CAROLYN:]{.underline}**

Because in the 6 months or however long it takes to blow up your
practice and, you know, get to the other side, I\'m not sure that that
business case over the horizon is necessarily keeping you motivated. You
know, the first time you can find someone\'s historical data or can
actually display it graphically in a way that works for them and
motivates them, I think is quite magical, even though we don\'t actually
pay for that and probably never will.

**[\>\> KEN:]{.underline}**

Is it safe to say you have a historical data component and a diagnostic
results component? Laboratory, radiology results, that kind of thing? Is
it as easy as those two pieces?

**[\>\> CAROLYN:]{.underline}**

I don\'t know that I would put those bounds on it. Only because every
study that I\'ve ever seen that tried to figure out why did you order X
tests has really had a lot of trouble. Because sometimes it\'s for
reassurance, sometimes it\'s for a variety of things and that gets hard
to fit into those categories. I think we could just ask any person
working in the administrative side of a radiology department for that,
where you have to write a reason for this test. Which is not often
terribly informative, but it has to be filled in, and that\'s their job.

**[\>\> KEN:]{.underline}**

The historical point I made only was that just as a followup to your
comment is that people want to understand \-- and I\'m thinking
prioritization here, you know, what\'s important first.

**[\>\> CAROLYN:]{.underline}**

Exactly.

**[\>\> KEN:]{.underline}**

Would the historical \-- what have you had before, and then if you had
something, can you show me the results. And it could just be textual
base, PDF, whatever it might be. But those two combined would be I think
of first importance to most of the constituents. And I\'d like to
forward that as kind of an entry point beyond just the laboratory
commentary in 1.1.1.

**[\>\> LILLEE:]{.underline}**

Again, you\'re only addressing ambulatory EHR, and we had a broader
scope. That\'s an important component to the ambulatory EHR discussion.

**[\>\> KEN:]{.underline}**

I didn\'t think I was limited to ambulatory.

**[\>\> LILLEE:]{.underline}**

Okay, just to make sure that\'s clear.

**[\>\> KEN:]{.underline}**

And I broadly painted physicians and clinicians across the continuum.

**[\>\> LILLEE:]{.underline}**

Right. Well, with that, Jon, can we move on to the next objective?
Because, you know, it will be interesting moving to low-cost and
low-risk EHRs. Low cost and low risk EHR is an oxymoron.

**[\>\> KAREN:]{.underline}**

Could I just backtrack for one second, Lillee?

**[\>\> LILLEE:]{.underline}**

Sure.

**[\>\> KAREN:]{.underline}**

One of the things we might do is just look at the strategies without
looking at some of the things that could be done under them, and
determine whether or not it\'s a strategy we need to come back to as a
high priority? So would you consider 1.12, increasing incentives for the
clinicians to use EHRs, a critical component that we\'ll need to come
back to and flesh out later at a further meeting?

**[\>\> LINDA FRISCHETTI:]{.underline}**

Hi, Karen, this is Linda Frischetti, I\'m going to jump in here.
Dr. Perlin was called away for yet another HHS meeting at this time,
that he need to look at. But I am carrying forward some comments from
him. In Strategy 1.1.2, that really has to do with incentives. Whereas
there is something a bit more broad in Strategy 1.2.1. And in 1.2.1 is
talking more about economic collaboration for EHR adoption, and with
that, that broader view, I would like to suggest that the Workgroup
focus attention (inaudible) incentives, which is really \-- you know,
probably going to be based more in HHS program.

**[\>\> JOHN:]{.underline}**

Can I make a suggestion, here? This is John Houston. When I read through
this document the first time one of the things that sort of jumped out
at me as not being here is almost you could say there should be a
separate goal specifically associated with the financing of EHRs. And it
really is a thorny issue, which I think probably deserves almost a
separate goal section in this document. Because it really will be the
thing that, especially as it relates to physicians, small physician
practices and small providers, is going to be a real hurdle.

**[\>\> LILLEE:]{.underline}**

John, I would tell you in the hospital sector, again, I\'ve been
involved in the Community, and really teasing up what the key issues
are, the very first thing you hear is standards harmonization, we don\'t
want to buy software that\'s not going to connect to somebody else\'s
software. Secondly, though, is just this cost thing. We can\'t afford
it, we can\'t afford it, we\'re having a hard enough time keeping our
doors open.

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

Absolutely.

**[\>\> LILLEE:]{.underline}**

Our ERs are burdened, that whole gambit. So cost is directly tied to
adoption.

**[\>\> JOHN:]{.underline}**

That\'s my point, though, I think it\'s deserving \-- rather than \--
you know, the way the document is laid out, you have goals, then below
goals you have objectives, and you have strategies. My point is you have
to almost raise to a goal level, the financial components associated
with adopting EHRs. It\'s a thread that almost has to \-- it has to be
elevated, I think, in terms of its importance.

**[\>\> KAREN:]{.underline}**

I think we\'re probably saying very similar things. I don\'t believe,
based on Karen\'s comments earlier, that we have the power to change
what\'s in this document. What we do, though, do have the power to do is
raise that as a priority for the work here. And for the reason that
we\'re synergistic is I was feeling that incentives were maybe a bit
limiting for the work of this high level group, and so I wanted to move
down into the 1.2s. 1.2.1, 1.2.2, which I think is much closer to what
you\'re saying. Is that true, John?

**[\>\> JOHN:]{.underline}**

I think in part, yes. Again, I was more looking at organizationally, as
much as anything, how to organize this document to be clear, so \--

**[\>\> KEN:]{.underline}**

1.2.2 appears to try and address the financial problem.

**[\>\> JOHN:]{.underline}**

I\'m just saying the financial problem is a huge issue. And to be
imbedded two levels deep in this document to me just simply says that if
you want to get the attention you need to, you know, you raise it to
level of being a goal. And I think also part of the problem with EHR
adoption is going to be \-- one of the problems with 1.2.2 in my mind is
it almost sounds like an all or nothing thing. And I can tell you that,
like in my \-- in my geographic area, one of our large payers is willing
to pay real dollars to physician practices for e-prescribing. And we
might be able to get some dollars from lab services to adopt, you know,
lab results reporting and things like that. But those are just simply
pieces that some third party recognizes as being a great benefit to them
to allow us to have.

