American Health Information Community

Quality Workgroup Meeting #4

December 13, 2006

**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}**\
Thank you and good afternoon everybody. And welcome to the fourth
meeting of the Quality Workgroup. Again just a reminder that the meeting
is conducted under the rules of the Federal Advisory Committee Act, I\'m
sorry, which means that it\'s been published in the Federal Register and
a transcript is being made and being made available to the public, so
when you speak or on the line, the telephone, please identify yourself.
And at the end of the meeting there will be an opportunity for the
public to make comments to the Workgroup.

With that I think I\'ll turn it over to Matt to review the roll call of
people on the telephone.

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

Okay. Calling in today, George Isham is here representing
HealthPartners, Jerry Osheroff from Thomson Health Care. Pam French is
on the line right now for Rick Stephens from Boeing who will be joining
the call shortly. John White from AHRQ. And I believe Carolyn Clancy
will be joining shortly. Carolyn Clancy will be joining shortly.

Susan Postal from HCA, Jane Metzger from First Consulting Group,
Margaret Van Amringe from Joint Commission on Accreditation of Health
Care Organization, Peggy O\'Kane from NCQA, Mike Kaszynski from OPM,
Sunil Sinha from CMS, Janet Corrigan from National Quality Forum, Josie
Williams from Texas A&M. Nancy Wilson from AHRQ as well.

Are there \-- Anne Easton from OPM, and Charlene Underwood from Siemens
Medical Solutions. Do we have other folks on the phone as well with the
member designee?

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

Hi. This is Steve Wojcik from the National Business Group on Health, and
I\'m substituting for Helen Darling.

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

Thank you. Any others? And just to briefly review what Judy said for the
Workgroup members, please keep your phones muted when you are not
speaking; and when you do come in to ask a question or make a comment,
please state your first name for those listen along know who is
speaking.

**\>\>\
**Okay. In the room we have Bill Rollow who is here from the CMS, Barry
Straube, and Kelly Cronin. Kelly, do you want to \--

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

I think we\'re still waiting for Carolyn to come over. She had a meeting
with the Deputy Secretary, but she should be joining us shortly. We will
also have Linda Kloss who is from the American Health Information
Management Association joining us shortly, and she\'ll be starting with
the first presentation on our agenda.

Just to give a little bit of background, we have had a contract with
AHIMA to try to develop best practices for State-level health
information exchange. And when they presented it to the Secretary and
AHIC back in September, the Secretary had asked them to reconvene their
steering committee of State leaders involved with health information and
exchange and explore how we could better coordinate a lot of the quality
and transparent initiatives with ongoing health information exchange
initiatives.

So they had considered that over the last few months and went back to
the Secretary at AHIC this week with some ideas and potential
recommendations on how to better coordinate those two initiatives.
Again, there is obviously a lot of complexity both from a planning, a
governance and operational level. But I think it will be helpful for the
Workgroup to hear what at least the folks who are really involved day
in, day out, at a State level and planning a lot of the health
information exchange infrastructure and policy, what they think are some
of the opportunities and ways that we could be better integrating these
two agendas.

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

Kelly, this is Linda Kloss. I am on.

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

Great. Well, welcome Linda. We then can turn it over to you if you would
like to go forward with your presentation.

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

I\'m happy to do that.

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

Okay. Great.

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

And thank you for providing the background. As Kelly said, between March
and August of 2006 we convened the steering committee and technical
advisors and looked at the question of best practices and State-level
health information, exchange initiatives. And in the course of
discussion in September with the members of AHIC, the questions arose
what is the relationship between State-level health information exchange
initiatives and the quality and transparency initiatives being further
developed in the States.

And we did limited research, but research for the purpose of teeing up
discussion about these issues by the steering committee, and that\'s the
subject of the set of slides that was sent to you yesterday. And I
appreciate the opportunity to just highlight these for you and hope that
this information will be helpful to you as you go forward with your
important charge.

The first page of the slide, the building block diagram, shows what we
learned about the various roles that State-level initiatives are
playing, and certainly we concluded that there is not one single model,
that a foundational worker, convener, educator, facilitator seemed to be
common to all. But some are playing a role of funder. Some are playing a
role of removing barriers to HIE, setting and advancing State-level
policy and standards. And some are actually doing technology and
information exchange activities, selecting technologies and managing or
subcontracting for technology operations.

Fundamentally these are all public/private entities, as you are aware.

The next slide shows us that, the recommendations that came out of our
first report in September were that one of the things the groups needed
were some greater clarity and strategic synergy among States and between
States and the Federal HIE efforts. Various study of the salient
financial models for sustainable HIE. Engagement and leverage with
public and private payers and the health information exchange roles.
Understanding, advanced understanding of how State policymakers and
governmental agencies should be involved, can be involved to enable the
success of the information exchange and vehicles for ongoing support and
knowledge sharing among State-level HIE initiatives.

And as Kelly mentioned at this meeting, the question arose, well, what
about quality initiatives. And so the next slide really shows what we
have studied from September to the middle of November for follow-on
topics, all drawing from those recommendations on the previous slide,
with the exception of the one that we are going to talk about just now
which is the health information exchange, quality and transparency
initiatives. So is that set up clear?

Hard not to \-- to do this by telephone.

So I\'ll jump ahead and tell you what the limited data set that we
collected shows about quality improvement involvement with State-level
HIEs. And you should be looking at a slide now with some numbers on it,
55 percent, 33. Is that where we are at?

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

Matt \-- we got it.

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

Thank you. Our steering committee consists of nine State-level health
information exchanges. So the N on these statistics are 9. And I don\'t
want to understate that the percents have any great meaning. But \-- so
if we look at 55 percent, we are saying five of the nine organizations.
Thirty-three percent is 3 of the 9, so just to scale it. This is
certainly not looking at 100 percent of the States by any means.

But we did learn that 100 percent of these health information exchange
organizations see quality as an absolutely mission critical function. So
they are certainly part of the quality landscape by their own mission
and by the mission and charge that\'s been given to them through the
public/private collaboration, their sponsors. Fifty-five percent are
now, or contemplate or are planning to be suppliers of data for
performance reporting. A third of them, supplier of data for disease or
chronic care management. A third of them reporting, actually reporting
performance to the purchasers or payers. Two of nine, so certainly a
very small percentage see themselves in a role of actually doing public
reporting functions. And a third of them certainly envision that they
are advising or overseeing initiatives being managed by other entities,
so really helping to coordinate these issues.

The next slide will look very familiar to Dr. Isham, and we borrowed
this from the slide that he shared with the AHRQ conference in November
on data collection for quality improvement initiatives. And we used this
in the presentation to AHIC, just to make a point that quality
measurement and reporting is a highly complex activity today. And the
survey that we did of State-level HIE programs certainly showed, and you
will \-- if you care to read the full report, you will see that they
inventoried the number of organizations within their States that they
know are engaged in this. And I think we conveyed or tried to convey
their sense of uneasiness with lack of coordination going on at the
State and the huge opportunity for silo data collection. And even the
notion, I think, as is certainly depicted in this slide, that the cats
out of the bag. So they certainly had full knowledge of how complex this
is.

And yet we are advancing certain recommendations to HHS, and to AHIC.
And we felt this could perhaps be valuable as your Workgroup goes along.

Number one, to clearly articulate the need for explicit coordination
between State-level health information exchange and other State quality
and transparency initiatives. Instead of letting this all play out sort
of biologically, put a marker down there should be explicit
coordination.

Secondly, underscoring that each State is different. Each State must
determine its preferred model. But some studies should be done of what
those models are that are most cost effective, and particularly
underscoring the need to assist with data standardization and all of the
aspects of data quality and certainly work to reduce or avoid additional
duplication of data collection efforts. As Dr. Clancy and Dr. White will
tell us, we really learned a lot about the data collection barriers at
the November conference.

More integrated model, and we drew a model. This actually was prepared
by the State-level HIE steering committee based on their experience. And
this is, you know, admittedly very simplistic, but data capture, health
information exchange function. Certain basic roles for health
information exchange organizations who have technology functions. So
they are either doing this or overseeing it or somehow engaged in
setting standards or encouraging standard approaches by local or
regional HIEs.

Some HIE organizations are also the data aggregator, and then as they
saw information analysis and interpretation for quality reporting, they
don\'t see that as an HIE entity\'s role but certainly saw that one of
the models might be to unify some of the data collection, data
aggregation functions and feed those to other analytical or reporting
entities rather than everybody collecting their own data which, as
experience is showing, is all slightly different.

So that was a model, and really went on to encourage the further
exploration of those models.

Number four, formal and funded role, to provide data services to, for
quality measurement may actually turn out to be a very critical,
sustaining, financially sustaining role for HIEs. We see that now as
being a source of revenue for some health information, State-level
health information exchange organizations. And these entities are
struggling with financial sustainability. Will HIE alone be a
sustainable role. Encouragement that health information exchange
representatives be getting involved in national efforts to design
integrative data strategies and, at the same time, strengthens their
relationships with quality organizations in their own States and local
level.

And a call for broad stakeholder dialogue to really understand more
thoroughly than we did in this study what States are doing to integrate
State-level HIE with quality and transparency initiative. Explore
business models and look at government\'s structures. And those were the
key recommendations.

The final page is pretty provocative but, again, this is in the view of
the State-level health information exchange groups. Kind of imperative
that we look ahead to the 2 or 10 years out and start thinking about how
these very critical and integrative functions are going to be
coordinated going forward by a multi-stakeholder health information
community or its successor and permanently, if you will, by design,
linking quality and transparency and other population health with this,
as well as care delivery, the research, the policy end of how, how do
these technologies actually at the end of the day improve care. The
standards and certification, the law and regulation and the work of
health information exchange organization.

So they have met the vision forward to AHIC for some, really, discussion
about what happens going forward. And I think the strong urging of these
State-level HIE leaders of the need for coordinating mechanisms.

With that, I\'ll stop and certainly answer questions. And thank you for
seeing this early in preliminary information and considering it as part
of your important work.

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

Linda, thank you very much. It was a great overview. And I should also
note that we can share the full report with the workgroups who, and
that\'s \--

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

Yes.

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

\-- to give them a more comprehensive understanding of what was
discussed and some of the data that was collected across the nine
States.

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

And we were, we were gratified that some of, the kind of recommendations
and the issues that surfaced and, I think, important November AHRQ
sponsored meeting were very much in mind with what the State-level HIE
group was saying.

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

Mm-hmm. That\'s great.

It is also timely that this is all coming to completion and that this
Workgroup is in the process of trying to wrap up a visioning process.
And I think since the State leaders were forward-looking, helpful for us
to put this into the context of how we\'re envisioning our broad charge
when it is hopefully realized. So it is good timing from that
perspective.

**\>\>\
**Fine.

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

Does the Workgroup have any questions for Linda, about the work or about
what this means?

**\>\>\
**There is a report of the Phase I project, and you can see who is
involved and all the listing of the, on a Web site called staterhio.org.
Staterhio.org. It\'s all the work product on this research.

**\>\>\
**If I might ask Linda a question.

**\>\>\
**Yeah, go ahead.

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

Linda, hi. This is Bill Rollow at CMS.

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

Hi, Bill.

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

Hi, how are you?

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

Good.

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

So in a number of these places, I guess I have a couple of clarifying
questions. In a number of these places where they are, in addition to
something at the State level, were there more local HIEs, or was this
typically the, sort of most microscopic level that was present in these
States?

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

No. The participants in this are always the State-level entities. So
within those States there may be multiple local RHIOs. And that\'s why
the critical role, that building block slide is so key. How the States
are organizing themselves depend on a lot of factors. Certainly
stakeholder relationships, what entities already exist to leverage. But
in, obviously in Rhode Island it is a single entity and in California it
is multiple entities. And still there is a need for some State-level
coordinating body to make sure that local organization \-- or that we
are leveraging relationships with State government, with Medicaid, that
State policies and standards are in line and even roles such as funders.
But then in States like Utah they are actually in charge of technology
operations, and so we have the range. But I think the message is, as you
are envisioning models, think about health information exchange
organizations both at the local and the State levels.

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

This is George Isham. Can I ask a question?

**\>\>\
**Yes. Love your diagram. Thank you.

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

You\'re welcome. On the issue of the geography of this across the
country, has anybody attempted an actual map of what exists today? I
notice that when you were talking about quality measurement and
reporting there was 50 \-- 55 percent or so that were involved in this
activity but not all. Are these a varied group of organizations by
function?

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

They are. Our research was limited to working with nine organizations so
we actually did not pick them at random. We picked them based on which
State, health information exchange organizations \-- you know, appeared
to be a mix of models but also were advanced and in place for a year or
plus. So it was a selected list. Kelly does have a map of how
State-level health information exchange organizations we did do \-- you
will find in the appendix to one of the reports an assessment as of last
spring of all of the State-level entities and their characteristics. But
you will notice that one of the recommendations were, here were to do a
more exhaustive look of the State-level HIE efforts vis à vis quality
than we were able to do in this study.

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

I would just add \-- this is Kelly \-- that what we have available is a
combination of \-- where legislation stands at a State level, both
proposed and passed. What executive orders have created, new governance
or public/private partnerships. I think just about all of them, as Linda
mentioned, you have a quality mission overall but are fundamentally more
focused on health IT and health information exchange. And we have a
rough account, it is not completely real time, but of what\'s happening
across States.

