American Health Information Community

Electronic Health Records Workgroup Meeting #13

Thursday, February 22, 2007

**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.*

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

Welcome, everybody to the meeting of the Electronic Health Records
Workgroup. Again, just a reminder that we operate under the auspices of
the FACA, which means this meeting is being broadcast out to the public
and there will be a opportunity at the end of the meeting for the public
to make comment. Also, Workgroup members please remember to identify
yourself before you speak and also speak clearly and distinctly and mute
your telephone lines when you\'re not speaking, to help reduce static
and noises.

With that, I think I\'ll turn the agenda over to Jonathan Perlin and
Lillee Smith Gelinas, our co-chairs.

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

Thank you so much, and welcome everyone to this conference call on
February the 22nd, 2007. Jon Perlin and I are delighted to have you with
us. We have a great agenda for you today, and are excited to get
started.

Jon, would you like to say hello?

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

Let me join you Lillee in welcoming everybody, thanking you, everyone
for their participation and indeed it is a very full agenda. Again, I
would simply ask that everyone keep the focus on how we translate our
learning into concrete recommendations to the Secretary in order that we
might meet the aspiration which is to make real the implementation of
electronic health records.

Let me thank Lillee Gelinas for carrying the water today. I am, due to a
scheduling mishap, in an airport at the moment. I\'ll probably be quiet
for the rest of the call. Certainly when I get on a plane. Thank you
very much, Lillee, for your expert leadership, and let me turn it back
to you.

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

I want to assure the committee that Jon and I do stay in close contact
and that we do have a solid co-chair leadership of this group and I just
want to thank Jon for that. He is incredibly easy to work with on a very
tough challenge here.

Matt, could we have introduction of participants, please.

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

Absolutely. On the phone for the call today, James Sorace, CMS. Alicia
Bradford from the Office of the National Coordinator. Robert Smith from
the VA. Bart Harmon from the Department of Defense. Pam Pure from
McKesson. John Houston from University of Pittsburgh Medical Center. And
Connie Laubenthal is here for John Tooker from the College of American
Physicians. Are there other Workgroup members who are on the phone who I
did not just mention?

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

This is Carolyn Clancy, I\'m here at ONC.

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

Anyone else, Judy, live with you over there in the building?

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

That\'s it. Karen and I are here.

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

Okay.

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

Okay, super, thank you very much. It looks like we have a quorum and we
can proceed. We would begin with review and acceptance of our minutes
from our January the 11th meeting that came with numerous attachments
here. Let me just be quiet for a minute and ask the committee are there
any changes, corrections, or comments to the minutes?

Okay. Hearing none, I just wanted to compliment the staff on the format
where the action items are very, very clear as we can refer to them. So
I thank you for that. There\'s been tremendous work, I know, that has
gone into putting together a robust group of minutes that clearly show
discussion as well as action.

So hearing no recommendations for change, I\'ll declare consensus and
we\'ll move on to our first agenda item, which is emerging items and
updates. Dr. Karen Bell, please.

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

Thank you very much. Actually, it\'s going to be very short. We have a
lot of work to do and it\'s a very robust meeting today. So I\'m going
to keep my comments down to a few. The most important one is in
reference to the next American Health Information Community meeting,
which is the 13th of March, but will be in California. Mountain View,
California. We\'re still setting up those logistics. But just wanted to
make sure that everyone here was aware of that and would stay tuned.

The relevant piece of information for today is that that is also a very
packed agenda, and we have been asked to postpone our recommendations
until the April or possibly even early June meeting. So we actually have
time to get these to the point where we\'re really comfortable with them
and we really feel are the best possible recommendations. We\'re no
longer under the gun to get something done in a very, very short
timeframe. So I thought that might at least give everyone a sigh of
relief as we start the meeting this morning.

And the last thing I would like to call your attention to is that at the
AHIC meeting of January 23rd, which again was a very packed schedule,
some decisions were made to move forward with a number of use cases. The
one that\'s most referable to this group, I believe, is that of
medication management. We will be developing those internally over the
course of the next several weeks, and they will be available for public
comment. The other two are in the area of consumer empowerment, i.e.,
making information available to consumers. And then the third one is in
the area of population health and that\'s in the, and that is focusing
on quality. So those three use cases are the ones we will be working
forward over the course of this coming year, i.e., what that means is
moving along to HITSP, the Certification Commission, our privacy and
security group, and all other interested parties.

So I think I am going to stop there and as we move on to the state of
the technology, I recognize that Dr. Middleton may not be on the line
just yet. Is that correct?

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

Yeah, that\'s correct. I talked to him as early, or as late as this
morning and I know he was planning on doing the demo and he'd just
tested it, so maybe he\'s just a couple minutes behind here.

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

Well, what I would like to suggest is that we have been trying for
several sessions to also bring in a demo of the Cleveland Clinic's
electronic health record, and it is probably one of the premier ones,
not only in the country, in the world, and so they spend a lot of time
traveling around the world and we keep losing their ability to present
here.

So I\'m just very briefly going to say that I will continue to try to
align one of their possible days for presentation with this meeting, but
I will also underline for you that the reason I think this is important
is that this is an electronic health record, an institutional electronic
health record that has some very unique features. I think most of us are
aware that a lot of the large delivery systems have a patient portal,
and as does the Cleveland Clinic. But the Cleveland Clinic\'s patient
portal is not just to acquire information. It is also a mechanism
whereby patients communicate with all of the providers at the Cleveland
Clinic. And I also want to underline the fact that Cleveland Clinic is
not one building. It is probably about 17 hospitals at this point, maybe
even have moved up to 20, multiple physician's offices throughout the
area in Ohio and beyond, and is really a very extensive network.

In addition to allowing all of those clinicians access to the same
record and patients access to their own information as well as
communicate with their providers, the Cleveland Clinic has also, again,
a very unique feature which is related to the fact that there are many
patients who are referred into the clinic for one-time situations. So
for instance someone from Kansas may be referred in. When that is the
case, the referring physician from Kansas has access to that patient\'s
medical record while they are there at the clinic and for one month
after. So that any referring physician has access to all the information
he or she needs as the patient returns home. And this attention to
continuity of care is a very important feature, and one that again is
fairly unique. And I also recognize that our own federal systems, the
VA, the DOD, are not, are in need of these same type of services to the
same degree as patients going in the private sector but it is a unique
feature and one I\'m looking forward to sharing with you when it comes
forth. But did want to at least underscore why we think it would be
important for this group to see the full range of capabilities that an
EHR can offer from this point of view.

Now I understand that Blackford is now with us?

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

Yes, I am, sorry for being late.

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

Not a problem, but I am going to invite you to jump right in.

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

Okay. What I\'d like to do is, let me just get the application started.

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

And I\'ll jump in here and I know we\'ve done these live demos before
but for members of the public and Workgroup members, you might have to
click a little button that says click here to open the new window in
which Dr. Middleton is going to conduct his demo. But once you do, that
you should see that window pop open and you\'ll be looking at his
screen. And Dr. Middleton, I\'m seeing your screen, so it looks like you
can go ahead and open the application. One more note, while Dr.
Middleton is getting set up, this demo should happen in pretty near
real-time. It varies about depending upon people\'s connection speed,
but your computer should catch up, so if it looks as though you\'re a
little bit behind what Dr. Middleton is actually talking about, just be
patient and your computer should get up to speed.

So I think Dr. Middleton, if you\'re ready, we\'re all ready as well.

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

Okay, I\'m sorry, I was on mute, and I had begun. Can you hear me now?

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

We can.

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

So I was saying I\'m a primary care general internist at Brigham and
Women\'s Hospital and corporate director for clinical informatics,
research, and development at Partners HealthCare, and the IS group, my
group is responsible for the product design of the Longitudinal Medical
Record, or LMR that I\'ll be demonstrating today.

What I have done here is log on to the LMR, our Web-based EMR, and
chosen a demo patient named Tom OETest. Can everyone see that?

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

Yep, that\'s up on the screen.

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

I don\'t see it on my screen.

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

So what people should be seeing soon is our summary page in our EMR
called the Longitudinal Medical Record which displays of course the
patient name, and a wide variety of information in summary form. And let
me just go through this briefly to give an orientation to where we are.

The top of the page shows the reminders that are due, alerts or
reminders that are firing for this patient. For example, he has had
coronary artery disease on the problem list, and a beta blocker is not
on the medication list, recommendation for considering beta blocker for
this patient. Below the reminders is the to do function. Below that the
problem list, medication list, allergies, advanced directives, all in
that leftmost column. In the middle column, flow sheet view of data can
be shown, let me expand that. So there\'s a recent set of flow sheet
data. All of the notes from across the enterprise are summarized here,
and below that then immunization records, social history, procedure
record, and other sources of information as well.

In the rightmost column is an area for patient-submitted e-mail
communications from our patient portal called Patient Gateway which
hopefully we\'ll have time to take a peek at. They appear here for the
receiving primary care or specialist physician to review and go over
with the patient. The source, the e-mail for the patient can be listed
here, or other e-mail aliases, and then a visit history, caring
physicians, care providers, and healthcare maintenance reminders are
shown at the bottom on the right-hand side.

So that gives a quick overview of the summary screen layout. Note the
little icon here at the top. This PG for Patient Gateway with a pencil
on it means that the patient is enrolled in the Patient Gateway
application, which is a patient-facing portal revealing an abstract of
the information, including laboratory tests and results, problem list,
medications, and whatnot, to the patient for their own review.

This icon at the top indicates, one of our enterprise initiatives
focusing on smoking cessation, that this patient is a smoker and
considering using this tool to launch some smoking decision support. And
this last icon, the page with a star on it indicates that the patient
could have, could be, a smart form could be used for documenting
clinical encounter and receiving decision support. So does that basic
layout of the homepage make sense? I\'ll just continue, then.

Each of these areas can be looked at in more detail. For example, if I
were to open up the problem list, I could review the existing problems
as well as see comments that might apply to anyone who documented this
problem. In addition, this little icon next to the diabetes mellitus
problem shows there\'s a disease monograph, what we call a disease
monograph, available for reviewing the diabetes mellitus status of this
patient. So if I click on that, a new window will pop up \-- can
everyone see that, Matt?

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

I can see the new window opening up for me right now.

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

And this shows a diabetes disease monograph, as I\'ve said, which will
summarize the data for this patient only, over time, on a variety of
clinical parameters for diabetes-related care. So, for example, some
charts at the top, an access link to our virtual diabetes center for
additional decision support and information, other information,
reminders. And notice of course that it\'s easy for the clinician to
review. For example, under last foot exam, the last foot exam documented
in this record, a dummy patient, if you will, was June 21st, 2000. So
that\'s one of the ways we provide individual patient data review and
decision support using those disease monographs, and they\'re created by
the Laboratory for Computer Science over at Mass General by Henry Chueh
and his group.

Going back to the summary page, then, this is a restricted patient
because he\'s a demo patient. The same thing can be done for
medications. For example, I can review the med list in great detail and
see, for example whether or not this is an on formulary or off formulary
drug based upon the red, yellow, green indicators in the second leftmost
column on the med list.

It also has indication about the co-pay requirements for each or any
medication that\'s prescribed. The next button is a little I, a yellow
circle with an I on it. That shows an info button which if clicked, for
example, for any medicine, or clicked anywhere they appear, takes you to
our knowledge link resource which is a tightly coupled set of resources
available for looking up a wide variety of information on drugs, tests,
procedures, care pathways, protocols, guidelines, what have you. So you
can see with one click on the info button next to Ambien, I\'m taken to
the medication monograph on zolpidem.

Other aspects of the chart summary, I won\'t go through all of them, but
another important one is the healthcare maintenance. This is where one
can review all of the existing healthcare maintenance alerts and
reminders and others that might be firing for this patient given our
knowledge base and decision support operating in the background. And of
course you can update any one of these by simply clicking on it,
clicking on the rectal exam, for example, and updating with a new
finding, whether it was done here or elsewhere.

By the way, I should point out that the electronic medial record system
here includes the full scheduling system, I can see the schedule for
myself today or for any other provider by reviewing schedule. I can also
change to any other date, of course, simple kind of practice management
decision support, or work flow support is built in.

Going back to the chart, though, and just looking at the demo
suggestions, I\'ve reviewed the medication history and problem list, let
me look now at the clinical notes environment. For Tom OETest here we
can review what notes exist on the charts for him and then show three
different ways or describe three or four different ways notes can be
added. So if I look at the notes list, I can see all the recent
encounters and documentation that has occurred for this patient and
it\'s obviously useful to be able to filter the list in a variety of
ways so I don\'t have to sort through potentially thousands and
thousands of notes. I can look for notes that are just by me or by any
provider, or look for notes that are by my practice or any practice, so
here by choosing this filter I found all the notes pertaining just to my
practice.

If I want to view notes in sequential fashion, I go into a notes view
module which allows me to scroll through notes or even more usefully,
perhaps, to search for any occurrence of any text string in any note.
For example, if I was interested in the occurrence of mammogram
documentation in any clinical note, by searching for mammogram, all of
these notes have something to do with mammogram, it\'s mentioned in
these notes in the left-hand list.

Now, by way of documentation, this electronic medical record allows the
user to really do it their way. There is no best way or preferred way or
single way. We have a wide variety of users, of course, in the Partners
HealthCare environment, across Harvard Medical School, in both community
and academic practice settings, in both primary care and subspecialty
care, of course. So we use the usual assortment of dictation, which can,
notes can be uploaded to the EMR. Unstructured free text notes, people
can type directly into a notes window in the free text form. They can
use templates, which I\'ll show you an example of. Or they can use what
we call a smart form. Part of a recent AHRQ research grant that has
supported our development of smart forms which try to combine decision
support, documentation, and data review into one seamless workflow
environment for the end user.

If we were to use a template, for example I could type up a note in a
free text window here, I can do certain things like review the meds and
bring them in in one fell swoop if I\'m compiling a note here in a free
text window. Alternatively, I can go through a more structured and
templated note, for example one I use frequently in primary care is the
BIMA, Brigham Internal Medical Associates urgent care template, and here
for example a patient comes in with cough, I can say for example this
patient has had a productive, and then continue through the rest of the
documentation by actually typing into the templated note all the
findings and observations. Obviously, it can include pre-canned text
within template sections, or it can pull forward from prior notes text
for editing and insertion into today\'s note.