And it doesn\'t go to \-- you know, in 1.2.2 speaks to overall the EHRs
being some monolithic creature, as \-- you know in the cost and efforts
associated with purchasing and implementing it.

And I think there is some \-- this is going to be an issue.

**[\>\> LILLEE:]{.underline}**

Karen, is it not possible to raise this issue to a goals, since that
seems to be some consensus here across the Workgroup? Because I agree
100 percent with what he\'s saying.

**[\>\> KAREN:]{.underline}**

I certainly understand the importance of this. I think the overall goal
falls more \-- and I don\'t think we can actually change the overall
goal. That\'s very much similar to what the original strategic framework
that came out in April of 2004 is. And this goal is truly about adopting
electronic health records. Now, in order to do that, the financial piece
is huge. And maybe what we might be able to do is move that as the
number one objective under the goals, so it is \-- it\'s clearly there.
And is the first barrier that needs to be addressed.

**[\>\> JOHN:]{.underline}**

I leave it to you guys, I just thought I\'d bring it up \--

**[\>\> CAROLYN:]{.underline}**

It\'s clearly got a couple main components. One, assuming I as a
clinician wants this, where do I find the scratch to do it. The second
page, though, is if I do it and do really good job, am I like cutting my
payments in half. Which is a very real risk right now. I could be doing
a superb job in an ONC system \--

**[\>\> JOHN:]{.underline}**

You\'re raising an excellent point, the dollars and cents are on both
ends. The costs associated with being good reducing errors and not
retesting, whatever else.

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

I think there\'s also sort of a reality check that Chip Kahn and others
raised at the last Community meeting with regard to this. If in fact
people do think there will be negotiation around the Part D payment
updates, that could end up being some type of incentive for health IT
adoption, particularly EHRs, and it would be helpful to think within
that context. What specific payment methodology could be built into or
consideration around a Part B payment update?

**[\>\> KEN:]{.underline}**

Electronic episodes of care?

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

That would be one option.

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

Possibly. Possibly.

**[\>\> KAREN:]{.underline}**

I think that\'s where we have opportunity to really think through. If we
recognize this is such a high priority, we would prioritize this as
number one, then think about various tactics and strategies that we
would recommend moving forward.

**[\>\> JASON:]{.underline}**

This is Jason Dubois. I think that\'s a good way to go about it.
Actually I don\'t want to discard Strategy 1.2.1, because inherent in
the discussions here, is the idea of the need for expanded safe harbors
and antikickback. Antikickback, safe harbor, and stark law sections,
which I think gets to the point that Dr. Clancy brought up, where are we
going to find the scratch to do this?

**[\>\>JOHN:]{.underline}**

What you\'re saying though goes to the second part, if you find the
scratch you\'re going to break the law.

**[\>\> LILLEE:]{.underline}**

Right.

**[\>\> KAREN:]{.underline}**

In the interest of time, I\'ll just summarize this and take away that
we\'ll reorganize this, and make this the first objective.

**[\>\> CAROLYN:]{.underline}**

Yes.

**[\>\> LILLEE:]{.underline}**

Yes.

**[\>\> KAREN:]{.underline}**

With respect to EHR adoption. And we\'ll include all of the strategies
to offset costs, underneath this. And then at the next meeting, we will
begin to delve into what those tactics could be, with the idea to making
recommendations by the end of the year. But that there will be a series
of strategies under that very clear primary objective.

**[\>\> JASON:]{.underline}**

And Karen, I don\'t think \-- in the strategy section here, 1.2.1, I
don\'t think you can stop at saying just hospitals public, health
agencies and health plans are interested in supporting physician
adoption. I know I wouldn\'t be doing my job if I didn\'t tell you that
laboratory and other service providers are very interested in helping to
get docs what they want, including a complete EHR.

**[\>\> KEN:]{.underline}**

That includes employers, I might point out.

**[\>\> JOHN:]{.underline}**

You don\'t have physicians there, either.

**[\>\> KAREN:]{.underline}**

Yeah, we\'ll make that a little bit more robust. And then on what we
will do is also be able to provide you at the next meeting a listing of
activities that we know that are occurring in these areas, as well, and
then as we go through the prioritization process you can help us
determine which ones we need to push on more. If that\'s okay.

**[\>\> LILLEE:]{.underline}**

And Karen, just one more comment. In talking to a group of CIOs about
this whole conundrum, there was a group that said you know, one of the
reasons that we\'re not buying or adopting, whether it\'s physician
practices, hospitals, whatever, is it\'s kind of like the big screen TV
craze, you know. New technology comes out and you just wait for a whole
bunch of people to adopt it, and then the price comes down. And I was
really struck by that, that comment. This wait and see attitude. And
that leads us really well into this next objective around clinical
knowledge. Because the wait and see attitude is a barrier to excellence
in care.

I last week just took a whole group to the AHRQ Web site, to the health
IT Web site, and we just drilled into it, and I\'m just amazed at how
much \-- how busy everyone is, that we don\'t know what we know. And so
although this current clinical knowledge piece begins to tease out a
number of the issues relating to clinical knowledge, I was \-- I was
amazed at this wait and see attitude conundrum versus really getting on
with implementation of accurate clinical care.

**[\>\> CAROLYN:]{.underline}**

I\'m seeing a whole new feature on their Web site, Lillee, we can talk
later.

**[\>\> LILLEE:]{.underline}**

Okay. I just want to tell you I tried \-- I was just amazed how many in
the private sector just are not aware of the outstanding work that has
already been accomplished. And so there\'s something around current
clinical knowledge, just something as simple as awareness.

**[\>\>KAREN:]{.underline}**

In other words, we\'re developing a recommendation already on how to
bring this information out to the private sector.

**[\>\> LILLEE:]{.underline}**

Yeah.

**[\>\> KAREN:]{.underline}**

Okay. With that mind, we have a third objective here. You know, we\'re
actually moving through the document fairly quickly, given all the
discussion we\'ve had.