And actually working internally to try and keep that more current and
also connected with more the Federal programs and the Federal funding
that\'s going out to them.

I should also mention that the next round of nationwide health
information network procurement will be focused on States and regions.
So unlike last year where the funding went to systems integrators and
health IT companies, we are now going to be refocusing that effort and
taking it to regional- and State-level health information exchange
organizations. And the quality use case will be one of the use cases
that guide their work.

So we are trying to help all of this fit together since we know that \--
the network services part of what we have to do is going to be
insurmountable and actually mobilizing the clinical data. We know we
need to, also as a workgroup, think about the electronic health record
and how that\'s going to be a source of data over time. But at the same
time we need to be mindful of what\'s going to be coming from the
network services that will be bringing in labs, pharmacies and the
clinical data from EHRs as they mature.

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

Kelly.

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

Yes.

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

This is John White. Since you mentioned the one funding opportunity,
would it be inappropriate to mention our funding opportunity right now?

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

Sure go ahead.

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

Just for the folks briefly, there is a funding opportunity announcement
for grant opportunities from AHRQ entitled Enabling Quality Measurement
Through Health IT. If you want to take a look at it, go to the AHRQ Web
page, www.ahrq.gov, and look under Funding Opportunities. Thanks.

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

Kelly, I\'ll sign off now.

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

Yes, are there any other questions for Linda about the work that was
done by HIE and the States' leaders?

Well, thanks a lot, Linda. We appreciate the time you have taken.

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

Okay. Bye bye.

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

Okay. With that opening presentation, hopefully that will give some good
background to our next discussion which is going to be focused on our
vision. I just wanted to thank, start off by thanking several of you on
the phone who have really contributed a fair amount of good thinking and
time over the last three weeks in trying to update and make
modifications to this vision. I think we have reorganized it in a way
that\'s probably more logical and have gotten some really good
contributions from many of you who don\'t have the time to be doing
this. So we certainly appreciate it.

And Carolyn has just joined us. So I\'ll turn it over to her. We are
getting started about visioning.

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

Welcome, everyone. We have already done our accepting the meeting
summary, heard from Linda Kloss.

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

Actually, I didn\'t take care of that.

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

Oh, okay. I knew I would pick up on something.

I think that Workgroup members have had an opportunity to see the
minutes and anyone else could take a look at them. Any objections to our
simply accepting the minutes written?

Hearing none, we will declare the minutes accepted.

So Linda already

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

Linda has talked. Just a couple of questions. Not a huge discussion with
\-- started with talking about, a little bit about the process we did
with the vision. And I think we were going to ask a couple of people who
really contributed to this to go over their perspectives?

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

Yes, thank you. So for those of you who have been looking at the vision
document, you can see that we have articulated a, both a broad charge
and a high level vision. You will also notice if you looked at prior
versions, or had the time to go into that in some detail, that there
have been quite a few substantive changes.

And I think that we wanted to ask first to hear from Jane Metzger.

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

Okay. Let me describe what we \-- there was a small subgroup that was
working on this. And we decided that, in our call we decided that we
would add this high level vision that you see.

And then when it came to all the detailed information in the table, we
defined our work to be expanding from a prior focus on measurement to
really fully incorporate quality improvement, including all the way to
the point of care, and to introduce the notion of really the whole
national quality enterprise and how measurement and quality improvement
fit within that.

We did quite a bit of reorganizing and rewriting of the material in the
table. And it now starts with a description that Janet Corrigan
developed for the national quality enterprise. And you will see this is
quite a bit broader. And it even goes into the research that
contributes, both the evidence upon which folks try to improve care, as
well as a research on learning about how to do that, how to take
research results and improve, actually bring them to the point of care.

Then we organized the next few sections of the table first around the
description of key stakeholders\' experience. This is, talks about the
national quality enterprise from the perspective of the consumer, the
physician, the hospital, the health plan, the employer, et cetera.

And then the next section talks about defining characteristics of the
health care system, and this really has a process orientation. So it
starts with receiving care, which is obviously the patient. Delivering
and counter based care, managing the health of populations, improving
quality, et cetera. And we decided that a lot of the other topics that
needed to be covered really could be grouped as defining characteristics
or attributes of the national quality infrastructure.

So in this section you will see some of the topics that were in the
table previously but haven\'t been organized in exactly this way. Things
like metrics, how they come about, and what their characteristics are.
EHR adoptions, PHR products, et cetera.

So that, a number of individuals spent quite a bit of time building out
this new structure with content, which has been distributed to everyone.

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

Well, Jane, as I\'m rereading this again, I am pretty breathless about
the amount of work that you and your Workgroup put into this. So in
addition to sort of admiring that, I guess I wanted to just tee up a
couple of specific items. One is, at the end of this discussion I would
like to have some sense from members of the Workgroup and anyone else
who wants to comment about how comfortable we are with the much broader,
high level vision because we will be presenting this to the members of
the Community on January 23, if I have the date correct.

A second is, and this is just my own observation, but I would be
interested in yours or other reactions. It does seem to me that there
are areas where it gets a little bit squishy to figure out what goes
into the mid-state and what gets goes into the final state. Part of that
is because there is so much of this work in progress or in process
already. So just to give you a concrete example that jumped off the page
at me, where you talk about the research community. I really hope that
the \-- well, I know for a fact that there are people right now on their
own, in a sort of small scale way, testing and continuing to refine
guidelines for their particular application. I\'m losing the research
page here. Thank you.

There are folks who have developed their own guidelines and are
continuing to refine them based on the evidence of how they are used in
practice today. So one might disagree as to whether that is the end
state of 2014 or the end state of 2010. But I would guess that there are
a number of points where we could debate that point. And I\'m not so
sure that we need to hammer that home in terms of whether it goes into
the intermediate or the end state box. I think we would celebrate any
acceleration as a plus. And if anyone has objections to that statement,
let me know.

The third point I just wanted to call your attention to, because we did
receive an e mail from a couple of EHR vendors. And that relates to, are
we just talking about AQA, QA vendors; or in light of recent
developments on Capitol Hill, to reward physicians through the Medicare
program for reporting on quality, might we have some flexibility in that
definition?

So what I wanted to say on that point was, we are acutely aware of that
issue as well and very, very appreciative of having Bill Rollow from CMS
with us today. What we have been told by CMS is that they are incredibly
supportive of the alliance\'s work and don\'t see any change in that
stance in general and that the ink is sort of drying on what, the
instructions they have been given by the Congress. So we will come back
to that issue. But I wanted folks to know that we are acutely aware of
it and will bringing it back to you for your attention, but I don\'t
want us to get distracted today.

So again just to tee up those issues, I would like to make sure we are
comfortable after we hear from a couple of people \-- I\'m going to
return to the issue of, are we comfortable with this much broader high
level vision.

The second issue is, I think we should not distract ourselves with a
great deal of worry unless something seems just glaringly horrible about
whether a future state is mid-state or end state because that gets very
dicey in terms of predicting. And the third issue is, we will bring back
to this group probably at our next Workgroup meeting the question of
whether we stick to our very specific charge of AQA/HQA or whether we
allow some additional flexibility to accommodate and to \-- I\'m trying
to think what\'s the right verb here, Bill \-- to be responsive to
anticipate the needs of physicians who will be attempting to report on
quality to the Medicare program given this new opportunity that starts
in July of 2007.

Yes. George Isham, are you on the phone?

**\>\>\
**Yes, he was.

**\>\>\
**He was.

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

I am. I just have to un-mute my phone. I\'m sitting in an airport.

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

I\'ve been there, too. I wonder if I might just ask you to share some of
your comments on the vision?

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

Okay. Firstly I also appreciate the tremendous amount of work that\'s
gone into this and, you know, coming from nothing to clearly something
we can work with. I do appreciate that.

I had a call with Kelly and her colleagues and was talking a little bit
about the notion of how you accommodate the development of the state of
the art measurement over this period of time from now until the long
term. And for example, let\'s assume that in the current phase we
develop measures by specialty and, for most of the major political
conditions and we eventually figure out how to create composite measures
which capture the key facets of what should happen for each disease or
condition.

And we then take that concept and develop a person centered measurement
system where a person is either well, by their gender and by their age,
require a certain number of preventative care and behavioral sorts of
behaviors in order to keep good health; but as they become ill and
chronically ill over time with diseases, then also require a set of
measures that represent the best care for those conditions or illnesses
or conditions over time. And the measure basically is whether each
individual gets what they need in order to be healthy or to, you know,
to be treated by the health care system.

So I don\'t want our current frame of thinking about this entire
exercise to be framed by the current notions of how we think about
quality measurement by individual disease condition or individual
condition or even individual specialty. So that was my first point. I
hope that\'s not too general a point, posted in the question. I see
it\'s been, we tried to incorporate it in the matrix. I forget which
section exactly, but I did see it when I reviewed the revised matrix.

My second point is that, that this is a dynamic \-- my second point is
that quality problems and improving quality should be closely linked to
existing quality issues or problems in the health care system. And
between now and 2014, it occurs to me that we may well address some of
the existing quality problems and substitute other issues which would be
at the top of our list to be working on, hopefully over that period of
time.

So therefore I hope as we begin to think about translating quality
measures into systems requirements for HIT and automated medical records
and personal health records, we develop a concept of dynamic nature to
this concept so that that encoding or that imbedding and those tools can
be updated as those priorities change and that focus changes.

And I don\'t know where we accommodate that notion in the matrix, but we
need to have, not a fixed set of targets, but rather a system that
accommodates a more responsive set of measures over time as our
priorities and our issues change. So that would be my second big point.

I think the third one is that, almost flows from the second which is, as
we think about priorities and the quality problems that our measures
need to address and, therefore, need to be imbedded in our HIT systems
and automated medical records, they ought to be closely linked to
existing problems and not be linked to just things we can measure.

And I know that is an issue that Corrigan and others have addressed in
terms of thinking about priorities and how to establish them over time.

My last comment relates to my review of the matrix in the last day or
two here. As I look at the population health or population level
section, it occurs to me that we have not considered the relationship to
public health and public health surveillance systems. Immunization
databases, for example. And I know that in quality measurement, one of
the big enablers for addressing immunization issues, in Minnesota, for
example, has been the ability to link to existing public health
databases that, related to immunization, public health registries on
immunization. So I think we are fairly silent in the whole current
additional table about the relationship, quality measurement and the HIT
and emerging information exchange standard to needs and relationship of
public health data and public health issues.

So I would also make that comment. So \-- those are my comments.

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

So, George. Thank you. I found that very, very thoughtful. Just in
reverse order, I might ask Kelly Cronin to speak to the population
health issue because, not this week but the meeting of the American
Health Information Community prior to that, there was a very explicit
request that the AHIC actually sponsor a Population Health Workgroup.
How that was ultimately resolved, given the fact that there can\'t be an
ever expanding number of workgroups, and the fact that what would be
encompassed by population health touches on both our work as well as the
work of the Biosurveillance Workgroup and so forth, was to fold it into
the Biosurveillance Workgroup, and I think it has a new name. Did you
want to just say a few words about that?

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

Yes, we actually tried to get the input of John Lumpkin, who is one of
the new chairs for what we were calling biosurveillance. Now it\'s
redetermining the name, which is public health population health focus.
But there has been a realization that there is going common
infrastructure. Not with registries but other, the certification
processes, what data electronic health, what networks will be mobilizing
clinical data for. A lot of the secondary issues or uses of data for,
outside of clinical care observations. You know, they share a lot of
common policy and infrastructure issues. And in essence to try to really
understand the full scope of population health issues we, you know, had
a bunch of the Co-chairs and people from HHS spending a lot of time on
this, trying to figure out what are all the constructs that we should be
considering. So not only health status monitoring, public health
surveillance, population based clinical care, population based research,
but also sort of health communications and prevention type work.

Out of all the types of activities, what we need to be thinking about,
what\'s in common and what\'s unique, and how do we \-- try to address
this across all our workgroups. And I think we are still refining the
revised (inaudible) part to this. But our Surveillance Workgroup really
has started off with the traditional Public Health Workgroup, figuring
out how to opportunistically capture data from clinical care to public
health on a real-time basis. And consider more broad view, what could be
done for patient safety and other public health priorities. And it is
likely that many of the population health issues will be addressed by
that workgroup.

But certainly as this relates to population-based clinical care, making
sure that we have not only the evidence we need to develop good measures
but have the infrastructure in place to actually do the measurement and
quality improvement. We share a lot in common.

So I think it is very likely that Carol and John Lumpkin and others will
continue to refine how we are going to coordinate these issues and when
it comes to things that are concrete, like registries. And if we are
trying to make them interoperable with an emerging nationwide health
information network and all the standards that enable that flow of that
information we will have to make sure that not only do our deliberations
sort of build on each other\'s work but that the recommendations are
complementary.

**[\>\> George Isham:]{.underline}\
**One more comment on that (inaudible) our experience in Minnesota in
working on a number of issues which, where the delivery systems overlap
with public health, and immunization is one obvious example. Another is
tobacco control, where the guidelines that have been, or whether the
evidence based reviews on effective approaches, which the CDC has done
outlines both, you know, governmental functions as well as private
system functions in terms of what the role of private caregivers are and
effective tobacco control.