This includes a full history and physical assessment and plan. I can add
new sections to the template if I wish, from the left-hand side. If I
wanted to insert the patient data, I have the same ability here, for
example, to insert data from the rest of the record into the note, or
from the problem list or what have you. Oops, there\'s no problems to
pull on this one. But that\'s the idea of a text template or structured
template note.

The last version of documentation that we have in place today, and it is
in the midst of a randomized control trial, is the idea of a smart form.
And what a smart form does, for example for disease-specific or even in
general purpose across multiple conditions, it allows a very
sophisticated set of decision support to occur in one environment, as
I\'ve already described, for the end user. So here if I invoke the smart
form, you can see what\'s now been on the fly created for the clinician
user is an environment for data review in the leftmost column,
documentation in the middle column, and then guided decision support for
problem-oriented management and work flow support on the right. In this
environment I can also insert templates like we saw before, the very
same urgent care visit note can be used to populate the middle section
here for clinical documentation.

On the right-hand side I can review the problem list, I can add new
problems, right here in context, if you will, I can derive additional
information about problems by clicking on the info button next to the
problem. Here, for example, I\'ve invoked the knowledge link E-medicine
resource for looking at an asthma monograph. I can review the procedures
simply by choosing the other tab on the left-hand side. I can review the
current medications and non-medications, if there are any, that are
known to this patient. These data by the way are dummy patient data and
may not make clinical sense, obviously. A lot of garbage flows into
these demo patients over time. You can review today\'s vital signs as
well as a chronological record of recent laboratory data and recent lab
tests or last known values for relevant data. And I can review, of
course, health maintenance items here on the left-hand side. And the
last module is the end of visit module which does the end of visit order
capture, charge capture, and routing of the patient, if you will, for
order entry.

So the middle kingdom here, the documentation environment is similar to
what you\'ve already seen. We at this point also can pop up subwindows,
if you will, for more structured data entry, but in general practice I
haven\'t been using that. I\'ve just been using the structure data
templates. On the right-hand side you can see there\'s a wide variety of
decision support occurring already in this patient. For example, it
might suggest since this patient is a smoker, I start a nicotine
replacement. If I\'m not sure what to do in choosing nicotine
replacement or prescribing bupropion, I might ask for some guidance.
Here we can pop up a guidance tool. This is a static decision support
graphic which shows how to start either nicotine or other smoking
cessation therapy. I might want to e-mail the tobacco counselor
suggesting that this patient is ready for tobacco counseling or smoking
cessation if he\'s at the point of willingness to consider that. I can
also do other simple clicks here, to, for example, print the referral
form, print the smoking cessation in Spanish, print tips for smokers,
and what have you. In addition, once all these things are clicked, when
I get, when it gets time to actually finish the documentation, I can
execute the rule set and add that conveniently, for example now it\'s
going to ask me to print the various forms I\'ve just clicked. I can add
that documentation with a single click to the plan section of the
clinical note. Let me pause there to ask if there are any questions
about documentation. If there are none, I\'ll just continue.

Looking at laboratory data or population data, if we wanted to view
historical lab data the basic work flow is that clinical labs come back
to the ordering physician in what we call the results manager area for
work flow management. Here, for example, there\'s one test result, a
microbiology test result for a patient, showing their microbiology test
results on urine. The results manager allows not only review and
documentation of the result review but I can also write a letter, for
example, to the patient, and in this case, given that it\'s a
microbiology report and that the finding is remarkable for a E. Coli, I
can write in here for example, if I can type, and very simply add that
to a pre-canned letter asking the patient to call for prescription
guidance given that she has had a UTI. Let me not do that in this case.
I can also write ticklers to remind myself to follow up certain lab
results or patients over time. I can add items to the to do list so that
the reminders in any other way that I need to have, I can have them fire
it in the to-do list. And I can also quickly document a patient
telephone consultation or conversation here in the patient calls area.

So that\'s how we review the individual results coming in after a
clinical encounter. All laboratory results of course are available
online. We can review labs across different domains, chemistry,
hematology, coagulation, what have you, and we have some color coding in
here which facilitates the end user in finding the most recent labs
quickly. You can see at the very bottom here, this little spinning
orange icon indicates these lab test results are less than 72 years old,
yellow is one week, green one month, blue six months, purple one year.
So here, for example, are the chemistry panel results for this patient
and I can view down into individual detail, if required, for any
particular result. All the laboratory results come from any source
system across the Partners environment into the clinical data
repository, so labs done anywhere across 11 hospitals and dozens and
dozens of outpatient care areas are available to the EMR. In addition,
X-ray and EKG and other image data are also available here. This test
patient actually doesn\'t have any chest X-rays or other X-rays, of
course, or I think not an EKG either. Oh, yes, so there is an EKG, for
example, to look at. So all those image data are also available online
if you wish to review them.

Let\'s see. I\'ve gone over the med and preventive care reminders and
showing the smart forms I gave some sense of how we view chronic disease
management. One other thing we do, though, to facilitate chronic disease
management of populations, is enable the end user to access a wide
variety of reports on their own patient care, their own practice, and do
comparisons of their patient care to their practice or national
benchmarks. Here, for example, you should now see the report central
environment, here\'s where we\'ve created a bunch of canned reports,
allowing the end user to see, for example, what their asthma practice
pattern is, defines those with potential asthma based on perhaps use of
corticosteroid or inhaled bronchodilator as well as documented asthma on
the problem list. One of the new ones we have created is a snapshot of
your clinic, if you will, snapshot report, which shows for the end user
their age distribution, payor distribution, top five medications used,
smoking status, top five problems, patients with chronic conditions, and
whatnot. So we\'re finding that the end user actually loves the data
more and more, and as we enter into pay for performance we of course are
building pay for performance reports which indicate how well the end
user is doing on the pay for performance benchmarks and whatnot.

Another thing we\'ve built are called quality dashboards. Here the
quality dashboard shows for acute care condition, acute respiratory
illness what this provider \-- this is my data in fact \-- what my
prescribing patterns are for antibiotics in ARE visits, my own average
against clinic average against the national average. As a doctor seeing
patients in the second or third visit perhaps that might justify by
overuse of antibiotics but I won't make any clinical judgment today, I
hope none of you will. It also shows, though, what broad spectrum versus
narrow spectrum antibiotics I\'m using compared to my clinic colleagues,
it breaks down the distribution of acute respiratory visit types across
the cohort and also shows the level of service for this population of
patients.

A slightly more interesting dashboard is one we built for coronary
artery disease. This shows some of the core measures, if you will, for
coronary artery disease, hyperlipidemia management, and gives some
visual cues to the end user quickly as to if their status on the
individual measures for that cohort of patients is up to snuff or not.
Red is bad, green is good, and yellow is sort of take note. Here, for
example, you can see the value for my patients with CAD, and the actual
count for this measure of who are in compliance or at benchmark. And as
a primary care doc, I actually mostly do urgent care, don\'t have a
large panel myself, so these data are somewhat spurious and only have
five patients with this diagnosis in my panel. But nevertheless, you can
see in more detail what each individual measure is reflecting in the
cohort of patients to whom it applies across antiplatelet use, beta
blocker, blood pressure management, lipids, the ACE inhibitors or ARBs,
BMI for these folks, smoking status. And we\'re experimenting with the
measure of zero defect care, where hopefully, if every measure is up to
snuff for a patient, they have zero defects in their care process at
least, and this allows the end user to target their follow-up or
interventions on those patients that are not yet at zero defect care.

We also give the end user an ability to create ad hoc query, if you
will, of the EMR database to create a patient list of any kind that they
wish for management and what we\'re building is the ability to act then
upon the entire cohort defined by an arbitrary patient list or
parameterized list of patients so that the end user can send off letters
to the patients via paper or perhaps even send off a letter
electronically to the Patient Gateway. If I were to look at a different
patient here, Tom OETest is another patient who happens to have a
Patient Gateway portal established. \-- I guess I\'m almost coming up on
time but please tell me when I need to stop. \-- This patient has a
Patient Gateway connection established to his record and to his provider
and I wanted to write the patient a secured confidential e-mail, I
simply click on that Patient Gateway icon with the pencil on it and I\'m
taken into the mail environment where I can write a letter to any
patient that is so enabled. And here is Tom OETest. If I want to write
him a letter \-- oops \-- you basically get a e-mail environment. I had
a problem with pop-ups here before. I\'m not sure if I\'ll be able to
demonstrate writing this patient but let me try one more time. Well, for
some reason the demo environment here is not allowing the pop-up to
work. But that would create an e-mail environment where I could send a
confidential e-mail to that patient.

In the record we have a wide array of other tools that I simply won\'t
have time to show. But we have specialized tools for, for example, in
oncology management, oncology care, managing an infusion flow sheet for
outpatient infusion care for oncology patients, a BMT flow sheet,
oncology staging, and access to OncPro resources. Here, for example,
I\'m not an oncologist and I only have a read-only access to this
resource, but here, for example, the oncology flow sheet would allow an
oncology therapist, nurse, or clinician to document in a protocol
format, if you will, the infusion protocol, whatnot.

All of the tools that you have seen today are customizable by the end
user at a level \-- of course we do a great deal of customization in the
design and development shop within informatics and IS. There are other
reports that are made available as well. Administrative reports and
administrative functionalities is available as well. Everything requires
signature to document and dedicate, if you will, to the database. There
are a wide variety of other results methods that I don\'t have time to
show, and of course all online training and health resources are made
available. The handbook is the knowledge-based resource that\'s used by
knowledge link. All of these information resources are available online,
and let me stop there and perhaps take some questions.

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

Blackford, this is Karen Bell. Thank you so much. That was really an
outstanding demonstration of a lot of the capabilities. I have a couple
of quick questions. Number one, this is a system that\'s been in place
for I think over a dozen years. How do you add in information for
patients who are new to the system that may come with a paper chart
that's about three inches thick?

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

Sure. This system, Karen, is actually a descendant of the prior
ambulatory medical record that was in use at the Brigham, and this
Web-based EMR has only been available for about six or seven years. I
just wanted to clarify that for you.

When a new patient comes in, of course the registration data is taken by
registration clerks and that will instantiate a chart. There is an
opportunity to actually scan in documents from any other source, if you
will, and have them made available via the in-patient scanning which can
also be used outpatient, of course. In this case there are no scan
documents on this demo record, but documents can be scanned in. That\'s
usually not done, though, in fact. What the implementation practice is
typically, is to instantiate the medication list, instantiate the
problem list, and perhaps, if one is eager and aggressive, instantiates
some cardinal, key critical data from the patient\'s past medical
history such as healthcare preventive maintenance items such as mammo,
pap, pelvic, cholesterol, what have you, if the user is so inclined.

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

My second quick question is related to a comment made earlier. Last
meeting. About physicians concern about managing large amounts of
information coming in. Now, if this is gone live for about six or seven
years and most of the patients that you\'re seeing stay within the
Partners system or within the Brigham system, is this about as complete
records as you would see so that you\'re really looking at a very robust
and very complete medical record? And you can certainly manage the size
of that?

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

Well, it is a, certainly I\'m a proud papa, Karen and it is a
comprehensive and robust record, with full features and functionality.
We haven\'t gone through the certification process yet but we\'re
planning to do so. By way of the information load, however, to answer
your question, I think this is perhaps about as bad as it can get. And
in fact this record, given that it's a demo patient, has a lot of
spurious data which your average adult chronic care patient really may
not have this volume. But of course things accumulate over time. And
some of our records have yes, over a dozen problems and potentially 30
years worth of data.

**[\>\> Karen Bell:\
]{.underline}**Actually I have a few more questions but I don\'t want to
dominate. So I\'ll sit back for a few moments here.

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

This is Jim Sorace from CMS. I was just curious, what\'s been your
experience and this is a big question so maybe a very brief summary, in
terms of how users respond to reminders and prompts and how best to
couch them so that people act appropriately on them?

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

Yeah, that\'s a great question. This is an area, you know, of
long-standing academic investigation here. Lots and lots of papers are
available, if you\'re interested. Fundamentally, we think the user is
now, in this environment, expecting alerts and reminders. It doesn\'t
mean that they don\'t ignore a great many of them, though, if they\'re
very comfortable or confident about what they\'re doing. I think the
average user here certainly does appreciate the healthcare maintenance
alerts and reminders, appreciates the drug/drug interactions and drug
allergy alerts. I didn\'t get to demo that, but those would all occur
during prescription order entry and whatnot. The expectation is that
this tool is a support or buttress, I think, for clinical practice, and,
you know, we have the usual feeling here among our users. They don\'t
want to practice without it.

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

I do have one other question, Blackford. And that has to do with the
fact that we\'re well aware, and Dr. Clancy is sitting opposite me here,
the study that AHRQ did last spring that demonstrated the large delivery
systems using HIT truly have improved care. One of the questions I have
for you, because I know that your delivery system is quite diverse, you
have the academic physicians within the Brigham setting and then you
also have a number of physicians in small practices throughout the
Boston area. Do you see there\'s any difference, or have you been able
to look for and detect any difference in quality improvement depending
on the clinical setting, the physician setting?

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

We haven\'t done that kind of analysis that I\'m aware of internally. We
certainly know that the EMR is a critical factor in achieving our pay
for performance objectives, and that physicians using EMR are more
readily available to achieve those P for P objectives. But within system
quality differences, I haven\'t seen those data, or I probably couldn\'t
talk about it if I had seen them anyway. But I agree with the notion
that this, we have probably achieved here, from comparison of this
system to other non-EMR-enabled systems, better outcomes and better
throughput.

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

Thank you.

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

I\'m just showing a quick peek at the prescription writing module. One
can search for a new med by any route, and in our system you can use a
practice favorite formulation or go to a new formulation, for example,
of Zocor, and here I\'m getting a alert that the patient previously was
on Zocor, so I can activate the inactive or continue a new order, and we
spent a lot of time devising the right strength and form combinations
and route and frequency combinations so that we aim to decrease the
incidence of medication administration error, or medication prescribing
error rather, at the time of order entry in the prescription screen.

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

Blackford, this is Carolyn. Can you just talk a little about who sets
policies around clinical decision support and other things? And I\'m
thinking of two things in particular. One is an updating function, in
terms of new information becomes available and therefore a prompt or
message to clinicians, you know, needs to be revised or refined. The
second is the issue of opt in versus opt out. Yours is clearly an opt in
kind of system. Does that ever give people pause in some areas?