1.3 is around the current clinical knowledge, as you bring out, Lillee.
We have three strategies here. So first off, is this objective an
important one, is it articulated in a way that you can relate to? And
then if it is, or please make comments on it, do the three strategies,
the three overarching strategies, make sense as well, and would you
consider them relatively high priority for the first go-around, here.

**[\>\> KEN:]{.underline}**

This is Ken Wallbillich. Overall the concept of the sharing of best
practice, and I\'ll just comment about academia for a moment, is
commonly found in the collection of specialties that are able to
collaborate, and unfortunately, the best practice for that collaboration
appears to be analog, such that there\'s a continued friction in the
flow of the information between those that are established the best
practice for any given malady.

Once that friction is reduced, then you have a methodology in place that
allows for the collaboration of best practice. We find that results then
in the decision support adaptation. Ultimately the adoption takes place
after there is consensus.

So it appears that in academia, there seems to be an existing push to
begin knowledge management techniques that is founded on electronic
collaboration.

Are there any comments?

**[\>\> CAROLYN:]{.underline}**

I think that\'s right, and I\'m sorry Blackford isn\'t here today,
because I think within their system they\'re doing very innovative kinds
of things with kind of virtual asynchronous collaboration on some of
these issues

**[\>\> KEN:]{.underline}**

Standardized order sets, et cetera?

**[\>\> CAROLYN:]{.underline}**

Well, there\'s that, which I think we need to make a lot of progress
towards, but they\'re using sort of intra \-- well \-- it\'s like an
intranet, as a way for docs who are dispersed geographically to
collaborate, so consensus can come through virtual collaboration instead
of these in-person meetings.

**[\>\> KEN:]{.underline}**

Reducing the feedback loop.

**[\>\> CAROLYN:]{.underline}**

Yes. Which I felt was very innovative, and they\'re trying a lot of
different sorts of strategies. Having said that, I think there are a
number of interesting policy questions here for which there are no good
answers. Where does the public good end and the kind of business
proposition begin in terms of disseminating knowledge. And having sat
recently at a symposium at the Mayo Clinic, I have to tell you that we
came up kind of against a brick wall with this one.

Should \-- if the Mayo Clinic is going to be a leader I\'m just using
them because it was their conference, in disseminating lots of
information about best practices, new knowledge and so forth, should
they get paid, what\'s the business model for that. If it derives from
public funding for work that was done by the Mayo Clinic, it\'s a
license \-- you know, there\'s a whole lot of issues there that I don\'t
think anyone has really touched.

**[\>\> KEN:]{.underline}**

If we take any given malady, and I\'ll use one for example just for
tongue in cheek approach here, you know, the best practice for the
gallbladder, if you will, the folks in greater Boston might have best
practice X. The folks in Baltimore have best practice for gallbladder Y,
and folks out in California say best practice is Z. I think that a
potential tactic would be for the federal government to fund a consortia
that puts together X, Y and Z and comes up with Q. Because ultimately
that best practice for any given malady might be the only \-- you know,
payment that takes place as a result of that collaboration.

But clearly, right now, the friction in the flow of information, the
feedback loop to establish what best practice is for any given malady,
is too long. So I think having electronic means to have knowledge
management is kind of the cornerstone to the discussion point in this
strategy \--

**[\>\> JOHN:]{.underline}**

I\'d just raise a point, it goes back to my earlier comment about what
data is available when. I guess the other question I have in looking at
Objective 1.2 and talking about this regarding 1.3, the other question I
guess I have is what functionality is available when. Because I don\'t
think necessarily If somebody wants to put in a low-cost, low-risk EHR,
it\'s going to necessarily have advanced clinical decision support and
other things like that. It may just simply be the basic nuts and bolts
having electronic information where you used to have paper in the past.
How is \-- I guess the question I have is how is that addressed in this
document? Because I don\'t think \-- again, I don\'t think it\'s a big
bang to throw EHR in there.

**[\>\> KEN:]{.underline}**

If you at the point of entry have captured just basic metadata about the
content, that will allow the next phase or wave of knowledge management
decisions to take place, only because you have this tremendous metadata
history from capturing information about the information.

**[\>\> JOHN:]{.underline}**

No doubt, I\'m just saying \-- I\'m just sort of verbally thinking okay,
you almost have to say, though, you\'re going to take a \-- when you
think of an EHR, it isn\'t, again, this big \-- you know, monolithic
thing. It\'s sort of this \-- sort of a, you know, like rings on a tree.
They grow out from \-- each ring is grown upon the top of each one
before it, and you have functionality on functionality and features upon
features. And I guess the question is how do you define what the EHR is,
and at what point does this type of decision support and advanced
knowledge come into an EHR. When looking at people that don\'t have a
lot of money to spend, how do you prioritize data, and then
functionality of an EHR?

**[\>\> KEN:]{.underline}**

This particular knowledge management might be a federated item where you
have islands of information that are then federated through search
capabilities that don\'t cause the investment for any one entity to be
experienced, but simply because of the capture technology for the
metadata, about the data, you empirically start to glean then the
knowledge from the basics. Everyone gets just the basics, and as a
result of just that phase one kind of approach being implemented, you
have then for free, essentially, the ability to go back later and
establish decisions, support tools, based on the information that was
captured, and even in the smallest value proposition.

**[\>\> KAREN:]{.underline}**

Now, in many ways \-- Karen Bell \-- what we\'re really talking about is
interoperable data so we need to assure \-- again, this gets back to
that discussion we were having a little bit earlier, we need to assure
that there are standards for the data, as well as its implementation.
And I think while it\'s not the absolute answer to what is an EHR, what
are the functionalities, the fact that we have a certification process
that certifies an electronic health record that has certain
functionalities in it, certainly helps define what at least \-- and I
would say this body, because this body flows into the AHIC, and the AHIC
makes recommendations regarding what certification process should use.
It\'s part of the journey.

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

But there is no EHR that you\'re going to get two months, three months a
year, two or three years out.

**[\>\> KAREN:]{.underline}**

Right, there\'s always going to be an iterative process moving along. So
I guess I come back to the original question. Is this Strategy 1.3.1
something that\'s absolutely must have, a critical component to move
forward for starters? Or is this something we might be able to think
about it a second wave?

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

Second wave.