As you look at that, for example, as it\'s been executed in Minnesota
over the last 10 years, it\'s been a partnership between the Department
of Health and the county health departments as well as the organized
delivery systems, which resulted in some very real impact in terms of
tobacco control. And in the most recent example would be, the
recommendations for HIV screening that have come from the CDC and the
differing recommendations that have been out of the U.S. task force,
both of which impact, you know, their delivery.

So I think regardless of which workgroup is clearly primarily focusing
on that, our vision needs to accommodate or have placeholders in it for
those linkages, those cooperative relationships at both the community
level, the State level as well as the Federal level.

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

George, thank you for that. You know, as I\'m actually looking at the
matrix, and you may not have easy access to it as you are trying to
block your ears from having too much airport noise. On page 14, you
know, there is a very specific row labeled \"Population Reporting and
Feedback\", and it strikes me that we could be a bit more expansive. It
is currently written as, implicit attention that the population we are
referring to here are all of the individuals who are enrolled in
HealthPartners for a period of time or something like that.

And I think that we could certainly make a note and get that back out to
folks about \-- that by definition, greater levels of interoperability
will kind of blur that distinction a little bit and frankly will enable
more collaboration between the clinical care system and community
resources and public health to actually address the needs of a lot of
chronic illnesses.

**\>\>\
**Carol, this is (inaudible). I have a question and a comment. First of
all, George, when you were looking at that and thinking about public
health, because we struggle with that regularly in the rural hospitals
where we are.

We had a long discussion yesterday at a NORCO (ph) meeting around the
development and gaining of information in a community, health
information that work around telephone exchanges between facilities,
between providers and between payers, as well as pharmacy. And I wonder,
do you see that playing a role in the areas you just discussed as well?

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

I\'m not sure I got all of your comments. But I think that a question
\-- also another population based question is the assemblage, the
assembly of information across custom populations that may overlap
different geographic boundaries.

**\>\>\
**You said that better than I did, but thank you. Yes.

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

I mean, if that\'s what you are talking about, I can think of a number
of private applications that would want to do that using this kind of
information exchange and this kind of vision.

And I\'m thinking primarily of private health plans that have multi
State applications. There may be research applications. They want to
look at the same things.

**\>\>\
**I think from a stand alone, really understanding what we have from a
population base, we have got to have that as well.

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

They are different kind of ways to define population other than
geographic. They can be defined as Medicaid populations in a certain
number of States, and they can be defined as employer populations. There
are a number of different ways, of which this system needs to be
responsive in terms of aggregating information.

**\>\>\
**Yes. That\'s the point.

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

George, your other point about priorities that I liked a lot, you won\'t
be surprised, it does seem to me that on page 7 \-- this speaks to, I
guess the engagement of the research community.

There is a mid-state expectation that evidence gaps are identified
through a national priority goal setting process. I think that that
might be \-- you know, very, very minor word-smithing, could allow us to
indicate that this is a dynamic process similar to the Institute of
Medicine report that you worked on and other recommendations that have
come from there and what the National Quality Forum is trying to do now.

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

In addition to that, Carolyn, I\'m also thinking about CMS in terms of
its application at the other end of this process, in terms of possibly
looking at aggregating and providing information that would drive pay
for performance updates by different procedures or specialists or so
forth.

And therefore the priority question not only applies at a population
level, which is reflected in that previous report you referred to, but
also would apply at a finer level which I think is specialty, clinical
situation, that aligns as more with how one would think about
aggregating data and paying for it at the back end.

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

Great. Well, that\'s very helpful.

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

The top 10 quality problems for dermatologists, the top 10 quality
problems for surgeons, the top 10 quality problems for internists,
pediatrics and so forth, as an example.

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

Thank you, that\'s great.

Other comments on George\'s comments on this visioning matrix?

**[\>\> Margaret van Amringe:]{.underline}**

This is Margaret. I have a comment on the high level vision, but I\'m
not sure if I\'m going out of order by giving the comment.

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

Yes, that would be fine.

**[\>\> Margaret van Amringe:]{.underline}**

Okay. I also really think the redrafting is very good. I like the way
things are flowing. I only have a minor comment on the high-level
vision. It is on the last sentence where we talk about the progress on
the nation\'s quality goals are reinforced by public reporting on
metrics by financial systems. And my feeling is that the word
\"financial\", the words \"financial incentives\" is really too narrow
and that I think, while it is very important to have incentives that
drive behavior in a way we want the quality expectations to go, that
alternately since we are really talking about our vision, is we want to
have reimbursement policies that, by their very nature (inaudible) the
quality expectations that we have of the system.

So while we still may have some incentives payments, you want to have
some transformation of the reimbursement policies themselves. They match
where you want to go in quality.

So I would prefer if we used something along the lines of saying that
the quality goals are reinforced by public reporting and by a \-- and
not limited to these words by any means \-- but a payment framework that
aligns expectations for quality with resources or something in there
that really talks about the overall payment or reimbursement framework
and not just limit ourselves to incentives.

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

Comments on that suggestion?

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

This is Jane Metzger. I think that\'s a great suggestion. I wanted to
comment on the difficulty of figuring out the mid range versus the
ultimate goals. I think one of the challenges that we had as we were
looking on the revisions list, we were hoping that our recommendations
would help shape what happens in the mid column, and we had not yet made
recommendations. So I just wanted to make that comment.

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

That\'s completely fair.

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

This is Charlene. I have a \-- I support changing the last sentence. I
did have one other suggestion based on the material that Linda provided.
Under the infrastructure piece, I don\'t know if we explicitly carve out
where we are with health exchange networks. And perhaps \-- I don\'t
know if we want to position it in the NHIN or in potentially the PHIN,
because if we put the status of those in there, we might be able to
demonstrate the convergence of PHIN and NHIN. We would hope they
(inaudible) subsumed in the far out States, but we might want to add one
or two more rows for infrastructure to help better reinforce the story
that Linda shared with us.

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

Charlene, this is Kelly. We can easily add some information on certainly
what would be demonstrated over the next month in 12 local markets and
maybe give more of a discrete snapshot of where RHIOs are, how many are
operational, how many are making money, how many are actually providing
data that we know of to potentially contribute to quality measurement,
which we know there is not that many right now. But there is certainly
many that have plans to, as Linda had indicated earlier. And I think the
one thing Linda did mention, we have another report that focused on,
sort of what the logical maturation might be for some of these
exchanges. And I think many of them, since they do consider quality, or
providing data for quality measurements, be fundamental to their
longer-term business model. But they will likely, you know, maybe not do
it in Year 1 or Year 2 but Year 3 or Year 4 or when the NHIN service
providers become more widely available as the market develops, they will
allow for that information to become more easily aggregated.

So I think we could easily add some detail there that would help us not
only understand where we are now but what we might expect to see towards
the mid-state and maybe even some of the enablers and barriers that
would get us there.

**\>\>\
**Yes.

**\>\>\
**And again I think that\'s where we want \-- we talked about, or it was
talked about yesterday at the AHIC meeting the relationship between PHIN
and NHIN. And I don\'t know if there is a stake you want to put in the
ground or if you have put a stake in the ground. Actually the PHIN is
subsumed by NHIN.

**\>\>\
**Yes, I think PHIN is in some more ways at a conceptual level, not the
NHIN, and really network to network. It\'s just that the public health
standards should be consistent with what the health IT standards panel
agrees to over time. So there will be a lot of overlapping consistency,
but I think PHIN is more discretely functioning towards public health,
traditional public health. Not so much for sort of population health,
clinical care construct that we talked about earlier. But it is just for
clarity purposes we could certainly add something in there.

**\>\>\
**Yes, I guess I\'m all for clarifying language. I think the tension
here is that we had agreed earlier on we were going to let the market
work. I\'ll certainly be interested in the report on whether any RHIOs
or health information exchanges are making money, because I would
suspect it is still an uphill struggle.

And I frankly am a little bit more comfortable thinking about health
information exchanges, a cluster of functions, which may or may not be
located within one organization or may in fact be distributed over
several organizations. And just as health care looks quite different in
different markets and communities, you might expect that that cluster of
functions is going to take different forms as well. But I think our
focus needs to be on the functions rather than, and the requirements
rather than exactly what the shape of the table is.

The more we can avoid the shape of the table, the better off I think we
are going to be in terms of moving forward.

**\>\>\
**I think \-- I have to agree with that. This is (inaudible).

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

Thank you.

Other comments on the visioning matrix?

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

This is Pam French, and I\'m participating on behalf of Rick Stephens
today.

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

And delighted to that you are here, Pam. Let me say that. Even though I
had to be late, I apologize.

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

My pleasure. And I want to say, too, that this matrix is a really good
start to showing what our long term vision is. I think by having this,
it will help us then as a next step prioritizing. One of the concerns I
have when I look at this, there is really good information here. And
again, I think you need a long term vision to ensure whatever steps you
take along the way, and we know in some cases these are going to be
developmental and we will have additional innovation as we move forward.

I think what might be helpful is to start with this matrix and maybe try
to prioritize some of these activities. But they are all really good,
but realistically I\'m not sure we can achieve them all by, for example,
midterm or mid-state.

And so either specific ones that we think will help enable the others we
should be prioritizing.

**\>\>\
**For those who, you know, did the hard work of putting this all
together, were there some thoughts about that as the matrix was
developed?

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

This is Jane Metzger.

I think one of the assumptions that underlies a lot of how things shaped
out in those mid- and end state columns was that there would be a
unified national quality agenda and a serious convergence. I\'m not sure
we ever said, you know, single set of metrics, you know, let\'s say a
hospital care, whatever. But that was an underlying assumption, that
there would be serious convergence in not just what the metrics were,
but exactly the definitions for those metrics and the reporting
requirements.

And if that\'s not really at the foundation of our vision of the future,
I think we are going to have to go back and make a lot of changes. And I
noted that Carolyn started today with a comment about, you know, some
immediate issues around our metrics converging or not, and I think it is
related to your question about priorities because the vision moves
forward. I think pretty much that\'s the most fundamental assumption
that drives the movement of the vision from current state to a future
state.

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

This is Janet Corrigan. And I could not agree more with Jane. I think
that the reason we will not have that convergence around measures unless
we set the national priorities, and there is a very strong consensus
base and buy in to that process.

Once you can get the national priorities and goals, I think then we need
to really work at the next step which is the convergence around the
measures. And a piece of that convergence is also the harmonization of
the measures so that we are really developing measures that not only
correspond with the national priorities and goals, but measures that fit
within a comprehensive measurement framework, that we really thought
through the different kinds of measures and how they supported the
greatest numbers of needs that are out there and how they fit together
and harmonize together. Those are all critical front-end building
blocks.

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

This is Bill Rollow. I think I would pick up on the comment just made
and say that \-- well, at least from my point of view, it is hard to see
exactly what happens with this document. And maybe for those of you who
participate in the fuller AHIC, it is much clearer what would happen
with it.

But you know, I agree with what others have said. I think this is, it is
a very ambitious undertaking at this point and it is very good shape and
very nicely done.

I would point out that there are some places where I think, in a given
section, what is said in that section doesn\'t really line up very well
with what is said on a similar topic in another section.

So just as an example of that \-- and it may not really matter very much
\-- but reflection on consumers in description of key stakeholders is
really very much about measurement and reporting, which is obviously
important, but not very much about personal health records systems and
consumer empowerment, which is in other sections of the matrix itself.

Further down than receiving care, for example, and also up in the higher
level brief description. It appears in those other places. So there is
some things back and forth where, if you just looked at a given section,
you might say, well, gee, this is not very fully descriptive of what you
are looking for, although it does appear elsewhere.

I would also, perhaps in a similar vein, just note that of the providers
identified as key stakeholders; this is limited to physicians and
hospitals. And I think probably some other provider types would take
some offense at that. You know, certainly CMS would work a lot with
nursing homes. And they are a critical part of, I think, the quality as
well as the IT agenda.

But aside from those comments, to me, I would come back to the same
thought that was just expressed which is, in a sense there is so much
here, that it is hard to sort of come away from it and say, now, what is
the critical message? What are the critical issues here?

And on the one hand, I think our discussion last time was to the effect
that the document needed to be more broadly about quality and not so
much just about measurement and reporting. Having said that, it strikes
me that there are likely some other workgroups within AHIC that are
going to focus on some of those other issues. And perhaps if we were
going to try to pull out just some critical issues, it would in that
case be appropriate to focus on the measurement and reporting related
things. I don\'t have a good enough understanding of the overall process
to know if that\'s true or not.

But if it were true, it seems to me it would be very useful to try to
pull out a handful or a dozen or some relatively small number of things.
The issue of measure standardization, which was just alluded to,
certainly would be one of the things on that list; but I think that
there would also be some other pretty significant things on the list.

Just as an example, it seems to me that one of the critical issues in
reporting, performance reporting is, will there be simply an
administrative data aggregation effort or will there be an IT based
effort that comes out of clinical systems that providers are operating.

And if the answer to that is we think there should be both, and we think
that they should both be available early in the process, think again of
the, you know, the potential for CMS to work through between now and
July, I guess, what the physician recording is going to look like.