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

Resistance is futile at one level. But, you know, I think most people
now are eagerly moving toward the EMR use across our environment. You
may know, our adoption now is probably, let\'s see, it\'s greater than
90 percent of primary care in the AMCs, greater than 30 percent of
specialists in the academic medical centers. Not quite so good in the
community yet: on the upward of 50, 60 percent in primary care and 20 or
30 percent in subspecialty practice. But given the latest best data that
you\'re well aware of in adoption across the country, we think we\'re
far along compared to the rest of the country.

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

Yeah.

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

Blackford, this is Lillee Gelinas. You did an outstanding presentation.
Is there a sense of cost to the physician for the technology?

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

Sure. In the AMCs, it\'s supported of course by the institutional
infrastructure for IS. There\'s no faculty cost per se, although there
are real costs that are supported by the individual institutions. The
charging structure in the community for docs who are not Partners
physicians but wish to use the EMR is not something I\'m intimately
familiar with but we have I think a fairly market-competitive, if not
slightly less, pricing structure that has an upfront implementation and
interface development cost and then and ongoing cost for maintenance of
interfaces and new knowledge and development of new decision support or
tools. I don\'t know what those latest figures are. I think it\'s on the
order of 2600, 3K, per doc, per user for implementation and then about
20 percent of that roughly ongoing.

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

Because, you know, part of the charges of this Workgroup as we\'ve been
discussing how to be effective is around the business case for
practicing physicians.

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

Yep.

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

And the issues related to that. We just hear time and time again that
there\'s no cushion for private physicians to invest in health IT.

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

Well, I agree strongly with that, and I think I have sent in to the
committee perhaps in some of our early meetings, some of the stuff I\'m
written on this very issue of the market failure for healthcare IT,
particularly in a small office environment. I\'d point you back towards
our American Journal of Medicine article, or the Health Affairs articles
that we have done. I think fundamentally, given the razor thin or
negative margins for most physicians in small office environments and
even small hospitals, and the fact that our analysis suggests that 89
percent of the benefit of HIT goes to folks other than the paying
physician, if you will, buying the HIT, primarily the benefit goes to
the payors, that it\'s really unfair and thus the market failure for
adoption at a variety of levels in the small office environment, for the
end user physician to foot the total bill.

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

What is the uptake of adoption across your system?

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

So I was just alluding to that. It\'s greater than 90 percent in the
academic medical centers of primary care docs, greater than 30 percent
of the specialists in those AMCs, and in the community, greater than 50
percent of primary care physicians and approximately 20 or 30 percent of
the subspecialists. We\'re about double the national average for
adoption, and nearly complete in primary care.

Carolyn, I wanted to go back a second to your question about the
knowledge management and updating governance, if you will. One of the
things I think I may have shown you previously but might be of interest
to the committee, we recognized that the knowledge management problem is
in fact one of the biggest problems in HIT implementation, adoption,
effective use, and transforming care. We have created a knowledge
management portal wherein we catalog all of the knowledge in the LMR,
the CPOE systems, the EMR applications, even the smart pumps, all that
kind of knowledge is being now cataloged and maintained in this resource
we call the knowledge portal. This allows a user to go in, for example,
and do a filtered-based search of all the knowledge assets in any of the
systems across the entire enterprise. The foundation on which we do our
governance, because not only does it allow to you keep track of what\'s
what, authored by whom, when it was authored, and when it\'s due for an
update, it also enables, the infrastructure also enables distributed
collaborative knowledge engineering. We know it\'s basically impossible
to get a room full of clinicians together with pharmacists and IT folks
to do the rule update and maintenance, so we do it all virtually in
E-rooms wherein we can do an update on the Gerios (ph), for example,
geriatric prescribing knowledge base, virtually, over time and over
geographic distance, without having to get everyone together. We\'re
finding this to be very effective. That\'s the tool part of it.

The governance part of it is that we\'ve created an enterprise
committee, the clinical content committee, which is an enterprise
empowered committee, if you will, that is responsible for saying what,
where are we supposed to go and what are the directions we should follow
for new knowledge or updating knowledge in the LMR resource, the EMR.

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

Thank you.

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

Any other questions for Blackford?

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

This is Karen Bell. I have one last quick one. Clearly you have multiple
physicians using the same electronic health record and having access to
a lot of historical information they didn\'t order themselves, which
means that they can be seeing abnormal lab results that perhaps someone
else didn\'t pick up or act on. What types of policies or procedures do
you have in place to assure that A, either patients don\'t fall through
cracks, or B, if something unusual is picked up that could be
problematic, then it gets to the right clinician?

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

Yeah. It\'s an excellent question, and I don\'t think we have any secret
sauce or magic bullets there. Every order is returned to a responsible
physician as I\'ve showed already in the results manager module, so if
you ordered it, you get a result. And if it you aren\'t able to retrieve
that result, it\'s your obligation to find a colleague or practice
partner who will review those results for you.

We have another system that I can\'t show here, behind the scenes, that
is the physician notification system. Any panic lab result, that is
something that is far out of normal range on any laboratory value or any
other result, the physician, ordering physician, or the responsible
physician on call, is paged immediately with those kinds of results. And
we found for example in papers that are available online, you know, that
that has improved the response rate to panic laboratory values by as
much as a third less time. Does that make sense?

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

Yes. Thank you very much.

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

Karen, I believe it may be time to thank Blackford and move on to our
next presentation.

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

Absolutely. Thank you very much, Blackford. Very nice to sort of see
what\'s happening in the real world, and I put that in quotation marks,
in addition to see the electronic health records you\'ve seen in the
federal state.

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

Can I interrupt you just one second with a quick technical note. I\'m
sorry. Dr. Middleton, if you could, so we can go back to the slides, if
you go back to where you started the application sharing and hit the
green door with the orange arrow icon to shut it down for all of us,
please.

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

Thank you, kindly.

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

Thank you.

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

Karen, just as I looked at what Blackford was highlighting there, the
dashboards and, Carolyn, for you, I know, this zero defect care screen,
I\'m not so sure I\'ve seen a lot of that in other EHRs. Since my time
on AHIC I have seen a lot of EHRs and I\'m not so sure I\'ve seen that
example of a dashboard that actually had status related to zero defect
care.

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

No, I have not seen that either, thank you for pointing that out.

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

Terrific.

Okay. Legal and regulatory review. Karen, I believe there\'s a letter in
our packet of materials.

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

That is correct. As you all recall, we had a very exciting, but too
short for the timeframe, set of public testimony from a number of legal
experts. Mr. Michael Kidney from Hogan & Hartson. We also heard from
Mark Tatelbaum from George Washington University and from Bruce Wolff of
Manatt, Phelps, & Phillips. They\'ve provided us with a good deal of
information about possible increases and decreases of liability
associated with electronic health records, which is summarized in your
minutes from last time, and also will be summarized as we move forward
into the recommendation mode. But we did have an opportunity to ask them
for a few additional questions. A number of people did have additional
questions, and they did respond in writing to the Workgroup.

This letter is now part of the public record, and will be available on
the Website. Our intention is not to read the entire letter, because it
is actually quite long and would go beyond the five minutes. But I would
like to just highlight a few elements from the letter.

One of the questions that was asked about whether or not certified EHRs
that attended to and included in the functionality good ways of
organizing clinical information upfront so that it would come to the
attention of the physician and would not be lost, could in fact decrease
liability. And so they did agree that perhaps we might be wanting to
speak with the Certification Commission about ways that a certified EHR
can present information so as to decrease liability.

There was also some question about clinical decision support systems. I
believe that here the response really did fall in the area that
physicians have a responsibility to review available records. So that if
in fact turning off various modules or not using available clinical
decision support would be tantamount to not reviewing available records,
that could be \-- that could be a problem. And I think that really
underscores the fact that if we are moving towards clinical decision
support, it is clinical decision support that is truly helpful and not
something that is easy to ignore or suppress. And again, there\'s a full
discussion of all three in response to that as well.

There was a further question regarding information overload, and again I
think the issues here that they responded to are very similar to ones
that they made earlier in that if the information is well organized, it
clearly will be important to move in that direction.

The other kinds of questions resulted in responses that refer to some of
the previous work that they had had, and the entire letter itself went
on for about six pages. So what I would like to suggest is that we make
this, this is available online, everyone review the letter and everyone
review the previous information, and we will take that into account in
our further discussion about possible recommendations in the medical
liability area in the future. So that \-- and again, if anyone has any
other further questions or concerns, related to this area, then we can
again get back to the team and they can continue to inform us.

Is there anyone who has any questions or concerns or have any other
comments about this particular area? Before we move forward with our
2:00 testimony.

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

Karen, related to our previous Workgroup meeting, it\'s all about
there\'s been terrific testimony but it\'s the so what. What is the
recommendation that\'s going to come out of this? And I\'m struck by one
of the presentations that really clarified how much information hits the
physician and the caregiver as a result of EHR, just that overloaded
piece. So I would really want to encourage what Karen just said, that
the Workgroup members look at this in the spirit of reminding us the
terrific testimony that we have had up to this point, and crafting what
the recommendations would be as a result.

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

Thank you, Lillee. We\'ll come back to more on this later.

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

Yeah, because I\'m not there yet. I have to honestly say I\'m not sure
what we would be recommending.

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

Dr. Bell, this is Jason DuBois, I just got on a little late, and I
apologize. Which of the four letters is the one you want us to take a
look at? Is it the recommendation planning cover letter?

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

No, it is a letter that, it should be in your packet.

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

I\'m looking at it on the Website. You said it was up here.

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

Not this Website. It will be on our Website where one looks at the
Workgroup letters and recommendations and the work of this Workgroup.

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

Okay.

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

A memorandum to the American Health Information Community, Electronic
Health Records Workgroup from Melissa Goldstein, Michael Kidney, Mike
Tatelbaum and Bruce Wolff. Dated \-- subject follow-up to legal
regulatory panel at Workgroup\'s January 11, 2007 meeting, and we just
received this yesterday. So it was sent out to everyone just yesterday.

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

Okay. It\'s the memorandum there?

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

It\'s a memorandum and it will be available on the Website, this
Workgroup\'s Website.

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

Great, thank you. I\'m printing it out now.

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

Thank you.

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

Okay, great, let\'s move on. We\'re right on time to the organizational
aspects that we wanted to discuss. Is Chuck Parker with us?

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

Yes, I\'m here. Can you hear me?

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

Hi Chuck. We can hear you fine. And I believe there\'s a slide deck that
supports your presentation as well?

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

Yes, there is. I do appreciate that. What I want to discuss today,
there's a couple of issues, one is an update from the field here again
working as many of you know, the DOQ-IT project itself is focused on
that small- to medium-sized practice that is not affiliated, like with
the academic medical groups. And to pick up on a point of what Blackford
was mentioning is one of the things I\'d like to talk a little today in
the first part of the presentation is kind of how we are seeing
acquisition being made by small- to medium-sized practices. Obviously
there\'s that pull out the checkbook, we're going to write a large
check. But one of the things that we\'re getting into is how do we help
them find alternative methods to afford these types of technologies? And
I\'m going to cover four areas and then I\'m going to go into a little
bit more detail about some of the ASP environments, as Stark is starting
to have an implication in that area, particularly in the community-based
models at this point.

Moving on to slide 2 \-- I don\'t have control of the slide deck, so
I\'ll just have to say move on to slide 2 \--one of the things we're
seeing here, and one of the ways we can negotiate with vendors, is the
stepped payment methodology, which is, you basically negotiate upfront
with a vendor to create stepped payments so that, particularly we see in
the first part of this is that they\'re not paying a full payment at
first because they\'re not using the full application at first. So they
start to kind of move through this and allow them to ramp up their
payments as they go through that interim step, if you will, of the loss
in productivity that they have usually, typically learning the EHRs.

On the next slide, what we see here is in the areas with the milestone
payments, this is the one that we typically do see a significant number
of areas of opportunity in the marketplace. And the reason we see this
is that the milestones are based upon reaching defined, set marks within
the contracting and implementation. We tend to see a lot of this and
encourage this because in the marketplace it\'s kind of, it puts the
vendor on the hook to some degree to reach certain milestones so that
they\'re making sure the small vendor, I\'m sorry, the small physician
office can make sure that the vendor is, still has their vision in mind
and making sure that they\'re reaching those next sets of goals that
they need to. So typically you have, what we see is a like a 25 percent
model, split four ways. So there's 25 percent upon contract signing, 25
percent on the day they go live, 25 percent on what we consider
functional levels of the front office, so e-prescribing, appointments
and scheduling, and then also in essence lab results coming in as well,
so some of these front office pieces. And then a 25 percent payment due
sometime in the 90-day future afterwards, where the docs are able to
achieve a certain level of documentation. It does require some upfront
costs but it is staggered and allows necessarily an ability to pay for
these things and here again somewhat keep the vendor engaged in the
process as well to ensure things are moving forward.

On the next slide, what we do see in this case is the modular payments.
Now, this is a little bit different in the sense that the application
has to support that capability in essence, it has to be delivered from
the vendor, by using modular payments. We see this, for example, some
examples of that today we see in the marketplace are Allscripts, with
their application modularity and we're starting to see some vendors now
who are breaking parts of their application apart and creating starter
sets, if you will, so as e-prescribing has become a significant focus in
the future, what we\'re seeing is we\'re seeing vendors uncouple that
e-prescribing functionality as a first module that will then, you
basically buy an additional key that unlocks the rest of the
application. So we\'re starting to see that. It\'s nice in that you can
structure based upon the workflow that you're working on at that time,
and it truly is a pay as you go strategy. You\'re only purchasing what
you\'re utilizing at that given time.

The next model that we see is, on slide 5, is around the areas of how
you actually would rent an application. This is somewhat similar in
concept to what you do with an application service provider, but instead
of actually renting the application and placing on a server, that
application and technology all resides within the physician office.
It\'s somewhat beneficial to the physician office in the sense that the
vendor is still on the hook in these rental agreements to maintain and
place the upgraded versions of the software, so in essence you\'re
wrapping all your maintenance and service fees in this particular area.
This is not unlike a lease or a long-term application use and like I
said it\'s also very similar in concept to an ASP, it's just that all
the hardware is located onsite. It does include all the, you know,
benefits of the fact it does have considerably lowered upfront costs.

The last one that I think we\'re seeing a significant interest in, on
slide 6, is in the area of application service providers, which are
hosted applications, where the services and services are hosted offsite.
There\'s less technical resources needed at individual locations.
Obviously there\'s a pay as you go strategy with a single source, and
there\'s ongoing costs, though, some of the negatives are the fact you
never own the license, you\'re basically paying a monthly subscription
fee. It does have a positive tax benefit across the states and also at
the federal level, in the fact that the leases can be taken off of those
as a credit.