**[\>\> LILLEE:]{.underline}**

Carolyn, what do you think? You know the amount of knowledge and
evidence that\'s in this sector.

**[\>\> CAROLYN:]{.underline}**

I\'d say it\'s a second wave. So in terms of presenting where we are to
the Community, I think a sort of succinct description of why we
recognize how important this is, I mean, instead of just building on the
amazing enthusiasm demonstrated at the last meeting when the road map
was presented, I mean, I thought the presenters were going to be carried
out on a float or something. It was really a great moment. But also,
letting people know that we haven\'t lost sight of this, but in
terms \-- I always love Jon\'s term, aerodynamic, I think it is a second
wave issue.

**[\>\> KEN:]{.underline}**

If we could just address it in a fashion that allows for kind of a phase
one to at least address the fact that we should be capturing metadata
for future decision support, or research even, or collaboration, that
would be enough.

**[\>\> KAREN:]{.underline}**

Maybe one of the things we may end up doing, I\'m just throwing this out
as a possible process, is developing our own road map in this Workgroup
that looks at second wave, third wave, recognizing that there will be
recommendations on a set of high priority items right up front, but that
all of these are important strategies moving forward.

**[\>\> JOHN:]{.underline}**

You almost have to have a graph that has on one axis data element, data
type, and on the other axis you have functionality.

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

Yeah, a road map.

**[\>\> LILLEE:]{.underline}**

I like that idea of the EHR Workgroup road map, Karen. It\'s down a
little bit more into the big one, from the big one.

**[\>\> KAREN:]{.underline}**

Yes, okay.

**[\>\> BART:]{.underline}**

Comment? This may be an area where \-- this is Bart Harmon with the
Department of Defense \-- may be an area where some of our work across
DoD and VA may be a helpful lesson learned. We talked separately about
priority and plan sequence, the idea being that it may be more important
to get to the moon than it is to get across the street, but we probably
plan to cross the street first because it\'s so much more feasible.

**[\>\> LILLEE:]{.underline}**

Yeah, good point.

**[\>\> BART:]{.underline}**

If we keep them all with priority as a pure discriminator, and then plan
a sequence based on a lot of other concerns, this may be easier to
explain, also.

**[\>\> LILLEE:]{.underline}**

Good comment.

**[\>\> KAREN:]{.underline}**

Thank you, Bart. For sure.

**[\>\> LILLEE:]{.underline}**

Karen, moving to the next objective, if we could.

**[\>\> KAREN:]{.underline}**

Uh-huh.

**[\>\> LILLEE:]{.underline}**

I have a question for you, because when we talk about equitable adoption
of EHR, these two strategies, 1.41 and 1.42, sound like subsectors of
that whole cost of EHR discussion we already had. What was the thinking
around culling these out in this way? Because they just look to me like
other financial issues to address. Whether you\'re small, large,
advantaged, disadvantaged \--

**[\>\> CAROLYN:]{.underline}**

I was just going to say my sense is on one level this is exactly the
same issue and on another level \-- and of course defining these terms
always has a little bit of sensitivity to it. But my interpretation was
that the focus was on clinicians practicing in settings that simply
don\'t have the opportunity to tap into revenue streams. They are not
going to be handed hardware and software by an insurer. In fact, many of
their patients don\'t come with insurance at all.

And recognizing that they have sort of an extra chasm to cross, if you
will, or broader leap to make.

**[\>\> KAREN:]{.underline}**

Understanding that, are there specific things that the federal
government could do to support them, as opposed to other clinicians? And
what can be done in a nonfinancial way to support them, as well. Because
they are \-- when they are defined in certain ways, then perhaps there
are other steps that could be taken. So that\'s why they were looked at
separately.

**[\>\> KEN:]{.underline}**

Having a ubiquitous episode of care, electronic episode of care, with a
reimbursement approach that spans those that are disadvantaged, might be
a tactical approach to addressing the financial side of this equation.

**[\>\> KAREN:]{.underline}**

And you would \-- not that we get into details now, but one of the
things that you would perhaps consider is that maybe we would do that
for safety net providers as opposed to providers in general?

**[\>\> KEN:]{.underline}**

Yeah.

**[\>\> KAREN:]{.underline}**

I think there are some things we could do and we could consider as a
group. So is this a first wave of the road map or second or third wave
of the road map?

**[\>\> HOWARD:]{.underline}**

I\'d say it\'s at least a second wave. This is Howard.

**[\>\> LILLEE:]{.underline}**

It\'s not first. Again, it would be the tipping point rule that if we
could get large adoption in a segment of the sector that it would
certainly advantage the smaller guy.

**[\>\> KEN:]{.underline}**

Yeah, the regional approach first followed by an outreach.

**[\>\> LILLEE:]{.underline}**

Okay, can we move on?

**[\>\> KAREN:]{.underline}**

Absolutely.

**[\>\> LILLEE:]{.underline}**

Goals two, interconnecting health care.

**[\>\> KAREN:]{.underline}**

I\'m not sure we need to go through every single one of these
strategies, but we might want to scan them and see if there are any in
particular that jump out at any individual that they feel might be
important for the broad charge of this Workgroup.

**[\>\> LILLEE:]{.underline}**

Okay, I just want to emphasize to you from the private sector, this
whole adoption of standards, standards harmonization, was the ground
zero for much discussion in the last 6 weeks.

**[\>\> KAREN:]{.underline}**

All right, then I will make that key.

**[\>\> LILLEE:]{.underline}**

It\'s a source of frustration, it\'s a barrier. I can probably give you
a lot more adjectives, but \-- you know, it is \--

**[\>\> KEN:]{.underline}**

The lightning rod.

**[\>\> LILLEE:]{.underline}**

It is a lightning rod.

**[\>\> KAREN:]{.underline}**

But I think that then comes back to how do we prioritize the standards.
What are the ones we need immediately, what are the ones we need next
month, next year. That\'s where we have the process in place now, but we
need to hear from you all what \-- how to prioritize the standard
development.

**[\>\> LINDA:]{.underline}**

Karen, I agree. This is Linda Frischetti. I believe for the first six
months of AHIC we\'ve had quite an experience in learning how these use
cases fall down into the standards activities that have been set up by
your office. And we understand that we will have produced, within a
year, the standard to support the initial October \'05 AHIC use cases.