If it is important to say that there should be both IT based reporting
as well as administrative reporting, that\'s a huge issue, and I am not
here to argue that that should be the statement that would be made.
That\'s probably for others to think about and decide whether it is
appropriate or not.

But that\'s the kind of critical issue that I think you want to have
come out of a process like this.

Another, I would say, related issue perhaps would be the issue of
attribution between physician and patient. So from a measurement and
reporting point of view that\'s a fundamental issue. How do you do that
attribution? Alternatives include doing it retrospectively, which might
typically be an approach that\'s used when you are using administrative
or claims data, or doing it prospectively, which would become perhaps a
much more likely and perhaps good option if you were using IT systems
based reporting.

And I would argue potentially, at least for further discussion, that on
prospective identification of physician and patient, meaning they both
essentially somehow designate each other as the person to whom the
performance is being contributed \-- medical home, personal care
physician, whatever different mechanisms you want to think of \--
that\'s another critical issue that potentially, I think, would be
useful to come out of a thought process like this.

It will be a very practical issue that, again, you know, will have to be
dealt with in the context of measurement and reporting in the next
period. And it fits very closely, I think, with an overall IT agenda for
measurement and reporting.

So sorry to go on so long, but those are couple of the kinds of ideas
that I think would be useful to try to pull out of this.

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

This is Jane Metzger. I wanted to comment about this issue of either
other workgroups worrying about some of the things that came into this
table through recent efforts to expand the scope. I think some of us in
the subgroup felt very strongly that there is no other workgroup
basically worrying about the contribution of the EHR to quality
improvement. And that\'s not to say that the initial set of \-- maybe
those are the priorities for the initial set of recommendations from
this group.

But I think solving the whole quality improvement challenge, overcoming
the whole challenge will require some serious focus on the capabilities
in those tools and how they get used. So I don\'t believe that that is
explicitly being addressed by the other current workgroups.

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

Jane, this is Kelly. I think that\'s right. And I think actually a
majority of what\'s in this matrix has really not been touched on by the
other six workgroups. There is some overlap with consumer. The Consumer
Empowerment Workgroup spent a fair amount of time developing their
vision. And there is some areas of overlap, in particular when it comes
to what we expressed in sort of the end state, the widespread use of
consumer knowledge sources and self care tools.

We focused a little bit even in the near term on consumer empowerment on
shared decision-making or the need for some decision support. So there
is some overlap. But I would say for the most part there are fairly
unique concepts or ideas in our vision.

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

This is Jerry Osheroff. Could I comment on some of the last couple
comments?

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

Of course.

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

This document, as people have pointed out, really is very rigid. It
looks at a central problem from a bunch of different perspectives.
That\'s the central task of this Workgroup. And if you try to sort of
boil it down to what is the greased path through this thing that all
these pieces add up to, as I understand it, basically revolves around
figuring out what the target that we are trying to hit that will drive
improved quality in this country, and figuring out what we need to do to
get information and tools in the hands of people who are making
decisions and taking action that so that they are driving closer to
hitting those targets. And then you need to extract data about what
happens so you can report on the quality improvement that hopefully you
achieve and then continue around the improvement cycle.

So it seems to me, sort of echoing something that was said a little bit
earlier, that there may be a way to sort of boil this down for the
purposes of thinking about what the most essential next steps are into
sort of what the streamlined pathway is of things that need to happen in
order to make all these good mid and end state things happen. And then
use that as a tool for thinking about what some of these critical next
steps are and then using all the details in this document to make sure
that those recommendations will fully deliver on all the nuances that
need to fall into place.

**\>\>\
**That\'s very helpful. Thank you.

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

This is Bill again. I would want to, based on what Jane said earlier, if
there really is not a lot of this content elsewhere, even though I
think, Kelly, you said that in the consumer empowerment group there is
some overlap. To me then a very, very critical issue is the ability for
provider and patient communications to be facilitated by IT.

**\>\>\
**Okay. Well, actually that has been the explicit focus of the Chronic
Care Workgroup \--

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

Okay.

**\>\>\
\--** Workgroup in particular so \--

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

Okay. Good.

**\>\>\
**Not necessarily how it that would lead to more of a measurement focus
but, I mean, you could put it in the broader context of coordination of
care or quality improvement.

**\>\>\
**As long as that\'s somewhere. That, to me, would \--

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

Well, and it \-- so I\'m hearing a lot of very, very interesting themes
here. And, Bill, I\'ll thank you and the Congress for keeping us very
focused on practical issues. And thank Pam French and others who are
saying, look, this is very, very rich document, but we are going to have
to, sort of (inaudible) high level targets here.

It does strike me that the document did exactly what I hoped it would
do. So thank you all for that.

I have found in lots of discussions trying to figure out getting to some
next phase of improving both how we measure quality as well as beginning
to think about using that information to make care better.

It is actually pretty difficult. It is really, really easy to take hold
with what we are doing now. And we have to go through a phase of that.

But after that round of shooting fish in a barrel, trying to figure out
what it would look like if we got it right isn\'t so easy. And I
actually think we have gotten a good piece of the way there. I think we
have heard some very specific suggestions for how we can fine tune it.
And I don\'t think they are going to be that hard to incorporate. And
actually, I think, Kelly it might be kind of fun to put at least a
colored print version, areas where specifically other workgroups are
picking up on these things so that people can see under coordination of
care, yes, the Chronic Care Workgroup is focusing on secure messaging
and so forth so that that becomes pretty clear.

Having said that, I think that the two issues that we probably do need
to highlight, at least in a presentation, if not in the vision
statements themselves. One is Jane\'s comment of making the very
implicit assumption very explicit that we expect continued convergence
around a national quality agenda. I would never predict that we are
going to get there in a smooth and easily visible path.

But I do think we are seeing lots and lots of things in the external
environment right now which do begin to indicate that we are heading
towards that convergence, or at least that\'s the glass half full
interpretation.

The NQF began work on national priorities. There is lots of talk about
harmonization. Almost every other report you read basically says we need
one set of rules. Now, sometimes they say those would be our own rules,
but nonetheless the idea that we need some uniformity is not a foreign
concept and, I think, has been out there for several years.

I think one other area that is a little tricky for us to navigate is, I
would read this document as there being an implicit assumption that
every piece of information that could be used for improvement, which we
said we very much wanted to keep within our sites, is also going to be
information that\'s publicly reported. I find that almost impossible to
believe. I cannot believe that the information that\'s going to be
reported to some audiences isn\'t a higher level, similar to where we
are, whether it is clinicians in their particular work environments \--
and I do agree with the comment about doctors by the way \-- but
clinicians and organizations are going to need some very granular
information in order to make very specific improvements in their
setting. And that\'s not going to be terribly useful or helpful to an
external audience. An external audience might want to know that those
steps have been undertaken, and I don\'t think we know yet how to convey
that effectively.

But I think that\'s got to be part of the initial assumption set. Would
you agree with that, Jane and Charlene and others?

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

This is George. I certainly would agree with that. And I think not only
would it be not necessarily publicly reported, but it will be
nonstandard and driven by local issues and problems.

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

Yes.

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

This is Charlene. I would also agree.

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

I think if we can get that right up front, A, it will serve an important
educational function. Because right now, for the past number of years,
we have been in touch of data hungry phase and data capture itself is so
difficult. You know, that it feels like any information we can capture
we ought to put out there because we don\'t have enough, and we don\'t
have very little \-- Bill, to your \-- but I think we are not that far
away from a state where we are not going to want to do that at all. We
are going to want to be much more strategic. I would say that\'s kind of
our near term second phase of work after we address our very specific
charge.

The other specific issue that you keyed up, Bill, that I didn\'t want us
to lose sight of is the issue about which data and timing and so forth.

Clearly CMS is going to be in the hot seat, I think, for \-- and I know
you have already gotten some feedback through public comments and so
forth, even before the Congress acted, about, well, I\'ve made an
investment in electronic health records. I want to be able to report
that way. It is very clear to me we are going to be living in a hybrid
measurement world for a while. What I think we need to be very clear
about is addressing both, how do we work with vendors to automate this
for those clinicians and health care organizations that are making the
investments right now or in the near future; and also, how do we think
about enriching, but that\'s going to be my word \-- I\'m happy for any
substitute \-- admin data, with clinical data elements that can be
obtained from other sources, whether that\'s an HIE, RHIO or some other
source. So for example, using billing data to know that our hemoglobin
A1c test was ordered is fine. You are not going to get the results
unless you\'re fed some clinical data that shows you that result.
That\'s never going to come out of a billing stream, unless you do some
very clever patches which, I hate to say, is a sustainable strategy. I
don\'t think it is.

So I think that\'s going to have to squarely come out in our
recommendations as well.

Do we have anyone else that (inaudible).

Let me add \--

**\>\>\
**Let me say also, I agree with that notion as well. And I wouldn\'t be
afraid to suggest, even though it is not a very popular suggestion, is
that for a time we may need to rely upon survey as well as chart review.

**[\>\> Carolyn Clancy]{.underline}\
**You know, I think that\'s fair, and (inaudible).

**\>\>\
**Important information and progress that\'s being made using those so
called primitive tools. And the second thing is, is that those
approaches lay the groundwork for figuring out how to use the automated
tools.

**\>\>\
**George, I couldn\'t agree with you more there. And I don\'t think that
we \-- we really don\'t know exactly how to use the automated tools. And
even with the, our particular grant right now, trying to just get the
information out of hospitals, let alone doctors' offices, is an
extraordinarily difficult task to do that, and I could not agree more
with those comments.

**\>\>\
**And the other comment is the current, the edition of Annals of
Internal Medicine has this article talks about quality in her practice
and notices as a byproduct, that the higher quality performance within
that group is not associated at this point in time with the, with
whether or not they have automated medical records or not. And that is
totally credible to me because the current application of automated
medical records doesn\'t really provide the functionality for the, for
actually generating the data, the quality improvement processes within
clinical settings needs to use in order to actually improve care.

**\>\>\
**And it doesn\'t support improvement of care either.

**\>\>\
**So I think we need to lay a pathway which is, which any good
consultants knows you have to lay, which is you have to figure out the
processes in your organizations. And then you have to use the automation
tools to, in a sense, achieve the vision you laid out in terms of
alternative workflows and altered processes that lead to better
performance.

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

Well, thank you for that, George. So we have heard a number of comments
and we will definitely incorporate them into a revised version of this
quality matrix which we will get out to you in a red line form for your
perusal.

Pam, I would like to put you in the hot seat for just a moment. And here
you are, just stepping in for the day, but I know you are deeply
interested in this issue as well. If there is one area where I would be
very interested in your input, if I could put you on the spot, not this
second, but when we send out the revised version, it would be in the
section labeled "For Consumers," which I think is page 3.

**\>\>\
**Mm-hmm.

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

I think we are still sort of scratching at that and some of that has to
do \-- or chipping away at it, might be a different way to say it. Some
of that has to do with the fact that we know we are not doing a
wonderful job now managing consumer (inaudible) information. There is no
group I meet with that\'s trying to do something important in quality of
care that doesn\'t recognize this as a problem. But I think we are still
not there in terms of articulating what a better state would look like.
Since I think you are probably closer to people giving you feedback
about what information is out there and what information they want, what
\-- when we send this around, if you could take a good look at that, I
would be most appreciative.

**\>\>\
**No, I would be happy to do it. And we certainly hear a lot of feedback
from our employees on what they would like so I would be happy to try to
incorporate that and some of what I have heard from large employers,
into that section.

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

Well, that\'s terrific. I know when some of us sat down with folks in
care-focused purchasing last week, I found a note to myself today in
capital letters that the one area we all agree we could work on
collaboratively, because there is so much to do, is actually figuring
out how to communicate this information much more effectively to the
public.

So what I would like to do then now is to turn to some draft
recommendations, to the American Health Information Community for your
consideration. So I think that you would, should have received this
file. And for those of you have tuned in by Web, we are going to turn to
that vision.

I mean turn to that section of the, turn to the specific file, and we
will be showing it on the screen.

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

This is Kelly. Just to give you some idea of timing and what will be
expected from the Workgroup. On the January 23 AHIC meeting, Carolyn and
Rick will be presenting to the Secretary and AHIC what we think, and
what we are all comfortable coming up with in the way of recommendations
for the specific charge. So that\'s really focused on how to make sure
that certified health IT can capture aggregate and report data for a
core set of ambulatory and inpatient quality measures. Certainly our
vision goes way beyond that and really focuses on the broad charge. And
we will be able to spend as much time as we need to in subsequent months
working on recommendations on the broad charge and really, you know,
thinking about the essential steps in each part of the vision that we
think is really important and, as Jerry suggested, you know, perhaps
really work on that streamline path to the end state.

But for the purposes of the next three to four weeks we really wanted to
try to focus in and figure out with we need to do in the short term, you
know, at the particular focus on what we can implement in 2007 to
advance this specific charge. Particularly now we have CMS moving
forward in a definitive way and, you know, some real momentum building.