On slide 7, what we\'re seeing here in this instance are some models of
how we actually see ASPs being deployed in the marketplace. There\'s
those that are deployed directly by the EHR, meaning that either they
own the service or have contracted directly with third party providers
to offer their services. There\'s centrally hosted, locally managed
services. This is the area that we see the most explosion of growth in,
now that the Stark legislation has, the Stark relaxation has actually
kicked in. And these are typically hosted within the community for an
IPA, PHO, employee groups of physicians, also typically surrounded by,
or defined as within a community of practice. They are typically hosted
by the hospitals since hospitals typically have the data centers that
have the needed redundancy capabilities built into them inherent within
these communities. But it also provides a sense of locally managed
services in the sense that the people who are in control and own the
system are local and are typically the docs of those, some of those
users that are local there.

The third area is locally arranged hosting services, and this is kind of
a hybridization, if you will. It\'s taking a company such as an EDS, or
a Perot Systems and utilizing them as a third party hosted group. And
some of the reasons they do this and some of the areas we see this is
where you don\'t have a strong physician, I\'m sorry, community-based
hospital system, or a single model where you may have competing
hospitals in that area who are trying to offer the same similar
services. And you would offer this through a third party such as those
types of providers like EDS, or Perot. A benefit there is that in the
third party resources they can offer more than just the EHR itself. So
for example, if you want to also offer practice management services, if
you want to offer, for example, e-mail services, or even beyond that
some things such as lab viewers and also radiologic viewers so you can
actually have those available to the physicians. Those are something
that you can\'t get with an EHR vendor-supported ASP. So we\'re seeing
some of these third party pieces of the puzzle show up as well.

On slide 8, just moving on through the service here. What we\'re seeing
in this particular area, and I\'m sorry, is this is some costs
associated with this. This was a HIMSS report that was put together
about two years ago, came out approximately 2005. It\'s somewhat
up-to-date still today because the applications themselves really
haven\'t changed significantly in cost. And the models themselves of how
you actually purchase really haven\'t changed. So I would say less than
5 percent variance, difference in the models that were demonstrated in
2005 to today. But it does show you some overall costs when we talk to
physicians how they can get in these applications more effectively and
given that as we heard that year 1 costs are what really kill physicians
and what are basically the show stoppers and so how do you actually get
into these different types of applications? The one model that I didn\'t
talk about is the finance model today, and that\'s really how you go out
and you can use a lease or a bank, bank financing to get in the
application. We typically try not to get into that because obviously its
ongoing expenses are considerably higher than if you were taking a look
at one of the other three models there on that particular system. So on
the purchase model we do have ways of breaking that cost up as well,
where you\'re cost shifting so years 2 and years 3 become bigger and
that\'s with the stepped or the milestone payments as well. But this is
giving you a idea and this is a tool set we help and work with
physicians on to kind of create here\'s some costing models here for
this particular area.

Moving on to slide 9, I did want to talk a little more about the ASPs
and what\'s going on and what we\'re seeing in the communities here.
Some of the pros of this, using the hospital or community-based EHRs,
are that they can offer more than just EHR software. As I mentioned
before, we\'re seeing them offer things like e-mail services to these
physician offices in addition to, in some cases, practice management as
well. It doesn\'t really require significant level of technical staff as
well within the physician office. You know, that\'s one of the little
dirty secrets that most of us within the industry haven\'t really
explained, I think, in this particular area in that while there is cost
savings in staff, for example, file room clerks, the issue is that if
you are setting up an EHR in a physician office, it does now require
some level of technical competency within that practice you have that
either train staff or you have to acquire that knowledge base. There is
standardization within a community of data and resource and that
standardization obviously also lowers costs. So it does provide a single
unified model, and provides an easier mechanism, for example, for lab
companies to be able to transmit data in a more unified format,
e-prescribing can be more efficient in that sense as well. And typically
just referral information between specialist and primary care could be
more effective.

One of the cons that we do see and this is a significant area that is
actually a cost barrier in that sense is do you have high speed access,
can you acquire enough bandwidth to ensure that the application can run?
Because the servers aren\'t located at your facility you now have to
have some level of high degree of redundancy or network capability
connected to that network. That becomes a difficulty particularly when
you get to more rural areas who aren\'t serviced by your typical larger
Verizon, Comcast, Time Warner, AT&T areas where they don\'t typically
have that. Now, interestingly enough, we actually see a considerable
amount of high speed access available in what I would consider to be the
ultra-rural areas such as Montana, far parts of West Texas, where the
universal service fund has actually kicked in to enable those networks
to be placed out there in those market spaces. In the con is also
there\'s still an ownership question: who legally owns the data? And it
becomes more of a significant issue once you start taking a look at the
secondary uses for that data. When you\'re doing research, when you\'re
doing potential quality, population health-based quality improvement
measure sets as well. One of the things that we\'ve heard before, just
recently on some of the other calls is there still are tax implications
for those 501(c)3 organizations in donating in that 85 percent area,
being able to provide services out to physician office who are
for-profit entities. This still applies in the ASP areas because in a
sense they\'re providing a discounted service to those physicians as
well. Still is a concern, still need to have some clarification.

On slide 10, one of the areas where I think we wanted to talk about here
just a little more about the market space we see. Now the DOQ-IT project
within Massachusetts, I wanted to note that we are working with about 34
different organizations and when we talk about organizations that is
either IPAs, PHOs, or physician office organizations in other formats.
The 34 that we are currently working with, all but two are creating some
level of ASP. And I would say that more than 50 percent of those have
started that process after the August timeframe with the relaxation
issues that were taken care of at that point. I would say that most of
them were investigating this, had models in place from a legal
perspective but the relaxation now has accelerated that opportunity to
release those to the community of physicians.

What\'s interesting to note is that three are mixing models to allow
physician office variation, in the sense that not only do they offer an
ASP but the particular vendor they\'ve selected allows them to have both
a server-based model in the physician office and an ASP, because the
interaction in the back end, they have the connectivity to allow that to
happen so they\'re offering a mixed model in the sense to meet the
physician demand and/or whatever they feel from their security
standpoint.

And then at least three of our communities will offer more than one
vendor in an ASP environment. They\'re large enough organizations, they
feel that they couldn't meet the demands of the physicians, and since,
for example, an IPA, where they don\'t own the practice, they felt it
was going to be very difficult to demand that they all go to only a
single vendor in that sense. I know that Micky is going to be on a
little later but I did want to mention the Mass eHealth Collaborative as
well in this area, in their three communities, one community went with
an ASP model, one is a mixed model, the largest organization is mixed
where they have ASP environments within the specific subgroups within
that environment, but they do have an HIE in the background tying them
all together. One of the other groups went with individual servers in a
health information exchange in that sense as well. So in that sense
we\'re seeing that there is a, even in the demonstration projects,
we\'re seeing ASP-type environments being quite popular in this sense.
Now, shifting my talk a little further back to another area on slide 11.

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

Could we just check in on a couple of questions on this piece, Chuck?

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

Sure, go ahead.

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

Is there anyone else that has any questions that they\'d like to ask at
this time, or comments?

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

Hi, this is Howard Isenstein from the Federation of American Hospitals.
Sorry for joining late. I have a couple of questions. You know, looking
at the HIMSS data, I\'m really surprised that the ASP model isn\'t
significantly cheaper than the other three. From your real world
experience, I mean, would you say that the HIMSS data is on the money,
or that the ASP is even more cost beneficial?

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

I would say it\'s, in my opinion, in what we\'ve seen today, in the
deployments we already have, it\'s relatively close in the market space.
I would say that some of the costs that you may not be thinking of, for
the, in the ASP environments, is that typically in the ASP, they take on
help desk level 1 support. So in essence they become the first line of
interface for the physician office. And in that sense it adds a
technical cost associated with that services and software.

You know, the benefit comes when you have a significant number of
physicians and that can spread the costs, the fixed technical cost and
the staffing cost across the backend across a broader range of
physicians. So in your, in my opinion towards your statement, yes, these
costs go down if you have 200 or more physicians in a typical ASP
environment on a single vendor solution set. There are even more
significant advantages when you get into the 500 to 700 range, and these
models do become, the costs do become considerably more compressed, more
cost-effective when you\'re able to spread them across a broader base.

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

And my other question is, what you\'ve shown is a considerable movement
among vendors on what, of trying to come up with solutions that work for
the small physician office place. I mean, it seems like they\'ve
definitely moved from say, two years ago, where transfers like here\'s
what we got, take it or leave it. So are they, it seems like the
competition is heating up more and is that reflected on the pricing as
well?

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

Yeah, we don\'t see it on the pricing though we do see a change in the
way of acquisition. There\'s where the competition is. Most vendors feel
like they\'re priced competitively and they feel like they really can\'t
drop their floors significantly more than where they are. Typically they
have also, most of them have written most favored nation language into
their contract clauses so that if somebody else gets a better price it
kind of has to affect a significant group of physician practices.
They\'re very leery about dropping that price. So we are seeing them be
more creative in how they acquire new licenses, and being able to extend
these different types of models to the practices. I will say that most,
the complicating factor still today is that the vendors will still lead
with here\'s the single monolithic price, pay me upfront and that\'s it,
and you have to ask or know to ask that particular vendor for what are
the alternatives and how to get into those alternatives.

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

Chuck, this is Jim Sorace from CMS. Have these community-based ASP
models been superior at actually getting the EHRs populated with data
from local data supports sources that are important? So, you know, local
hospital labs, maybe even national labs, mammography centers, that type
of thing. Do we have any experience on that yet?

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

Well, it's particularly beneficial when the community hospital is
actually the commercial lab provider in this area and that\'s where we
see a significant number of them saying hey, this is a profit center for
the hospital and a way for us to maintain that by offering this as, the
EHR as another model, extension. But they are very, they\'ve been very
effective in being able to get that information populated. Since it\'s a
standardized interface, these vendors can create those interfaces just
once and it makes it much easier to populate that data across. Now,
given that, you do have master patient index issues that tend to have to
be put in place. But that\'s easier here again because you\'re
aggregating to a, you're aggregating costs across multiple physician
offices.

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

And any similar experience with imaging and e-prescription and other
types of data sources?

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

Yeah, e-prescribing is certainly something that\'s been very effective
in this particular area and here again because you can aggregate. In
some cases we\'ve seen where e-prescription can help pay for the systems
because they\'re such a good benefit cost. With digital mammography,
digital imaging, and other areas, yes, it\'s easier here again managing
those services, particularly if the community hospital is engaged in
those as a profit center. But even when they\'re not, here again
providing that common location and single location for multiple docs
makes it much easier in the marketplace.

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

So do you think this might contribute to savings in the future, I guess?

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

It should. Because you\'re connecting, we haven\'t seen that effectively
proven out yet. I think you see some models such as what Partners has
demonstrated within closed loop systems where it does. But we\'re still
in that, trying to evaluate that from a community-based system whether
or not it will. All indications are that it should, though.

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

Chuck, this is Karen Bell. One of the questions I have has to do with
the ownership of the data. I\'ll pick on Blackford because he happens to
be on the phone, but suppose I'm practicing back at Partners and they
have an ASP model and I decide I no longer want to be part of the
Partners system. Who owns my medical records? And who is responsible for
maintaining them for the length of time that they need to be maintained
under Massachusetts state law?

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

That\'s something that we\'re still trying to resolve with HISPC and
other areas but specifically speaking, in that particular area that
becomes part of a data use agreement that physicians sign on with when
they involve themselves with these particular ASPs. And what they are,
what we\'re seeing from a legal perspective is that their data becomes
part of a community. If that, if you as part of the practicing physician
want to leave, you\'re entitled to take the data on your patients with
you so there\'s an export, whether it's in paper-based format, which we
hope doesn\'t happen, or with the new CCD type of application where
you\'re able to export it into an electronic format. You are entitled to
take that data with you, but it stays as part of the community record
because now you are updating part of the community record.

The important thing that we start to see with ASPs, and it becomes very
critical here, and Blackford did a very good job demonstrating that
without actually talking about it, is this patient-centric view of the
healthcare record, and it's one patient, one record, as opposed to the
physician-centric view, which typical EHR vendors deploy today. And that
once you get to that model in these communities, it becomes very
difficult to say that individual record is a single provider\'s. So what
we see in the data use agreements is that they are entitled to the data
on their patients, so there\'s an export of that data, and they may have
data from referring physicians in that record but they\'re allowed to
take that with them. But that data does not leave the system because
it\'s part of an integral operating platform at that point.

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

And \--

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

This is John Houston, can I ask one question to clarify that?

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

Yes.

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

Does that also mean to say that if I\'m a patient from a physician and
I\'m say a dermatologist, and if I\'m deciding to opt out using this any
longer, that I would get the entire patient record for all of my
patients including visits and encounters and information unrelated to
the services I provided, say, services of a cardiac, cardiologist or
whomever else that is unrelated to my specialty?

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

According to the data use agreements that we\'re seeing today, yes,
you're entitled to that, but there are filters that can be applied to
filter that out so you don\'t, if you leave and don\'t want that data
you can filter that out. But according to the rules, you would be
entitled to that data.

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

What about a vendors ASP? Does the vendor do the same, allow the
physician to take with them in electronic format all of the records that
they have generated on that patient?

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

Yes, and specifically within the DOQ-IT project, when we\'re looking at
helping physicians work through these issues with vendors, we
specifically delineate and say that you need to have clauses issued in
your contracts that say that you own the data. So specifically, most of
the vendor arrangements that we see today, is that the physician always
maintains ownership of the data. They\'re just holding the data at the
third-party location.

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

But that\'s, you made an interesting point. You do that as part of your
work around DOQ-IT.

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

Right.

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

A physician who has been approached by an ASP vendor may not know to do
that.

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

Right. I would say that we don\'t negotiate on behalf of work with the
physician practices. We in going through these discussions and saying
here are the outlined issues that you need to be aware of when you\'re
negotiating these types of things.

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

So the bottom line you is educate physicians on what they should be
putting in their contracts so there is a body of knowledge that you\'ve
accumulated that you can impart and maybe that\'s the segue into DOQ U.

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

Yes it is. Specifically, actually, it makes a very good \--

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

Hello?

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

Yes, can you hear me? Yes, it\'s a very good point. It actually is in
this part of this particular area, in this body of knowledge we\'re
delivering in the marketplace. If you want to get back to the
presentation here, in essence of time, I did want to cover a little
about what\'s going on here with this new product that is coming out in
the marketplace called DOQ-IT University. And this is a product and
project that was funded by CMS, and Jim Sorace, who is actually on the
call today, actually he\'s one of our task leaders with the project
that's funded by CMS.