So I think as we go through the activities for Strategy 1.1.1, where
we\'re going to look at other sources of data, and prioritize those
sources of data, we will need to just be conscious of making sure that
we do that in a way that we will be handing them off into the standards
process that you have already started within your office.

So with that said, I do agree that we probably don\'t need to go through
the individual objectives and strategies within Goal #2. But as you\'ve
already stated, and others on this call have stated as well,
understanding that Goal #2 is a critical enabler for private sector as
well as Federal sector, as well as anybody participating in
interoperable health information exchange.

**[\>\> LILLEE:]{.underline}**

Well said, Linda.

**[\>\> KEN:]{.underline}**

Is it possible to categorize the standards into capture classification?
And output? Are those the three broad categories by which standards
would apply?

**[\>\> LINDA:]{.underline}**

John, this is Linda Frischetti. Typically, that is \-- those three, the
capture, storage, and display or output, that\'s what\'s used when
you\'re talking about the \-- you know, the data that moves through
systems. Standards doesn\'t use quite that same taxonomy. In fact, we
would like to see the same standards preserved throughout those three,
those three stages of the life cycle of the data. So that there is no
mapping for storage, and then remapping for display, that type of thing.

Does that make sense, is that consistent with your statement as well?

**[\>\> JOHN:]{.underline}**

I was considering the standards that would apply for the varieties of
data that are in \-- at the point of ingestion, the classification of
that data, essentially the capturing of the metadata about the data is
that middle step, and would there be standards that would surround, wrap
that classification stage. And then of course the \-- if there was
harmonization between the classification and the potential output based
on the variety of different data types that could be described, that
those three constituents wrapped together would be kind of the
embodiment of what we\'re describing here in this particular strategy.

**[\>\> LINDA:]{.underline}**

In terms of the classification, the metadata capture, maybe we could
take that conversation offline. I\'m not quite sure the purposes for the
metadata capture, there are certainly many purposes that you would want
to do that. And maybe if we could talk offline that would help me
increase my knowledge on this subject.

**[\>\> JOHN:]{.underline}**

Very good.

**[\>\> LILLEE:]{.underline}**

Okay.

**[\>\> KAREN:]{.underline}**

Given this discussion, should we move into Goal 3?

**[\>\> LILLEE:]{.underline}**

Yes.

**[\>\> KAREN:]{.underline}**

And now we\'re around consumer use of personal health information, as
you can see from the objectives that are listed here. However, the
Chronic Care Workgroup has focused on the need to provide \-- or to have
better communication between patients and providers through use of
secure messaging and other forms of remote monitoring, so what I\'m
wondering is whether you would find Objective 3.2, with the strategy
beneath it, 3.2.1, an important thing to focus on for this Workgroup?

**[\>\> LILLEE:]{.underline}**

Explain again, Karen, how this is different from what the Consumer
Empowerment Group is doing?

**[\>\> KAREN:]{.underline}**

It is what the Consumer Empowerment \--

**[\>\> LILLEE:]{.underline}**

It is what they\'re doing.

**[\>\> KAREN:]{.underline}**

It is what they\'re doing. And the question becomes, does this Workgroup
also consider this a high priority, to be able to bring in information
from remote sources, either through secure messaging, i.e., secure
e-mail, which is an oxymoron I know, or through remote devices into an
electronic health record. Or whether this would be, again, Wave 2 or
Wave 3.

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

I think it\'s a subsequent wave.

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

Yeah, I agree.

**[\>\> LILLEE:]{.underline}**

Yeah, I agree on that, too. Okay. Linda, just as a point of
clarification, having seen the VA system, the things like myhealthevet,
and some of the things you\'ve been able to do, that came after the
implementation of Vista?

**[\>\> LINDA:]{.underline}**

It did. I guess, though, it does not need to. Certainly as we look
towards an interoperable future where a patient\'s information can move
across multiple systems, and the consumer would have the option to have
a personal health record or something similar to that, that would not
need to be tied to a specific implementation of an EHR, but yet could
incorporate and pull in information, or send, information to multiple
provider EHR systems.

**[\>\> LILLEE:]{.underline}**

Okay.

**[\>\> JOHN:]{.underline}**

I have one comment on \-- I have a specific comment on 3.1.1.

**[\>\> LILLEE:]{.underline}**

Okay, please.

**[\>\> JOHN:]{.underline}**

And this is a nit more than anything. It talks of no standard exists
today to ensure that they meet a minimum set of requirements, that\'s
another \-- the paragraph underneath 3.1.1. And one of my concerns is
that I see the development of PHRs substantially associated with
individuals managing chronic conditions, and people that are otherwise
healthy probably are less likely to be engaged in \-- or \-- you know,
engaged with a PHR of some sort.

And my concern is it sort of goes back to the question is, is that when
you\'re dealing with standards for PHRs, I think \-- I the concern that
I have is, again, when you\'re dealing with chronic conditions and
potential specialties, what standards might be applicable to a general
PHR versus a standards associated with specific chronic conditions that
might have a PHR associated with them, are going to be entirely
different.

And I think we have to be very careful at not looking at PHRs at a high
level.

**[\>\> KAREN:]{.underline}**

John, I would ask you whether or not we might even want to go back one
step beyond that. Because nobody really knows what a PHR is.

**[\>\> JOHN:]{.underline}**

I agree with that.

**[\>\> KAREN:]{.underline}**

And perhaps given that, our particular strategy should be finding ways
to assure that consumers have access to their personal health
information. And then that can be multiple ways that that can occur.

**[\>\> JOHN:]{.underline}**

Sure, but I think PHRs are not just accessing their information.

**[\>\> KEN:]{.underline}**

It\'s control.

**[\>\> JOHN:]{.underline}**

It\'s control. It\'s also participation in providing certain types of
information. If you\'re a diabetic, a PHR may have a convenient way for
you to chart your \-- you know, glucose levels and your testing and your
insulin and things like that, medications.

**[\>\> KEN:]{.underline}**

Medications.