So what we did was we tried to go back and take the priorities and some
of the conversations we have had over the last three meetings and turn
them into some preliminary ideas. Again, not really specifying exactly
what, or how things should happen or who should be involved and when,
things that need to be completed. We would really like to talk through
that as much as we can today and then again in early January. But the
goal for today is at least to start this discussion on what are the
ideas that we can all agree on in terms of what we should be covering
for recommendations and the, for the specific charge, and try to define
more around those ideas that we do agree on. The "who," in terms of who
really should be taking on certain responsibilities or certain tasks.
What exactly they should be doing. When does it need to be completed
and, in doing that, you know, taking it to some practical or feasible
considerations about, you know, do we have the funds to act on this and
can we actually get something accomplished.

So we did put together some basic guidelines for thinking through this
that we can refer to as we go through this list.

But the first category that we started with was automating the data
capture and reporting to support the core set of AQA and then underneath
that the HQA measures.

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

Yes. So the possible recommendation area and actions are first to
analyze the data elements required for each AQA measure to identify
groups of measures with similar data collection, changes and identify a
core set of measures to move forward in 2007. In other words identifying
which data elements cut across a number of measures.

I hope you will notice that while I think I said that relatively easily,
this is a fairly monumental exercise. We think it needs to be done.

The second is to map data elements required for a core set of AQA
measures to available standards to identify any gaps in agreement or
availability of standards. That information would clearly need to be fed
back to HITSP.

A third is to identify documentation and other workflow changes that
need to be adapted by providers and vendors to enable their capture,
concurrent with care delivery for a core set of AQA measures. And, Bill,
you will see in that recommendation we were trying to get at the issue
that you had teed up previously.

The fourth was to define standards enabling exchange of data required
for quality measurement for a core set of AQA measures. And I\'m
reminding you all that when you hear AQA and HQA, you can think of that
in your minds with a little asterisk, meaning that we may revisit this
as CMS becomes a little more clear, given their incredibly recent new
directions from the Congress.

And then the final step would be to move forward to the certification
commission requirements for electronic health records to capture data,
to support automation of a core set of AQA measures. And the next set of
recommendations essentially is identical, except it speaks to HQA.

**\>\>\
**This is (inaudible). The next one I think talks about HQA in the
title, but AQA in the various bullets.

**\>\>\
**Thank you. We knew that. No, I\'m just \--

**\>\>\
**Might be more accurate than the paper version there.

**\>\>\
**Yes.

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

This is Jane Metzger. In the CCHIT item, in that first group, is that
\-- is the intent there just to be sure that CCHIT is covering the data
capture requirements? As you know, I sort of live in the world of the
physician process and clinical decision support, and I would be sorry to
have certification focus on measurement while not at the same time
covering the other capabilities that are needed to improve performance
around those measures.

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

I think it is a good point.

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

This is Jerry Osheroff. Can I jump in with a comment here?

**\>\>\
**Yes.

**\>\>\
**Yes.

**[\>\> Jerry Osheroff:]{.underline}\
**With regard to that point, I had a conversation with Mark Leavitt, I
guess a couple of weeks ago. We were talking about the clinical decision
to support components of both the inpatient and ambulatory certification
things. When you look at the CCHIT tables, there is many disparate
things that sort of deal with improving quality or measuring quality
through CDS or whatever, and it is very difficult to get an overall
sense of what\'s going on.

And he \-- in that exchange that we had, I guess we are both electrical
engineers so both of us have this desire to have this sort of overall
picture of what\'s going on and what we are trying to accomplish and
what, what all the \-- how you get from there here to there kind of
stuff. So he had made the comment in that discussion. We had talked
about developing this model of what sort of things need to happen both
on the CDS side and data collection side in order that the certified
systems will drive improved outcomes. And the notion of having there be
some picture or some outline of what that looks like for specific
targets, whether you are talking about improving medication safety or
improving core measures performance or whatever, the idea of having
something like that is very appealing. But the challenge is, he said
that CCHIT is not really the appropriate organization to be developing
something like that.

He said this is a sort of thing that should probably come from, you
know, HHS or AHIC or whatever, where we sort of map out what the care
processes are, what the points where you could deliver clinical decision
support, points where you need to get data out. And then a mapping like
that could serve as the framework for doing a lot of the things that are
being talked about here and addressing Jane\'s point of not just sort of
looking at the measurement side in isolation or, even worse, looking at
the measurement for certain very specific goals without considering
overall the kind of things that need to happen for the dynamic kind of
care improvement that hopefully this group will be helping to drive over
time.

**\>\>\
**Thank you. So we can add that. Your specific suggestion, Jane. And I
appreciate that comment, Jerry.

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

And this is Kelly. I think \-- so essentially what we want to be focused
more broadly on is functionality and operability criteria that would be
relevant to not only quality measurement, but clinical decision support.
And specifically maybe some of the, be mindful of the character and
processes that would have to be taken into account in developing that
criteria.

**\>\>\
**Yes \--

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

The second comment about how the guidance might be framed \-- this is
Jane Metzger again \-- is that anybody whose spent the time to look at
the CCHIT criteria knows that there\'s a roadmap. And I think this is a
very important aspect of the criteria because it basically serves to
give purchasers and vendors notice of what\'s coming.

And so I think guidance from this Workgroup should also consider the
urgency of things. Because CCHIT goes through a process every year of
thinking about priorities and also thinking about the vendor marketplace
and the amount of lead time that needs to be given to vendors to develop
new capabilities.

So I hope that the guidance can also either make specific
recommendations for what roadmap here \-- that would certainly help on
the other side of the fence \-- or at least indicate priorities or
urgencies that could be taken into account.

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

Thank you, Jane. I think that\'s incredibly helpful. If there is one
thing I\'ve learned from accreditors that the joint commission and NCQA
in particular, it is the concept of giving the vendors lead time is
incredibly important.

**\>\>\
**And considering that we are focusing on a specific charge of a core
set of measures, do you think that we should be specifying sort of when
these criteria relevant to the core set is of measures should be part of
the certification process or when it, how it should be integrated into
the roadmap?

**\>\>\
**Well, first of all, I think that the recommendations should group
things that need to go together for them to have the desired result on
the other side. But it would also be helpful if when it, when the
guidance is framed, this Workgroup were to say, for this and whatever
other reason, we feel strongly that this needs to be in next year\'s
certification; or because there is, this is not going to be mandated
reporting, we think for at least another year, it could go into 2009. I
think guidance about whether it is of immediate concern and therefore
should be in the next year or maybe can wait a year would be very
helpful. You know, one of the operating principles of CCHIT is that it
takes guidance from HHS on matters like this. So framing it in that way
will have a big impact on what happens as it gets folded into
certification.

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

Thank you, Jane. That\'s very helpful. You know, it strikes me that
guidance should actually come from the AHIC so that we should key that
up as a specific question for them to consider.

On one level, HHS guidance might be narrowly framed as what directives
CMS is likely to encounter. On the other hand, sitting around the AHIC
table by design, major players from the private sector to bring market
power to this entire enterprise, and my guess is we would hear from the
private sector \-- correct me if I\'m wrong, Pam \-- a stronger sense of
urgency than waiting to see what Congress is going to do.

**[\>\> Pam French:]{.underline}\
**Yes, I think one of the concerns is that we want to get this
information out, and sooner the better. And we think that there are some
measures that there is some agreement on. And again, we think of it kind
of as iterative process, that there will be continued innovation along
the way. But again we are not really, I think wait for a Congressional
solution. There is no telling when that might be. And I think there is
enough of a concern about the lack of information being available that
we have got to take steps where we can to move this forward.

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

And, Jane, just to get back to your point about communicating a sense of
urgency. I guess one of the issues we are going to have to encounter as
a workgroup, which in turn gets translated into requests or demands or
whatever of staff here, is to what extent we communicate that urgency,
not just verbally as in we need it now, but also do we actually have to
lay this out for HITSP and CCHIT in a way that makes it much easier for
them to take action on it as opposed to, well, fix your roadmap and let
us know how soon you can get to it.

I guess \--

**\>\>\
**Well, speaking \-- I cannot speak for HITSP. But we have a policy that
actually was formalized within the last few months that basically gives
meaning to the roadmap in the sense that it says that capabilities that
are not widely available in the vendor community can be introduced into
actual testing 18 months after they\'ve appeared on the roadmap.

Now, we wrote into that an exception that there could be shorter lag
times, if you will, giving vendors the time to prepare if there were
regulatory changes or specific direction. And I\'m forgetting now
whether it says from HHS or AHIC. But I think it says \-- it may say
from AHIC. But in any case \-- so it\'s, if it is urgent and it should
be an exception to that policy, it would be important that that be
conveyed as part of the guidance.

**\>\>\
**Thank you.

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

This is Jerry.

**\>\>\
**And that\'s clearly specific language that we can check out as well.

If you look at the chart on the screen or in the handout in front of
you, you will also see that in addition to the specific recommendations,
there is also who, what and when. So in terms of the first row that
applies to both AQA measures as well as HQA, we know that there is
already work in progress. And we will certainly circle back to see
what\'s happening with the \-- and I may leave a party out so, if I do,
please forgive me \-- the AMA, NCQA \-- CMS involved here \-- consortium
of working with electronic health records vendors, certainly would rely
on the work Terry Cullen has done with the Indian Health Service, as
well as involving the HIT subcommittee of AQA. HQA does not have a
comparable group to do that with. In either case, I think we would want
either alliance to sort of bless what we\'ve put together, even if they
were not actually helping to create this roadmap.

We have talked a bit about when in terms of urgency, including whether I
need to follow up on what is the specific language that the
certification commission uses so that we can align ourselves as closely
as possible. And the what looks like the substance of the recommendation
to me. Is that correct? Okay.

Any other comments on these two sets of recommendations? I\'m looking at
the first two slides then.

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

This is Jane again. I think the, back to this issue that keeps popping
up which is convergence of measures. There\'s been a lot of discussion
at CCHIT about the need to support data capture, quality improvement and
reporting as driven by external reporting.

And a lot of general capabilities are in there, in the roadmap, as Jerry
mentioned, that could apply to a huge range of measures.

One of the issues that has been raised is at what point could CCHIT say
specifically the vendor has to be prepared to report these external
reporting record formats. And the inability to do so, so far, has been
this question of which set of measures, because obviously that would
need to be specified.

So I think if the guidance from this Workgroup says that basically
inpatient and ambulatory EHRs need to be prepared for this set of \--
I\'m not sure what the wording is \-- but agreed upon measures, that
guidance alone will clarify a lot of things at the CCHIT end.

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

This is Jerry, I have a comment about the third row in both of these
slides.

**\>\>\
**Mm-hmm.

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

Identify documentation and other workflow changes. And here it is linked
to just the gathering the data for the core measures. But as Jane has
pointed out, there is an opportunity to, you know, make recommendations
that will cover both the CDS part of it as well as the data gathering
part of it. I wanted to mention in the "who" category, if you are trying
to identify changes, it would be helpful again to have a framework of
what the workflow looks like in the different environments where there
is specific opportunities to deliver information at the different
stakeholders\' meetings that make that decision or to gather the data
that\'s needed for quality reporting.

There is an activity that CMS is supporting with the MassPRO QIO under
the eighth scope of work to develop training modules for doctors\'
practices to help them understand to how to do care management better
and specifically leveraging clinical decision support to accomplish
that.

So one of the activities that\'s happening within that project is a sort
of mapping of these workflows, as I was just mentioning. And the
opportunity for gathering data and delivering clinical decision support
within those workflows. So that could potentially provide a framework
for getting this thing done not only for capturing the data but also for
delivering the clinical decision support information. So under the "who"
category for that, particularly if it is going to be looked at in the
broader category, I just wanted to mention there might be opportunity
for synergies there. If you like, I can send you some of the very early
stage work products that sort of map out those workflows and the goals
of each step and the opportunities for clinical decision support
intervention.

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

Thank you very much for that. And we are of course very fortunate to
have the prime architect for a lot of this work, namely Bill Rollow,
with us today. Just to clarify, Bill. It is my understanding that a lot
of the focus of that work was on small physician practitions?

**[\>\> Bill Rollow:]{.underline}\
**Well, certainly the docket work is.

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

**[\>\> Bill Rollow:]{.underline}\
**But the project that\'s being described that MassPRO is doing, I
don\'t think has any real \-- it doesn\'t \-- I don\'t recall that it is
limited to one type of practice versus another.

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

**\>\>\
**The primary focus is actually in the smaller offices, but the workflow
mapping is being done in such a way that it will not only apply across
different sized out patient practices but also apply across the
inpatient side as well. So the material that, you know, I could share is
sort of generic across all those different settings which I think is the
ultimate scope of what went through this group\'s purview is.

**[\>\> Carolyn Clancy:]{.underline}\
**Does that fall within the boundaries of what the certification
commission does?

**\>\>\
**Well, I mean I think when it comes to implementation, I think \--
(inaudible) you may have a comment on this \-- but I think we are \-- at
this point ambulatory EHRs are not talking about looking at how things
are working as it is implemented in an office. It is really more of a
software testing based process. But it is not to say that for inpatient
or network services down the road, they might go more towards that, or
PHRs, if they take that on. But \--

**\>\>\
**Actually the certification process itself really does assure that
they're functional in the physician\'s office (inaudible) an audit of
the office (inaudible) in the laboratory setting.

So at this point the inpatient would (inaudible) piece. A small part of
the overall certification process (inaudible).