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

Just for clarification, Sue is the task leader in that capacity. Go on.

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

Anyway. In this case. DOQ-IT University was officially launched in
January. They\'re on slide 12, I\'ve included a link to that particular
Website. This link gets you past the security at this point. And the
reason I suggest that, or I provides that to you, this is our demo,
working site that we work with our technical advisory panel members.
This courseware actually does allow us to track and eventually will
allow us to apply CME credit for the physicians who are going through
this particular program. Bu this particular link gets past all that
registration area. If you want to utilize this, you can certainly jump
into it and see what this DOQ-IT University application (inaudible).

This project is, as I mentioned, a CMS-funded initiative to spread the
learning and wealth of knowledge we\'ve acquired during the DOQ-IT
project over the last three years. And to effectively disseminate that
more to those practices who and where DOQ-IT cannot reach. Or provide
that for even those in DOQ-IT to be a little bit more efficient in this
particular process of how do we get them through the knowledge base.

At this point care management e-learning is coming in March, one area
where it\'s not fully vetted out yet. We\'re still acquiring some of
that knowledge. Just so you know, this project is actually worked
(inaudible) there's a 17 member technical advisory panel that comprises
members of AAFP, ABIM, ACP, and others. HIMSS is on this. There are
health plans, actual commercial health plans. CMS is on this, AHIMA. And
there are three solo practicing docs who are out in the practices who
actually do this as well, who are on this particular committee as well.
So vetting this through multiple resources and research areas to make
sure that we\'re gaining and acquiring the knowledge.

On slide 13, it\'s, this is, if you click on that basic link I showed
you, this is what will pop up, with the exception of the green check
where I had gone through one of these particular areas. But what we see
is sort of our adoption model where we take the physician practice
group, helping assess where they are, helping them plan to go and
understand okay once you understand where you are, where do you want to
go and helping them plan for their EHR deployment.

And then there are three pathways they can work on in that planning
stage which is culture change, how do we actually get the people within
the practice to understand what\'s going on. And Karen, as you
mentioned, this vendor selection piece. This is where we\'re helping
physicians with tool sets that they can download or actually look at and
take this lesson to figure out how do I help understand negotiation of
these contracts with vendors. There\'s also RFI, RFP processes in there
if they want to go that route as well. And then the bottom one is
operational redesign. How do we get them through these particular areas.

And then once you get into implementation, what are the expectations for
implementation, how do you actually get into implementation. Then how do
you continue this process of evaluating (inaudible) and then care
management is another module that will get them into these paper quality
demonstrations, provide them the necessary detail to get into the
things, we saw what Blackford was demonstrating with diabetes
management, getting to that zero defect care type of application process
as well.

So this is where we are with DOQ-IT University today as far as the high
level. Each one of these, and if you go on to slide 14, basically will
show you this is one called operational redesign and it shows you some
of the areas of where we can get into these and the lessons contained
within there. At this point there are 17 functional lessons today. We
are continuing, this project started in November, in earnest in
November, and so as of today we have 17 functional modules within those
categories that you just saw.

In this particular one of operational redesign there are six categories.
How do you do the process, what is process redesign and description of
the tools. What is patient flow, how do you map it. How do you do point
of care documentation. How do you manage documents themselves. What\'s
the office communication structure look like, and the clinical processes
in getting ready for care management.

So in every one of these processes, just as an FYI, care management is a
portion of them. Given the fact that DOQ-IT itself is, has in its nature
a focus on adoption of electronic medical records, the care management
bit does have electronic process.

This is basically the end of presentation, so if you have questions
about this particular section as well \--

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

Chuck, this is Karen. I know that these have all been tried and true. To
what extent would you say that these processes have actually been
implemented and tested throughout the country?

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

I would say that as part of the DOQ-IT project, this was part of our
training we utilized. I would say that we\'re continually modifying
these, so I can\'t say that every one of these processes has been vetted
everywhere in the country, because this is real-time learning and we use
a continuous rapid cycle development process within this learning
environment. So that as we learn new processes out in the field, and so
it\'s taking things such as in Colorado, some of the work flow redesign
that the Colorado areas have done and accomplished and demonstrated. We
incorporate those as we learn them and are able to aggregate them
effectively. So I can\'t say it's across the board been tested
everywhere, but these processes are in play today in all the QIOs.

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

Thank you very much, Chuck. That was great.

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

This is Jim Sorace from CMS. I just wanted to add parenthetically that
we\'re making this available for physician offices that are outside of
our direct IPT, or those that have already agreed to work on the DOQ-IT
project.

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

It\'s not limited to any, not only is it not limited to that, it's not
limited to Medicare, so any physician or physician office person would
be able to log on to this. They simply need to go to the MedQIC area of,
and be able to basically you have to do a search for the DOQ-IT
University and anybody can log on to it.

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

Karen, perhaps one of the things we need to consider as a Workgroup
going forward, is spread of this. This isn\'t a case of development. It
would seem like it would be an opportunity for spread.

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

Certainly seems that way. And now that it is available online where we
all can see it and review it, I think that it may be helpful for us to
all do that before the next Workgroup meeting, and spend a little bit of
time thinking about how to make this information more available.

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

There\'s a huge field uptake issue here.

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

Yeah.

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

And this is designed to also be worked within the QIO, so not only would
you be able to access this online, you can work with the local QIO to
also gain additional knowledge through this tool set.

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

Right, right.

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

And even the medical societies in each state. So we can really think
through about ways to disseminate. Thank you.

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

I think that\'s the operational action here.

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

Uh-huh.

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

Great presentation, Chuck.

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

Thank you.

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

Thank you.

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

Karen, just a way of point of order here, we\'re about 20 minutes behind
but we have 45 minutes of presentation left. Is that right? We have
three financial presentations about 15 minutes apiece?

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

No, they\'re not 15 minutes apiece. I think this is all together.

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

All together. Okay.

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

Yeah. It\'s around one particular topic, because this particular group,
and it is a group, have come together to essentially be the first in the
nation to define an approach on credits for EHR use when it comes to
malpractice premiums.

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

Right.

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

So we thought it would be helpful for the Workgroup to hear from them
and I believe that they\'re all on the line, is that correct?

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

This is Jack King, I\'m here.

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

Denise Funk, I\'m here.

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

Hi. It's Micky Tripathi. I\'m here as well.

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

Thank you. Well, I think probably the best thing to do is to let you
then just jump in and take over.

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

Thank you.

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

Thank you very much.

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

Micky, do you want to make any opening comments?

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

No, I don\'t think so \-- well, I can just do a very brief one and then
I\'m happy to talk about the Collaborative to the extent anyone is
interested at the end. But the Mass eHealth Collaborative is running
three pilot projects in Massachusetts to outfit about 450 physicians
with electronic health records and launch health information exchanges
in each of the three pilot communities. One of the things that we\'ve
been pursuing is risk reduction, and in particular risk reduction that
could be brought about by electronic medical records and health
information exchange, and wanted to try to engage a malpractice insurer
to consider first evaluating that and then second perhaps offering
credits to the participating physicians for, on their malpractice
premiums for their participation with the electronic health records and
health information exchange. And we were just delighted to work with
PIAM, the Physicians Insurance Agency of Massachusetts, and Connecticut
Mutual Insurance Corporation, who came forward with a premium program,
with the real live premium program that we\'ve announced in three
communities and we\'re going to start engaging the physicians in trying
to figure out how to get that implemented and see who is interested. Let
me just pause there and just turn over to Denise and Jack to describe
the program itself.

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

Great. Denise, you\'re going to go first, right?

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

Yeah, I\'m going to lay some of the financial groundwork, and some of
the background from a liability insurer standpoint, which may be a
slightly different perspective than the group has seen before.

If I could go to the next slide, please. Thank you. What I wanted to lay
the groundwork on was the incredible amounts of money that are currently
being expended as part of the litigation, medical malpractice
litigation, that goes on countrywide and in particularly in the
Northeast. These numbers that are on this slide are taken from the
National Practitioner Data Bank, which you may be aware collects all
indemnity payments for physician practitioners made as a result of a
malpractice claim or lawsuit.

This data is specifically related to 2005, the year that the most, the
most recent year data is available. And as you can see, from our
perspective in Connecticut, the total indemnity payments, indemnity is
really the money that goes to the patient or to the estate, was almost
104 million dollars in 2005 alone. Connecticut has the dubious
distinction of having the highest average payment in the country, over
730,000 dollars per case. In Massachusetts, as a point of comparison,
the total indemnity paid in 2005 was 123 million. So in relative terms,
Massachusetts fared somewhat better than the state of Connecticut. But
in the overall context, for 2005 the national total of payments was 4.1
billion dollars. That does not include legal defense costs, which adds
another billion dollars to that number. And in Connecticut, for our
cases, we paid out additional 4 million dollars just for the defense
costs related to those paid cases. So you can see at the outset here,
the amount of money that we\'re talking about is considerable, so
anything that could make a reasonable dent in those numbers would be
helpful for, obviously for patients and for physicians, as they are the
ones who end up having to pay the premiums for these cases.

If we could go to the next slide, please. So obviously from our
perspective, loss prevention is a critical element of this approach. The
best claim is the one that never happens. For everybody, all concerned.
And the benefits of a fully integrated EHR are obvious to this audience,
but it also plays in terms of either preventing a case or actually
defending a case, what I will refer to as litigation decision making.
The benefits of having just point-by-point legal, I\'m sorry, legible,
accurate, and complete treatment documentation is incredibly valuable.
The first thing that happens when either a plaintiff attorney is
contemplating bringing a lawsuit against a physician, and then
subsequent to that our review of a case for a defense or settle posture,
is the medical record. That\'s the focal point, initial focal point for
any litigation activity. So that\'s key. Obviously, the systematic
follow-up on test procedures, medications, all of these things are very
common sense. But they are, represent a good percentage of the number of
lawsuits that actually result. One that is somewhat unique on the
defense side is that the EHR can prevent medical record alteration. Now,
this doesn\'t happen very often, but when it does, it almost
automatically makes it impossible for a case to be defended. That act in
and of itself can trump all other elements of a case. Continuity of
care. Tracking patient visits, missed appointments, compliance. All of
these things are key in a large percentage of cases that we see being
brought against physicians.

Let\'s move to the next slide and talk a little bit more about the
decision making. Just as a point of departure, I\'d like to point out
that two-thirds of all lawsuits are closed with no payment. So that
means that the vast majority of cases that we deal with, we don\'t
ultimately pay out indemnity but obviously we do have to spend a lot of
money in defending those cases until they\'re closed, which can take a
good number of years.

As I said before, medical records are always a principal focus in
malpractice litigation. Does the medical record speak for itself in
describing treatment? Can someone pick up that record and follow
logically the treatments, the conversations with the patient, informed
consent? Whatever the key elements may be, are they documented? It\'s
the old saying, if it isn\'t written down, it didn\'t happen. And
that\'s particularly true when we have a bad patient outcome. As I
mentioned, if the document speaks for itself, a plaintiff attorney may
choose not to file a lawsuit, even if there was a bad outcome because
experts can support the treatment decisions that were made and it makes
it very difficult for them to pursue a case.

As I said, two-thirds of all these lawsuits are closed with no payment,
so the plaintiff attorneys in undertaking these cases also need to use
judgment in evaluating whether they want to pursue the lawsuit. If the
medical record speaks for itself, the defense of a lawsuit may be
greatly facilitated. Again, as the record describes the treatment and
how the decisions were made, that can really provide substantial
assistance to us in defending a lawsuit. If these things aren\'t in
place, getting back obviously to the EHR, a lawsuit may be impossible to
defend, regardless of the actual medical treatment that was rendered to
the patient. We get into the classic he said, she said, patient\'s
family recalls one set of situations, the doctor recalls another,
neither of which are written down. So it becomes much more questionable
as to whether a case can be successfully defended.

So taking those elements as our basic premise, we concluded that
combining a sound clinical practice with an integrated EHR should have
an impact on malpractice premiums, and as a result of that we came to
develop a program with Jack King at PIAM, which Jack will describe, that
combines these elements together to provide premium credits for
physicians.

Jack, I\'ll let you take it.

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

Great, thank you very much, Denise. Just a few words about, if I could
have the slide that talks a little about who we are. Great. We\'re a
broker, we\'re owned by the Mass Medical Society, we started in 1993. We
specialize exclusively in insuring doctors and we\'re often faced with
having to develop special malpractice programs because physicians are
frequently looking for ways to reduce those costs.

Before I go on to the next slide, I just want to set the stage a little
bit because it was about a year and a half ago when a fairly large
physician group in southeastern Massachusetts approached us and asked us
to do, look at potentially developing a malpractice program for them.
And we turned to a couple of different companies, but pretty quickly
settled on CMIC and between CMIC and us we developed a program for this
particular group which was quite creative, if I do say so. And it
included a number of special credits for the physicians in this
particular group. And one of the things that it featured and was the
first time we had ever, I had ever seen this offered, was an EHR credit
for all of the physicians in the group that developed or had an EHR
program. And as we explained to the group, this had never been offered
to anybody in Massachusetts before, and at the time we didn\'t think it
had even been offered to anybody in the country. But after a lot of soul
searching on the part of that particular group and a lot of discussion,
they decided not to move forward with the program. But the germ of an
idea had in fact already been created. And I don\'t think we realized
even at the time what the implications were going to be.

About eight months later I was in a discussion with, I met with Micky
Tripathi, and he explained to me, having met with some of the insurers
here in Massachusetts, and I\'ll let him speak to this issue more
himself, but he indicated that they had looked at the possibility of
developing a malpractice insurance credit and thought about it and then
decided not to do it. And knowing that on this particular case that we
had worked on, that CMIC had in fact been potentially willing to do it,
I decided to maybe bring the Mass eHealth Collaborative together with
Micky to see if there may be some synergy there.

So if I could have the next slide, please. We had a somewhat interesting
set of circumstances here in Massachusetts in that we had the
Massachusetts eHealth Collaborative and the medical society itself
needing to have a credit and urging the insurers to come up with a
credit, but there was certainly local malpractice insurer reticence. And
they certainly were given a lot of opportunities to do something about
this. But we then had, fortunately had a potentially willing insurer in
CMIC, and we happened to be a broker that was working with the
physicians so that when you, when they said at the beginning we were a
broker, I guess you could say we were a broker is this situation in that
we brought together the willing and malpractice insurer and the
Massachusetts eHealth Collaborative, and the result is something that we
think is going to be very special. The program that we\'re pulling
together here in Massachusetts actually is for the Mass eHealth
Collaborative and for all other physicians practices that meet certain
criteria, that have a legitimate and \-- EHR. And we\'ll talk about the
ones that we\'re starting with and we hope that this list will grow.