**[\>\> JOHN:]{.underline}**

Medications, exactly, or other types of things associated with being
diabetic. Whereas if you have COPD it\'s something else, or if you have
a heart disease it\'s something else. So I\'m just \-- they\'re all
different, and the standards associated with each I think are very
specific rather than being general standards for a PHR.

**[\>\> KAREN:]{.underline}**

I think that makes wonderful sense, and maybe we\'ll go back, then, and
rethink this language, and bring it back to you. That captures not only
the \-- allows you the ability to interact and all those other things
that you described.

**[\>\> KEN:]{.underline}**

Control. Control.

**[\>\> KAREN:]{.underline}**

Intents of this. And it\'s not as well articulated as you just said, so
that\'s great.

**[\>\> LILLEE:]{.underline}**

Nicely said.

**[\>\> KAREN:]{.underline}**

Okay.

**[\>\> LILLEE:]{.underline}**

Karen, I want to be mindful of time, because it looks like we have 25
minutes left. Looking at the agenda, as we move forward here I just want
to make sure we\'re going to allow some time for the Item #7 on the
agenda.

**[\>\> KAREN:]{.underline}**

Right, and I think we\'re actually almost done.

**[\>\> LILLEE:]{.underline}**

Okay.

**[\>\> KAREN:]{.underline}**

So as we go into 4, if one looks at this fairly quickly, there\'s one
strategy here that really underlines what I think was articulated a
little bit earlier about allowing the efficient collection of quality
information. And developing patient centered quality measures. So I
think that there may be, under the 4.2 objective, some strategies that
perhaps at least some of you might find to be higher priority than
others. So I just throw that out as a \-- so just take a quick peek at
the 4.2 objectives and strategies and give us some feedback on those.

**[\>\> LILLEE:]{.underline}**

Carolyn, your opinion would weigh heavily here.

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

Carolyn has left.

**[\>\> LILLEE:]{.underline}**

She did? Darn. Okay.

**[\>\> JOHN:]{.underline}**

I would say \-- I would tend to think \-- I would hate to say this, but
I think prioritizing quality is below \-- is a sort of a two or a three.
Simply because I don\'t think, until you have the data in a form that\'s
shareable, can you necessarily \-- historically, you know, do quality
related activities. I know I understand you need to have the data, need
to make sure you get the data you need for quality related \-- you know,
doing quality measures, but once you get past that, I would think it
really becomes sort of a tier two, tier three type issue.

**[\>\> KEN:]{.underline}**

This is essentially a knowledge management first. If you have knowledge
management, you\'re going to deal with the quality issue as a result of
the decision support tools. But you\'ve got to capture the data first, I
agree with you.

**[\>\> KAREN:]{.underline}**

And I think for those of you who were actually at the last Community
meeting, and Carolyn certainly was, and I\'m sorry that she had to
leave, it looks as if there will be an opportunity for either a fifth
workgroup to begin to address these quality issues, or something
similar. So that ultimately, there may be a way to tee this up for
another venue.

But what I think I\'m hearing, though, in terms of really encouraging
adoption of electronic health records, then this may not be as top tier
as clearly our 1.1 objective is. Our new 1.1.

**[\>\> JOHN:]{.underline}**

It could be a result of some other things.

**[\>\> LILLEE:]{.underline}**

I\'m going to throw some caution here. In the private sector, this whole
issue of quality and capturing quality data as a part of care is a
continuing issue, and a high priority.

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

For whom, though?

**[\>\> LILLEE:]{.underline}**

For hospitals.

**[\>\> KEN:]{.underline}**

How would you \-- hospitals are hard-pressed to \-- they can capture,
but how do they measure?

**[\>\> LILLEE:]{.underline}**

Well, both. But, you know, just the notion that most quality data
capture right now is a chart retrospective, highly labor intensive
process that is inaccurate.

**[\>\> KEN:]{.underline}**

Friction in the flow of information. Absolutely.

**[\>\> JOHN:]{.underline}**

I don\'t disagree with you, I think the point is if you\'ve got the
first goal, though, I think is in order for quality, is have the data in
order to be able to mine it, correct?

**[\>\> KEN:]{.underline}**

Capture, classify and then study.

**[\>\> JOHN:]{.underline}**

So my point being is simply our first goal in all of this exercise in my
mind is you\'ve got to get \-- if you don\'t have EHR, you don\'t have
the data.

**[\>\> LILLEE:]{.underline}**

That\'s correct.

**[\>\> JOHN:]{.underline}**

So therefore everything else becomes sort of my mind simply a tier two
or tier three, because let\'s get the data first, let\'s figure how to
get the data, then you can make it available for quality.

**[\>\> KAREN:]{.underline}**

Then the other side of the coin, is on the ambulatory side, not the
hospital side, if we had intraoperable lab data, which we\'re working
on, and interoperable diagnosis, which payers are working on, and a way
of looking at medications, which the EHR \-- which the Consumer
Empowerment Workgroup is working on, we have electronic access in an
interoperable way to large data banks that can measure quality using AQA
measures without EHRs.

**[\>\> JOHN:]{.underline}**

I\'m not trying to minimize the importance of quality, and quality data,
it\'s just that I think it logically follows rather than leads.

**[\>\> LILLEE:]{.underline}**

You know, and in the private sector, the issue is really getting ramped
up with pay for performance, that\'s the only kicker.

**[\>\> KAREN:]{.underline}**

You know what we might do, I mean, this is one where clearly for
hospitals it\'s much more of an incentive to adopt electronic health
records, and to capture the data, than I think it is in clinicians
offices right now. Because again, in the clinicians \-- the measures can
be extracted from other sources.

**[\>\> LILLEE:]{.underline}**

Right.

**[\>\> KAREN:]{.underline}**

For clinicians.

**[\>\> JOHN:]{.underline}**

Good point about the pay for performance, but again, I think the point
is let\'s get the data, and get data that\'s of meaningful quality then
I think the quality stuff can follow shortly on appeals, but as you
said, if you do it the opposite way, if you \-- you know, you\'re still
sorting through and trying to get the data, and much of it is
inaccurate.

**[\>\> LILLEE:]{.underline}**

Right.

**[\>\> KAREN:]{.underline}**

All right. Well, in the interest of time, I think we have at least the
high priority, the critical components that we need to move forward with
the broad charge, including that discussion that we will need to have at
a later meeting on how we go about prioritizing, with better
information, the must haves for the standardization process.