**[\>\> Carolyn Clancy:]{.underline}\
**So your point, Jerry, is that that piece needs to be captured in our
recommendations for short term work?

**[\>\> Jerry Osheroff:]{.underline}\
**Yes.

**[\>\> Carolyn Clancy:]{.underline}\
**Okay. That\'s fair. And obviously, in the who column we would be
reaching out eagerly to take advantage of what MassPRO or anyone else
has done in this regard. I was trying to make the distinction between
what is effectively software testing and what is practice redesign by
any other name. Obviously they are intrinsically and intimately linked,
but they are separate. I mean, it is not possible for me to imagine how
the certification commission can actually look at who is doing what in a
practice.

**\>\>\
**No, just make sure that the product itself \--

**\>\>\
**Yes.

**\>\>\
**\-- is being used and does function as opposed to be doing
(inaudible).

**\>\>\
**Okay. This is like the work you showed us, Jane. With the \--

**\>\>\
**Yes. Yes. Okay.

**[\>\> Jane Metzger:]{.underline}\
**Well, no. The work I showed you was Leapfrog, which is different. This
looks at the implementation, the implemented EHR. Certification looks at
the product. The Leapfrog evaluation looks at the implemented EHR.

**[\>\> Carolyn Clancy:]{.underline}\
**One other question I had, just getting as concrete as possible, is how
far along is the AMA and NCQA CMS consortium?

**\>\>\
**I think it is an excellent question, that to be best answered probably
requires actually specific look at it.

**\>\>\
**Okay.

**\>\>\
**So \--

**\>\>\
**How far are they along in what aspect?

**\>\>\
**I think we are, just concerned about that, trying to craft a
recommendation that\'s going to take into account what\'s already been
done and identifying data elements or data requirements, or the AQA
measures that would then translate into the developing criteria for
certification.

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

This is John White again. At the last AMA, NCQA, CMS consortium meeting,
the second workgroup, Workgroup B had taken one measure, applied it to
one EMR, which I believe was Siemens \-- and started to look at how they
could pull out data. They made an example of that.

Is that specifically what you are looking for?

**\>\>\
**Yes, that\'s helpful. So basically we have a pretty good ways to go
and would need to figure out what combination of folks could work
together on this in a relatively short time frame?

**[\>\> John White:]{.underline}\
**Yes. And there is another meeting coming up soon. So if you wanted to
touch base with them, you would \-- certainly already possible.

**\>\>\
**Okay.

**\>\>\
**And certainly I\'ll take that back to the consortium as well, guys.

**[\>\> Carolyn Clancy:]{.underline}\
**That would be great. Because the last thing we need to do or certainly
want to do is duplicate work. This would not be, in my view, productive
redundancy.

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

This is Jane Metzger again. Bill Rollow mentioned a very important
reality for quite a while, and that is that we are going to have some
combination, in the real world we are going to have some combination of
manual and EHR-generated measurement data. And figuring out, you know,
exactly how that\'s going to work and how that\'s handled by a \--
whoever it is to whom data are submitted, seems to me is an important
piece of the puzzle. And I\'m not smart enough to say what the immediate
actions should be. But it seems to me there should be some around that.
I agree with the, let\'s work on the EHR world. But we are in transition
for a long time to that being the common practice.

**[\>\> Carolyn Clancy:]{.underline}\
**Well, I agree with you completely, Jane. And when I spoke glibly about
adding clinical electronic elements to administrative data, of course
that was 10,000 feet above where the actual action is in terms of who
needs to do what and what that would look like. It does strike me that
we could certainly go back to Marc Overhage in terms of what they are
doing in Indiana to find out how much of a map that is, as well as go
back to the report from AHIMA, to find out, are there other examples
that we could learn from. Because I think that very much has to be part
of the map as well, and we may be able to have a simplifying assumption
to keep the list of recommendations short, but it is almost a parallel
process.

**\>\>\
**I wonder \--

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

(Inaudible) this is George.

**\>\>\
**Yes.

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

You know, many private systems are just beginning to engage this very
question.

**\>\>\
**Right.

**[\>\> George Isham:]{.underline}\
**And I don\'t know how you find them and collect that experience. We,
for one, are working very hard on this very issue within our own system
(inaudible) medical records and reporting functions and manual
processes.

So, you know, I just make that comment. Maybe there is a role here for
some sort of an effort to find out what private systems are doing and
figure out which of them are addressing these issues and how you can
harvest the lessons from it.

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

I think that\'s a great point.

Just speaking from the perspective of your own organization, George, how
willing might you guess would people be to share some of that?

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

Well, I think we would be very willing. You know, we are both a medical
group and a health plan. The health plan part has to work with a number
of systems which now have automated medical record systems.

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

Right.

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

The sooner we get to standard, open source protocol, which allow those
private care delivery systems, medical groups if you will, to interface
with our need to collect the data in a more streamlined and efficient
way, the better off we are going to be. That\'s not a proprietary kind
of issue for us. It is a need that we need to figure out how to solve,
you know, early on.

**\>\>\
**And I think if we are going to move very forward very fast it is one
we have to solve early on.

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

Right.

Because for us, now \-- and again this goes back to the earlier point
around the manual collection of data. As you know, Carolyn we are
collecting data that is not just the basic stuff that\'s available
through claims data. We are actually collecting the values, the blood
pressure values and the hemoglobin A1C values, the cholesterol values
and so forth to create a much more sophisticated performance than those
we\'re initially talking about.

And the sooner we get to the ability to automate that function the
better off we will be. And the lessons we have learned from doing the
chart reviews and the manual polls are actually to us in terms of how we
approach this, using an automated medical record environment.

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

That\'s very helpful, George. As we come up with a strategy to figure
out how might we find out in a fairly efficient way what\'s in private
systems are doing, how we could pull them together perhaps to
crystallize what some important insights are and to refine our own
specific recommendations moving forward.

Let me just promise you we will be following up with you.

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

All right.

**\>\>\
**Can I just ask a question, I think, about one of these elements as it
applies to the ambulatory side but more, I think, to the hospital side.

**\>\>\
**Mm-hmm.

**\>\>\
**And that\'s again that third one about identified documentation and
workflow changes, et cetera.

**\>\>\
**Mm-hmm.

**\>\>\
**That the presumption, it seems to me from the language there, is that
the measures specs themselves are fixed, that the changes that occur
need to be made on the workflow or documentation or EHR capture side of
things. And I\'m wondering whether that\'s a given as opposed to, for
some kinds of things, the workflow or documentation potentially might
drive some changes in the measure specification.

I know that when we did this kind of work on the ambulatory side now
about \-- can\'t remember if it was two or three years ago \-- it
certainly seems that potentially changes on the measure side might be
appropriate.

For hospital care, I wonder if that might be even more the case. Some of
the measures on the hospital side are pretty complex. And I don\'t know
how readily that information is captured in current workflows, et
cetera, or necessarily should be, and whether it would be appropriate to
consider changes in measure specs in addition.

So I\'m not making an argument here, but I\'m wondering if others have a
thought about whether that door should be left open in some way.

**[\>\> Carolyn Clancy:]{.underline}\
**Could I just throw that back to you to make sure I\'m understanding
it. In other words, we are talking about attempting to automate in some
fashion, both for an electronic health record world and in a hybrid
world the collection and capture of data required for measures, which
are almost developed in a data free zone. I don\'t mean a data free zone
because they are looking at clinical evidence and what\'s the
relationship between the process of care and selected outcomes that we
care about. But they are not, in general, developed with any eye towards
how easily can we capture this information.

And your point is that, as we create this map we may actually identify
opportunities where we say, well, we can get 90 percent of what we need
very easily and efficiently if we stop here or if we in some way reframe
the measure.

I definitely see that as very much within our scope, at least in the
medium term. I think the trick is more one of timing. And again we might
tee that up as a discussion point for a presentation on the 23rd of
January.

I don\'t know that \-- I don\'t know that there is a right or wrong
answer here. I think the question is, as you look across the universe,
how do you create the most momentum going forward. The universe of this
country anyway. How do you create the most momentum going forward? And
at the same time, there is no question that we are going to get to a
space where data capture is definitely going to have an impact on how
measures are crafted. I think the issue then becomes this classic
mid-state/end state recommendation.

**\>\>\
**I think this point relates to the earlier point I made way earlier in
the conversation around the fact that the whole environment needs to be
somewhat dynamic.

**\>\>\
**Yes.

**\>\>\
**Not only to change with respect to priorities but also with respect to
experience, you know, in terms of how these things actually end up being
rolled out and deployed in real operating systems and where the
shortcuts may be, you know, become apparent and where the trade offs in
terms of specifications may be, you know, very wide sorts of things. But
I think that comes from experience with deployment. And I think the
principle of modification and refinement and lessons learned with
implementation, I think, needs to be somehow generally expressed.

**\>\>\
**Carol, I recently had the opportunity to work with one of the
hospitals in Waco, trying to evaluate their measures. Just a core
measurement stat. And the questions that they had as they tried to pull
those measures, kind of in my mind really highlight this issue. And I
think as we move forward and as we get more experience, we\'re actually
looking at it and evaluating what we have, there has to be the option
for us to redefine and clarify. So I agree that that should be left on
the table.

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

Well, thank you very much. And we will try to capture that in these
recommendations.

I mean, it seems to me the dynamic has at least two implications here,
or three. One is in terms of priorities in terms of what is facing
health care and how the health care system is doing, both nationally and
in some cases regionally.

A second area relates to the changing scientific base. So if we find out
that angiotensin receptor blockers are as effective as ACE inhibitors,
then the measure needs to be changed to reflect that. And the third is
in the construction of measures themselves. So I guess I would like to
envision a future state when a specialty society is creating guidelines
and measures, A, that those two processes are done concurrently and they
are done with an eye towards data capture. But that\'s at least
mid-state at least, if not end state.

**\>\>\
**I think the other unstated fear of many in the private sector \--

**\>\>\
**Yes.

**\>\>\
**\-- will be that, if some of these things get very specifically
encoded in standards and laws and regulations, that then the system
becomes rigid and unable to move forward and learn from itself.

And, you know, I say that very explicitly, not to be challenging or
provocative. But I think it is a challenge to us to, in a sense,
accommodate that fear and, you know, make explicit the intent that this
is a dynamic learning system, if you will.

**\>\>\
**Your point is well taken. And I think it is probably the strongest
statement I\'ve heard recently, although not directly in support of the
existence of a National Quality Forum.

**\>\>\
**I don\'t want to, I don\'t mean to be provocative with it.

**\>\>\
**No.

**\>\>\
**But I think that it is one that, you know, deserves some attention.

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

This is Kelly. One of the concepts that\'s been kicked around just sort
of loosely over the last couple of years on occasion, realizing that we
have such a dynamic, you know, state, that we are going to have a
continuing set of measures that is going to expand over time. And it is
going to be very challenging for the health IT industry to be responsive
to that changing environment, given the lead time and their product
development life cycle. So I\'m wondering if at some point we should be
discussing some ideas or solutions that would enable industry to focus
on product development that would really lead to good innovation, but
perhaps not tie them down with this constant need to try to take into
account modifications to specifications or new specifications based on a
growing set of measures. And one idea that\'s been thrown out there,
that we don\'t have to talk about now but maybe at some point, is the
software development kit that could be updated and just would allow for
a much more, you know, much easier automation process potentially.

**\>\>\
**Kelly \--

**\>\>\
**Well, you know, from that point of view again, you know, early
experience with the first generation of automated medical records is the
sometimes frustration of people in terms of how you get encoded, you
know, decision support routines that you know work in manually; but you
cannot get the attention provider to get them kind of encoded or
implemented in software. And what\'s the expense associated with that,
the time and trouble and so forth. And I think it almost becomes a
characteristic we want to encourage in the software system, where there
are more clients or reliant or responsive to the need for updating
change with respect to changing standards and conditions and so forth.

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

This is Jerry \--

**\>\>\
**As a characteristic that is very frustrating in the early
implementation of first generation consent. And therefore, you know,
when we think about the whole message from the matrix we created, you
know, this up until 2014 kind of message and the distance we have to
travel over that period of time, we certainly are not going to be want
to be dragged down by a system that\'s not responsive to this demand to
accommodate the development of this field.

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

This is Jane Metzger. I totally agree, but I think there is a way to
actually ensure that systems have tools, not hard coded clinical
decision support.

I think what we don\'t want is to head toward hard coding of, let\'s
say, guidelines for immunizations. And so far certification is looking
at the tool set that would allow the site to set up the criteria for
prompting and to change those.

And, you know, over time there may be smarter ways to make it easier for
individual physician practices to download from somewhere the right
rules. But I think that we don\'t \-- if we state the requirements
correctly to CCHIT, we can be heading in the direction that George was
just mentioning, as opposed to setting it up so that things are hard
coded and then, in that vendor development, vendor update cycle.

And I think that a lot of work needs to happen on this front for
medication related decision support. And that\'s one of the, one of the
areas we cannot just solve by certification, but it is going to take a
lot of other effort. But I think this relates to the kinds of guidance
that are given to CCHIT.