If I could have the next slide, please. And Denise, please feel free to
add anything that you want on this. But basically the way the structure
works here in Massachusetts is that to be eligible, to get to the EHR
credit, you first have to have good claims experience already. So as you
can see, participants have, need to be claim-free for at least 5 years,
and 75 percent of the practice has to at least meet that criteria. And
so once the good claims experience is established, physicians can get up
to 10 percent credit just based on the good claims experience. Once they
have that and once they attest to having the appropriate EHR in place,
there\'s an additional 5 percent credit. And there\'s an additional two
and a half percent credit each for having an incident reporting program
and an office self-evaluation. And obviously combined there\'s a
potential for up to 20 percent in credits here. The EHR credit itself is
5 percent.

Denise, did you want to add anything to that?

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

No, I think that\'s fine. I think the only thing I would add, Jack, is
that we\'re requiring that the EHR have been in place and operational
for a year. As we know, these systems have pretty good time and effort
to getting up into full operation, so we want to make sure that that
period has in fact passed before the credit goes into place.

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

That's a good point. The way we\'re structuring the program also in
Massachusetts, the program is open to any practice of any size that
meets the criteria for the Mass eHealth Collaborative physicians, and
non-eHealth Collaborative practices have to have five physicians or
more.

Now, if I could have the last slide, please. The vendors that we\'re
starting the program with happen to be the vendors that have been
approved by the Mass eHealth Collaborative or have been endorsed by the
Massachusetts Medical Society. So these five vendors are the approved
vendors, and we\'re hoping that this list expands moving forward.

Any questions?

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

This is Karen Bell. Before I ask a question, I would like to make a
comment. The vendors that you have listed here are all certified by the
Certification Commission for HIT, so that I think that you\'re setting a
very good precedent not only by moving forward in this direction in
general, but by having recognized, certified EHRs that fill very
specific criteria not only for functionality but interoperability and
for security. So thank you.

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

Thank you. Micky, did you want to add anything to this?

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

No, I don\'t think so. I think this kind of explains the foundation of
it and would rather spend what little time we have answering any
specific questions that the Workgroup might have.

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

Okay.

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

This is Karen Bell. I have two. Number one, I assume this is applicable
to all specialties?

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

That\'s correct.

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

Yes, that\'s correct.

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

Okay. And secondly, how do you share this information with your
colleagues around the country?

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

Well, as yet we\'ve kept it really in Massachusetts, so it\'s just
starting to get some public recognition. So I have to be honest, I
don\'t know that we have a national approach on this.

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

Since you are on a national call, that\'s open to the public, is there a
particular contact person that you would be able to recognize or
identify, should anyone else want to learn more about your program?

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

Certainly, Dr. Bell. I think I would probably be a good place to start.
I have several people on our staff that are working on this, but I
would, I think I would like to be the contact person.

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

Thank you very much, Denise.

Well, before I ask for any other questions, I really would like to thank
you so much for not only the presentation today, but for moving forward
in this direction. I think it clearly is sending a very strong message
on how important it is to have good documentation and EHRs in place, and
will be a very strong driver in terms of supporting physician adoption.
So thank you again for taking that first step.

Lillee, any other comments or concerns?

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

No. This is clearly a bright spot on the horizon, as we just came out of
our legal and regulatory piece. So I really thank you very much. Jack,
Denise, and Micky, you did a terrific job.

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

Thank you very much.

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

Thank you.

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

Let\'s move on now to some of the meat of our discussion today. We\'ve
had outstanding presentations to help inform our decision-making. But we
need to move now to the AHIC recommendation planning discussion.

Plowing through my documents here, Karen, the piece for this \--

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

There are a couple. One is the letter dated February 16th to the
Workgroup that outlines the three questions. The second is the copy of
the letter that this Workgroup sent to the chairman of the AHIC dated
May 19, just to refresh everyone\'s memory on the old recommendations
that are cooking along. And then thirdly, there are a set of documents
entitled testimony summary and recommendation discussion items, on each
of the critical components that we are addressing: the financial
business case, the legal regulatory area, the organizational, and state
of the technology, and privacy and security area. And these have been
designed to essentially facilitate the very meaty discussion that now
needs to occur with respect to forthcoming recommendations.

And what I would suggest is having had all this material that perhaps we
look at each of those critical components with the eye of asking three
questions of ourselves, the ones that are on that letter. Have we heard
enough testimony in this area to feel that we can make a decision about
moving forward and we can make some recommendations? Or do we need
further testimony? And if so, what is it? And if not, what are the kinds
of recommendations we might want to think about honing in on? We do not
need to make the recommendation today. We just need to begin to direct
ourselves in an area where we might be interested in making a
recommendation and we can get into the specifics on the next go-round.
Does that make sense?

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

Yes, it\'s a lot to absorb here. Do you want to just take the critical
components, each one?

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

I think so. Has everybody got their handouts on this?

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

I\'ll start because I have to leave a few minutes early for a different
meeting.

In terms of information that we need, I think an overarching question
that we\'re struggling with is are we at what some would call a tipping
point, or are we seeing any evidence that we\'ve crossed the chasm from
sort of the early adopters to the early majority? And I\'d have to say I
have no idea. But it does seem to me that some information about the
impact of Stark would be very helpful. If we try to frame up
recommendations to bring back to the Community, the overarching, sort of
underlying theme is the if the market broken or do we need to do
something here or make recommendations that address what is the market
failure?

Just moving on, I would make two other comments. If you start to think
about what the federal government can do, in theory, the federal
government could incentivize or encourage demand from the private sector
through contracts with OPM, defense contractors, and so forth. Having
made that observation, let me just say I think we are way lacking in a
clear path here. And in fact when I think about the RFI that the
National Business Coalition on Health uses, and some other tools that
I\'ve seen, you can tell that there\'s a huge amount of enthusiasm for
IT writ large but basically they allow folks to check off anything
they\'re doing any time, anywhere, without getting real focused about
it. And to that extent, I think we need more information on what has
been this experience. Are these all like little prototypes that we\'re
hearing about today, the Illinois Blues are reported to be something
with the e-prescribing and so forth. Are they just trying this because
it might work or is there some way to pull together a more systemic take
on this.

And then the last area, I think that we could be thinking about is
electronic prescribing. Which would represent kind of a threshold leap
or something from focusing on the use of lab results. On the other hand,
the advanced standards will be reported to the Congress very shortly and
so forth. So \--

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

That\'s great, Carolyn, thank you. Because I do agree, I think you asked
a pithy question that shouldn\'t be lost on the group. And that is the
impact of Stark and is the market broken. In the private sector that
impact of Stark is one of the key discussions. I know everyone thought
that maybe it was going to be a barrier buster, but I clearly don\'t
know where we are. But I know that right now the market\'s not driving
the work from early adopters to mass uptake. It\'s just not happening.

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

Well, and then there\'s always a question of, which I think is part of
that Lillee, because I\'ve certainly heard others make the observation
you\'ve just made. And what is the lag time, and I don\'t think we have
any prior experience to know. Is that people need to sit and cogitate
six months and organize themselves in order to be able to provide these
services, or in fact was this a necessary but not sufficient incentive?

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

Well, you know, I go back to the presentation I forgot which one had
the, I think it was an HFMA charter we were just talking about the
different comparisons of financial models on a year to year basis, the
hosted rental finance purchase piece, and in talking to so many
physicians in the private sector, it does boil down to the finances. I
was trying to really get a sense of what is the true cost of market
uptake for the small practice. I think we\'ve seen outstanding results
from closed practices, whether it\'s Cleveland Clinic or the Veterans\'
Administration or Kaiser Permanente, that\'s a whole different deal than
what the majority of the market is for the private physician.

And if the implementation cost is accurate on this graph, anywhere
between 80 and 100 K, that means the average physician would have to lay
off two to three FTEs to get the money to implement IT. We just haven\'t
crossed that financial business case place yet, which was I think one of
the true intents of the critical component around the financial and
business case. And it was one of the key issues that was raised by this
Workgroup very, very, very early on in our work. I haven\'t seen, and I
just ask the Workgroup for your input, have we seen good compelling
cases that, of pilots that really can address this financial business
case for the average practicing physician?

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

Lillee, this is Blackford. Can you hear me okay?

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

Please, yes.

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

In Massachusetts, I think Chuck was alluding to some of the factors here
locally that have been very powerful stimulants to adoption and they
frankly go right to the bottom line, if you will, for the small office
environment physician. The P for P programs and other forms of
incentives that increase return of withhold or provide a bonus payment
for EMR adoption or use of EMR, or provide a bonus payment for attaining
quality benchmarks, I think are the types of things that have not yet
been adopted nationally or programmatically, that rectify part of the
market inequities. I think, I don\'t mind using the term market failure,
but I\'m afraid that may not be perhaps useful in the political context
or in the policy discussion. But I think we really are at a logjam, at a
variety of levels, for the small office environment. And absent some
kind of intervention of one form or another financially, I\'m just
concerned the small office environment will be very, very delayed or
perhaps never adopt.

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

Thank you, Blackford. You said it much more eloquently than I did. But I
think we\'ve seen outstanding case studies of closed physician systems
that have great systems and great results. And it has so informed, I
know my thinking, from August 2005 when AHIC was launched. But what we
haven\'t seen is that that private physician issue, which will lag this
whole project. I know we haven\'t read every word on the page, but
Carolyn, thank you so much for getting to the heart of the matter
quickly and informing our discussion. But in terms of more information
that we need, is there agreement across the Workgroup that we really do
need more on the impact of Stark?

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

This is Karen Bell. I think one of the problems that we do have with the
Stark legislation that was alluded to a little bit earlier by one of our
presenters, and that is that a number of hospitals have been concerned
that they will lose their tax-exempt status \--

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

Right.

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

\-- if they were to make significant donations. And what I can share
with the Workgroup is that some of our staff, Jodi Daniel who is the,
our director of policy here, has been working with the IRS, and with the
American Hospital Association to try to resolve that to everyone\'s
satisfaction. And we do believe that in the next several weeks, that
issue will be resolved and hospitals will feel more comfortable that
they will not lose their tax-exempt status should this move forward. So
it\'s going to be very hard to assess the impact of Stark, though that
is written into some of the measurements that we will, we have moving
forward on adoption, until that actually is clear and not-for-profit
hospitals recognize that it is safe for them to make these donations.

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

And Karen, I\'ll be a little bit more direct with what I hear from CEOs
of not-for-profit hospitals and their board. It's they fear literally
being thrown in jail. It\'s not just losing their status. It is a legal
noose that is a huge fear in the private sector. So we would be well to
do everything we can to eliminate those fears.

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

Well, in many ways, I think what we\'re talking about, and maybe this
is, this may go to a recommendation, it may not, but I think we at least
have this large area that Carolyn so wisely pointed to, is that we need
to make sure that the intention of Stark leads to the implementation or
leads to results. And part of that is tax-exempt, part of it is legal
concerns, so I think we\'re probably, we might need some guidance or
some other vehicle that will allay these fears and concerns. And maybe
ultimately that could be a recommendation of this group. But I would
throw it out that something related to Stark in allaying hospital
concerns will be important.

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

This is Howard Isenstein. I mean, the regs came out on Stark and the
administration said here\'s our solution. Last year, you know, there was
a lot of talk about getting some bill with Stark language in there. I
mean, I\'m not sure what we can do at this point. I mean, you know, the
reg is the reg, and our hospitals and others have said it\'s not, we\'re
still nervous and it\'s not adequate. And you know, we want legislation.
But that didn\'t happen. So I mean, I\'m not sure what, short of that,
what we can recommend or do about it.

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

Possibly guidance, Howard.

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

So have OIG, I mean, who \-- the recommendation would be ask for OIG to
issue guidance or what?

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

Well, since the reg is a CMS reg.

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

Yeah.

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

CMS would issue guidance on this, if we feel that it\'s important
enough.

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

I mean \--

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

I have to concur with Howard, it\'s important enough.

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

And do you think that would do it, though, issuing guidance?

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

You know, we can certainly discuss that with OIG, and \--

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

Certainly it absolutely couldn\'t hurt. I mean, I totally agree. It
absolutely couldn\'t hurt. I'm just, I mean, I think that\'s a fine
recommendation. I just, what I\'d like to know, what we could also do is
I think we should get a general counsel or two at a hospital or a system
to say what is the guidance you want that would make you much more
comfortable before we go to CMS. I mean, what do you think of that?

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

I think that\'s a great idea.

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

I think we have to be crisp on what our recommendations are.

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

Right.

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

If there\'s clear implication for us that we need to make a
recommendation in this area because what\'s out there now isn\'t
working.

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

Right. Well, I mean, I certainly can have, I mean, why don\'t we plan on
then, I could ask AHA, and our own in-house counsel for guidance
suggestions, and then also I think we should have someone in the field
that is at the local level that would also help something like that for
the next session or how do you want to proceed?

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

That would be fabulous. If you\'re willing to take that on, and tee up
some names of some folks, who would be willing to do this, then we will
definitely put them on the agenda for the next meeting.

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

Okay, I\'ll do this. I\'ll send it around internally and then send you
an e-mail of suggested names.

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

Great idea.

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

Fabulous.

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

This is John Houston. I mean, there are still, I think, for the solo
practitioner in a small physician office, a lot of other issues other
than simply getting some type of assistance from the hospital in order
to implement EHRs in their practices. I think there\'s still economic
issues and efficiency issues that I suspect those physicians are still
wrestling with.

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

John, I\'m still on Page 1, the critical component business case and
preparing for this meeting I have asked around this issue the fourth
bullet, is there significant non-monetary value in adoption of EHRs, for
the small physician practice or other ways that there could be a ROI,
and to a physician they tell me unless the monetary issue is addressed,
I\'ll never achieve the ROI. I won\'t get there. I can\'t pay for it.

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

Well, I understand, but I mean you\'re assuming that the ROI and the
payment is going to come from the provider, the large providers, the
hospitals.

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

Oh, no, what they were saying, unless there is some relief, whether the
government gives them some grant or relief, or whether it comes,
wherever it comes from, that the non-monetary value is a non-issue right
now. It\'s all a monetary issue. Maybe I\'m not making myself clear.