So I think that we have actually accomplished that very first piece of
our road map, here, in terms of (Inaudible) critical components. The
critical components, and how we will begin to address them at the next
meeting.

So that being the case, are you comfortable with moving on, Lillee?

**[\>\> LILLEE:]{.underline}**

I am. If the rest of the group is. I just want to take the time to make
sure everyone has weighed in. You guys are great.

The first responder EHR, Karen?

**[\>\> KAREN:]{.underline}**

Yes.

**[\>\> LILLEE:]{.underline}**

And I see the Federal Register that was with our materials?

**[\>\> KAREN:]{.underline}**

That\'s right, and I commented on that a little bit earlier. Around the
whole piece.

However, we do need to begin to start thinking about recommending to the
AHIC that HITSP move forward with standards so that critical first
responder, patient information can be made available. In an
interoperable format. And what I would suggest is that if \-- since we
don\'t actually have the critical dataset right now, that we ask for at
our next Workgroup meeting, which is in July, before the AHIC, for a
fairly robust or fairly complete list of data elements that may need to
be standardized so that we could bring these to the \-- or you could
make that recommendation to the August AHIC.

**[\>\> JOHN:]{.underline}**

Can I make \-- I read through this DHS \-- DHHS, I\'m sorry, request for
information document. And there\'s some variance, though, between what I
think we\'re talking about here in the first responder and what I think
is a much broader charge, which is a voluntary system for the storage of
personal data. Because if you look at the middle of 2.2 A \-- 2A, I\'m
sorry, they talk about storage of things such as birth certificates
wills medical information, so I think that there\'s \-- there\'s I guess
the first responder database is a subset or maybe even separate from
what ended up in the Federal Register.

**[\>\> KAREN:]{.underline}**

It is, and it is a different piece. What\'s in the Federal Register is
for your information, and that is moving forward. However, there is the
need for, and it\'s by next, not this, but next hurricane season, a need
to at least be piloting first responder electronic health records in a
number of settings where there may be \-- it may be a situation. And
while that addresses some of these things, what we\'re really looking
for right now because there will be \-- it\'s a time issue, here, is
having a critical set of data elements come to this Workgroup,
essentially then be endorsed by this Workgroup, and then going to the
AHIC. So that HITSP can start developing data standards for them, so
that they will be interoperable.

**[\>\> JOHN:]{.underline}**

Why don\'t I think that\'s already been done in large measure?

**[\>\> KAREN:]{.underline}**

I don\'t know, but there\'s no \-- for instance, there\'s no
interoperable mechanism for sharing a blood pressure result.

**[\>\> JOHN:]{.underline}**

I understand that, but I thought there was sort of the minimum data
set \-- you know, the \--

**[\>\> LINDA:]{.underline}**

There are actually a couple emergency responder minimum data sets. One
of them is EMTs in the field, which is only at this point in time
beginning to \-- and please somebody correct me if I capture this
incorrectly \-- beginning to be mapped to more traditional health data
sets, such as Nomad and LOINC and those. So that work has started. I
believe that HITSP would be an appropriate place for the harmonization
of that work to continue.

I would encourage this body to really just recommend that HITSP take on
that harmonization work, and not do that, or attempt to start that
harmonization work here.

I think that what we could do would be to instead recommend maybe the
stakeholders such as the EMT, the emergency room physicians, the public
health service departments, FEMA, you know, whoever are the stakeholders
actually should participate in that harmonization activity.

**[\>\> JOHN:]{.underline}**

Sounds like a simple recommendation in the make, it sounds like you made
it.

**[\>\> KAREN:]{.underline}**

And as you recall, there were representatives here from a number of
different agencies several months ago that talked about a lot of that,
and I think that\'s where you may have remembered that from.

**[\>\> JOHN:]{.underline}**

Right, my mind just \--

**[\>\> KAREN:]{.underline}**

But I think \-- yeah, I think the bottom line is that we need to be able
to make a very specific recommendation to the AHIC, moving forward. And
at this point, we can \-- it can be fairly broad, and I say specific
recommendation, because it has to be an absolute one, but it can be
fairly broad that HITSP through \-- a use case needs to develop a
harmonized set of standards for emergency response, and that will be
enough to make HITSP go in that direction.

**[\>\> LINDA:]{.underline}**

I would agree. And some critical elements of that is, as you\'ve already
said, the data standardization, the ability for that data to move across
multiple EHRs, from multiple sources into EHRs that are designed
specifically for emergency responders. Certainly we want the market to
be innovative, and not, Karen, as I\'ve heard you talk about in the past
before, not have a \-- you know, a government EHR, or any one specific
EHR that\'s mandated for all environments, and communities. And then to
have that information available, to leave the EHR, and be seamless with
the other IT health systems that are in place.

**[\>\> KAREN:]{.underline}**

Thank you very much, Linda. Maybe what I would suggest is we use the
same process we exercised with the original set of recommendations.
There\'s been a lot of robust discussion, we can then take that back, do
a draft recommendation, and then circulate that amongst all of you for
your final signoff, and could at the next meeting we can officially sign
it off as the recommendation that will go to the AHIC. Is that
acceptable to everyone? And then we will have that recommendation made.

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

That\'s fine.

**[\>\> LINDA:]{.underline}**

Excellent suggestion, Karen.

**[\>\> KAREN:]{.underline}**

Okay, thank you.

**[\>\> LILLEE:]{.underline}**

Okay. What else do we need to accomplish on that one? Or did that get
what we needed?

**[\>\> KAREN:]{.underline}**

I think we got what we needed on that one.

**[\>\> LILLEE:]{.underline}**

Okay, great. So we usually like to take the last 15 minutes for public
comment, would this be a good time for that now?

**[\>\> KAREN:]{.underline}**

I believe so.

**[\>\> JOHN:]{.underline}**

Could we spend 2 minutes talking about what the next \-- the next
meeting holds in terms of \--

**[\>\> LILLEE:]{.underline}**

Of course.

**[\>\> JOHN:]{.underline}**

I just wanted to get some clarity on that.