I can tell you that folks involved in that process are very aware of
this. And when they talk about, you know, what set of measures, they are
thinking more \-- we need to be sure we can support the reporting
requirements for some specific set of measures, not anticipating hard
coding decision support around sets of measures.

Also vendors can certainly provide starter kits and templates and things
that are already set up for a site that make it easy for them to be sure
that they are capturing the right data elements.

So that\'s another concept that, to speed implementation. But again you
would want those templates to be flexible enough so, if next week, an
element was added to a measure that now needed to be a codified data
element, that folks at a site could add it.

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

This is Jerry \--

**\>\>\
**The example is, what is in the current, you know, and I think Carolyn
knows this, as well as the others close to the AQA process. If you look
at the first starter set of measures we are talking about here, you
know, as soon as we can replace those with more sophisticated measures,
the better off the quality improvement community is going to be.

And so, you know, we need to make sure that we enable the accomplishment
of that change when it logically occurs.

**\>\>\
**These comments that are being made now, I think, really underpin the
importance of having the kind of framework that I was talking about
earlier. If there is a common picture that can be shared among the
vendors and the measure developers and the guideline developers and the
CDS implementers and all these different folks where everybody is
working from a shared understanding of what the clinical workflow looks
like in different settings, what the opportunities are for either
insinuating knowledge into the process to help support better decision
making or get data elements out of the process. If there is a generic
map that captures those issues that every one can sort of use as a
foundation for their thinking, then that provides a very powerful
framework rather than having templates of individual interventions for
the immunizations or whatever that can be modified.

If there is this common underlying foundation, then the vendors can use
that to build the systems to provide those generic kinds of capabilities
at the different steps. CCHIT can certify specific aspects of those, you
know, over time.

So I think having this common framework that sort of lays out who the
players are, what the workflow looks like and what the goals and CDS
measurement strategies can be very helpful making it so that we don\'t
have a very rigid thing and we\'re not choosing templates that have to
get tweaked and that ultimately may break when new kinds of needs arise.

**\>\>\
**All of you are convincing me, and you have been very persuasive, so
thank you for that.

I guess the issue I\'m struggling with again comes back to one of
trajectory. Do we need that framework in the long run? Oh, yeah. Big
time.

I guess the challenge I\'m struggling with is that most of the measure
developers currently do their work, probably even as we speak, in
isolation of any kind of framework for data capture. And in terms of,
you have to walk before you run. It is the sequencing that I\'m
struggling with a little bit.

So I think that we can do some exploring about whether anyone has taken
a crack at developing such a framework. Because I think you said it
very, very well, Jerry, and your comments built on comments made by
George and Jane and others, but \-- and certainly the Everest of our
ambitions is not to codify and make electronic health records perfectly
able to support measures that we hope go away in the not terribly
distant future because we can do a better job of creating measures that
are better.

But, you know, it is how \-- it is the sequencing of steps that I\'m
struggling with a little bit here.

**\>\>\
**We have this sort of first crack at the framework, as I was saying,
that grew out of some of the MassPRO activities. And I would be happy to
send that to you, and you can see if that\'s something that\'s useful to
help the efforts going forward.

**[\>\> Carolyn Clancy:]{.underline}\
**Well, that would be very, very helpful.

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

Carolyn, this is also \-- this is Charlene Underwood. There is also the
work that the workgroups are working on with AMA, NCQA and the CMS
effort. There is two workgroups there. One looking at the data capture
aspects starting in primary care, the other looking at reporting
aspects.

So that work, Tom Murray, Karen Kmetik, and I\'ll \-- I\'ve got her name
wrong probably.

**\>\>\
**No, you said it right.

**\>\>\
**Anyway, and they might be able to provide input to this framework.
Because, you know, they have got two task forces that are working on
this. It is AQA, rather than HQA, but the concepts are similar.

**\>\>\
**No, I think that\'s fine. And we will definitely follow up with that.
So that\'s very helpful.

**\>\>\
**And there are some more \-- there is some work going on as well as
trying to look at the codes and how to capture more of that. But that\'s
very rudimentary at this point, as you know, but certainly I would talk
to Karen about that because they are doing a lot of work in that
workgroup right now.

**\>\>\
**Right.

**\>\>\
**And some other workgroup as around measure specification. As we sent
them to the NQF to be certain, when they come back, we are able to
capture them.

**\>\>\
**Good.

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

This is Charlene. One other thing, I think as an interim state, I know
there is \-- and I\'ve seen this in proprietary systems as well, I
think, the vendor community starting to merge with \-- again, core of
the success of this is that the measures we define can be defined in
standards, whether \-- this is, no matter. Whatever term, whatever
bottom line, denominator and numerator we need. Because as you start to
standardize those data elements, then the vendors can start to actually
make sure that, in our systems, we start to design or map to those or
whatever strategy we have to use. So that\'s like a really near term,
urgent kind of thing, that we start to merge the measures in that
direction.

As an interim step though we will be able to extract data. You know, you
can politicize technologies to pull data out of the sources, in an
institution, to do some approximation of the measures. And I know one of
the studies that we have been doing at one of our sites is able to just
\-- it is just one of the hospital measures, is able to pull about 67
percent of the data for, you know, in a manual, in an automated way
rather than a manual way by pulling across the multiple systems they
have in place.

So again, I think you will see the vendor community, as you start to
standardize and define what you report on, it will be broader than EHR.
They are going to use other technologies to get there.

You know, read some of the reports that come out of, you know,
dictation, those types of things.

So we just have to just be a little careful that it is a little broader
in EHRs in terms of you look at the technologies.

**\>\>\
**That\'s a good point, because a lot of information is required for
measures that don\'t reside in EHRs. I\'m thinking of pharmacy databases
for example.

**\>\>\
**Right. If you can pull data \-- if you can get it from them, from the
pharmacy databases.

**\>\>\
**Yes.

**\>\>\
**So again, it\'s like \-- you want to be in that. Even when we get it
to the EHR, we are still going to be pulling data, I think, from other
sources.

**\>\>\
**And you need other sources to determine denominators \--

**\>\>\
**Yes.

**\>\>\
**\-- other than the record, the sum of the records themselves.

**\>\>\
**Certainly in volume we will.

**\>\>\
**So, you know, I don\'t know, CCHIT is going to become more than EHRs.
But it starts to just call the question of, you know, is it the EHR \--
it is going to be a set of CCHIT technology that, you know, practices
and hospitals have to use to be able to do this, or probably in the
foreseeable time.

**\>\>\
**So I would take these last several comments to mean, that the initial
recommendation that we had crafted as, analyze the data elements
required for each AQA or HQA measure to mean that we should be thinking
broadly about data elements from a variety of sources, both because we
are going to be living in a hybrid world for some period of time and
also because some of these data elements are not going to reside only,
or may not reside at all in the electronic health records.

**\>\>\
**Yes. Or near term.

**\>\>\
**And definitely we will capture Jerry\'s sense and take a good look at
the MassPRO project so we have a sense of this generic framework, which
I think is clearly of great importance, idea and concept that we need to
retain. And I\'m just still struggling with the timing issue there. God
bless you.

Turning to the third slide, which is another recommendation which talks
about providing feedback to providers in RHIO or near real time. And the
specific recommendation here is to create common patient identification
algorithms for the same measures to support development of clinical
decision support.

I think that this complements rather than replaces prior comments
related to clinical decision support. Tell me if I\'m wrong.

**\>\>\
**When there is a common patient identification algorithm, let\'s \--
what\'s in mind there?

**\>\>\
**A care algorithm or a \--

**\>\>\
**A patient identification algorithm.

**\>\>\
**Yes, but what does this mean? I\'m not sure I get it.

**\>\>\
**I think it is a function of how do you, how are we going to be
capturing data, probably from different data sources, and pulling it
together.

So is it something that would be part of a master patient index or
locator service, or how it would work even within an EHR system.

**\>\>\
**How do you know that patient admitted to the hospital who has a heart
attack has a contra indication to beta blockers or not.

**\>\>\
**These are the clinical care algorithms or whatever. That\'s what you
are talking about?

**\>\>\
**Well, you would need a patient identifier or some strategies for
identify patients who are, an algorithm is how it is worded here, to
make sure that I\'m getting the information on Bill Rollow who is
sitting across from me as opposed to from Charlene Underwood who is on
the phone, in terms of contraindications for a particular measure. That
would be one example.

**\>\>\
**So is the issue here that the provider, either at the point of care,
may not may not have information that\'s relevant to that decision
making?

**\>\>\
**Yes.

**\>\>\
**Is that what this is trying to focus on?

**\>\>\
**Yes.

**\>\>\
**And, frankly, does not have.

**\>\>\
**Yes.

**\>\>\
**Well, I understand that. But I just, I was not understanding what this
was aiming at.

**\>\>\
**I think this is a really important one. Because there is really not a
common set or consensus around what are the best algorithms, and there
are many out there.

And I\'m not sure whether we can have them created though before there
is some analysis of the differences in the algorithms being used to see
which ones tend to have more specificity in them.

They are all really balancing, trying to identify the right patient with
obviously some lack of good hits because of the issues of
confidentiality.

So I don\'t know whether we can start with the word create or whether
there is an activity that antecedes that in terms of evaluating and then
creating common algorithms.

**\>\>\
**I missed a word in what you just said, Margaret.

**\>\>\
**Well, I\'m not sure if there\'s \--

**\>\>\
**You said you don\'t know \--

**\>\>\
\--** start with the word create or whether we have to say, sort of
evaluate or identify the, identify good patient identification
algorithms, and then that can support development.

There was \-- it is the worth \"create\" that\'s bothering me.

**\>\>\
**Okay. Okay. I\'m getting it now.

**\>\>\
**Yes. Because, I mean, this is just a very important piece. Extremely
important activity.

**\>\>\
**So would the word \"evaluate\" work better for you?

**\>\>\
**I think so. Either evaluate, evaluate and identify.

**\>\>\
**Okay.

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

This is Jerry. I think there is an issue that might even be further
upstream than what we are talking about now. As Bill was saying, the
object of the game is, you know, you can say that all patients of X
block should get beta blockers or whatever. But then there is a whole
bunch of exceptions. The idea is to make sure we can get the data about
what those exceptions are to make sure we are applying CDS or gathering
data about appropriate populations. But it seems before you spend a lot
of time and energy figuring out how to manage these data elements, we
have to have a better understanding, in general, what kind of things
define the exclusion so we will know where to focus our energy on which
pieces of data that we want to get a hold of.

**[\>\> Carolyn Clancy:]{.underline}\
**So this \-- I guess I\'m interpreting that, Jerry \-- I agree with the
point, but I\'m interpreting that as getting back to the issue of a
generic high mark.

**[\>\> Jerry Osheroff:]{.underline}\
**I wasn\'t not thinking of it in that context. I was thinking more of
the issue of, okay, we say that these are the exclusion criteria for the
different quality measures. Or if we lay all the different quality
measures out on the table and there is, we are defining a specific
population, which includes who is excluded from being appropriate for
that measurement. It seems you need to look at all those things, laying
out on the table so you can have a generalized picture of what the
exclusion criteria look like before you can identify and create the
algorithms for tracking that data down.

**[\>\> Carolyn Clancy:]{.underline}\
**That\'s an interesting point. I\'m just taking a deep breath listening
to it. Because when I think about the current state of measures
specification it is not, it is not actually clear to me how much of this
is articulated as part of measure specifications. Janet, if you are
still on, would you comment on that?

We may have lost her. Does anyone else have a comment on that?

**\>\>\
**I\'m not sure I really fully understood the last comment. I mean, it
is true when you have come up with the metrics, you always have
exclusion and exclusion criteria if there is some need to try to kind of
risk adjust those measures; but you don\'t have other, you know, risk
adjustment information.

But I guess I thought this was a little bit broader. It was trying to
find, essentially locate information about that patient, regardless of
whether it turns out to have a value to the exclusion, inclusion of
criteria.

**[\>\> Carolyn Clancy:]{.underline}\
**I think it is about both, Margaret, actually, which makes it a little
bit tricky.

**\>\>\
**So I think \--

**\>\>\
**I think there is a lot of variability with respect to this.

**\>\>\
**Yes.

**\>\>\
**I think for HEDIS measures, they are very specific about these sorts
of issues.

**\>\>\
**Mm-hmm.

**\>\>\
**If I understand that we are talking about, patients qualify for which
measures. If that\'s sort of the question we are talking about?

**\>\>\
**Yes.

**\>\>\
**Yes. They are very specific about the methods and the data sources and
so forth.

But I think there are a lot of other data types which are not, there are
a lot of other quality measures which are not specified with that degree
of precision \--

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

But I think \-- this is Jane Metzger. I think you are, part of your
question was, when these data elements are being discussed and decisions
finalized about what is it going to say for this piece of the
denominator for this measure, is anyone at the table asking the
question, A, is this something that\'s routinely documented in the paper
medical record or not.

**\>\>\
**That\'s correct.

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

Is it easily captured in an EHR. Are there the necessary standards. What
are the other sort of practical issues down the road that we should take
into consideration before we make our final decision.

And I don\'t believe that is part of the current metric development
process, although I don\'t sit at the table.

**\>\>\
**I think \--

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

This is Charlene. That\'s the work that I know that the AMA has been
trying to start to lead this year, was to get those discussions to
happen with the vendor community.