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

No, I understand.

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

They absolutely want to go down the ROI path. They, no one is saying
it\'s not a good idea. Oh, it will help us get to defect-free care. But
where the financial issue is is right in their pocketbook.

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

I think one of the things that we learned over the course of time and we
tried to summarize some of this this for you on sheet is that it costs a
lot to put particularly the certified systems in place, because they are
good, they are robust. They do have functionalities and the protection
in terms of security and the guarantees of interoperability as they come
out.

And today with Chuck\'s presentation, we really can see that this is an
ongoing to cost over a long period of time. Which most of the community
right now believes should be borne by the physician. And I think the
physicians are telling us it\'s just too high, they can\'t do it. So the
real question is, are there things that we can address that will change
that dynamic a little bit? One of the things that we heard in the past,
that we heard were pay for performance programs, some were purely on
outcome. We also heard that improved outcomes after EHR adoption can
take up to three or more years to come forth. We heard about pay for
use, where pay for performance programs in many ways were weighted in
the beginning so that as they were adopted, there was increased payment
for structural changes. I think Bridges to Excellence was a good example
of that, we also heard about a program in California and there are a few
others. So I think one of the things we might consider is are there,
given all of the presentations we\'ve heard and all the public testimony
we\'ve heard, is there something in that that can help us make some
recommendations on how reimbursement can be monitored or changed in some
way in order to better align the business case.

And I know that there\'s one piece of information that we haven\'t had
before, because it\'s come out fairly recently, but it\'s the new
Congressional legislation that\'s been passed. And I think Jim Sorace,
are you still on the line?

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

Yes, I am.

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

Reference to that and what\'s in it?

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

Well, basically we have, the last Congress passed a pay for quality
reporting initiative that will give about a 1.5 percent payment over a
six-month period, which would be the latter half of 2007, for practices
that submit data and report it through the claims-based processing
system. It also provides for payment, doesn\'t actually specify what is
to happen in 2008 and 2009, but it lays open the possibility that we
could pay on structural measures in 2008. And this would include things
like e-prescription and perhaps other items. And I actually forwarded
you an e-mail and I can do it again but if people want to go to it, the
Web sites that are, give more information on this.

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

What was that piece of legislation again, the number?

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

I\'m sorry, it was the Tax Relief and Healthcare Act of 2006, HR 6111.
And it\'s actually posted to the Website. I forwarded, Karen, I sent you
a e-mail earlier today. I don\'t know, maybe that could be entered into
the minutes here. Or if you want, I can give it to you.

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

That\'s all right, I\'ve not been on e-mail all day, so I will get that
back to everybody tonight.

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

Great suggestion, thank you.

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

But basically it\'s for a six-month period at the end of 2007,
claims-based process, and then opens up a possibility for structural
measures to be reported on in 2008.

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

And structural measures could be around \--

**[\>\> Jim Sorace,]{.underline}**

I actually think if you go to the bill, e-prescription measures, use of
registries, it\'s open.

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

It's completely open?

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

Yeah, those two are mentioned, but it\'s open and we\'ve been having
some discussions here.

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

So it is possible that some recommendations from this Workgroup might
inform what could be some, an approach to paying for structural?

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

I think that would be a possibility. I mean, I think that would be a
very appropriate thing to look at.

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

Any other thoughts on, we\'re still on our financial business case and
the Workgroup recommendation discussion. We\'ve talked about Stark,
we\'ve talked about monetary issues, adoption discrepancy between small
and large practices. Any other thoughts around supporting the small
practice to close the adoption gap?

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

I would just add one thing. We had, we had asked before to have an
update on the VistA Office.

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

Right.

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

And apparently they are still working on that. There\'s been a, an
evaluation report that\'s come out. CMS, however, could not be on the
call today. So we might actually hear a little bit more about VistA
Office at our next meeting.

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

That would be good.

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

That may help us there.

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

And I think further as the staff are taking notes here what Blackford
was saying around the stimulants to private physicians not yet adopted,
we just need to keep those at the top of our mind and informing our
discussions here.

Shall we move on?

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

I think we should, Lillee, and I think we have a few that we will
construct a little bit and then get people\'s feedback on for the next
go-around. Okay?

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

I think that\'s terrific. If we could have just as good a discussion on
the next one, that would be great.

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

One thing \-- this is Jim Sorace from CMS \-- one thing real quickly and
that is if you have standards for transmitting data, then I think that
actually mitigates some of the Stark issue concerns, because the
hospitals and whatnot can pay for the software, but if it\'s able to
exchange with other groups that can still provide those services, it\'s
less of a hold.

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

Thank you.

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

Legal regulatory. This actually relates to the discussion we had last
week, as well as some of the presentations we had earlier from folks
that pointed out that there could be some legal issues. And you also
have the letter that you just received yesterday. One of the things was,
that was mentioned was the possibility of some recommendations to the
Certification Commission in terms of how data is presented and formatted
which might decrease liability and we certainly heard today from a
malpractice insurer who is providing incentives through decreased
premiums to advance EHR adoption. So I think that we certainly have a
very fertile ground here for a few recommendations in at least those two
areas. And I would just wonder if there are others that people think
would be important. I also note that we had on this list clarifying some
of the legal questions relating to Stark, so we\'ll move forward with
that, too.

Any other thoughts or comments on this in terms of where we should be
going, or other testimony we should need?

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

This is Jim again. One thing I think we might want to think about is
again the incentives that the data providers have to update their
systems for common standards and for interoperability with CCHIT
systems.

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

Yeah. I think that\'s in our state of the technology side.

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

Okay.

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

We can spend a little time with that there.

As everyone reviews this document and thinks a little bit about what
we\'ve already heard, I think the real question again is we\'ve got some
possibilities here to move forward with, with recommendations. Are there
others? And is there any, more importantly is there any other testimony
you think you might like to hear at the next meeting?

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

Regarding legal, regulatory, specifically?

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

Yep.

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

Okay. No. Not for me.

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

I thought the Masspro presentation today was extremely helpful, as well
as the discussion on malpractice relief. That was terrific. If there\'s
a recommendation perhaps that needs to come out of that?

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

In terms of perhaps how we might be able to move forward and engage
other parties around the country?

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

Right.

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

I think we can all think through a little bit about who to engage and
how to engage them to make that type of an approach a little bit more
generalized, generalized around the country.

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

That whole notion of promoting malpractice insurers incentives to
advance adoption.

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

I would also like to let you know that over the last few days, and
including today, the National Governors Association is meeting, at our
behest, through a contract, and they are addressing, among other things,
the state-based issues regarding licensure, and other state-based
approaches that could impede the free flow of information between
physicians, or between physicians and their patients or providers and
their patients, so we actually may have more information on that at the
next Workgroup meeting also.

Any other thoughts or comments on this particular arena?

[**\>\> Lillee Gelinas**]{.underline}

Hearing none, let\'s move on \--

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

Okay.

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

\-- to the critical component organizational. This is another area where
we\'ve had a great deal of conversation. Organizational encompasses a
number of issues, including all those cultural barriers, work force
education and training, professional certification to HIT. We\'ve had
testimony and discussion around work flow redesign, resources, and the
lack of knowledge around EHR selection practices, which increases the
risk of right purchase. So once again, we will need to craft some
recommendations around this particular issue. And these are just some of
the questions that the staff have put in front of us to consider: are
online consultant services sufficient to support adoption? Are there
resources sufficient to support the adoption goal? Are there sufficient
training programs available for all support staff? And how can patients
be more engaged in supporting HIT adoption among clinicians?

And I had a smile on my face and was reminded of what it\'s taking in
hospitals at least today in getting patients engaged, for instance, in
reducing hospital-acquired infections and the little notes on their
hospital gown that says did you wash your hands before you touched me.
That\'s a fairly simplistic example, but engaging patients in supporting
HIT adoption among clinicians may be a area we really want to put some
attention to because consumer-driven healthcare, consumerism is
certainly getting much more play these days than in the past.

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

Lillee, it\'s Blackford Middleton. I think that\'s a great thought and
I\'m not sure if there\'s some way to explicitly acknowledge or
recognize a potential codependence of some kind between those PHR
efforts now taking off around the country, and some are more notable
than others. For example, the Dossia effort is perhaps more notable. How
do they interact with the EMR objectives of the President, and the
current, the AHIC recommendations, whatnot, I think might be worth some
thought.

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

I hope the staff captured that.

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

Karen, and Judy, and team there, I have a question for you. In the
Louisiana/Mississippi area, if you talk to those patients and consumers,
they\'re clamoring to have their own record, in the post-Katrina era
here where they\'ve completely lost their record. Is there anything
coming out of that part of the country with some of the recovery effort
that we can learn from, where consumers are pushing for HIT adoption? As
a pilot, or, that was really what we would call a disruption. Anything
happening there that can inform our conversations here?

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

The best I can tell you on that one, Lillee, we\'re all going to be at
HIMSS next week. So we will be visiting some of the sites. We are doing
some site visits, and I\'m sure a number of other folks on the call will
be at HIMSS as well and perhaps we can report back at the next Workgroup
what we find out, because we\'ll be in the thick of it.

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

Because I was just there. There\'s only three or four hospitals
operating. Lots of physician practices did not come back. And we hear
about these pilots for rebuilding healthcare in New Orleans and in
Biloxi and the Gulf Coast area, but if we could find out what is really
happening, and as a result, because consumers and patients really got
high motivation for wanting to own their own record. Is there anything
happening there that we haven\'t heard about so far that could inform
us? It's a real wake-up call, I think, for all of us.

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

Certainly, we\'ll certainly do whatever research we can do on the topic,
and thank you for bringing that up.

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

That would be great.

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

That\'s a good idea \--

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

Go ahead.

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

Sorry. It\'s Blackford again. I have one other, I\'m not sure if it
appears here or perhaps under the technology bucket. But one of the
things we\'ve done in some of our analysis is to try to estimate not
only sort of the cost benefit picture for EMR adoption and for office
sizes of different, different office sizes and whatnot, but to also
explicitly measure the costs of knowledge engineering, if you will, that
goes along with the implementation. Chuck alluded to some of this in his
presentation. We know, though, when an EMR is implemented, the clinical
environment, whether it\'s practice staff or implementation staff or
whomever, have to wrestle through what are the basic rules, alerts,
templates, forms, guidelines, protocols, and whatnot that they wish to
implement, even in the vendor systems off the shelf, they often as you
know are incomplete in many ways, and may get a practice to kind of the
first base position, if you will, but not beyond to second and third
base.

I\'d like to suggest one of the recommendations, and I\'ve discussed
this with Carolyn Clancy, I\'m not sure if she\'s still on the phone but
one of the recommendations might be that we compile to the extent
possible knowledge in a machine-ready or human-readable form such that
it facilitates or eases the knowledge engineering burden for
implementing EMR. One might imagine a resource, national repository of
some kind, where one could simply look up, as I sort of demoed in our
knowledge portal we\'re developing here, look up the healthcare
maintenance reminders and whatnot that you may then more readily
implement into your EMR, as opposed to having discover, do the knowledge
engineering, convert them into the right terms and languages and
whatnot. I think this is a major obstacle that if it were ameliorated to
some degree or removed even, perhaps, would facilitate adoption.

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

Blackford, this is Jim Sorace from CMS. I agree with that
wholeheartedly. I\'d also like to add that we need to better understand
some types of exclusions and how better, how best to document when
patients, when these things don\'t apply to specific patient
populations. That part needs to be included in the task.

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

Yes.

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

This is Karen Bell. Carolyn had to leave but I was at AHRQ all morning
and one of the things we were talking about is the degree to which the
various specialty societies as they develop their guidelines develop
them not only in an evidence-based format, but also develop them in the
machine-readable format and with measures that can be extracted from a
HIT environment. So I don\'t know, again, I think it\'s a very
interesting concept. I think it will take time, obviously, to move
forward. But I think that there may be some sort of an opportunity for
us to work with the clinical entities that are developing these
knowledge bases, and promulgating them so that they can be done in a
format that is usable down the line for CDS. So I think somewhere along
the line, we\'re moving towards a recommendation in that arena.

What about the, and before we move on, what about what we heard today
from Chuck, with respect to DOQ U. There is a lot of information that\'s
there. We were offered an opportunity now that\'s available to us to
look at it and perhaps we may be interested in either adding more
support to that so that it becomes more widely available, we may want to
make some recommendations to either push forward with that or not. So
maybe one of the things we might do is everyone on the Workgroup really
look at that closely, and determine to what extent it is worth further
support and perhaps a recommendation. I can throw that out as well.

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

We shouldn\'t reinvent the wheel. If we can learn more about DOQ-IT and
make recommendations for spread.

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

Uh-huh. Everybody has some homework on that one, then. Thank you.

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

Any other thoughts on the organizational issues? I have to admit I\'m
struck a little bit about solid recommendations about overcoming
cultural barriers. No matter what the improvement work is, at the end of
the day, culture trumps strategy all the time.

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

As they say, culture eats strategy for lunch.

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

There you go.

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

This is Bart Harmon from the DOD. This is a suggestion framed as a
question. Is there any way that you could tie together allowing provider
practices to use the fact that they\'re using a certified EHR as a
marketing tool and then also find ways to educate patients to look for
providers that are using certified EHRs? Because it seems like the
public voting with their feet could be a very powerful force. I just
don\'t know how to pull that together.

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

Hi. This is Alicia. Can I make a comment on that, Karen?

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

Of course.

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

I think perhaps the Workgroup could consider a recommendation around
that that would be aimed at the Certification Commission, regarding
their outreach with that perspective toward providers and patients,
about how to market the fact that they\'ve adopted a certified EHR to
their patients and to other providers.

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

Okay. Well, just to sum up, I think we have the possibility of some
recommendations in three or four areas here. One is around the marketing
piece. Secondly, is around supporting DOQ-IT, if we think that\'s
appropriate after further review. Thirdly, we have one around compiling
the knowledge base and some things of that nature. And I think that\'s
it. So we have three possible ones that we can move forward with here.

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

Yeah.

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

Okay.

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

I like it.

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

So we\'re going to flesh them out on the next go-around and give some
direction.

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

I know.

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

We\'re going to keep on going here?