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

Matt, if you can begin the process for opening up our line for public
input, while we\'re waiting to see if anyone queues up, we can use those
couple of minutes while we\'re waiting to go into the next step.

**[\>\> MATT:]{.underline}**

It\'s already done.

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

Thank you.

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

Thank you, Matt.

**[\>\> KAREN:]{.underline}**

Maybe I\'ll just end right here, and talk about in terms of the
timetable, the next meeting, in July, will essentially be an opportunity
for our staff to bring back to all of you what we know about the
priorities for primary care, in terms of data standards. We will tee up
some public testimony for that, as well, and that will be an opportunity
for the Workgroup to begin to prioritize the directions that HITSP needs
to take with standards development.

**[\>\> JOHN:]{.underline}**

And how long is this meeting going to be?

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

About 2 hours.

**[\>\>JOHN:]{.underline}**

Because we\'ll have to make sure, then, if we\'re going to have that
testimony, it\'s got to be laser sharp and very focused and very
concise, short. I know my experience on NCBHS is sometimes you can get
very long, rambling conversations and some of it not on point, so I
think where we get the testimony \--

**[\>\> LILLEE:]{.underline}**

I agree, that can get really down in the weeds.

**[\>\> JOHN:]{.underline}**

We\'ve got to get very specific to what we\'re trying to get
accomplished in very short \-- testimony, short meetings, I think I get
a little \--

**[\>\> KAREN:]{.underline}**

Good point. We\'ll try to be a little bit more honed in on that one
then. The second piece is we will bring back to you prior to the
meeting, obviously, the other top priority strategies that we have
agreed on.

I will also pull together what is \-- what we know is happening in the
federal government to support those strategies, and any information that
we can pull from the private sector, and we\'ll look to all of you to
flesh that out even further.

So that we can then begin to prioritize which of these strategies \--
taking some actions are going to be the ones the most important to
develop recommendations around.

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

Great. Thank you.

**[\>\> LILLEE:]{.underline}**

Okay, are we ready for public comment? Matt, do we have anyone on the
phone?

**[\>\> MATT:]{.underline}**

No, no one is calling in. I\'ll leave it up to you if you want to wait
another minute for people to get in, but after that it will have been
open for about four minutes with no calls.

**[\>\> LILLEE:]{.underline}**

Okay, great. Does the team have any other recommendations for our next
meeting? I thought that was a really good conversation we just had.
Okay.

**[\>\> KAREN:]{.underline}**

I would \-- this is Karen Bell. I particularly would like to thank all
of you. This has been such a quick process, we\'ve gone from very
intensive work, pulling together a first set of recommendations to
provide to the AHIC, and to the Secretary. Many of those are now in
progress, are being rolled out. And we have very quickly now jumped into
this new role to think about where we\'re going in the future.

What I would just like to share with you is that we are hoping to add a
little bit more rationale in terms of how we\'re going to set the
meetings up. Now that we\'re pulling our own staff on board and have a
little bit more time to plan appropriately, we are going to try to set
them up in such a way that they are a few weeks before the ensuing
Community meeting, and that we have all the preliminary work done
beforehand, so that there is a better relationship between the Workgroup
meetings and the AHIC.

So we will try to do that, as well as limit them to two hours. Moving
forward. And to that end, try to focus in a way that you\'ve described,
John, and thank you for underlining that. So thanks again for all your
energy and effort.

**[\>\> JOHN:]{.underline}**

I have one other question, and unfortunately Dr. Perlin is not on the
phone. Last meeting I was looking \-- when I was reading the summary of
the minutes, we had talked about the fact that Mr. Isenstein and myself
had agreed to participate in the consumer empowerment subgroup regarding
recommendations related to patient identification, authentication and
access to personal information. I have never heard anything related to
that, and I was just wondering whether I\'m missing something, forgot to
do something, or \--

**[\>\> KAREN:]{.underline}**

No, you have not. You have not, but thank you for bringing it up,
because I can address it.

We had some \-- we needed some guidance as to exactly how we could set
this up, and we have received that guidance, and it does need to be
functioning as a subgroup, i.e., under full FACA compliance. We were not
clear about that until last week.

So we now have that guidance from our legal counsel. And secondly, we
are in the process of coming to \-- I believe, agreement on Co-Chairs
for that group. We\'ve not yet locked them in, so as soon as we lock
them in, then the group will be announced, and will be up and running.
And thank you very much for your patience, it took a little longer than
we anticipated. But you\'re still there and you\'re on task.

**[\>\> JOHN:]{.underline}**

I just wanted to make sure I wasn\'t doing \-- wasn\'t supposed to be
doing something I wasn\'t doing.

**[\>\> KAREN:]{.underline}**

It will come, I assure you. And thank you as well to everyone else who
is involved.

**[\>\> LILLEE:]{.underline}**

Karen, one thing as you were giving some thanks, one of the things that
strikes me in how this Workgroup has worked so well together is the
talent that was assembled around the table appears to have been the
right talent selection. And that\'s the hardest part of any group, but
this Workgroup has quickly come together with its own culture, so to
speak, of no nondiscussibles and making sure that we have broad \-- cast
a broad net, so to speak.

So that is in reflection one piece that has also proven to be very
successful.

**[\>\> KAREN:]{.underline}**

Absolutely. And I\'m looking forward to the day we can all be in the
same room at the same time.

**[\>\> LILLEE:]{.underline}**

I agree. (Laughter)

**[\>\> KAREN:]{.underline}**

That will be one of our goals before this is over, we\'ll have a
celebratory meeting with all of us in the room at the same time.

**[\>\> LILLEE:]{.underline}**

So Matt, is there no public comment? I just want to make sure.

**[\>\> MATT:]{.underline}**

Nope.

**[\>\> LILLEE:]{.underline}**

Karen, with that, let me on behalf of Dr. Perlin thank everyone for
joining. Linda Frischetti, thank you for hanging in there with us. Thank
you to all of you that are there in the Mary Switzer building in
Washington, DC, and everyone that\'s on the phone. I want to commend you
for your hard work, commend the staff for great preparation that we
always have for these meetings. And we look forward to seeing you again
during our next Electronics Health Records Workgroup meeting. Bye, now.