And I did want to add that, again, it is not only \-- you know, does
this particular element fall within the workflow, but it is part of a
collection of stuff that would generally get caught in a specific
workflow. Because again, if you are saying capture this piece here and
that piece there, then there is different pieces of workflow they are
going to have to implement to get to the whole. So again, it is kind of
back to that recommendation that was beginning of the call, needing a
framework of how these different pieces fit in the workflow and guiding
the process to fit with it.

**\>\>\
**That work has begun. It is still very \-- there is still a lot of
undefined specifications, if you will. As we work through those, I think
some of the questions around the exclusions of \-- for example, some of
the measures that go together, one that comes to my mind, that I had a
question to ask recently about how to specify those were, you take the
initial core set and you talk about beta blockers. And you give beta
blocker initially, following an AMI. And then the question becomes, what
if you now, go to cardio, and that go to cardio says, okay, it is now a
contraindication. How that first measure up and the second measure tie
to each other, and whether the denominator and the numerator are going
to be the same, and since they are not going to be the same because now
the patient is excluded, how are we going to even valuate that? Not only
at the hospital but also at the physician level. So there is so much
around those exclusion criteria and how they tie into the flow of work
that we have not done, but that work has begun.

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

Carolyn? This is Carol Ostrowski, and I work with the NQF.

**\>\>\
**Great.

**\>\>\
**I would venture to say that a lot of, some of the pieces you have just
been discussing are not really part of the examination process that goes
on here. And of course one of the questions here is, you know, to what
extent should activities begin to encompass some of these problems. Some
of the things that turn out to be serious problems and in actual
implementation.

But I would like to go back to your recommendation about this common
patient identifier, and you focused it on clinical decision support.

I think it is actually even more fundamental than that. Because as long
as we have patients treated in facilities that are related to the same
health care system, for example, or any time we begin to think about
being able to look at episodes of care or care over environments, we are
going to have to be able to be sure that we are tracking this same
patient and getting the right information on them regardless of where
they are.

So I think your patient identification question is right on. But it is
really not just for clinical decision support. It is going to be much
more fundamental than that.

**\>\>\
**No, I think that\'s a very important point. And certainly I\'ve heard
lots of people express frustration as they tried to recover their energy
level to address this within a single health care system.

**\>\>\
**Yes.

**\>\>\
**One that could be relatively tightly closed where there are not common
strategies internally across different sites within the same system.

**\>\>\
**Right.

**\>\>\
**Even trying to do that across one State, and it may vary from State to
State is one of the reasons I think we are frustrated with it.

**\>\>\
**Yes.

**\>\>\
**And it is increasingly common that there are the same names. And
getting the rest of the algorithm in place, in many instances people are
using proprietary algorithms. So there are algorithms out there. So I
agree with the previous comment. But it is not just a matter of creating
them. We really need to know what algorithms are out there and what the
perception of quality is of the algorithms, and then whether they are
propriety or whether there is some possibility of being able to use them
more widely.

**\>\>\
**Yes. Well, I \-- we recognize and take complete ownership of the wrong
verb.

**\>\>\
**Oh.

**\>\>\
**But, no, I appreciate your comment.

**\>\>\
**Just supporting the statement.

**\>\>\
**Yes. I would like to just cover two more recommendations that we might
bring forward to the AHIC in the short term. And for a brief moment we
have been reflecting, but intensely reflecting, on the fact of a short
timeline between now and the next meeting. So I want you to know that we
are aware of that challenge.

The first set, recommendations of the remaining two talked about
enabling data aggregation. And actually gets into the issues that Bill
Rollow and others had teed up earlier, and George had seconded, about
articulating the key challenges associated with linking claims data from
multiple sources that relates to how do you identify physicians, claims
adjudication, processing and so forth, which a number of folks are,
like, completely up to their eyeballs in right now, trying to do in the
public sector as well as in the private sector.

A second is the idea of exploring the benefits and challenges of linking
clinical data to other data sources, including claims. And we brought
this up earlier in terms of thinking about taking advantage of the
experience of Marc Overhage and potentially folks from other health
information exchanges.

The third part of this gets at defining decision rights and
responsibilities for use of data once it leaves a provider system. Now,
this is not limited to the quality sphere, I think that\'s pretty clear,
and gets at the much, much larger issue of secondary uses of data.

There are a number of parties taking this challenge on very seriously,
including the Markle Foundation. And I know that the Office of National
Coordinator is acutely aware and struggling with the issue, does this
particular issue just get pulled out from all individual workgroups to
create a set of policies. But we wanted to tee that up for your
consideration.

And then the last is defining the security and privacy considerations to
address issues related to patient identification once data leaves the
provider system. And again, that\'s also part and parcel of the
secondary data use issue.

So if you could provide some comments on this. I think in some way our
prior discussion has pretty much led us to what seems to me to be a
logical inference, that this is part and parcel of the data, creating a
map of data elements needed for a core set of measures but would welcome
and open to any additional comments.

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

The only \-- this is Charlene. I thought that Linda\'s picture really
did a good picture laying out the current state of where IG is in doing
that.

I just question to the extent any of these other health enterprises are
even to the point of linking the clinical data with the claims data. So
again, is it a point of one or is it a general. But I definitely think
we should use AHRQ\'s experience as a means to send guidance to the
other, to the work that Linda was laying out and potentially to the
States then.

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

This is Kelly. I think that it is probably not likely in the next three
or six months there is going to be many regions in the country that
could actually implement this where we could actually learn from
lessons.

**\>\>\
**Oh, yes.

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

But certainly, you know, as IHIE gets into it we will learn a lot. And
perhaps Hudson Valley, New York, and a handful of other places. But I
think there is an opportunity with this next round of NHIN procurement.
Not clear how many regions of the country we\'ll reach. But if in fact
they are, you know, going to be following this quality use case that we
are going to be informing, I think we have an opportunity to say that in
the next 18 months, or however long, there will be an opportunity to
link clinical data that\'s coming from trial implementation to claims
data. And we could even be encouraging, you know, some demonstration of
how the, you know, AHRQ and CMS funded regional collaboratives, like the
quality price, or the AQA pilots \-- not sure of the current term.

**\>\>\
**Names for them.

**\>\>\
**But, you know, we could be merging more of those efforts with some of
the trial NHIN implementation. So I think we need to be mindful of
probably more of an 18 month time horizon as opposed to 3 to 6 months.

**\>\>\
**Yes. I think your word is okay. It is just, the experience base will
be a little low to start with. That\'s all.

**\>\>\
**Yes. And probably a bit chaotic and disorganized.

**[\>\> Carolyn Clancy:]{.underline}\
**Any other comments on this set of recommendations? I realize we have
all been working very hard, to say nothing of the offline work that
preceded this meeting, and that we are coming to the homestretch.

The last recommendation I wanted to bring up for our discussion was that
of aligning performance measurement with the capabilities and
limitations of health IT. And this really keys back to a comment that
Bill Rollow made earlier. And I\'m actually thinking this might be a
longer-term recommendation rather than in the short term. This actually
does get into the issue of bringing \-- well, having measure developers
have data capture very squarely within their sights as they are
developing measures.

Now, there are some measure developers who clearly do that now. There is
no question about that. A number of them are proprietary organizations.
But they do that because it is efficient and creates a much better
business model for them.

For measures coming out of physician specialty organizations and other
clinical organizations, I think that is much less likely to be the case.

So I could envision in terms of a presentation that we will tee this up
as sort of quasi-near future but not immediate work that we would be
undertaking. Any comments on this in particular?

**\>\>\
**I don\'t know, Carolyn. I think it ought to be near future.

**\>\>\
**Uh huh.

**\>\>\
**So, you know, it may not get it near future. But I really do believe
that the measure developers really should have this in mind. I think
they should be utilizing it and if they don't have it in place we ought
to be putting it in place. I\'m squarely for putting this sooner rather
than later.

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

That is Charlene. I would, too. But I\'m not sure the word is the
testing process. But what will be coming out of it is starting to be
some consensus on that data strategy.

**\>\>\
**Right.

**\>\>\
**And once we can start to map to a consistent data strategy at the end
of the game, we will have more flexibility to do different kinds of
measures. So however we drive there, you know, because this process will
get us down to, how can we start to have consistencies of capturing data
that will feed one or more measures in a common way?

**\>\>\
**Yes, I would agree with that.

I think it will get us to \-- the current measure will get us all to the
NQF set. It will get us all to a single point of care, specification and
measurement sooner rather than later.

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

This is Jane Metzger. I would echo the prior comments. I think that just
as I\'ve said several times today, converging measures and having a
unified national quality agenda, is sort of one of the underpinnings of
all this making it work.

I think having measures that are implement able is really at the root of
this. So I would vote for sooner rather than later.

**\>\>\
**Well, let me just say I\'m getting a pretty clear signal on the
response here. So thank you very much for that.

And it is also yet another reason for me -- or should I say for us to
follow up with Karen Kmetik on a number of these issues.

**\>\>\
**Mm-hmm.

**\>\>\
**So \-- public comment \-- (inaudible).

I think we have reached the part of the meeting where we can be asking
for public comment.

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

Okay. For folks following along on the Web, there is going to be is a
slide up there in just a second. It is there now, with the phone number
to call in and then you need to press star one once you are connected.
And if anybody from the public is already called in and is waiting on
the line, now is the time to press star one to get in the queue.

**\>\>\
**I\'ll also mention quickly, while we are waiting a few more seconds to
see if anybody calls in, there is an e-mail address and you can submit
comments that way as well.

**\>\>\
**Is Jon Teich still on the call?

**\>\>\
**5:30?

**\>\>\
**5:30, yes. Right there?

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

It doesn\'t look like anybody is calling in with comments for the
meeting today.

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

Thank you very much.

So just to summarize quickly where we have been, because we have covered
a lot of territory here today. But I can\'t think of a single syllable
that I considered superfluous or gratuitous, which I think is something
of a comment on the quality enterprise that we are trying to automate.
It would be much easier if that enterprise were in a different place
than it is right now. But I think that also reinforces the importance of
the work that we are doing.

First we heard some really terrific comments, and I have to thank Jane
and Charlene and others who contributed to recrafting the visioning
matrix. I think it is very broad. We are going to incorporate the
comments that we have heard, and we will get a red line version out to
you for one last look.

We also heard a number of comments around the specific organization and
have \-- the specific recommendations rather. And we have a very clear
short term to do list. And right at the top of that to do list is
following up with Karen Kmetik on a number of specific dimensions that
relate to work that\'s currently in progress with the AMA, CMS, NCQA
consortium. In addition to that, Jerry, we will be very much looking
forward to getting information from you about the MassPRO project. And I
can\'t promise you that we won\'t be calling you for additional insights
and input there because I thought your comments were incredibly helpful
on that regard.

We will be also conscious of the timeline and the amount of work we need
to get through to get to the next meeting of the community on January
23rd. Be sending you out some options for an interim meeting between now
and then. Let me just tell you we will not be three hours. It will be
much more focused and less open ended and comments because I think we
have got a lot of good comments today, and it will be very much focused
on the presentation to the community on January 23. And \--

**\>\>\
**We did have one meeting on the 9th. We will probably need two.

**\>\>\
**Okay. We have one meeting on the 9th scheduled. So I guess what I\'m
actually saying is that we may need an additional meeting in addition to
that.

Someone here is shaking their head so \--

**\>\>\
**That is problematic. Because of the timing, and it needs to be \-- and
since it is closed meeting, it needs to occur before the next public
meeting. Because any decisionmaking has to be done in a public forum. We
could not finalize anything.

**\>\>\
**Yeah. Although I think, I mean, if we need to, we could have something
on the 11th or the 12th to turn around quickly. Because it is going to
be publicly presented to AHIC on the 23rd.

**\>\>\
**Just to refine it and wordsmith it.

**\>\>\
**That\'s obviously \--

**\>\>\
**Make the decision at the 9th and then you can polish it.

**\>\>\
**Well, just so you are capturing all of the details here, our next
meeting is on January 9. It is possible that we will need something
within the next couple of days after that which would be strictly about
refining. I\'m very sensitive to scheduling issues. So if you can\'t
make that, we will probably be in a position to accept some notes or
comments electronically or any other means.

And I want to really thank all of you again for the input you have made.
We have got a clear to do list here. Be looking in your e mail in the
very near future for a red line version of the matrix in which we hope
to capture all your comments.

Pam, if you are still on the line, we will be waiting for any additional
comments you have on the consumer piece of that matrix because I think
that is so critically important, and absent very explicit and specific
attention is likely to get shorter shift than it should.

**\>\>\
**We will be happy to do so.

**\>\>\
**Thank you. So we will be getting that to you in the near future. Our
next meeting is on the 9th. We may need to follow up with one or two of
you very specifically. So if you hear from us, don\'t feel picked on,
but consider it a badge of honor that we felt in need of additional
expertise.

For those of you that we won\'t be seeing between now and the end of
this calendar year, please let me wish you happy holidays and a terrific
happy new year. And I hope you come back recharged and refreshed because
we have got a lot of very important work to do. Thanks again.

**\>\>\
**Thank you. And the same.

**\>\>\
**Thank you, Carol.

**\>\>\
**Thanks all.