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

Let\'s keep going. State of the technology. In previous Workgroup
recommendations we have talked about interoperability, we\'ve seen HITSP
and CCHIT standards and criteria development come to the forefront. The
testimony from 19 presenters to us fell into five categories.
Interoperability, interconnectedness, clinical decision support,
functionality, and usability. And there have been a number of issues,
including standardized interfaces, assessments of usability are limited,
and there\'s this general buyer beware in this arena. Bolded is software
immaturity and lack of many EHRs with the features that are really
needed by frontline care and discussions regarding EHR data elements,
functionality, and so forth that clinicians need to exchange
information.

So in terms of us making recommendations, during our January 23rd full
AHIC meeting, the committee made recommendations for additional use case
development in the areas of consumer access to clinical information,
medications management, and quality. The CCHIT is now expanding into
specialty and in-patient EHR certification. And their expansion road map
is available for public comment through March 2nd. Are there any
comments that we, as a Workgroup, should make to CCHIT in its public
process? And then what other recommendations do we have? So let\'s start
with the most obvious one here, and that is Workgroup recommendations to
CCHIT in their work.

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

This has to do with, I'm going to be a little bit more specific about
this one, because the timing is right on this one. They\'re thinking
about moving into the specialty arena and how to do that and some of the
specialty areas that they\'re looking at are additional modules related
to pediatrics, they are looking at where on a road map would they put
behavioral health PHR, and they\'re also looking at how they might move
forward with certain functionalities. For instance, the American College
of Cardiology has been quite clear about wanting to move forward with
something for cardiologists. But when you really think about it, it\'s
wave form capability that\'s important for the cardiologist, as well as
DICOM, or the ability to transmit radiological studies. So there may be
certain aspects that are important to certain specialties that are also
consistent with other, with what other specialties need. So I think the
real piece, important piece here is that the Certification Commission is
really looking for feedback on where to go in this next step of
certification with respect to physicians and EHRs. And what\'s likely to
give us the biggest bang for the buck? So that\'s really the question
that\'s before us, and we can do that through public comment at the
Certification Commission even without a formal recommendation to the
AHIC.

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

Well?

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

Any thoughts on that, or is that something we should discuss more next,
can\'t be next go-around because basically the bottom line is you\'ll
have to go check out the, it\'s March 2nd, so you would probably \--

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

Next Friday, a week from tomorrow?

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

Yep. You\'ll probably want to go to the Website between now and then,
see what the Certification Commission has there, and if you think that
public comment is appropriate, then make it. And maybe it would be best
if members of the Workgroup did that individually rather than the
Workgroup itself speaking as a single voice.

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

Uh-huh. When will we be able, Karen, to see what comments did come in
and be able to at least consider those?

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

They will be out within a few weeks of the public comment period
closing.

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

Because I\'d be curious to get everyone\'s just thoughts on the comments
that did come in, and maybe we can at least lend a voice of consensus or
support.

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

Isn\'t our lines of communication, though, through the AHIC, and so our
recommendations and comments really need to be them with regards to
things like CCHIT, correct?

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

That is correct.

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

Yes.

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

So I mean, our line of communication really isn\'t directly to the CCHIT
anyways.

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

No, but as individuals and it is public comment \--

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

I understand that, but, and I guess I understand you were saying maybe
we as individuals should do things, but I think that we also need to be
very careful where our recommendations go and how they need to be
couched, because it would be the AHIC then some way communicating with
the Secretary or commenting on the CCHIT.

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

Right, the Workgroup's recommendation, as a Workgroup, would go to AHIC,
exactly.

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

All that said and done, when it\'s done, it would be helpful to know
what the comments were.

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

I think we feel there\'s more that needs to be done and that can go to
the Secretary.

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

Then the next question is that, do we have the right or the ability to
ask CCHIT to talk to us about recommendations once the March 2nd date
passes?

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

Absolutely. The Certification Commission has addressed a number of other
Workgroups.

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

So we could ask them to characterize some of their feedback on these
particular topic areas?

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

Absolutely.

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

Then naybe we should try to do that for our next set of meetings.

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

Okay. CCHIT testimony coming up. That also may be a time to ask them,
because they have not gotten into the issues of usability, but to really
ask them about what their thoughts may be, or how they might be able to
address the issues of software maturity and usability moving forward.

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

Okay. Is it time to move on to the last one?

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

I do believe, on privacy and security. This has been a particularly
important adoption issue for us to consider because both physicians' and
the public\'s privacy and security concerns are critical in adoption. We
have certainly contemplated much testimony. We\'ve had three presenters
discuss several key aspects, and I won\'t read through all of the
components that are in the work that you have in front of you, but
significant work has already taken place in the National Committee on
Vital and Health Statistics' subcommittee on confidentiality and
privacy, and we have talked about that.

Previous EHR Workgroup recommendations that were forwarded in May 2006
led to the formation of the AHIC Confidentiality, Privacy, and Security
Workgroup, and you all know the focus of the CPS Workgroup. As we
continue to look for strategies to recommend around policies, guidance
and protections related to the inclusion of genomic data, which as you
know is a key topic for the Secretary, we really understand that we have
a lot more to learn in that particular area, and that we do need to
address the privacy and security concerns of a very broad use of data
for public health quality improvement reporting and research.

So for us, given that when we think about large volumes of patient data,
I am reminded of one of the opening remarks of Secretary Leavitt before
our full AHIC meeting a couple of months ago when he said can you
imagine the size of the storage facility to store the genomic data of
every American? And I had a mental model of this huge, huge place that
would have to store that amount of data and just think about the privacy
and security concerns related to it.

So given that we do now have a CPS Workgroup that was not in place when
this Workgroup was first formed, are there additional privacy and
security issues that we'd like to bring to the attention of that
Workgroup for their deliberation? Are there any recommendations that we
want to make that are independent of the CPS Workgroup? And is there a
particular priority for this Workgroup that we need to discuss as well?
This is a really big deal, and I\'m hoping we can have some good
discussion around this.

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

This is John Houston. Being on the CPS Workgroup, I can tell you two
things because I just got off a conference call earlier this week on the
meeting in that group.

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

Oh, good.

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

And I don\'t know if you all know, but one of the chairs of that
Workgroup just stepped down, citing lack of progress of that Workgroup.
So interestingly enough, the time the Workgroup was really asking the
members for some ideas as to where that Workgroup needs to go in terms
of topics. Now, also being a member of NCVHS, I leaned heavily on the
fact that we have this paper, this letter that we sent out in the
summertime \--

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

Right.

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

\-- which outlined a whole variety of privacy issues associated with
NHIN. So that\'s really publicly what I pronounce as being what I think
needs to be done next, is start going through that list. But just so
everybody knows on this Workgroup, that this CPS is really looking for
what do we do next, what are the big pressing issues that it needs to
address very directly. And it\'s also I think looking maybe for some new
leadership there, too, and I\'m not sure how that will get addressed.
But I think it\'s important to bring those up.

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

Thank you, John. This is Karen Bell. I think that\'s very, very helpful.

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

Yeah.

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

One of the things that strikes me is we, through the work you\'ve done
with NCVHS and through this Workgroup, we\'ve identified a number of
issues around privacy and security. Perhaps it would be helpful if we
outlined all of those and that would give everyone the option of adding
anything we might have missed, so everyone would look at it and say
okay, here\'s some of the gaps. And then start prioritizing what we
think are the critical ones for the CPS to then take up. Does that sound
like a reasonable approach for us?

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

Sure.

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

Would that work for you, John?

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

It would. I\'m going to probably stay fairly silent in some of that
because I\'ve already voiced my opinion, myself. Though, I mean, I\'d be
more than happy to try to provide feedback to make sure that we\'re on
the right track with some of the suggestions.

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

You know, Karen, this is Lillee. I really need to get immersed in those
26 recommendations in that letter or report. I\'m, I probably haven\'t
looked at that since it came out last June.

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

So would it be helpful if we just downloaded at least the executive
summary and the 26 recommendations and just sent them out to everybody?

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

That, but also here we\'ve got a member of the CPS Workgroup here, and
as with all things, we need expert opinion in order to form our
recommendations, and I would really like to know if their 26
recommendations, what are the top 5, where do we go, what do we do next?
Because we obviously can\'t address all 26, so to speak, in one lump
sum.

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

Interesting, again, being part of NCVHS and really being intimately
involved in the drafting of that letter, I can tell you that I have a
lot of, was it pride and ownership of that letter myself, and I think
it\'s hard for me even to decide which of those 26 are most important. I
could probably hone it down to maybe 8 or 10 that I\'d say boy, we
really need to work on first. But it really almost becomes a
philosophical read. When you go through that document and read through
it, I think it strikes everybody a little differently what the priority
is. That\'s part of the problem. And that\'s one of the things that we
really struggled with as a subcommittee under NCVHS, was how do you
couch these recommendations and there was a lot of good faith difference
of opinion of the relative importance as well as what people\'s position
was on each recommendation. So a lot of the recommendation ended up
being couched in a way because we couldn\'t come to consensus because,
in good faith, we just had a difference of opinion.

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

John, if we were to, and I'm just putting this out as a question, if we
were to really focus on the fact that we\'re trying to move forward, EHR
adoption among physicians \--

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

Right.

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

\-- would that help us prioritize some of those you think because it
comes from one particular point of view?

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

Sure, I think it would. I think that that letter also, by the way, was
to remind everybody, was, it was really trying to examine the privacy
issues of the NHIN. So if you take the NHIN that, the global scope out
of that letter, obviously the privacy issues become much simpler and
much more localized. What my concern is, is that, and I think most
people would agree, that especially for the small practices, the way
you\'re going to find EHR adoption is through participation in a RHIO,
or in other types of community-based programs. And I think when that
occurs, or if that occurs in that way, then a lot of the issues that we
are, a lot of the recommendations we made really become applicable
again, so you can probably dodge some of the issues or decide to defer
some of the issues based upon that scope, but I really think what it
will end up happening, at the end of the day, you\'ll end up having to
address them nonetheless.

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

Okay. Given the discussion and given the lateness of the hour, if
everyone\'s comfortable with, again, pulling this letter forth, assuring
that all the other pieces that we\'ve talked about are included, I think
we might be able to spend more time on this topic in the next Workgroup
meeting. And I\'m wondering, is there any other type of public testimony
we need to hear here, or do we think we\'ve got more than enough on our
plate right now that we just need to focus?

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

Back to the letter just for one second. I\'m assuming you were referring
to the NCVHS letter?

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

I was.

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

Just now?

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

Yes.

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

Maybe one way to deal with this is to take the 26 recommendations and
maybe circulate those recommendations on a spreadsheet that would allow
people to rank order their importance in their mind relative to EHR,
physician adoption of EHRs.

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

Yeah.

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

And then say okay based on everyone\'s opinion and their own ranking,
which ones do we really think need to be pushed forward to the CPS
Workgroup for consideration earlier rather than later.

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

And we would add to that, again, some of these other issues,
particularly around secondary uses of data. We don\'t have privacy and
security concerns addressed around that as well. So there are other
issues as well that we can add to that list. I think that sounds like a
good idea.

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

You know, Karen, it strikes me in closing out this part of the agenda,
that the seriousness of this issue, which is around making
recommendations for these critical components, is probably one of the
most important pieces of work for this Workgroup. Because the
recommendations that we will have to AHIC have far-reaching
implications, so I want to thank everyone. This is truly an all hands on
deck effort. I ask everyone for your best thinking and your best
dedicated effort as we go into round two of these recommendations, and I
really want to thank you very much with the seriousness around which
you\'ve taken this work.

Let\'s move now to public comments, can we? Matt, do we need to put a
process in place to make that happen?

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

This is Jennifer. Matt stepped away. I just put a slide up that has the
number in for people who are following along on the Web to call in.
Anyone who is already dialed in can just press star 1 to alert the
operator. And there\'s an e-mail address if anybody would like to write
a message after the meeting. So we\'ll just wait a few minutes and I\'ll
let you know if anyone calls in.

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

While we\'re waiting, this is Karen Bell. Again, thanking you all for a
lot of good work today. And I just wanted to call to your attention that
our next meeting is Tuesday, March 20th. And there is only one item on
that agenda, and it is recommendations.

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

If I might, this is Bart Harmon with the Department of Defense.

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

Yes.

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

This may be my last meeting. I wanted to bid you all farewell in case it
is my last meeting. We haven\'t figured out who will be my replacement
on this Workgroup yet. But I\'ll be retiring from the military here
shortly and so I wanted to say farewell and thank you for allowing me to
be a part of your group and the opportunity to show you what we\'re
doing here recently. It\'s been a great privilege.

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

Bart, it\'s been a privilege to meet you personally. I so thank you for
the warm welcome at Walter Reed Army Medical Center. It was a tremendous
tour. Thank you for the dedication that you\'ve given this Workgroup. We
will miss your leadership and your contributions.

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

Thank you.

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

Thank you so much, Bart. And congratulations.

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

Thank you.

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

Also, since you made that comment, Bart, I would also say that once we
get through these recommendations, you will all be receiving a letter
which gives you the opportunity, because I know so many of you have done
so much work and it\'s been very much appreciated, but we also recognize
that you have another life. So as we move into the next phase of this
Workgroup, which will be to move into the area of hospital electronic
health records, then we will be giving everyone the option of signing on
for another stint or if you feel that you have other things calling you
and pulling you away, then you can let us know and we\'ll try to find a
replacement for you all. But I just wanted to give you all a heads up
that at this point we are absolutely grateful for each and every one of
you. You\'ve done a phenomenal amount of work and we\'ve got a lot
accomplished. So thanks again.

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

We have an opt-out option, Karen?

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

Not the co-chairs and not yet.

\[laughter\]

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

Not so fast.

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

Not yet. We have to get through the recommendations first.

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

And Judy, were you saying that our full AHIC meeting, the venue is going
to be coming shortly?

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

Yeah, I\'m working on getting that hotel, et cetera, tied down. I hope
to get that out to you tomorrow.

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

Okay.

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

It's coming, it's just, you know, a lot of little details to attend to
for that.

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

Oh, I don\'t envy you. I can\'t imagine.

Any public comment?

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

There is no one calling in today.

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

All right, there\'s no one calling in today. Any other business to come
before the interest of the Workgroup?

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

Nope.

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

All right. Well, thank you to everyone, you\'ve done a great job.
You\'ve all hung in there. We\'ve made it through the agenda. We have
given to staff, I hope, some good recommendations to keep the work going
forward. Repeating what Karen said, our next Electronic Health Record
Workgroup meeting will be Tuesday, March 20, please look at the AHIC
Website for further information about the meeting.

So thank you again. Meeting adjourned. Have a great afternoon, everyone.
Bye-bye.

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

Thanks.

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

Thank you.

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

Bye.